Advancements in Screening, Biopsies, and Treatment for Prostate Cancer

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Hi again everyone, and welcome to another episode of Butts and Guts. I'm your host, Dr. Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm very pleased to have Dr. Ryan Berglund on who is a urologist and member of the section of urologic oncology here at the Cleveland Clinic. Ryan, thanks so much for joining us on Butts and Guts.

Dr. Ryan Berglund: Thanks for having me on.

Dr. Scott Steele: So, for our listeners who haven't had a chance to hear you on other platforms, on other stations, why don't you give us a little bit of background about where you were born, where'd you train, and how'd it come to the point that you're here at the Cleveland Clinic?

Dr. Ryan Berglund: I was born in Chattanooga, Tennessee, and I did my med school and some of my training in New York, but ultimately did my residency here and I just loved this Cleveland weather. So I've stayed on at the Cleveland Clinic for the last 14 years, but I've been a member of the staff for 14 years as a member of the section of urologic oncology after spending some time in New York.

Dr. Scott Steele: Well, we're so glad to have you here. So today, we're going to talk a little bit about advancements in the screening, diagnosis and treatment of prostate cancer. So to start, can you give us a little bit of an overview about what prostate cancer is, any warning signs or symptoms that we should be on the lookout for?

Dr. Ryan Berglund: Yeah, thanks Scott. Prostate cancer, it's what we also call prostate adenocarcinoma. So when we talk about prostate cancer, it's a cancer of the gland, the prostate gland. It is the most common cancer in American men, about 300,000 cases diagnosed a year in the United States. It's the second leading cause of cancer death in American men. It's about 35,000 deaths a year in the United States. It's exceedingly common. So as the saying goes, if you live long enough, you'll get prostate cancer. There's a lot of truth to that. About half of men, almost half of men will have prostate cancer in their prostate at their time of death. About 3% of American men go on to die of prostate cancer. So you can see there's a wide chasm or gap between those who develop the disease and those who ultimately die of it.

Dr. Scott Steele: So, Ryan, with it being that common, are there risk factors that put you at an additional high-risk category for prostate cancer?

Dr. Ryan Berglund: There are three main risk factors. Number one, genetics. That's a big one. So it tends to travel in families. If you've had a single first-degree relative, so a father, a brother or son that's had prostate cancer, you have a significantly higher risk, just one would double your risk. And if you've had a couple or have had one that had it before the age of 50, it quadruples the risk. Also, African-American race. The second one is it is somewhat of a metabolic disease. We talk about some cancers that are metabolic cancers. So we know that people who carry too much weight or not physically active and don't eat a very healthy diet, are more prone to developing the disease and do worse stage for stage and grade for grade when they develop the disease. And last of all, age. The older you get, the more likely it is that you have the disease. So it is a disease that predominantly affects older men. The average age of diagnosis is in the mid-sixties. So those are the major risk factors.

Dr. Scott Steele: So, truth or myth? Prostate cancer is common. Second only to skin cancer is the most common cancer affecting men and people assigned male at birth.

Dr. Ryan Berglund: That's true.

Dr. Scott Steele: So, you mentioned those risk factors which are really, really extraordinary and you mentioned some of those statistics that are amazing, about 50% of men having it in their prostate death. So how do we screen for prostate cancer? How does that work and when should it begin and what options are there available?

Dr. Ryan Berglund: So prostate cancer screening is one of the great success stories. I would argue it's up there with colonoscopy in your own field. I mean if you look at colonoscopy, and I don't want to get out of my wheelhouse here, but if you follow the colonoscopy guidelines, correct me if I'm wrong, you roughly reduce your lifetime risk of dying of colon cancer by about 50%. Is that fair to say?

Dr. Scott Steele: Yeah, that's fair.

Dr. Ryan Berglund: So, if you follow the prostate cancer screening guidelines, you roughly cut your risk of dying of prostate cancer by about 40%. So the way that we screen is depending on your family history, et cetera, starting at around age 50, you get a PSA blood test and you get a finger or digital exam of the prostate. PSA is a screening test that was developed in the eighties. It's an enzyme that's uniquely produced by the prostate and by prostate cancer cells. And the higher that that number goes, more likely it is that you have prostate cancer.

So you really want to start around the age of 50 and then you check it as frequently as is determined by your genetics and also where your level is. So if you have a very low level and you don't have a strong family history, you check it every couple of years. If you do have a family history or your PSA is running a little bit on the higher side, you may want to check it more frequently. I do recommend that in patients that have a family history or African-American that they start getting checked in their forties.

Dr. Scott Steele: So, what can a patient expect if they need a biopsy and when would you do a biopsy to determine if they have prostate cancer that needs treatment?

Dr. Ryan Berglund: Biopsy is largely determined by PSA level and then the presence or absence of a nodule on exam. And so there really are two sets of guidelines, but roughly in the two and a half to four range on PSA, you're in kind of a gray area about whether or not you need a biopsy. In a biopsy naive patient with a PSA above four who has a reasonable life expectancy, you should really consider getting a biopsy. The exceptions to this, when patients get a lot older, let's say that we have a patient over the age of 70, medical comorbidities, that doesn't have a long life expectancy, I wouldn't even check PSA. But as someone who's expecting to live more than 10 years and kind of in that age to 50 to 70, I would say absolute at PSA of four. And then it's kind of a discussion point between two and a half to four.

Dr. Scott Steele: So, Ryan unique maybe to prostate cancer, maybe some other ones, but it seems like there are some patients that have slow growing cancers that may not even need surgery, even therapies, and it's an active surveillance plan with their physician. So can you talk a little bit about the different grades or stages of prostate cancer and what that may mean in terms of treatment options?

Dr. Ryan Berglund: It is kind of a tough concept to wrap your head around, but there are a lot of patients, I would say a large proportion of my patients that do not need their prostate cancers treated and just need them followed. There's some nuance to this discussion, but basically there are three categories of prostate cancer. There's going to be low risk, intermediate risk, and high risk roughly speaking. With our low-risk patients, roughly speaking, if you were to do nothing about the disease, about 20% or so of patients would die of the disease within 20 years. That's doing nothing. So you can see even for a young and healthy patient, if you watch the disease and only treat it if it starts to show more aggressive features, the risk of going on to die of the disease is very low if you stay on top of it.

So for my low-risk patients, a large proportion of them elect to follow surveillance. Intermediate risk patients, if you do nothing about it, roughly speaking, about 30% of patients would die of disease within 10 years, about 80% would die of disease within 20 years. So you can imagine a patient who's 80 and has a number of comorbidities, probably not a lot of value to treating that, but in a patient that has a reasonable expectation of living more than 10 years, you probably are going to want to treat it. There are some exceptions. And then high-risk disease, if you do nothing about it, about 80% of patients are dead of disease within 10 years. We're going to treat most patients even an elderly or frail patient, but we're probably going to treat that patient, then I would treat somebody like you for instance.

Dr. Scott Steele: So, has there been any advancements in treatment over the last few years that maybe have changed the way we care for patients with prostate cancer?

Dr. Ryan Berglund: First of all, we have a lot of different focal therapy techniques that we can use in our very low volume, lower-risk cancers. So traditionally, treatment has been a whole gland treatment, whether extirpated like removal or ablative where you either radiate or freeze the entire prostate, but we have ways that we can treat it focally. It's a very select group of patients. You have to know that the disease is in that one location and it's very small and it is not high risk. So focal therapy is one area. Another area is that our radiation techniques, for instance, are a lot different now than they were 20 years ago or 30 years ago. This is not your father's radiation therapy. I have a lot of patients that come in and say, "Gosh, my grandfather got radiation therapy back in the day, and it really led to a big mess in his life and he had a lot of problems."

Well, they're very good at targeting the gland very effectively. Last of all, surgery, and I know this has been important in your field as well, we've become very, very effective at minimally invasive surgical techniques, particularly with the robot. And so a surgery that used to have a minimum of a couple of days in the hospital, 25% transfusion rate and a reasonably high complication rate, has now turned into a surgery, which largely in my practice is an outpatient procedure with a less than 5% transfusion rate and a much lower complication rate. So the morbidity of surgery has gone down with our minimally invasive techniques.

Dr. Scott Steele: Yeah, kind of expanding on that, the Cleveland Clinic was the first in the US to remove a patient's prostate robotically through single incision in 2018. And you've been a proponent of minimally invasive surgery, as a matter of fact, toot your own horn, outstanding laparo-endoscopic resident all the way back in 2005. So how has robotic surgery... you mentioned a little bit about it, but how has robotic surgery in general evolved to help treat these patients?

Dr. Ryan Berglund: It is funny Scott. I can remember I started my residency in 2000, which was the same year that the DaVinci robot was FDA-approved, and we had one, and you wouldn't even recognize the robot then compared to what we have now. But it used to kind of sit out in the hallway and we're trying to figure out what to do with it. And we were here at the Cleveland Clinic, were early pioneers in using it to remove the prostate. Before the robot, we were actually removing prostates laparoscopically. But you can imagine that when you're using laparoscopic instruments, you really don't have a lot of degrees of freedom of movement. And it's almost like suturing with chopsticks.

I mean it's really, really difficult to do certain parts of the case. And so the robot allowed us to have numerous degrees of freedom to allow us to do very complex suturing and nerve preservation techniques. And it has evolved into a... first of all with high definition video, smaller instruments, more complex instruments and other tools that allow us to lose less blood, see better, have a better sensation of how strong the tissues are that we're working on. So it allows us to perform essentially an open surgery internally as opposed to trying to use the laparoscopic instruments. And so I think that's been the big breakthrough with the robot.

Dr. Scott Steele: So, let's shift gears a little bit and talk about the potential side effects from prostate cancer treatment. What are they and what options are available to help alleviate them?

Dr. Ryan Berglund: I'm really just going to address surgery and radiation. I'll give you my own take on each one. With surgery, you're going to deal, first of all, just with generic surgical risks, whether you get your prostate removed or you have a part of your colon removed, you're going to have a very small risk associated with anesthesia. You're going to have risks of bleeding, infection, pain, damage to other tissues, blood clots in legs and lungs. Those are what I'd call generic surgical risks. And that's just a risk going for surgery. Unique to prostate cancer surgery would be urinary and sexual problems. Everybody has urinary and sexual problems immediately following surgery. At the one-year mark, about 10% of patients report having sustained diminished urinary quality of life with two to 3% having a severe urine leakage problem. About 50% report having sustained diminished sexual quality of life, most commonly erectile dysfunction.

It can also include things like penile shortening curvature, other subjective complaints. We have to remember that the prostate is the organ that produces the semen, so you would not produce that anymore after having the surgery. So that's kind of surgery in a nutshell. With radiation, you're largely dealing with the negative side effects or the negative effects of the radiation on the normal surrounding tissue. So tissues like the bladder, the rectum, the bone marrow, they're all going to get a dose of radiation. There's an increased risk of irritation, bleeding, and even secondary cancers in the normal surrounding tissues. There's a similar risk of having urinary sexual problems because you're going to radiate the bladder, the sphincter muscle, the nerves that create the erections.

There is a higher risk of having bowel problems. There's some things that we can do to deal with that, but I mean, you probably see those patients yourself that have had prostate radiation therapy, the anterior rectal wall does get some radiation. The other issue with radiation is that if the disease comes back, it's a more challenging problem to manage. So if the disease comes back after surgery, we can give you radiation therapy. We have a very good chance of salvaging the relapse after surgery. If you have the disease come back after radiation, we cannot give you more radiation in operating or doing procedures on radiated tissues is very high risk, as you know well because you have to operate on radiated patients fairly frequently.

Dr. Scott Steele: Yeah, that's true. And so are there any other advancements on the horizon when it comes to treating prostate cancer?

Dr. Ryan Berglund: The big thing is, and you probably have experienced the same thing, I really feel like we're on the verge of a major singularity when it comes to biotech. It really is amazing what the pipeline is like as far as treatment for metastatic disease for many years. I mean, this is going back to the 1950s when the Nobel Prize was awarded to Huggins and Hughes for the hormonal therapy and the treatment of prostate cancer. We've been using hormonal therapy for decades. We had nothing else to offer patients, and now suddenly we have second-line therapies and other treatments that we can use to slow the disease down. And I don't think it's farfetched to say that our ability to turn metastatic prostate cancer into more of a chronic disease than an acute disease for our patients is just increasing as every day goes by. And I'm sure you're seeing the same thing with colorectal cancer.

Dr. Scott Steele: So now it's time for our quick hitters, a chance to get to know our guests a little bit better. So first of all, what is your favorite meal?

Dr. Ryan Berglund: Oh my goodness. Chicken wings, buffalo wings. Yeah.

Dr. Scott Steele: What was your first car?

Dr. Ryan Berglund: A Nissan Maxima.

Dr. Scott Steele: You've been around the world. What was your favorite place to travel?

Dr. Ryan Berglund: That's a tough one. Nicaragua.

Dr. Scott Steele: And finally, what is your favorite holiday?

Dr. Ryan Berglund: Oh, Christmas. Come on. Are you kidding me?

Dr. Scott Steele: And so, what is your final take-home message to our listeners regarding prostate cancer?

Dr. Ryan Berglund: One of the messages that I have, particularly to my patients that are largely men, and a lot of them don't take good enough care of themselves. The message is make sure that you have a regular medical doctor that you're checking in with on a regular basis. It's not just screening for prostate cancer, but it's screening for colon cancer, screening for heart disease. I'm now 51, and I see my internist every year. I've had a couple of too much information, but I've had a couple of colon polyps. I mean, a lot of these problems are very manageable if they're caught early. And the patients that go into die of prostate cancer are patients who have late diagnosis. And so if you kind of stick to the healthcare plan that your regular medical doctor, your internist has for you, a lot of this stuff is preventable, not just for me, but also colorectal cancer, heart disease, et cetera.

Dr. Scott Steele: Amen to that. So to learn more about Cleveland Clinic's advances in prostate cancer screening, more effective monitoring, better biopsies and breakthrough therapies, please visit clevelandclinic.org/prostatecancercare. That's clevelandclinic.org/prostatecancercare. You can also call 216.445.6246 for more information. That's 216.445.6246. Ryan, thanks so much for joining us on Butts and Guts.

Dr. Ryan Berglund: Scott, thanks so much.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.