Prostate Cancer Survivorship

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research in clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig phase one and sarcoma programs. Today, I'm happy to be joined by Dr. Petar Bajic, a urologist at the Center for Men's Health and the Glickman Urological and Kidney Institute. He's here today to talk to us about prostate cancer survivorship. So welcome, Petar.

Petar Bajic, MD: Thank you so much for the invitation.

Dale Shepard, MD, PhD: Absolutely. So maybe just start out, tell us a little bit about your role here at Cleveland Clinic.

Petar Bajic, MD: Yeah, so I'm an urologist who focuses in men's sexual and urinary health. And as part of that, we deal with a lot of what we call cancer survivorship, which is dealing with some of the consequences of cancer diagnosis and treatment. So I see a lot of men for sexual dysfunction, avoiding dysfunction, prostate issues, etc.

Dale Shepard, MD, PhD: Okay. So let's take a step back to start. There are a lot of people from differing backgrounds that might be listening in. Prostate cancer. How many patients are we talking about? What's the impact of prostate cancer on the population?

Petar Bajic, MD: So prostate cancer is one of the most common conditions that a man can get with age. It's one of the most common cancers. It's also one of the most common causes of cancer-related death. And it's the kind of thing where the older a man gets, the more likely he is to get it. Not all prostate cancers are deadly, but there are some that can be life threatening. So it's definitely a very common condition that has a very significant impact.

Dale Shepard, MD, PhD: And so what are some of the treatment options for prostate cancer?

Petar Bajic, MD: So one of the options that men who are diagnosed with prostate cancer may have, is actually active surveillance, which means just keeping an eye on things closely and making sure that maybe a less dangerous or less aggressive cancer doesn't become one of the more serious types. Men who require treatment for prostate cancer typically choose between either surgery to remove the prostate or some form of radiation therapy, which can be either implanted radioactive seeds or a different type of radiation that's delivered from the outside in.

And there are some other treatment options that are available in select cases. For example, cryotherapy. There's also focal therapies like high-frequency ultrasound. And then for men who have more advanced prostate cancer, they may be treated with things like hormone or androgen deprivation therapy, or even chemotherapy or other agents like immunotherapy. So there's a lot of different treatments out there.

Dale Shepard, MD, PhD: And it seems like if we're going to be talking about survivorship, and we'll get into more details, but I guess there's issues that come from the cancer itself. And then there are symptoms and problems that come from the treatments that we give. Active surveillance. If we're not actually treating people, you can eliminate some of those treatment-related side effects. So it seems like active surveillance kind of comes and goes in terms of popularity over the years. And where are we at this point with active surveillance, and how common is that at this point?

Petar Bajic, MD: It all depends on the grade of the prostate cancer, so kind of the severity of it. And we determine that based on a prostate biopsy. So we generally lump prostate cancer into five what we call grade groups, which are kind of a numerical designation of how worrisome the cancer is. One is the best one to have, and five is the worst. We've definitely, over the years, tried to find ways to best use active surveillance in a safe way to really only treat the men that really benefit from undergoing treatment.

So I would say that over time, the number of men undergoing active surveillance has increased. And nowadays we have a lot of useful tools like genetic tests, MRIs, and all sorts of stuff to better risk-stratify men, and try to better understand who might be the ones that cancer is more likely to grow or spread or become something more serious.

One of the things about prostate cancer is that in the early stages of prostate cancer, there are no symptoms. So a man may not have any outward symptoms whatsoever. And by the time he does develop symptoms, it can actually end up being a lot more of a serious issue. It may have actually spread outside of the prostate.

So we rely on tools like the PSA or prostate specific antigen blood test and other tools to try to determine when cancer might be present. We have some guidelines that we follow on who should be checked based on age and other risk factors. So, but yes, men who undergo treatments like surgery, radiation, etcetera, are going to potentially have some consequences of that in addition to if they don't undergo treatment and they develop symptoms from the actual cancer itself.

Dale Shepard, MD, PhD: And I guess from a patient selection, as we move through therapies and what to do, we've had a prior podcast episode on the IsoPSA test.

Petar Bajic, MD: Yeah. That's a great newer tool that we use a lot here at Cleveland Clinic. That's really been nice to spare many men from needing to undergo a biopsy, and it really helps us try to only biopsy the men who really need it and would benefit from that.

Dale Shepard, MD, PhD: Yeah. So let's jump into survivorship. When we think about prostate cancer survivorship, let's just start simple. What does that mean? Who is considered a survivor?

Petar Bajic, MD: So we consider the prostate cancer survivorship really as a journey that spans from even before diagnosis, from the initial testing through diagnosis and then through eventual treatment and for the rest of your life after that. So there's a lot to it, and there's physical things that can happen. There's also mental health components to this as well. So specifically with what I do in my clinical practice as a urologist focusing on men's urinary and sexual health, is I help men who may be having urinary or sexual difficulties, either as a result of their cancers or as a result of treatment for their cancers.

Dale Shepard, MD, PhD: And so let's kind of work through both of those. Urinary issues. What are the most common urinary issues that you encounter?

Petar Bajic, MD: Yeah. So the other, I guess, even more common prostate condition that can happen besides prostate cancer is benign prostate enlargement, which is also essentially something that pretty much all men will deal with at some point in their life. So, although that's not directly related to the cancer, many men in this age group also have urinary issues related to that. So that's probably the most common urinary problem that men have, because, like I said, the actual cancer doesn't necessarily cause symptoms.

Now for men who have undergone treatment for prostate cancer, in general, those men fall into, like I said, two groups. Most men either have surgery or radiation, and these are men who did not necessarily qualify for active surveillance. Some men can develop urinary incontinence, and that's more common in men who have been treated with surgery. And there are also different types of effects that can happen to the bladder related to radiation therapies, like overactive bladder type symptoms, having to urinate frequently and urgently. And some men can develop scar tissue in their urethra called a urethral stricture, which can impair their ability to empty. So those are just a couple of the urinary issues.

Dale Shepard, MD, PhD: And what are the interventions that you can use to help these patients? Because I think it's important for people to realize that these are treatable. Is that correct?

Petar Bajic, MD: Correct. So I think one of the biggest misconceptions that many of our patients have is that the side effects of cancer treatment are just something that you have to live with. But it's really important for men to take home from this that all of these issues are treatable. And it's just a matter of having those conversations with your care team.

I mean, when you're first diagnosed with cancer, the focus is really on how are we going to treat this cancer? How are we going to get rid of it? How am I going to move on to the next phase of my life? Once the cancer's treated, we don't always have an opportunity to circle back and say "Hey, listen, how is your quality of life doing? Are there certain factors that are suffering as a result of the treatment that you underwent and how can we best optimize those?"

So on the urinary side, for example, let's say just for example, a guy, he undergoes radiation therapy, either shortly after, or maybe years down the road, he may have some irritation to the bladder from that treatment and may have, let's say, frequent urgent urination. Sometimes there may be some blood in the urine. We have a lot of very effective treatments for that kind of bladder issue and even a lot of times we use for men who don't have a history of cancer. So there's medications. There's various procedures that we can offer.

Sometimes in men, if medications don't work, we might even consider something like injecting Botox into the bladder or even doing a nerve stimulator. So there's all sorts of different treatments for that. Just as an example for men who might have urinary leakage after undergoing prostate removal, this is also a little bit more common in men with more advanced or recurrent cancers that later on have to undergo radiation on top of the surgery to move the prostate, we have very effective treatments.

Like, for example, there's a device called an artificial urinary sphincter, which can restore continence in some of these men who may be leaking a lot of urine. There's also things like urethral slings. There's clamp-type devices that can be applied on the external portion of the urethra to prevent the urine from escaping. So there's all sorts of stuff out there. And that's just one of the things that we do in this survivorship area of urology.

Dale Shepard, MD, PhD: How about the sexual-health side?

Petar Bajic, MD: So sexual dysfunction is probably one of the most common things that can happen as a result of cancer treatment, not just for prostate cancer, but we see a lot of men who have been treated for colorectal cancers and other things.

Probably the most common sexual dysfunction that men come to the doctor for is erectile dysfunction, and erectile dysfunction is the kind of thing where for men undergoing surgery, it's something that pretty much all men will experience some degree of, at least at the beginning. The vast majority of men get either back to their baseline or pretty close to their baseline, but it can take time.

And unfortunately, some men don't go back to their baseline, and those are really the men where we need to make sure that they're having adequate follow up and that they know all of the available treatment options out there because it's not just Viagra. There's all sorts of stuff, not just oral medications, but there's devices that can be used. There's other injectable medications. There's even implants that can be curative for erectile dysfunction.

So in addition to the erection hardness issue, men can develop even incontinence related to sexual activity. So that's actually an issue that has been gaining increasing attention, either incontinence related to sexual arousal or incontinence related to orgasm are two things that can affect both men who have had surgery or radiation. And it's actually very, very common, even up to 70% of men who undergo certain treatments might experience that. And historically, we haven't done a very good job of asking the right questions to understand whether men might experience that. So there's certain things that we can offer for that as well.

And then certainly prostate cancer treatment can also affect the way that a man ejaculates, which can be a source of bother for a lot of guys. So for example, I just, I guess, some background information. So 80% of the fluid that comes out when a man comes from the prostate gland. Only a small percentage of that is actually sperm from the testicles. So if the prostate is removed or if it's kind of fried with radiation, it's just not going to necessarily have that same ejaculation. And that can be a source of bother to men.

So these are all things that we discuss in our survivorship visits and try to understand not just what a man is experiencing, but the level of bother associated with each of these individual things. I mean, I've definitely seen guys that maybe leak a little bit of urine if they really overexert themselves, but it's not really bothersome. It doesn't interfere with their ability to go to church or go to do other things in their day to day life. Other men might be extremely bothered by even just a small amount of that. So it's really a tailored approach that we individualize to every patient.

Dale Shepard, MD, PhD: And so you're dealing with the urological sort of implications. Is this part of a multidisciplinary group that's also looking at things like impact of hormonal therapies on bone or muscle mass and things like that?

Petar Bajic, MD: In a lot of hospital systems, we can be very compartmentalized about the specific organs that we're treating, but we definitely have a holistic approach. For example, I didn't really get into the consequences of hormone deprivation therapy and other systemic therapies, but that's something that we also deal with a lot. I'm always making sure that my patients who are undergoing those treatments are taking their calcium and vitamin D. And sometimes if they haven't had one in a while, we'll order bone scans and things like that.

So really there is a great multidisciplinary collaboration where we're working with the oncologists. We're working with the mental-health providers. I mean, we're regularly kind of making sure that people are having those resources available to talk through some of what they might be experiencing, how it might be affecting them individually and also affecting their relationship with their partner.

So there are a lot of resources and opportunities for collaboration available. And we're also looking at innovative new ways of trying to give patients the best possible and most satisfactory outcome and reducing the risk that they may regret what they had chosen.

There's established programs at Cleveland Clinic, taking advantage of peer mentorship programs. And we're also looking at this specifically in the prostate-cancer population of looking at how maybe matching patients up with a peer mentor who's been through this journey may help them understand what are even the right questions to ask at this point. How can I better inform and educate myself as I choose which way I want to go so that in the end, I have a less of a likelihood of regretting the decisions that I made? We're always kind of looking at new ways to optimize these pathways for our patients.

Dale Shepard, MD, PhD: What do you think are the largest gaps in terms of consideration of prostate cancer survivorship?

Petar Bajic, MD: I think one of the biggest gaps is just awareness on the patient side, that these things are normal and expected, particularly for patients who are undergoing these treatments, but even for men in the community who maybe don't have cancer. There's some major similarities here. I mean, urinary and sexual issues are something that pretty much all men will deal with at some point, and specifically in the cancer population and especially in prostate cancer, it's very commonly something that can occur as a result of treatment. So just being willing to talk about it, talking about it with your partner, with your friends, with your providers, and your care team, and making sure that we know what's going on with you so that we could figure out ways to help.

And then more specifically on, I guess, things that we can offer, I mean, I think that we're continuing to find better and more innovative treatments that have less of an impact on quality of life. For example, here at Cleveland Clinic, we're exploring the use of focal therapies for prostate cancer in select patients and trying to make sure that not only the cancer is treated and eradicated, but to minimize the risk of impact on quality of life. And also for treatments for the issues when men do get them, we're continuing to look at less invasive, easier ways that men can be treated for some of these issues and be more satisfied in the end.

Dale Shepard, MD, PhD: You mentioned sort of awareness and thinking about patient and patient awareness, but particularly later-stage patients primarily being seen by medical oncologists. I mean, here at Cleveland Clinic, I think we do a really good job of multidisciplinary care, but in a traditional path, oftentimes prostate cancer patients are seen by urologists and then they shift to a medical oncologist and maybe don't loop back around to urology to take care of some of these issues. So how do we let the medical oncologist know that you have things available and we can get help?

Petar Bajic, MD: Yeah, that's such a great point. And we talk about what are the best models for long-term survivorship care and who should kind of be the quarterback. Some places where it's more the medical oncologist; some places it's the primary care doctor. So I think the bottom line is we don't necessarily know what the best model is that's widely applicable to the overall medical community, but I think it's all about maintaining that communication between the care team engaging. The urologists should be engaging the medical oncologist and vice versa. Here we're constantly trying to look for opportunities to come and speak to the different departments and share what we have going on and what treatments we have available.

So really it's so important that we continue to work together. Like you said, at Cleveland Clinic, we do a great job of it, but even in the broader community to really take the best possible care of these patients and make sure that they're aware. Nowadays with the increasing utilization of virtual visits and also in various educational pathways online, there are opportunities where we're doing webinars and trying to educate the community that many of these things are available, and those have been very successful.

So I think we need to continue looking at on a broader scale, a national and even international level, continuing to offer great educational material for our patients so that even if their provider may not necessarily know about a certain treatment, they have that information available to them and they can maybe bring it to their doctor's attention and say, "Hey, is there anybody that you could connect me with to learn more about this?"

Dale Shepard, MD, PhD: And I guess sort of doubling back on the treatment part itself, what do you find is the most eagerly anticipated changes in treatment on the urologic side and the sexual-health side? What do you find most exciting for the future to make an impact?

Petar Bajic, MD: So, I mean, I think a lot of what we already have is very exciting for a lot of patients that undergo it, because a lot of these guys that come in who maybe had treatment even 20 years ago and just kind of were lost to follow up and they come in and we present them with what we have to offer. Even some of the treatments that have been around for a long time, like the artificial urinary sphincter. I mean, these are some of my happiest patients. I mean, you go from having, some men have five, ten Depends per day that they're soaking through. They're not able to do really anything that they want do. And then you take them from that, and they're essentially either completely dry or down to a single precautionary pad. I mean, it's dramatic quality of life improvement.

And similarly, one of the other types of procedures that we do is called a penile implant, which is a device that can restore erectile function, even in men who maybe Viagra doesn't work and other treatments haven't worked. These guys are all so extremely, extremely happy, and satisfaction rates for these treatments are in general across the board above 90% for both patients and their partners. And there's not a whole lot of things that we do in medicine with satisfaction rates that high.

But as far as what's to come in the future, I mean, these things are constantly being innovated. On the horizon, there's some kind of more high-tech things like the electronic artificial urinary sphincter, which is going to be probably able to be controlled from a cell phone. Whereas the traditional device has to be operated by a little pump concealed in the scrotum.

So there's some kind of cool techniques there, but I think the really exciting stuff is when we think about treatments and how do we even prevent guys from needing this stuff. I mean, I think that's really the future and what we're continuing to work so hard to better identify, and not just that, but also better identifying the patients who maybe don't need certain treatments. So I think that's really where a lot of the progress has been made in the last 10, 15 years is who can be safely watched and how do we best watch them so that if something changes for the worst, we catch it right away before it becomes something that they really may be at risk of a poor outcome. So there's a lot of exciting areas, I think. Those are just some of them.

Dale Shepard, MD, PhD: And it sounds like, unlike a lot of other areas in medicine, it sounds like you really do have some good tools.

Petar Bajic, MD: Yeah.

Dale Shepard, MD, PhD: It's more about getting the patients to them.

Petar Bajic, MD: Yep.

Dale Shepard, MD, PhD: So that's good. Very encouraging.

Petar Bajic, MD: It sure is. Yeah. I mean, I think that I always encourage my patients to educate themselves, seek out reliable sources of information online, like the Cleveland Clinic website. I mean, there's so much great content out there. And be willing to talk about some of these things. Realize that a lot of guys don't like talking about medical stuff. I mean, I don't know if it's cultural things or they just want to be macho. But I think what a lot of guys find is that these things are very common, and maybe even a lot of people in their own circle that they may not even know might be experiencing very similar things.

So, seeking out information online, participating in support groups. There's so many resources available. And I always encourage men to just be willing to start that conversation, and maybe even just with your partner to start, but eventually with your doctor and the rest of your care team. And I think that it's just the first step in getting the help that you need to get over some of these issues.

Dale Shepard, MD, PhD: Well, Petar, you've provided some great insight for us today. We appreciate all the work you're doing in this area.

Petar Bajic, MD: Thank you so much for the invitation and always happy to talk about this stuff and try to help our guys that are dealing with this.

Dale Shepard, MD, PhD: Very good. Well, thank you.

Petar Bajic, MD: All right. Thank you so much.

Dale Shepard, MD, PhD: To make a direct online referral to our Taussig Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled.

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