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What You Need to Know About Prostate Cancer

January 16, 2019 12:00 PM with Dr. Brian Helfand

Join Dr. Brian Helfand of the NorthShore Medical Group and Dr. Jianfeng Xu, as they answer your questions about all aspects of prostate cancer, from diagnosing, living with and treating it. Learn more about genetic risk score, symptoms, diagnosis, and other surveillance methods. Your participation and questions are welcomed. 

Diagnosis of cancer

Ben (Moderator) - 12:00 PM:
Welcome to the What You Need To Know About Prostate Cancer chat. The chat is now open and you can submit questions.

  Mark (Glenview) - 12:02 PM:
How reliable is the PSA test? Do you recommend annual testing? What is the % of false positives?
Brian Helfand
PSA is the most common blood test used for prostate cancer screening. Unfortunately, just because a man has a high PSA, does not mean that he has prostate cancer. other conditions including enlarged prostates, inflammation, exercise, sexual activity, etc can increase your PSA falsely. Therefore, the PSA test has many false positive results. The frequency of false positives depends on the level (e.g. less with higher PSA values) Despite this, I recommend annual PSA testing. I believe that a baseline should occur at age 55 if you are at average risk. High-risk individuals (defined by a family history of prostate cancer, other cancers, African American and/or genetic risk) should be screened regularly starting age 40-45 years. Genetic risk can be assessed by testing for a genetic risk score and high penetrance genes.

  Roger (Chicago, IL) - 12:06 PM:
Will I be able to have children after treatment?
Brian Helfand
Depends on the type of treatment that you undergo. If you undergo surgery, the only way to have children is to either bank sperm before surgery or obtain it from a testicular biopsy. After radiation, you could father a child. However, radiation can potentially impact the quality of sperm and consideration for banking sperm prior to therapy should be performed.

Brian Helfand - 12:15 PM:
I have the pleasure of sitting with Dr. Jianfeng Xu. He is one of the world's experts in genetics and has been the country's thought leader in developing genetic tests for prostate cancer. These tests should be used to guide all aspects of prostate cancer from screening to biopsy to treatments.

Brian Helfand - 12:20 PM:
According to Dr. Xu, prostate cancer risk should be assessed by 3 major components other than race. These include 1) family history of prostate cancer and other related cancers including breast, ovarian, colorectal, pancreatic and endometrial cancer 2) high penetrance genes including BRCA2, BRCA1, ATM etc 3) genetic risk score. Of the three components, the genetic risk score is considered to be the most relevant to the most men. This is because it can explain the reason why over 30% of men develop prostate cancer. The genetic risk score is calculated by measuring a number of variations throughout every man's DNA that are associated with prostate cancer. Based on the number of variations that an individual has, a risk estimate of developing cancer throughout a man's lifetime can be calculated.

- 12:24 PM:

  Eugene (Lincolnwood, Illinois) - 12:27 PM:
As part of active surveillance, how much reliance can be placed on a negative prostate MRI.
Brian Helfand
MRI have helped detect many more high-grade cancers. However, in active surveillance about 30% of men will have a negative MRI but have high-grade disease. Therefore, although we would all like to avoid biopsies, they are still necessary even with a negative MRI

  Aaron (Chicago) - 12:30 PM:
Can you describe a standard prostate exam, and when/how often do men have to get them done?
Brian Helfand
A standard screening for prostate cancer should include 1) assessment of risk for prostate cancer including family history and genetic information 2) a digital rectal exam (DRE) and 3) a PSA There are several ways to do a DRE, but all involve inserting a finger into the rectum to feel the prostate. This is important because about 10-15% of men with prostate cancer and aggressive tumors will have a normal PSA, but a nodule on the prostate that is detected during the DRE. The DRE should be performed annually for average-risk men starting age 55. It can be performed at earlier time points for men with increased risk. In addition, sometimes physicians will perform digital rectal exams for other purposes (e.g. evaluate the size of the prostate for men with lower urinary tract symptoms).

  Tommy (Morton Grove, IL) - 12:34 PM:
Is there anything new in the realm of prostate cancer and it's treatment?
Brian Helfand
We have made a great deal of progress in the world of prostate cancer. This progress has been witnessed in prostate cancer screening and treatment for both early stage (localized) and late stage (metastatic) cancers. In terms of screening, genetic assessment and tests are becoming increasingly utilized to determine which men would benefit from earlier and more frequent screening. In addition, there are many other PSA-like blood tests such as prostate health index (PHI) that provide more accuracy in screening patients. In terms of localized disease, we now actively follow as part of active surveillance protocols many men with low risk (non-aggressive) tumors that are localized to the prostate. This has represented a complete change in our management for these men. For men with localized but more aggressive (ie higher grade) tumors, treatment is still recommended. These treatments and their potential for side effects have decreased tremendously.

Brian Helfand - 12:40 PM:
As a continuation from the last response... Surgery is now performed routinely using robotics. The side effects of urinary leakage and erectile dysfunction have decreased with this as well. In addition, newer more focused radiation therapies are being increasingly utilized. In terms of advanced, metastatic prostate cancer, there are many new drug developments. These include over 3 FDA approved new medications designed to target testosterone receptors. All of these have significantly delayed the time to develop worsening disease. In addition, newer drugs are being developed including PARP inhibitors for men with genetic mutations. Finally, there are many newer imaging techniques that improve our localization of where the metastases are including PET/CT scans.

Brian Helfand - 12:42 PM:
Additionally... All of the new developments facilitate personalized care management from screening to the treatment of early and late-stage disease. The goal of this personalized care is to provide the right treatments at the right time for the right patients. At NorthShore, we have clinics in prostate cancer that are designed to help with these decisions.

  John Gray (Deerfield, IL) - 12:43 PM:
Does having a Father and Brother with prostate cancer put me at high risk of getting it?
Brian Helfand
Yes, prostate cancer is one of the most heritable of all cancers. Having first-degree relatives such as a father and brother increases a man's risk of prostate cancer. The age of diagnosis of these family members also can increase risk-- earlier diagnosis is associated with increased risk. But without that knowledge, having a brother and father increases the risk about 2-3x higher than the general population (about 1:3.5 chance of being diagnosed throughout the life).

  John (PROSPECT HEIGHTS) - 12:45 PM:
Can you compare open prostatectomy to robotic prostatectomy? Is robotic more desirable for treating PC in early stages? Or is the surgeons experience the only determining factor?
Brian Helfand
Surgeon experience is critical no matter what type of surgery that you are undergoing. This is particularly relevant in prostate cancer where outcomes including cancer control, nerves that control erections and muscles that control continence are critical. A surgeon should have performed more than 250 surgeries to be considered experienced. However, I believe that the only surgeons who should perform prostatectomy should be focused solely on prostate cancer. In general, open and robotic have similar cancer control and functional outcomes in terms of continence and erectile dysfunction. However, open surgery generally has significantly more blood loss, increased time out of work because of healing, and longer time to return of functions such as erectile dysfunction and continence. Based upon this, it is no surprise that robotic surgery is now considered the gold standard for prostate cancer surgery.

  Jess (Chicago, IL) - 12:49 PM:
If a PSA test comes back moderately high and biopsy results show normal cell morphology, what further testing should be considered and when?
Brian Helfand
About 30-40% of biopsies performed will miss prostate cancer on the first procedure. This is very frustrating for patients and urologists. In general, PSA blood tests should be followed after a biopsy. If the PSA continues to rise, then there may still be a suspicion of prostate cancer. In this situation, additional tests, such as a prostate MRI and blood tests such as prostate health index, 4K score, etc should be strongly considered. Additionally, a genomic test called ConfirmDX can evaluate the tissue and let a physician know the chances of missing cancer. Finally, the continued evaluation and suspicion for continued prostate cancer should be also made based upon a person's overall risk including genetic risk. If a man has a high genetic risk score or a high penetrance gene mutation, then continued surveillance is often recommended.

  Aaron (Chicago) - 12:54 PM:
What're the risk factors? Genetic and/or physical? What're the preventative measures I can take?
Brian Helfand
Risk factors for prostate cancer including African American race, family history of prostate cancer, family history of early onset breast cancer and/or other cancers including colorectal, pancreatic, etc. In addition, genetic testing can provide more direct information about your risk. While there are no absolute preventative measures for prostate cancer, it is thought that early screening is critical. In addition, a healthy lifestyle that includes weight control, diabetic control, and exercise is recommended.

  Bob (Wilmette, IL) - 12:57 PM:
Will I be able to work during treatment?
Brian Helfand
If you are undergoing radiation, most patients continue to work during therapy. However, some patients report some increased fatigue (that usually does not prevent work) after about 4 weeks of radiation treatment. Usually, most of my patients take off 2 weeks from work, unless they are at desk jobs. Motivated individuals can often be back to work in less time if desired.

Ben (Moderator) - 1:00 PM:
That's all the time we have today for questions. Thank you, Dr. Xu and Dr. Helfand, for your time and expertise!
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