Dr. Matthew Hayn (Guest): As you know, Melanie, this is an area that is fraught with controversy and most urologists, myself included, feel that men between 50 and 70 should be offered prostate cancer screening. That should be a discussion between them and their urologist or them and their primary care physician, to see if screening is right for them, especially men at higher risk of having prostate cancer, which are men with a family history - father, brother or uncle who had prostate cancer - or African-American men. Both those groups are at increased risk. We don’t think everybody should be screened, but, at the same time, it should be something that’s available to all men should they want it.
Melanie: What’s involved in that screening? Men typically don’t want to come and see a urologist in the first place, they’re not sure what to expect and sometimes it’s even the spouses that shove them in.
Dr. Hayn: Right. The right way to screen men for prostate cancer is two things: one is a prostate exam or a digital rectal exam, to physically examine the prostate; and the second is currently a blood test for prostate-specific antigen, or PSA. Both of those things should be done together to maximally make screening a good process.
Melanie: So then, what does the PSA mean? What are those numbers? We hear the numbers and sometimes that changes. What is the PSA?
Dr. Hayn: The PSA, the prostate-specific antigen, is a molecule that floats around in the blood. It is made by the prostate and it tends to be more elevated or to go up more quickly in men who have prostate cancer. The issue is that prostate size and other conditions of the prostate can impact the PSA level and so, therefore, not everybody with a high PSA has prostate cancer and not everybody with a normal PSA doesn’t have prostate cancer. So, when the PSA is abnormal, that’s when the discussion with the urologist is very important to see who may benefit from further testing, such as a biopsy or other things, to help diagnose the cancer.
Melanie: Besides PSA, are there other tools in your toolbox to diagnose? What happens if PSA is a little raised – and many men have BPH as they get older anyway--so what do you do if the PSA is elevated?
Dr. Hayn: I mean, typically for a man who has an elevated PSA and a normal prostate exam, we don’t find anything suspicious, we’ll have a discussion with them about a prostate biopsy to help figure out what’s going on. Other tests that can be done in lieu of a biopsy, you can do what’s called a “free PSA”, which is a variation on the PSA and the level of that free PSA test can help steer you in one direction or another; there is another blood test called the “prostate health index” that can help you do the same thing. There’s a urine-based test called the “PCA3”. All these tests aim to risk-stratify men with regards to their personal risk of having prostate cancer but the only definitive way to know is to have that prostate biopsy.
Melanie: So then, what do you do? If you diagnose somebody with prostate cancer, there are so many treatments, and we can’t get into all of those today, but I would like to talk about monitoring, watching the PSA, watching to see if cancer recurs or grows. What do you do, Dr. Hayn?
Dr. Hayn: So, I think what you’re alluding to is what we call “active surveillance”, which is a way to closely monitor and survey men who have low risk prostate cancer or non-aggressive prostate cancer. Active surveillance is a way to avoid over-treatment. Not everybody, not every man with prostate cancer needs to have an operation or needs to have radiation or some other form of treatment. Many of those men – in fact most men – with low aggressiveness, low risk prostate cancer can be monitored by the urologist to make sure the cancer doesn’t get worse and doesn’t spread and then put their lives at risk. We do that through a combination of checking PSAs over a period of time, repeating prostate biopsies at intervals – usually once a year initially – and what we’re adding to our program here is the use of prostate MRI and possibly MRI-ultrasound fusion prostate biopsy to help closely survey these men on active surveillance.
Melanie: Tell us about that.
Dr. Hayn: So, what that is, is that a prostate MRI is an MRI of the prostate, just like you get for some other organs. The MRI is very good at identifying lesions, or growths, within the prostate that could represent more aggressive cancer. One of the issues we run into with a standard biopsy is that we biopsy the prostate somewhat randomly and we may not hit every area of concern. The MRI can help us find growths or tumors that we may have missed. If a patient has an MRI and they find a growth on the MRI, then those MRI images can be synced up or fused to the ultrasound we do in the office. That way, when we do our repeat biopsy, we can very precisely target the abnormal area. If there is an abnormality found in the MRI and it’s particularly concerning, the patient can have an 80 or 90% chance of having an aggressive cancer there and we want to find that.
Melanie: And I know, Dr. Hayn, it is based on certain staging that you would do for the prostate cancer, but if you’re keeping an eye on this, how often would somebody have this MRI? How often would they have their PSA checked to watch?
Dr. Hayn: The active surveillance protocol varies depending on where you are. At Maine Medical Partners at Maine Medical Center, we are checking PSAs every 6 months for patients on active surveillance and we typically get that first prostate MRI and possibly fusion biopsy about 1 year after the initial biopsy. Then, subsequent follow-up is kind of dependent on what we find on the next biopsy. So, it’s kind of individualized for each patient but, initially, it’s a PSA every 6 months or so and a repeat biopsy and an MRI in about a year.
Melanie: Is it more important, if you look at the number in the PSA, if it’s high or is it the rate of rise, if you’re watching it rise up? Which one is more important to keep track of?
Dr. Hayn: You know, both. They’re both important. Prostate size can affect the overall PSA level the rate of change, what we call the PSA velocity, if it’s going up rapidly, that can indicate something’s changing. People have gone back and forth and studied this and some believe that the PSA velocity is very important and some people believe the PSA velocity is not useful at all. So, it’s not easy to generalize one or both of these to each patient. It kind of requires the urologist sitting down with the man and going through the numbers and seeing if there’s an area of concern there or not. So, I’m not really answering your question but they’re both kind of important, but neither one is a smoking gun that will tell you all your information.
Melanie: So, what’s on the horizon, do you think, for prostate cancer diagnosis and monitoring an existing cancer? What do you see on the horizon?
Dr. Hayn: I think, you know, truthfully, the prostate MRI and ultrasound fusion is the current state of the art for men on active surveillance, and for some other men who may have a high PSA who have had a negative biopsy in the past, trying to make the second biopsy better. Prostate MRI and ultrasound technology is fairly new and it’s gaining some widespread acceptance and adoption. So, that’s kind of the here and now. What will improve going forward is better molecular and genomic testing of the prostate and of the potential prostate cancer to try and precisely identify which men are at risk of the cancer getting worse and progressing, and the cancer spreading. That way, say, for example, a man has a prostate biopsy and they do particular molecular or genomic testing, we may be able to tell this patient, “Your risk of it getting worse is 5%,” and they can feel very comfortable about watching the cancer as opposed to a guy who has a risk of the cancer getting worse at 50% and he’s probably going to want to think about active treatment. I think that’s where it’s going--genomic and molecular testing, in addition to this MRI technology.
Melanie: In just the last few minutes, Dr. Hayn, give your best advice to men who are of the age to get screened or have been diagnosed, why they should come to Maine Medical Center for their care, as Maine is the first hospital in Maine to offer the important tool that we’ve been discussing--the high-tech prostate imaging.
Dr. Hayn: I think what we can offer at Maine Medical Center is, not just the MRI and the ultrasound technology which I think is wonderful and is a big step forward for these men, but, more importantly, we can offer comprehensive prostate cancer care. We have a genitourinary cancer navigator, named Tracy Robbins, who provides great unbiased recommendations and information for men with prostate cancer. We work closely with the radiation oncologists who deliver radiation for prostate cancer, and the medical oncologist as well. So, you’re not just coming to Maine Med to see the urologist. You’re seeing--in either a physical or virtual way--the whole team. That way, men can make informed decisions about their prostate cancer treatment. What we’d really like to avoid is treatment regret. We want men to be well-informed, to be engaged in what we call “shared decision-making” to allow them to make the best personal decision for them, for their prostate cancer and their situation.
Melanie: What great information. Thank you so much, Dr. Hayn, for being with us today. You’re listening to MMC Radio. For more information, you can go to mmc.org. That’s mmc.org. This is Melanie Cole. Thanks so much for listening.
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