Brachytherapy For Prostate Cancer

[ music ] >> good evening and welcome to conversationslive prostatecancer, i'm patty satalia. prostate cancer is one of the two most commoncancers among men. one in seven men will bediagnosed within their lifetime. prostate cancer can beslow-growing or aggressive and treatment optionsvary widely based on the particulars of each case.

how do you know what'sright for you? tonight our expertswill discuss detection, treatment and prognosis. they'll also takeyour questions. now, let's meet our guests, dr. richard ditlowjr. is an oncologist with the prostate cancercenter in camp hill, a practice devotedexclusively to the care and treatment of this disease.

dr. christopher yinglingis a urologist with mount nittany physicangroup in state college and is trained inrobotically-assisted surgery. greg petersen is directorof broadcasting at wpsu. peterson was diagnosed withprostate cancer in 2002 and says if he had known then what heknows now he would have chosen a different treatment strategy. you can join ourconversation tonight, our toll-free numberis 1-800-543-8242

and our email addressis connect@psu.edu. you may also tweet your questionor comment to wpsuconnect and use #wpsuconversations. thank you all somuch for joining us. >> thank you. >> i'll begin withyou dr. ditlow, doctors frequently say most mendie with prostate cancer not of it so give us thecurrent statistics. how many men will bediagnosed with prostate cancer

and what percentagewill be the slow-growing versus the aggressiveform of the disease? >> exact numbers i don't havebut roughly as you said one of seven men will be diagnosedwith prostate cancer throughout and the vast majority, you know and the patients wesee i'd say probably 60 or 70% are what wouldbe either low or intermediate-risk disease. so that means the othersare high-risk disease.

it's not a, it generally isa rather slow-growing type of cancer but stillroughly about 25 to 27,000 men die everyyear from prostate cancer and it also can be a verypainful and very painful and uncomfortabledeath to be quite frank because the metastasis ofthe bone can be very painful. >> the diagnosis of prostatecancer interestingly enough it can be devastating for anumber of reasons but mostly because it oftencomes out of the blue.

men are feeling just fine. they have no inkling thatthere might be something wrong so i'm curious to know what ledto your prognosis greg petersen? >> the year before i actuallygot diagnosed i'd had a sudden attack in my lowerabdomen region and i couldn't explain it. it lasted about two days,fevers, chills, went away. and so i didn't knowwhat it was. i was at a conference atthe time, out of town.

when i came back i sawmy general practitioner and he said well you know, this,this, it could be prostatitis. now tell you what, we'lldo a psa and do a psa and they came back justabout a point higher than it should be for my age. >> so it was inconclusive? >> it was inconclusive sohe said why don't you go and see a urologist andthen i went and saw that. >> you know it's interesting

because most menare asymptomatic and there's the newfederal advisory, the u.s. preventative servicestask force in 2012 advised to the shock of manypatients and doctors that they're not theroutine psa tests. >> correct. they kind of surprised theurology community a bit. i think and oncology communityas well when they came out with these recommendationsagainst the psa test.

the history of psa isactually relatively short. it was actually ibelieve identified by a penn state graduatestudent who had moved to buffalo and then developed it but itdidn't really come into vogue until the early 1990s. so, this was a new testthat we knew saved lives. it really drasticallydecreased the mortality, the death from prostatecancer numbers. the problem with the testis that it goes up for a lot

of reasons that have nothingto do with prostate cancer. >> the psa test, thenumber may be high and you don't have cancer? so it goes up for lots of thereasons that have nothing to do with cancer and they lead toa lot of extra procedures, biopsies and exams andstress and things like that that patients don'tnecessarily benefit from. >> and in fact maybe harmed from? >> correct, correct exactly.

>> in terms of lifelongside effects. now the interestingpart of it is that we still diagnosethe vast majority of our prostate cancersbased on either psa or just routine annualphysical screening, the dreaded finger exam. and those are still the twobest things we have right now to find early prostate cancer because there reallyare no symptoms

of early prostate cancerfor the majority of men. >> you know it's interestingbecause a lot of men don't like the idea that their doctoris now saying you don't get a psa test. they're saying, you know tostop looking doesn't make sense, maybe change what you do onceyou get a psa that's a little bit high but to not look, look for it seemswrong-headed to lots of people. in fact some say itwill lead to more deaths

and i'm wondering threeyears out, has it? >> well, i think we've seenmore advanced cancer being found that we didn't know aboutmeaning people coming in with more advancedcancer rather than finding earlier cancersso we're seeing a little bit of a stage migration wherewe're seeing the worst cancers upfront. as a urologist we tend tostill feel that there's a lot of value in a psa test.

it's important to kind of understand the fullpicture of the patient. if they have prostatitisor other acute issues that may cause the psa torise then you have to factor that into their evaluation and understand isthis a true psa value or is it up for other reasons? but we still think there's anawful lot of value in that test and it was a little bitfrustrating in a lot of ways

to see the recommendations of the u.s. preventativeservice task force. >> i want to get backto that in a minute but we do have ourfirst phone call, rhonda from statecollege, you're on the air. >> hi, my husband's familyhas a history of breast cancer and i was wondering if that putshim at risk for prostate cancer? >> interesting question,dr. ditlow? >> well, there issome connection

between the brca genes for breast cancerand prostate cancer. it's still though, it's rare. even, actually even the brcagenes for breast cancer aren't as common as you mightthink from all the media but there can be a connection. you have to be concernedif, i mean it is something to be considered if there'sa lot of family history of breast cancer and someoneyou know with prostate,

for their prostate cancer too. there is a possible connection. >> but she brings upsomething interesting and that's risk factors. we know that african-americanshave a higher incidence of prostate cancer. age plays a factor. what are other, dr.yingling, other factors that put someone at risk?

>> family history isthe number one thing. if you have a first-degreerelative or two first-degreerelatives your personal risk for prostate cancer drasticallyincreases so family history as well as race,some age [inaudible]. >> so if you have a familyhistory, ask for this psa test. is there somethingbetter than the psa test? >> currently, no. i think there are two components

that are very importantfor screening. psa is just an initialscreening test. it doesn't diagnose orrule out prostate cancer, it just helps alert us towho we need to look closer, more closely at to try tofigure out who could have it. so you still need a fingerexam, a physical exam. there are other teststhat we use to help differentiate aslight rise in psa and try to decide is it upbecause of cancer,

up because of other reasons? so, there's nothing rightnow that can replace the psa but there are other tests thatwe use as additives to it to try to help better understand it. >> go ahead doctor. >> i'd like to make thepoint too, the digital exam, the finger exam is mosti think is most important when you have yourvery first psa. because the psa normallyis 4 or less and so

if your psa comes back at2.67 that can be elevated because there are somepatients, their normal psa is .7 so if you don't know what yourpsa was before and you get a psa and it's 2.7 but the urologistfeels an abnormality well then you have to biopsy that becauseyou don't know what your normal psa you know was before. so and that's when the, i thinkthe digital exam is especially important when you haveyour very first psa. it's important afterwardstoo but that's

when it's really important. >> go ahead. >> i agree with that and i thinkit's also important to know that psa values tend to risethroughout our lives so that in a younger man, a man aroundthe age of 50 a psa of 2.6 or 2.7 may really bea very elevated psa. a man who is in their 60sor 70s maybe a psa of 6 or so may not be that highso you have to look at it in the big picture,things with the patient

and their overallsituation as well. but i agree aboutthe finger exam. >> and also the psais not just a number. if it's how fast it's rising soyou would watch it over time. >> so, greg petersen at thebeginning of the program we said that you would have donesomething differently had you been diagnosed today. explain why you say that? >> well, my psa was3.5 which was about.

>> you were 49? >> and i was 49, maybea half a point or more over what it should beand they did try a long, a course of antibiotics tosee if it was prostatitis. i got retested for the psa. the psa didn't drop down. so, after my first biopsyit was inconclusive. there was some, theysaid the cells looked like there's some changes butthere's nothing conclusive.

so i went through aseries of biopsies. i had three biopsies eachabout four or five months apart until on the third biopsythey actually found something. so, it told me. it tells me now it waspretty hard to find. it wasn't widespread. >> it was encapsulated. >> it was prettywell encapsulated. >> it had not metastasized.

>> and but you hear the wordcancer and you just say, i want to be done with this. but now i think i wouldhave done the wait, watch for waiting thing andwatch it closely for a while until something had to be done because that wouldhave eliminated some of the side effects that i had for the urologicalcomplications. >> i want to getback to side effects.

but two-thirds get a psathat is sort of inconclusive but 90% say i want atreatment for the exact reason that greg petersen said, thebig 'c' it's still a very, very scary thing, dr. ditlow? >> but yeah, excuse me, yes andi, that's put out as a reason for not doing psasbecause it's said, well if patients know theyhave cancer they're going to want treatment. well, you know yeah, imean you know that's,

i mean that you knowwe've tried. we've sort of, i wouldsay bowed at the altar of informing thepatient, informed consent, letting the patientmake the decisions, all of which i totallyagree with but when it comes to something like this, well no. you're going to want somethingwe don't want you to have and that just doesn't makeany sense to me either. >> there are lot of people whothink this comes down to money.

it costs money to provide thosetests and but there's no harm in the test whereaswith mammography where the recommendationshave also been changed, with mammography there isthe exposure to radiation. >> that's true. >> but let me take a phone call. we've got vernon who'scalling us from williamsport. vernon, you're on the air. >> good evening gentlemen.

>> good evening. >> why i'm 81 years of age. i'm having some prostateproblems and my urologistis very reluctant to do anything becauseof my age. he said he doesn't want medying on the operating table and he's reluctant to do even,i call it 'roto rooter' process and he did say he would agree to what they term the microwaveprocedure where they go in

and microwave that and itshrinks up the urinary tract. >> direct radiation maybewhat he's talking about? >> no, it's actually atreatment to actually. it's for a benign prostaticenlargement to improve voiding and the ability to urinate. >> well the only thing i had to,he's reluctant to do anything because of the urinarytract infection, what they call a host infection. that it clears up andthen it comes back.

and i've been trying formonths now to get rid of the doggone thingso that they can do one of these procedures becausei've been wearing a bag for a year you know. >> right. >> what advice would youhave for this caller? >> well vernon, i think you havea really frustrating situation that we unfortunatelysee in a lot of men. infections for men in thebladder, in the prostate,

those often have todo with an inability to empty your bladder completely so in general recurrentinfections are a reason to do a procedure, amicrowave or the roto rooter which we call a turp, a trans-urethralresection of the prostate. those are not prostate cancertreatments, those are treatments to help you urinate better, empty your bladder moreefficiently and then

in turn hopefully avoidthe need for a catheter or avoid recurrent infections. i would tell you that there'salways the hippocratic oath that we take, which the firstrule is "do no harm" so we have to look at you as a person anddecide are your risks of being under surgery and goingthrough surgery worthwhile to go through the treatment? i'll tell you that at 81, the age itself is notthe scariest thing.

our population goes much beyondthat and we often have people in their 80s that makeit through surgery without any trouble but we haveto look at the whole picture for you and without knowingthose things i can't tell you for sure but i'd keep looking. a microwave is an okay procedure and turp is a betterprocedure generally for people who have a recurrent, orrecurrent infections as well as urinary retention but ican't tell you that specifically

without knowing other details. >> dr. ditlow, anything to add? >> no, that's, no that's all. >> you would havesaid the same thing? >> i would not havesaid anything. that's purely urology. >> okay, okay [laughter]. thank you so much for your callvernon and best of luck to you. we go to bryan who iscalling us from export.

go ahead please bryan. >> yes, my father just passedaway from prostate cancer on october 11th andhe had elected to do a procedurecalled cryology where they froze the prostateand it still metastasized to his bones and to hisliver towards the end. and my question mightbe, i thought for one that it might have kept himalive having gone through that but would there have beensomething better besides

cryology, for instance radiationor removal of the prostate that might have been moreeffective or might have made him or allowed him to live longer? it's an interesting question because from what i'm readingthere isn't one treatment that is superior to the others. do you agree with that? >> i do agree with it and i think the most importantthing you have to take home

from prostate cancer is that prostate cancer isnot the same uniformly. different types of cancer,people who have an early stage, gleason 6 prostate cancertend to uniformly do well with no matter, with anytreatment you choose. people with an aggressivehigh-risk prostate cancer unfortunately tend not to doparticularly well with any of the treatments forcure, which treatments for cure mean radiation,surgery,

theoretically cryotherapy so. >> which is freezingwe should tell people. >> yes freezing yeah. so, without knowing the details of your father's prostatecancer i can't you again that there would have beena better option for him. >> but what we might want totell him is that he is at two to three times the risk that someone whose family memberdoesn't have prostate cancer.

what's your adviceto him dr. ditlow? >> well, it's not really advice but cryo surgeries i thinkgenerally used in patients who are older and maybecan't tolerate surgery and even external beam radiationtherapy and also for patients where there is a specific nodulethat they can you know freeze. the difficulty with cryosurgeryit's difficult for them to freeze the whole, from myunderstanding i haven't that and maybe you guys have, but myunderstanding is it's difficult

for them to freeze the entiregland because they have to be very careful becausethey can damage the surrounding structures if theyover-freeze things so that's, my understandingthat's the problems. you know the problemwith cryosurgery is that they may not be ableto freeze the whole gland and so therefore it maynot be a curative procedure in a particular person. my understanding, this torepeat, my understanding is

that the ideal patient issomeone who has a single, has a main nodule that in itselfcan just be frozen in someone who is older and hasno other [inaudible]. >> is hormone treatmentstill viable to shrink the sizeof the prostate? >> it is. it is, testosteronetends to be the fuel for prostate growth andprostate cancer growth and if you use hormones toblock the active testosterone in your system we do see aphysical change in the prostate

where it will shrink in sizewhich can make it more amenable to different proceduresnot necessarily surgery but cryotherapy or radiation that may increase sensitivityto radiation as well. >> so the hormone therapyis short-term or no? >> it varies. >> it varies, okay becausei've read about a lot of men who think there's,death might be better because the way they feel.

they're lethargic. they have hot flashes thatwomen you know, this is old hat for women but new to men. >> right, i think thatactually that's one of the most important thingsthat was not addressed by the u.s. preventative servicetask force that when they looked at all of this they lookedat death as an end point of all their studies saying psas where people were short-termweren't necessarily doing

better, long-termwe know they do. but one thing they didn'tlook at was side effects of the treatments we have. the treatment that i thinkhas the most side effects and the most problems isactually hormone treatment. >> wow. >> it's the one that mencomplain about the most. >> okay, i want to talk to you and your experiencegreg petersen.

you chose brachytherapy whichis well tell us what it is. >> it's small, radioactive seeds that are implantedthroughout the prostate. i had 128 seeds put in andthey're about the size of oh, about 32nd of aninch wide and maybe about an eighth of an inch long. they look like pencil leadsfor mechanical pencils. they're really small. >> and they're there for life?

>> they're there for life. and there's some, you knowthey say you could pass one in urine and i never did. and they give you a littlebottle to put in a lead pouch in case you find one but. >> because of the radioactivity? >> because of theradioactivity and you also, they told me you need tosleep apart from your wife for a couple of weeks, iguess no increased radiation

to anybody. but i had time to look at abunch of different modalities and a prostatectomy was. >> removing the prostate. >> removing the prostate and iknow people who have had that and have not done very well withit and i have a brother-in-law who did not do verywell with that at all, still isn't doingvery well with it, radioactive seed,the cryotherapy.

>> the external beam radiation. >> the external beamradiation and i chose the seeds but like i said knowing nowi probably would have waited because it wasn't, the factthat it took them three biopsies to actually find thecancer at all told me that it was a pretty,a pretty small. it was a pretty,nonaggressive cancer. >> you say that inpart because 20 to 40% of prostate cancer patientsend up with side effects,

complications as a result. >> what happened with you? >> after about a year ihad urological problems where i couldn'tgo to the bathroom. i had to catheterize myself,myself for about a year and a half, thisself-catheterization. and after about a yearand a half that cleared up so i could urinatewithout a problem. i still. i sometimes, i throwup blood clots once and a while

because of that and then justabout four years ago i was going to have both knees replaced which required acatheter to be put in. well i was on the table,i was out and i had. >> ready for surgery. >> ready for surgery and theycouldn't get a catheter in and dr. miller one of yourcolleagues happened to be in there and so he gotin, got a stethoscope and said boy he'sgot a pinhole there

so he finally got a catheter inme but the surgery was off then because of the possibilityof infection and so i had to do that, go through a turp tomake it wide enough and recover from that and then i could goback and have the knee surgery. >> was the pinhole a resultof the radiation seeds? >> most likely, yeah. >> i would say yes. unfortunately one of the sideeffects and that can happen with surgery as well isthat you can have scarring

of the urethra, the tube that drains the bladder runsbasically through the prostate. unfortunately i thinkthat's what happened. >> yeah and it just, hesaid it's only scar tissue, that i just had a pinhole left and dr. miller said he wassurprised i could even urinate but so i was and that happened. and then it just happenedagain a couple of days ago where it just out of the blue,i'm not urinating anymore so had

to go in and get itkind of cleaned out. >> now interestingly youhave been and you call it, your prostate cancerhas been undetectable for nine or ten years. >> yeah the psa. >> why do they sayundetectable rather than cured? >> well, from what iunderstand it's never cured. i mean there's apossibility it can come back. i've been told the possibility

after so many years nowit's been what, 13 years, 14 years is not really great because every psa i've had hasbeen you know less than .01 which is i guess basicallyundetectable in me so i'm knock on wood, so i guessyou still do the psa because the possibilityis it can come back. >> alright, i want to takean email and then a couple of phone calls thatare stacking up here. robert writes "doesdiet affect your chance

of getting prostate cancer?" dr. ditlow, i'll letyou field that first. i know obesity is a risk factor. >> yeah, it's one. there are a lot ofthings like that. there are some studies that showperhaps there is increased risk and there are other studiesthat show there isn't. the reality is we've alreadytalked about the real risks, the main risk is family history

and these other thingsmay or may not. >> but i have that interestingquestion because i have read that vegetarians have a lowerincidence of prostate cancer. >> yeah, there arecertain things in the diet that we think may decreaseyour risk a little bit. the problem with it is we don'tknow how early in life you need to start consuming those thingsto have the benefit at the age when you would developprostate cancer. but the one moleculethat i know of

and molecule is not the rightword, selenium, the one. >> selenium okay. >> it's the one thing thatwe know is protective. >> okay, interesting to know. jim from johnstown, thank you for your patience,you're on the air. >> hello, my question isand i've been doctoring with my urologist for overten years for an enlarged, abnormal prostate andsome recent tests showed

that i may now have thestart of prostate cancer but something new has comeup in the conversation and it's called thegleason score which i'm not too surewhat that's all about. >> let's talk about it. thank you for your call jim. the gleason score,you know yours. tell us a little bit aboutwhat it is dr. ditlow. >> well the gleason score isthe pathologist's evaluation

of how aggressive thecancer cells look. it's not totally an opinion. the pathologist does look forcertain criteria but it's not yet a test that we take theslide and put it in a computer and it spits outthe gleason score. and you get two numbers, thegleason, actually the scale goes from 0 to 5 or 1 to 5 andbecause prostate cancer tends to be mixed you get, you gettwo numbers and how it's used is that if the gleason scoreis less than 7, number 6

and your psa is less than 10then it's probably low-risk. if the gleason score is higherthan 7 and/or your psa is like over 20 that'shigh-risk and then in between is theintermediate risk. but the gleason score again isan evaluation by the pathologist >> and what about stagesthough because we also hear about prostate cancerin stage 1 through 4? >> staging happensin a variety of ways. it tends not to happennecessarily

by the gleason score,it happens more by initially clinical staging isbased on what we feel on exam, how much of your prostatewe think is involved or do we find it because of anelevated psa or do we find it by some other mechanism? after we remove a prostate youget a bit different staging, that's called pathologicalstaging. that looks at what wefind under the microscope, the extent of the disease.

does it go beyondwhat the capsule or the outside edgeof the prostate? does it invade into anyadjacent structures? so those are where we getour main stages and we look at whether or notit's spread outside to lymph nodes andbones as well. >> and how do you getthis gleason score? >> from a biopsy. >> from a biopsy, okay.

so, our caller is gone butperhaps he's not had the biopsy. we go to dennis who iscalling us sheffield. go ahead please dennis. >> ah yes, i hada prostatectomy. my samples of my biopsy, all12 samples came back positive and i talked to my urologist and know the differentcourses of action. i proceeded with the roboticsurgery and i have been. i've done extremely well.

i was up and around thefollowing day and i was home. >> [inaudible] you. >> yeah. >> you know, faster healingtime and less problems and now my gleasonscore is zero. >> wow, good for you. thank you for your phone call. you do robotically-assistedsurgery, why would a patient userobotically-assisted

versus standard surgery? >> well, to be perfectly honestthe cancer outcomes have not been very different,they've been very similar. people who do openprostatectomies still have very good outcomes from acancer control standpoint and we're almost equivalent interms of control of continence or leakage of urine afterwards. the main thing that ithink is an advantage for doing robotic surgery is

that we lose lessblood during surgery and there's probablya little less pain and a little bit fasterhealing afterwards. we can do it with really goodvisualization as well so we kind of have a better idea of whatwe're actually cutting through and seeing rather thandoing an open surgery which you do predominatelyby feel. >> you know choosing a surgeonis really important and i'd like to know when a man goes

into a doctor's office isthere some magic number? does he want to know you knowmy surgeon has performed 20 of these a year or 10 ayear to feel comfortable? >> i have no idea. >> you've no idea [laughter]. >> the answer tothat is, particularly with robotic surgery it's areally hard question to answer because the robot hasnot been around for more than about 10 years and 10 yearsago it was in very few locations

and it was monitored byresearch people and academics who were starting tolearn it so my generation, people who have been in practice for a few years we'rethe first group that actually learned itgoing through out training. everyone else learnedit after the fact and that's a bigdifference i think. now, that said the surgeons thathave learned it that have been out were really proficient opensurgeons and we're very good

at it so it's hard to knowwhat the right number is. >> is it a smaller incisionusing the robotically-assisted? >> it is. it's a series ofsmaller incisions rather than one larger incision. >> okay, so you'reinserting a camera? >> so it's a laparoscopic? >> it is laparoscopic surgery. these are basic,the robot actually, it's kind of a misnomer becauseeveryone thinks oh there's a

robot doing my surgery. the robot is justan instrument holder so we still do alaparoscopic surgery but the robot smooths my tremorif i've had too much coffee. it magnifies things and it'sa graded movement so that if i move severalcentimeters it moves one so that i have alittle bit of control of my ability to move it. >> those are the benefits.

are there any disadvantages torobotically-assisted surgery? >> to the health systemyes, we hear all this stuff about obama care and all theseother things that are out there, the affordable care act andit's a more expensive surgery. >> by what percentage? >> i don't know the exact number but it's severalthousand dollars. >> okay. >> so that's one ofthe downsides to it.

you know there is amechanical element to it so there's always therisk that it could break and there could beother problems with it but otherwise it'sessentially the same surgery. >> so let me ask and theni want to do a quick reset but how do you determine which patient you'll do therobotically-assisted surgery on and which one willget the open surgery? >> almost everyone getsthe robotic surgery.

i know i tell you that nationwide that'sactually been the trend that the vast majority ofsurgeries in the last five to ten years have switched frombeing open to being robotic and greater than 90% nowi believe nationwide are done robotically. the ones that we choose not to do roboticallyare typically people who have had extensive abdominalsurgeries before where we think

that there's a lot of riskto going into the belly with laparoscopic instrumentsand it's a little bit safer to do it open whereyou can control things and repair any injuriesthat you would see. >> okay interesting. i want to come back and talkabout radiation in a moment but if you are justjoining us i'm patty satalia and this is conversationsliveprostate cancer on wpsu. our guests tonight aredr. richard ditlow jr.,

an oncologist with the prostatecancer center in camp hill, dr. christopher yingling, a urologist with mount nittanyphysician group in state college and greg petersen, wpsu'sdirector of broadcasting who was diagnosed withprostate cancer in 2002. our telephone numberis 1-800-543-8242 and our panelists are readyto take your phone calls. of course if you would prefer to email us our addressis connect@wpsu.org.

you can also join us ontwitter by tweeting @wpsu. i want to talk alittle bit dr. ditlow about the differentforms of radiation. greg petersen hadthe brachytherapy. you use the externalbeam radiation, why and what's thedifference between them? >> well, excuse me. >> in fact there's a third. >> excuse me, as you'vealready heard, the implants

or brachytherapy which is seedsinjected, it's for mostly. it gives you a very high dose within the prostategland itself. you don't get quite so mucharound because you have to have solid tissueto hold the seeds in their proper geometricalpattern to get the dosage that you want. and the tissue aroundthe outside is not, is not good enough tohandle, to hold the geometry

so you use this for generallylower, low-risk cancers where you're not worried aboutit going through the capsule, that type of thing and sothat's what that's for. the external beam is usedmore for the intermediate and higher gradeswhere you are concerned that there may be someextension through the capsule that we don't know about and/orin high rate, high risk disease that the lymph nodesmay be involved. there's also a new type

of external beam radiationcalled cyberknife which. >> sounds high-tech? >> it is very high. it's a special machinethat does all sorts of but it delivers theradiation in about two weeks, five or six treatmentsas opposed to nine weeks. the problem is and it givesa much closer coverage of the prostate withit so the worry is that it's not covering enoughfor higher-risk disease

so it's really useful foragain low-risk disease and the advantage is thatthe patients don't have to go through nine weeks of treatment, just you know theadvantage of that. but there are reallyquestions of whether or not it covers enough areafor the higher gleason scores. >> when we're talking aboutradiation how likely is someone who has received anyone of those three or four different kinds ofradiation to then suffer

from impotence or incontinence? and what determines whetherthey'll have those complications or not? >> well, part of what determinesthat is other medical problems. i mean if they're diabetic, lookwhat causes long-term damage or complications fromradiation is scar tissue that internally forms and blocksoff the very fine blood vessels that go to all these organs. i'm sure everybodygets the scar tissue

but in some peoplemore forms than others. and so if you cut back theblood supply then that's when you get the, so peoplewho are already diabetic or have other problems. >> have poor circulation? >> already have a poor bloodsupply to begin with and so that increases therisks of that. that's primarily and age becauseas you get older the blood supplies aren't as good either.

>> okay. i'm going togo to a phone call. george is on the linefrom state college. go ahead please george. >> yes, i had a tunaprocedure close to ten years ago i thinkand it was helpful. it allowed me, it reducedthe size of the prostate and i could urinatemore comfortably. however in the course of time,well it had a secondary effect that it made orgasms moredifficult to achieve.

it was still possiblebut difficult. now, if i had a tuna againwhich it seems i need because i have alot of discomfort with the prostate now, wouldthis make orgasms impossible or would it further impede it or would it not havean effect this time? thank you. >> thank you, what didhe say that he had, what? >> a tuna procedure, i'm sorry,

a tuna procedure isactually a procedure for benign prostaticenlargements. it's for urinary troubles where men have adifficult time urinating. >> bph? >> bph, so differentthan prostate cancer, unfortunately one of the mostcommon side effects we have from any of those treatments for benign prostatichypertrophy is actually

that people have what wecall retrograde ejaculation or they don't have a typicalorgasm and that's a sign that we're actuallytreating things successfully because we're altering thestructure on the inside. unfortunately the side effectis that you don't get much that comes out when you have anorgasm and it bothers some men. i would tell you that if youhave another tuna there's a good chance that that would getworse or disappear altogether but i can't tell youthat specifically

because every man isa little bit different and some men do preserveit afterwards but if you had trouble the firsttime i'd say there was a good chance you'd have trouble again. >> alright thankyou for your call. we go now to frank who iscalling us from hillside. you're on the air. are you with us frank? >> ah yes, i had the seedimplants about 13 years ago.

>> go ahead, we canhear you frank. you had the seedimplants 13 years ago. >> and i have a psa doneat least twice a year but recently the psa jumpedfrom like .2 then it'll be .6. the next time it'llbe back to .2 again. what causes this? >> it can be a number of things. most likely my guess isthat there's a little bit of residual prostatetissue that's still viable

and alive that's there. but it can, small variations under half a point probablyalters, some dehydration and other things throughoutthe regular course of life but a small amount of viableprostate tissue can produce a little bit of extra psa and getyou in that range from .2 to .5 and it may come back and forth. >> and you're justtelling him not to worry? >> as long as itkeeps coming back

down you tend notto worry too much. >> i do rememberafter my surgery. >> yours went up. >> it went up andthen it went down. is that just common? i had brachytherapyand my psa went up, the higher than it used to, was and then suddenly itjust went down to zero. >> it can.

the theory is that thecancer cells are dying and they're just releasingall their psa at the time and so you will havean increase in the psa. >> and we're talking, whenwe say psa we're talking about a prostate-specificantigen, a protein. >> okay, which is thisprotein is an indication of a tumor, just? >> no, well more. >> no a higher, a highnumber it would be in?

>> just normal prostatecells make psa too. >> okay. i want togo to this email and then to our phone call. this email comes from david. he writes "what arethe doctors' opinions on taking finasteride to,"i'm hoping i'm pronouncing that correctly, "tocontrol prostate size and make the psa test reliable?" >> finasteride is kind

of an interesting medicationfrom our standpoint. there was a trial done severalyears ago to actually look at finasteride as a preventativemechanism for prostate cancer. overall i believe itreduced the number of prostate cancers we saw but unfortunately we foundhigher-grade prostate cancers so we don't use it asa protective measure. in terms of shrinking theprostate, it certainly works. we use it from a standpointof urination problems

that it can help reduceyour risk of needing a tuna or a turp those other procedureswe talked about briefly before. it also tends to cut yourprostate specific antigen, the psa in half after you'vebeen on it for six months or so. does it make it more reliable? i don't know. it can vary a littlebit with that. it does tend to kind ofnormalize it a little bit in the sense that itdoesn't fluctuate as much

so in certain cases i douse it for that purpose but i think you have toknow where you're starting and you have to know the trendand what the pattern is to know if it's really helpful. >> greg petersen i wanted to askyou what's the monitoring now that you're nine, ten years out with undetectableprostate cancer? >> a psa once a year isthe standard thing i do, go and give them blood andit's pretty simple to do

and i'm just you knowhopeful that it's not going to rise up or anything. if it's undetectablethat's pretty good. and then now there are someurological implications that they have to take care of. i may have to. i may need another, i go to seedr. miller on monday and i may. he may say oh you needanother turp or something but we'll find out, i'll findout but you know at least it's.

it's important because youknow he explained to me that you know your creat levelcan go up and it can be bad not to empty and notto, not urinating at all is really badand but if you don't. if you retain too muchurine that's bad too because it can causeinfections and things like that so luckily i haven'thad those yet but you know this is13 years after surgery that i'm still havingsome urologic problems.

>> i want to talk aboutover-treatment when we come back but first this email messagethat we got from pat who writes "does being an avid bicyclistaffect the prostate?" >> i would say it can and theway it affects the prostate is not that it increases yourrisk of prostate cancer or increases your risk ofa benign prostatic growth but it can affect your psa andthere are a number of things that we just know willtransiently increase the psa. anything that puts pressuredirectly on the prostate

which is actuallylocated right basically where a bicycle seathits you can cause. >> although there are bicycleseats man-made specifically for men. >> and their anatomy. >> actually that's true. but we see the samething with motorcycles. we see it with people whooperate heavy machinery. even when you have your psachecked recent sexual activity,

things like that canslightly affect your psa. >> okay, i wanted to ask. i read that an aspirina day may have an impact on reducing your riskof prostate cancer. is there any truth to thator is the verdict still out? >> again, it's in that range that some studies,yes, some studies no. i mean i've seen that too yeah. >> i'm not sure.

there are other things thati've mentioned, that lipitor or excessive coffee drinkersactually have a lower risk all these thingsi don't think any of us really know whatto make of those yet. >> [inaudible] i'm guessingthat the herbal remedies in that same, same class, okay. this question, we haveanother email question. this one comes fromdave who writes "if a digital exam only examinesone side of the prostate,

how often are the signs ofcancer on the prostate missed because the signs, bumpset cetera are on the part of the prostate thatthe doctor can't feel?" interesting question. >> prostates amazingly arenot uniform internally. they actually have differentparts of the prostate that have different functionsand in turn have different risks for having prostate cancer. the back side of the prostatewe call the peripheral zone

of the prostate andabout 70 or 75% of prostate cancers arise thereso we can cover the majority of the posterior, theback side of the prostate with the finger exam sowe feel a lot of them. that said, a lot of prostatecancers you can't feel, they're internal andthey're not in a location where you would be able to feelit so we do certainly miss some. certain men just their bodyshape and habitus just keeps us from being able to feel muchof the prostate so we miss them

but it's better thannot checking. >> and you're feeling fora hardness or softness or any irregularities? >> what i tell peopleall the time is that your prostate should feellike the soft part of the thumb and if you feel somethingthat feels like a knuckle that's the kindof thing that raises a red flag to us and makes us say we needto look closer and get a biopsy. >> and the psa should pick upthese, the ones you can't find.

i mean you feel becauseyou really go like that to begin with. >> i'm going to take bill'sphone call in a minute but you said whattook you to the doctor in the first place wasprostatitis which is what takes, which is the reason thatmost men end up going to see a urologistin the first place. how common is prostatitisand is it an indication that you are mighthave prostate cancer

or is there really nolink between the two? >> it's very common. we see a lot of men who have it. we see. >> even young men? >> absolutely, we seeuniversity students regularly about prostatitis and some men, prostatitis is justa stress response, in other men it's infectious.

it happens for a varietyof reasons and it shows up in a variety of ways. it's really not very fun to have but we don't think it increasesyour risk of prostate cancer. >> okay, good to know. bill from state college, thanks for your patience,you're on the air. >> yeah, hi doctors, okayyes, i have a question though. i've been using finasteride,prescribed by my urologist

for the last couple ofyears based upon a study out of one the newyork hospitals that it would allow theprostate to suppress the growth to make it more readily[inaudible] if you had to have a needle biopsy it wouldconcentrate the cancer cells. is that still a legitimateuse of finasteride? >> actually it's a similar,someone asked that question. it was somewhat similarbefore but we know that finasteride use,long-term finasteride use tends

to shrink your prostate so thatarchitecturally the prostate is actually different,it's smaller. it can reduce by 30 orsometimes up to 50% depending on how long you've been onit and your reaction to it. we also know that in theoriginal studies they were looking at this for a wayto concentrate it and try to hopefully helpprevent prostate cancer. we found that theproblem with it was that we found a higherpercentage

of high-risk prostate cancers. we don't know for surewhy that happened. we're not sure if it'sbecause the prostrate shrunk and it helped us find thosecancers a little bit earlier so we were seeing ashift because of that or if it was actuallycausing a higher rate of those cancers to arise. we don't think that's the case but it probably doesn't makea drastic difference in terms

of your prostate cancer risk. >> there's also anotherdrug that's pretty widely prescribed flomax. what's the mechanism for that? what does it do? >> so flomax operates by aslightly different mechanism. flomax, your prostate isessentially like a donut and you pee through the donuthole and it's right outside of your bladder and thereare muscles that line the,

basically the opening of thedonut, the donut hole as well as the bottom partof the bladder. flomax works on thosemuscles to expand it and give you a slightly largerspace to be able to urinate through which inturn keeps people from waking up as much at night. it gets you having astronger stream being less [multiple speakers]. >> and what about the sideeffects of that medication?

there's probably along list of them. >> there are a couple of things. people get rhinitis, itmeans they have almost like a head cold. they'll have a little bit ofrunny nose and congestion. occasionally people get abit light-headed from it and there's one sexual sideeffect from it and we spoke about it a little bit earlierwith a different patient but we get something calledretrograde ejaculation

which is it relaxesthose muscles so much that when you have an orgasmyou don't have much fluid that comes out. >> but i will say it's probablythe one drug i've ever heard that does what it says. >> that's very true. >> it's well-named. >> alright, we go to johnwho has an email question. he writes "are thereany new procedures

or exercises one coulddo to eliminate leakage after a prostatectomy?" and i'm probably messingup the pronunciation there. are there exercises? oh i read kegel exercises whichis what they recommend to women. >> the kegel exercisesmake a lot of sense. so leakage after a prostatectomyis what we call it. >> explain what kegel exercisesare for those that don't know. >> kegel exercise is basicallytightening the muscles

that control yourability to hold your urine so it's the pelvic floormuscles, the ones that are deep on the inside that are verydifficult to describe how to clinch but it's the kindof thing that you would use to cut off your streamor stop your stream when you were trying to urinate. kegel exercises strengthenthose muscles because that muscleis the only thing left that can hold your urine inplace after a prostatectomy.

prior to a prostatectomy yourprostate actually helps hold the urine in the bladderso once we get down to one thing weneed to strengthen that. kegel exercises for somemen are all you need. typically that's guys whohave very little leakage. people who have severeleakage after a prostatectomy if they're more thansix months or a year out they're probably goingto have that permanently. and then in that case we havetwo procedures that we use,

actually three proceduresthat can be done. one is something calleda urethral bulking agent, we don't do it very often but you can actuallyinject some material around that littlemuscle outside and try to tighten it up a little bit. the other things that weuse are something called an artificial sphincter. it's actually a balloonthat goes around the urethra

and actually has a mechanicaldevice that we implant in the scrotum, everythingis internal. you actually activate thedevice when you want to urinate and it relaxes theballoon and lets you pee and then it refills the balloon. it's a hydraulic system, it haswater on the inside or saline on the inside and itkeeps you from leaking. and the third option issomething called a sling and that's a smallpiece of mesh.

we use them in women as wellbut they're a different variety and we create a littlekink in the urethra, the tube that drains thebladder, to try to tighten it up and keep you fromdripping and leaking. >> you mentioned thesling and i think anyone who watches any amountof television has heard that there have beenlawsuits related to the sling. >> yeah, fortunatelythey're really safe and even in women those slingsactually really weren't part

of the lawsuits. unfortunately there was a lotof other mesh used in the past for other reconstructionsin women particularly for vaginal reconstructions,for prolapse. those are the onesthat were called back in the lawsuits and things. the sling material we use tendsto be really well tolerated. it's much more similar to themesh we use for hernia repairs, things of that nature andpeople do really well with it.

>> okay, alright. another email question, thisone comes from john who writes "what is the pca-3test used for?" and does he meanpca and not psa? >> no. this is anadditional test. because psa is no non-specific for prostate cancer we havea lot of men who have kind of a borderline rise in the psaor they have a family history or other risk factorsthat make us concerned

that you might haveprostate cancer. pca-3 is something we use,it's actually a urine test that we use to try todifferentiate who has a psa rise or who has real riskfactors for prostate cancer. so i would call it an adjuncttest, it's just an add-on test to the psa to helptry to figure out, do we really needto do a biopsy? how worried do weneed to be about you? so we use it a lot in menwho have risk factors or men

who have had a prior biopsy butwe're trying to avoid the need to re-biopsy them four monthslater because their psa went up a little bit higher. >> you know speaking ofother tests, you know the psa as we've been saying, it can'tdistinguish between aggressive and benign cancer but thereis a test out of sweden that will be availablebeginning in march 2016 and it's referredto as the sthlm3. i know you know alittle bit about it.

tell us about this andare you excited about it? >> well i only know aboutit because you put it in the information [laughter]. i got to look it up. but apparently it's a testwhich picks up, is only positive if the cancer is at leastat 7 or greater you know and therefore if it's, youknow and so therefore it knows that the people that,more prone to biopsy and because they probablyhave more aggressive disease

and that's my understanding. it's sort of experimentalin sweden right now and like you said it'scoming on the market. that's all i know about it. it also though it presumesthat you don't have to treat gleason grade 6disease which if you're going, anybody for activesurveillance if you're going to definitely do that, certainlythe gleason you know grade 6 disease is the one youwould at least consider it.

but i mean i've seenyou know patients with you know metastatic diseasewith a gleason 6 too i mean so but anyway it sort of assumesthat you know you don't care if they have gleasongrade 6 disease. >> so you know you justmentioned the word active surveillance or watchful waitingso on the one hand you know you, you sit back and don't doanything too irrationally and most people say if we'retalking prostate cancer there is some time.

you usually don't haveto do things rapidly but what's interesting is that you know how do weprevent overtreatment because i would guess youwould say greg petersen that in a sense maybeyou were over-treated? >> well, you know my own choicetoo, you hear the word 'cancer' and you just wantto get rid of it but then you know allthe stuff that's come out and how much treatment there hasbeen and how low my numbers were

and all that, i probably couldhave waited several years, many years maybebefore i did anything and that's what you know, but you know hindsightis always 20/20. but you know i'm glad, youknow i'm glad i did it. i don't have to worry aboutit now because probably by now i'd be doingsomething about it. >> so but how do we, how dowe avoid over-treatments? >> so actually there's been anamazing trend nationally to go

to more active surveillance,more waiting and keeping an eye on this rather thanrushing in to do surgery. when i started my trainingif someone suggested that, they kind of werelooked at cross-eyed and everyone thought itwas a nutty thing to do because there was cancer andyou needed to treat the cancer. now i think for the latestnumbers, i think 40% of men with low-risk prostate cancerare choosing active surveillance in the u.s. that'sa great thing.

so, we pick the men basedon their gleason score, based on their riskfactors, based on their psa and we have different ways thatwe can kind of categorize you in the low-risk, medium-risk orhigh-risk or even ultra-low risk and then we decide onwhat to do with you. more often than not nowwith low-risk we watch. >> it's the second leading cause of death among americanmen though. do you anticipate anychanges in that as we watch?

>> i don't think fromwatching because the reality of it is exactly as you werekind of saying that if you elect to go on active surveillanceit's, active surveillance. we use two different names. we use active surveillanceand logical waiting. active surveillance iswhat we push the most and that does not mean we justsay you have prostate cancer, we'll wait untilsomething happens. it means that we'revery pro-active

with how we monitor you. we continue to dopsas every six months. we repeat biopsiestypically one year out from your originaldiagnosis and then again after. soon we're going to startprobably adding mris of the prostate totry to identify if there's more aggressivedisease and that's something that's kindof on the cusp now nationwide. so we really keep a close eye onit and we know a sizable portion

of men eventuallywill need treatment for their prostate cancerbecause of progression but the advantageof that is the men who don't ever progresscan avoid the treatment so hopefully we'llstill head people off. >> in the complications? >> yeah, we'll head peopleoff who really need it and avoid over-treatmentwith those who don't. >> okay. we have another email.

this one is from herbert whowrites "i want a psa test but my doctor is discouragingme from getting one. he keeps saying it isn'tnecessary but i'm almost 50 and i think i shouldhave at least a baseline. what do you think? and if i pay for it out-of-pocketwhat will it cost me?" good question, i've heard lotsof people ask that, dr. ditlow? >> the first thingis if even the,

if you have any family history,any, it be your father, brother or son who has had prostatecancer you should have a psa. and i think even, eventhe people who say, who are against doing screeningpsas would agree with that and that's sort of left outof the whole discussion. what they are talking aboutis screening programs. that's what they're reallytalking about not doing when it comes down to it butif you have risk factors. >> routine.

>> routine asymptomatic but ifyou have a family history first of all that's, youshould have a psa. knowing what we've talked abouthere tonight i mean the psa by itself doesn't have, youknow you then should have, if your psa is positive or high and you have a biopsy thenyou'll know exactly what kind of cancer you're dealing with and then you can have anintelligent discussion with a urologist or a physician,you know or a physician

about what you shoulddo about it. i mean and that's you knowthat's i think the way, the right way to go. >> you've had a numberof biopsies and i'm just wondering how,how risky are the biopsies? did they cause any of theside effects we've talked about earlier? >> no, you have to. i was given prophylacticantibiotics after each biopsy

because it's a, theygo through your rectum and they use a needle togo through your bowel, to pierce your bowel to gointo the prostate in a bunch of different placesto get samples so it, there is some riskin the procedure but it's pretty low i'd imagine. i'm talking on top my head here. >> it's, the numberwe quote people is 1%, so one out of 100 peoplecould potentially end

up with an infection, potentially sepsis meaninga fever and sick enough that you'd have togo to the hospital. >> there could be somebleeding with it as well. it's not the most comfortablething but men actually, pretty uniformlyafterwards say it wasn't as bad as they expected. >> actually the preparationwas worse than the biopsy. >> i think the other worrywith biopsy is that it's,

if the prostate canceris encapsulated that you have just nowdumped the apple cart and now the cancer could spread. >> fortunately prostate canceris a very slow-growing prostate cancer, it's not aggressiveand we don't see that happen. other cancers inother places can do that with needle biopsies. prostate cancer justdoesn't, biopsies tend not to seed cancer inother locations.

it doesn't increase yourspread of metastatic disease. it's a pretty safe procedure. >> okay, we have just acouple of minutes remaining but i'm hoping to get donfrom bellwood on the air. what's your question please don? don, are you with us? if we don't get. >> thank you, areyou hearing me? >> i, yes i had externalbeam radiation.

i had external beamradiation treatments in 2012 and my problem is that in 2013my psa went from .8 up to 4.5. in six more monthsit went up to 4.9. in six more monthsit went up 5.3 so we see a worrisome velocityas they call it and i'm under a lot of stress. my doctors are watchingand testing of course every six months but i just find it hardday-to-day almost to bear

up under this because thedoctors i have here say there's nothing i can really do asfar as further treatments as you've mentioned,you gentlemen tonight like prostatectomy or moreexternal beam radiation. i can understand why notthe latter but i just wonder if you have some thoughtson what i should do? >> yeah, we just have acouple of minutes so i'm going to let them get toit right off the bat. dr. yingling?

>> yeah, we certainly haveother treatments we can do. there are hormonaltreatments, things like that. we generally shy away fromsurgery after radiation because internally itdoes change the structures and it makes surgery a littleless safe and more complicated. but there certainlyare other treatments. the other thing and i'm notsure if you can speak to it, i know occasionally we seesomething called psa balance after radiation and.

>> in other words it goesup because of the radiation? >> but i believe he said. how long ago was yoursurgery or radiation? how long? >> i don't know if donis still on the air. >> ah 2012 i think. >> yeah, that's apretty long time, yeah. >> so shouldn't, he shouldn'thave the balance at this point? >> no, we usually see that righttowards the end if we see it.

we see it towards theend of the radiation which is why quite oftenurologists will wait about two or three months afterthe radiation is over to do a first psa but that's unlikelythat's radiation balance. and i'm sorry i can'ttake another phone call. i just want to start with abit of a round-robin beginning with you greg petersen, lotsof young, lots of men out there who are concernedabout this issue.

what advice wouldyou have for them? >> don't be squeamishabout getting a dre. i know a lot of peoplewho, i have cousins who just wouldn't do it becauseit was an anathema to it. it may be embarrassingbut it can save your life. talk to your physicians,do your homework and it's, you have to take care ofyourself and you have to listen to yourself but don't besqueamish about something like that and i knowsome men are.

>> that's the way peoplefelt about colonoscopies and. >> yes exactly. >> then katie couricdid it on air and i think the rateof colonoscopies. >> right so, you get. >> colonoscopieswent up off the roof. >> yes, talk to your doctors. >> dr. ditlow? >> you know i'd justsay if you're over 50,

especially if you have you knowfamily history talk your doctors into doing the psas. knowing what you know now imean you may not need treatment and don't necessarily feel thatif you have a prostate carcinoma and it's gleasongrade 6 that you have to do something you knowtreatment-wise with it but still get the psa. you can't have that discussionunless you know you have the cancer.

>> dr. yingling? >> i agree. i want to echo everythingthat they just said. i think the number one thingis don't be scared of finding out what's going on so don'tbe afraid to get a psa. don't be afraid ofa finger exam. it takes two seconds,we don't enjoy it either but it helps a lot and if youhave prostate cancer it does not mean that you haveto have treatment.

it does mean that you're goingto be incontinent or impotent or have all of these sideeffects down the road. it may mean we justneed to manage it but it can also save your life. >> and what are survivalrates for prostate cancer? >> the low-risk prostatecancer it's outstanding, close to 95% for10-year survival. high-risk prostate cancersare lower than that but a lot of that also depends onage and other [inaudible].

>> okay, thank you all so much. i'd like to thankour guests tonight, dr. richard ditlowjr. an onocologist with the prostate cancer center,dr. christopher yingling, a urologist with mountnittany physician group and greg petersen, wpsu'sdirector of broadcasting. i'm patty satalia forall of us at wpsu, thanks for joiningus and goodnight.