F1: From Kerkow media coming up on the show, cancer of
F1: all kinds, including prostate cancer, is curable if you find
F1: it in time because we can do surgery or radiation
F1: and cure you. But unfortunately, in about 50 thousand men
F1: per year, we find the cancer too late.
M18: Out of 4500 hospitals ranked by US News, Johns Hopkins
M18: Medicine ranks in the top three in the country. I
M18: personally have watched people travel from the farthest corners of
M18: the globe to access the quality of care, cutting edge
M18: technology and benefit from the research performed at Johns Hopkins.
M18: One of the many doctors responsible for Johns Hopkins reputation
M18: and top ratings in urology and oncology is Dr. Kenneth Pianta,
M18: and he'll be joining us today on medicine. We're still practicing.
M2: I'm Bill Kurtis. But first, of course, our hosts, quadruple
M2: board certified doctor of internal medicine, pulmonary disease, critical care
M2: and neuro critical care and still fighting on the front
M2: lines of the war on covid. My very good friend, Dr.
M2: Steven Tayback. How are you doing, Steve?
M5: I'm well, thank you.
M2: As you've heard joining us from Johns Hopkins Medicine, Dr.
M2: Kenneth Pianta. He's the director of research for the James
M2: Buchanan Brady Urological Institute. He's the co-director of Prostate Cancer
M2: Research Program for the Sidney Kimmel Cancer Center. He's a
M2: professor of urology. He's a professor of oncology. He's a
M2: professor of pharmacology and molecular sciences. Welcome, Dr. Pianta. What
M2: do you do with all your spare time? Ken, this
M2: is not meant to be a softball question, but it's
M2: going to sound that way. I'm trying to understand from
M2: your inside perspective what is it about the environment you
M2: work in at Johns Hopkins that produces these kind of outcomes,
M2: these ratings in this international recognition?
M6: Well, I think part of it is tradition. Johns Hopkins
M6: was founded as the first research university in the United States.
M13: And we've always placed the tripartite mission of patient care,
M13: education to students and research on equal footing so that
M13: we're always seamlessly combining those. And the other piece of
M13: tradition is Johns Hopkins Hospital and the medical school itself.
M13: We defined American medicine at Johns Hopkins with William Osler
M13: starting out saying we're going to do medicine differently. You know,
M13: the term medical residents started at Johns Hopkins because Auclair
M13: made the doctors live in the hospital to be trained.
M13: And so that's where the term residents came from. You know,
M13: we have this dome at the hospital with with the
M13: wings of the old building and medicine rounds were referred
M13: to the fact that they would go round and round
M13: the dome to the different wards. And, you know, we
M13: carry that sort of tradition with great pride. And people
M13: love to work there. And we've always attracted really smart
M13: people who love medicine and love taking care of people
M13: and really love combining that with the research that powers
M13: the next generation of medicines forward.
M2: Dr. Partan, your department chair talked about while other hospitals
M2: use robots for urological surgery, Hopkins actually makes their own robots.
M2: Is that you're making like Da Vinci robots?
M1: No, we use commercial robots like everyone else. But what
M1: we are doing is creating the next generation of robots
M1: to work with MRI machines. We have Danceteria in our
M1: department is making a special robot that does that. The
M1: Hopkins Wedding School of Engineering is developing the next generation
M1: of robots to integrate imaging with robotic surgery. A lot
M1: of that is not just hardware, it's software.
M2: We're living in a Pretty High-Tech era. We've come a
M2: long way in medicine, but still so many men die
M2: of prostate cancer. What are we missing up here and
M2: what do we have to do to fix this?
M1: So, you know, in this time of covid and so
M1: many people dying of covid, it's an infectious disease. We
M1: got to do better. And we tend to forget about
M1: these other illnesses that are plaguing the planet. You know,
M1: if you look around the world, 10 million people a
M1: year are dying of cancer in the US. Six hundred
M1: thousand people are dying of cancer. Thirty thousand men die
M1: of prostate cancer every year. And cancer of all kinds,
M1: including prostate cancer, is curable if you find it in
M1: time because we can do surgery or radiation and cure you.
M1: But unfortunately, in about fifty thousand men per year, we
M1: find the cancer too late. We find the cancer after
M1: it has escaped the prostate and metastatic cancer virtually of
M1: all kinds is incurable. And prostate cancer, unfortunately, metastasizes or
M1: spreads to the bones as really its first site.
M17: And it causes a lot of problems for guys in
M17: the bones, including pain, and eventually kills them. And we
M17: can talk about how that happens. But essentially we fail
M17: because we don't cure people, because we don't find the
M17: cancer in time.
M5: Let me ask you a question about that, actually, because
M5: I've been quoted by colleagues that if you're 50 years old,
M5: you have a 50 percent chance that you actually have
M5: prostate cancer and at 60, you have a 60 percent
M5: chance that you probably already have prostate cancer and so
M5: on and so forth.
M3: And it would beg the question, would it not make
M3: sense to prophylactically remove the prostate? And then obviously the
M3: major impediment to that is the major side effects. What
M3: is the thought process about that and where are we
M3: in terms technologically of mitigating the terrible side effects of
M3: impotence and incontinence?
F2: So I think there's two aspects to that question, Steve,
F2: that we just need to touch on, because the other
F2: thing you hear all the time is that prostate cancer,
F2: you don't have to worry about it. You're going to
F2: die with it, not from it.
M17: We do see that 80 percent of men aged, if
M17: you look in their prostate, if they've gotten killed by
M17: a car accident, you'll see prostate cancer. So essentially, prostate
M17: cancer exists in two forms. One form is this indolent,
M17: slow growing, low grade cancer that probably shouldn't even be
M17: called a cancer, but it still is. And we find
M17: it by screening. And those are the guys that can
M17: be treated with active surveillance. We don't need to treat
M17: their cancers. We're a lot smarter about that now than
M17: we were even a few years ago. The other kind
M17: of cancer is the aggressive prostate cancer. That is not
M17: the kind you find on all types, but is the
M17: kind that's growing quickly that we have to get out
M17: before it spreads. So prostate cancer is definitely has a
M17: hereditary component. If you have a father or an uncle
M17: who had prostate cancer, your your risk of developing prostate
M17: cancer is double. If you have two family members, it quadruples.
M17: And if you had three family members, you're going to
M17: get it. So it is familial. There are some genetic
M17: drivers like BRCA two that lead to a higher incidence
M17: of prostate cancer. And we definitely say if you have
M17: a family history, you should start screening sooner.
M2: What are the signs that men should look for, which
M2: means perhaps they should come see you or someone you recommend?
M17: Yeah. So that's the problem. There are no signs. There
M17: are no signs until it's too late. And that's why
M17: we recommend in all the major medical associations recommend that
M17: starting at age 50, you should at least have a
M17: discussion with your caregiver about whether you want to get screened.
M1: The screening consists of a prostate specific antigen blood test,
M1: the PSA blood test, as well as a digital rectal exam.
M1: And you should to have that yearly starting at age 50.
M1: If you're African-American or have a positive family history, you
M1: should start that at age forty five or even 40.
M1: Why is that controversial? That's controversial because before we were
M1: smarter about active surveillance, we were probably over treating men
M1: with that low grade kind of cancer.
M17: But the whole way we treat prostate cancer has really
M17: evolved a lot over the last few years.
M5: And what about the PSA?
M3: Because I've heard so many stories about perhaps you shouldn't
M3: even do it because it gives you confounding results that
M3: an elevated PSA is not necessarily indicative of cancer. You
M3: see it with prostatitis. You see it for syndromes that
M3: are may or may not even be related to cancer.
M3: What is your feeling about PSA? And should everybody, in addition,
M3: be going for more of a high resolution MRI of
M3: the prostate? And where does that fit into the surveillance?
M1: Yeah, so PSA, it's the best cancer biomarker ever discovered,
M1: but it's also got some drawbacks. And that's because it's
M1: not just made by cancer cells, it's made by all
M1: prostate cells, including if you get benign prostatic hypertrophy or
M1: if you get prostatitis, an infection of the prostate or
M1: if you get any kind of inflammation, PSA can go up.
M1: Let's look at the numbers. If you look at the
M1: US per year, about 10 million men have a PSA
M1: blood test drop. Of those 10 million, one million of
M1: them have a PSA that's greater than four, which is
M1: the trigger number for saying you need to have a
M1: closer look about whether you have prostate cancer or not.
M1: Of those million that have a PSA greater than for
M1: only about two hundred thousand of them, they all get
M1: biopsied and only about two hundred thousand of them have cancer.
M1: Of those two hundred thousand, about one hundred thousand of
M1: them turn out to have that low grade cancer that
M1: people can live with anyways. So the ding against PSA
M1: is that 10 million people get tested to find one
M1: hundred thousand men that need to be treated. And it's
M1: a cheap blood test as we're smarter about these paradigms. We're.
F2: Need better tests, right, for those million guys that are
F2: getting biopsy? Eight hundred thousand are getting a biopsy they
F2: didn't need to get because it was negative.
M1: We're looking for other urine biomarkers. We're looking for other
M1: blood biomarkers. We're doing MRI to see if we can
M1: rule out somebody needing further testing like a needle going
M1: into the prostate. But we're not there yet. We haven't
M1: found anything that's going to impact that significantly.
M3: For one hundred thousand being worked up to me, I say,
M3: who cares if it's a minimal cost? To me, it's
M3: the anxiety of the number of people who are getting tested,
M3: have an elevated PSA now are in panic mode where
M3: only a small number of those actually go on to
M3: have the disease. And then I look at it from
M3: the intensivists side, because how many people have come into
M3: the unit after a simple prostate biopsy that now we're
M3: in septic shock because you're obviously biopsy in an area
M3: that's notoriously very clean and filled with bacteria. And it
M3: would seem like we should be further along in terms
M3: of our ability to do better surveillance.
M1: So first of all, I don't want listeners to think
M1: that everybody who gets biopsies gets septic. It's actually a
M1: pretty rare event.
M4: As I mentioned earlier, we're working on a robot that
M4: works with an MRI machine, so it doesn't have any
M4: metal in it that will allow us to zero in
M4: on a lesion that we see by MRI and then
M4: be able to put a needle in it very specifically.
M1: But even more on the horizon right now. It's happening live.
M1: Time is, as Steve mentioned, the reason guys get septic,
M1: meaning that they get in bacteria in their blood, is
M1: that the current way to do a biopsy is you
M1: have to stick a probe in the rectum and you
M1: have to push that needle across the rectal wall and
M1: sometimes poops gets through, so to speak. What we've been
M1: developing now is what's called a peroneal biopsy approach, where
M1: you go in sort of underneath the testicles in the
M1: scrotum and go in that way into the prostate. And
M1: that area sort of between your in the fold of
M1: your legs basically is called the perineum. And you stick
M1: a needle through there. You don't you never hit the rectum.
M1: So all you're doing is cleaning up the skin and
M1: going through there. It doesn't hurt any more than the
M1: other kind of biopsy because you get numbed up and
M1: virtually leads to no septic episodes. The other thing, and
M1: this is a bit wonky that Steve probably can appreciate
M1: one of the reasons why cancers get missed, prostate cancer
M1: gets missed, is that the side of the prostate farthest
M1: from the rectum, it's called the anterior prostate. And for
M1: a needle to go from the rectum through to the
M1: anterior prostate, that needle has to be really long and
M1: there are only so long. So the cancer has to
M1: get pretty big before they find it. And it turns
M1: out that guys with a.. Prostate cancers have bigger tumors
M1: when they're found and more often those of escaped and metastasized.
M1: So the peroneal approach actually gets rid of that because
M1: you're coming across the other way and the needle doesn't
M1: have to be any longer. But you sampled that part
M1: of the prostate better.
M5: Let me ask you a question, if you've had an
M5: MRI and you have absolutely no lesions on the MRI,
M5: would there be a time when you would still proceed
M5: with a biopsy in spite of the fact that you're
M5: not seeing a focal lesion? Yeah, so am I.
F2: Is not as good as you're thinking it is.
M4: MRI is much better than a CT scan, but it's
M4: still even with three Tesla magnet, the prostate is so
M4: heterogeneous that it's pretty easy to hide a cancer in
M4: there and we're better at it than we used to be.
M1: But MRI is not yet ready to be a gold
M1: standard to replace a biopsy.
M3: So you're still using the PSA elevation as your main indicator,
M3: or are there other indicators that you're using?
M6: PSA elevation is still the number one reason to get
M6: a biopsy.
M4: We do our biopsies using MRI, ultrasound fusion systems so
M4: that we are looking at an MRI to try. And
M4: if we see something on an MRI, we're pretty sure
M4: we need to biopsy that.
M1: And then we use the ultrasound, the computer fuses to
M1: the ultrasound image and that guides us in. But if
M1: the MRI doesn't see something, it doesn't mean it's not there.
M1: So it's sensitive but not specific.
M2: Ergo, your recommendation, just to repeat for our listeners, is
M2: that after the age of 50, they get an annual
M2: rectal exam, a digital rectal exam and a PSA test. Correct.
M2: We're going to take 30 seconds and we'll be right back.
M7: Hi, I'm Robert Ross, host of Cars that Matter, you
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M7: think you know the ones that matter. Join me as
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M9: We're back with Dr. Kenneth Pianta and Dr. Steven Tayback.
M9: Some years ago, I got a chance to tour your
M9: proton therapy center, which is probably the most amazing site
M9: anybody can see.
M2: Do you use proton therapy with urological issues like this,
M2: or do you kind of go right to you don't
M2: really need your prostate. It's better off if it comes out.
M10: Prostate cancer that is localized to the prostate can be
M10: cured in two ways. One is surgery to remove the prostate.
M10: The other is some form of radiation therapy that certainly
M10: involves external beam radiation therapy, which means that the photons
M10: are generated outside the body and shot into the prostate area.
M11: Or there's still some cases where we use see the
M11: implants as well as external beam radiation therapy.
M10: When you take an external beam radiation, you can break
M10: it down into photon external beam radiation therapy and proton
M10: external beam radiation therapy and proton machines were originally designed
M10: because they can be very accurate in treating the planning
M10: and hitting their what they're supposed to hit and not
M10: doing too much other damage. Right. In sparing normal tissue.
M10: And actually, the first use of protons were for kids
M10: with spinal tumors where you really had to protect that
M10: spinal cord. To be honest, protons work great for prostate cancer,
M10: but they don't work better because we have something called
M10: computed tomography plant conformal 3D planning, which basically means we
M10: use a CT scan in multiple parameters to draw lines
M10: around the prostate tree. Just that. And so protons are
M10: just as good, but not better for prostate. So guys
M10: who want to get radiation rather than surgery, they have
M10: a choice between photons and protons. And quite frankly, it
M10: doesn't matter.
M3: Would you hesitate to be using radiation? I would imagine
M3: for the most part if you've not had any metastases,
M3: but would you be using radiation and hormone type therapy
M3: in a young man with prostate cancer?
M6: Yeah, so great question. And the reality, again, is it's
M6: patient choice.
M10: Both are equally curative and there are guys who do
M10: not want to get cut. They don't want a knife
M10: near them. And they look at the statistics of incontinence
M10: and impotence and maybe they're a little better with radiation,
M10: maybe not. But because it's equally curative, they choose that
M10: I'm not out of place to say more young men
M10: choose surgery than radiation.
M11: But it's also a choice. But most guys, younger guys
M11: especially go, I don't want to live with cancer in me,
M11: get it out. I want to see it in the bucket,
M11: so to speak. And that's really reasonable.
M3: So you've actually mentioned it, though, so we should probably
M3: go a little further that the side effects of both,
M3: I guess you see it with radiation, but it's certainly
M3: more advertised for surgery of incontinence and impotence. What percentage
M3: are we talking about of those people who undergo treatment
M3: that wind up with long term incontinence and or impotence?
M10: Yeah, so always a tricky question, but not so tricky.
M10: So the first thing you have to ask is how
M10: good was the guy's erections before he started? Right. Because
M10: everybody's having sex five days a week and even when
M10: they're 70 and that's part of it. Right. But the
M10: reality is you do have to have a good erection
M10: to start with. Take that aside. The major side effects,
M10: the major morbidities associated with a radical prostatectomy are incontinence
M10: and impotence. And of course, at Johns Hopkins, Pat Walsh
M10: defined and pioneered the nerve sparing radical prostatectomy before he
M10: started doing that in the 80s. No guy was able
M10: to get an erection after surgery because you took the
M10: nerves out that helped you get an erection. Now, what
M10: they try to do is there's two nerve bundles on
M10: each side of the prostate. You only need one of
M10: them to have an erection.
M5: So as surgeons tried to leave the one on the
M5: side that doesn't have cancer, so to speak, what would
M5: you say would be the percentage of men who wind
M5: up having their pre surgical function remain postop?
M6: Yeah. So it takes a while to recover. But I
M6: think most folks would say it's seventy five to 80
M6: percent of men will recover their ability to have sex
M6: and have good sex.
M5: So obviously we've been talking about surgery as an option
M5: for the treatment of prostate cancer.
M3: And maybe speaking for the listeners, it would be nice
M3: not to ever have to even deal with surgery or
M3: prostate cancer treatment. The question is, is there something that
M3: a man can do relative to lifestyle or diet that
M3: will actually have a real impact on preventing prostate cancer?
M10: I wish there was.
M12: Unlike so many cancers where we know true risk factors,
M12: prostate cancer is not one of those cancers where we
M12: can alter lifestyle in a way that we know is
M12: going to decrease your risk of prostate cancer.
M10: I can tell you this is just good health advice, right?
M10: Obesity is bad. Being fat is bad.
M12: If you look at all men with. Stage cancer, those
M12: men who are overweight, who are diagnosed with prostate cancer
M12: or no matter when they're diagnosed, their overall mortality, cancer
M12: specific mortality is higher than if you're not overweight.
M2: I see. So is there an immunotherapy that is currently
M2: under research for prostate cancer?
M10: So there are several that are being studied for prostate
M10: cancer and the history of prostate cancer and immunotherapy is
M10: actually pretty interesting because the first immunotherapy that was ever
M10: really approved for a cancer was PROVENGE, the special vaccine
M10: therapy that was so controversial back in the 90s about
M10: whether we should be giving that to people.
M11: But when you really talk about immunotherapy these days, you're
M11: talking about the checkpoint inhibitors, the immunotherapies that let the
M11: immune system turn on to fight cancer and that are
M11: so successful in diseases like melanoma, kidney cancer, bladder cancer
M11: and just about every other cancer, but not prostate prostate cancer.
M10: There is no approved immunotherapy. We are on multiple generations
M10: of testing for new immunotherapies. We are defining subsets of
M10: men who will respond to a checkpoint inhibitor.
M11: But it's a small percentage of men with prostate cancer
M11: somewhere in the range of three to five percent. We
M11: can identify those guys now and we'll give it to them.
M11: But immunotherapy to date is not a success story for
M11: prostate cancer.
M3: So, I mean, historically, we've seen men on Lupron and
M3: you said, if you come to me, chances are I'm
M3: going to remove your testicles, which implies that the male
M3: hormone is a negative factor relative to prostate cancer. And
M3: yet I've heard mixed feelings and mixed opinions about this,
M3: especially as men grow older, their testosterone levels often wane.
M3: And many men are seeking for testosterone replenishment for various reasons.
M3: Is that a negative factor relative to prostate cancer? It
M3: would seem that if you're giving medications like Lupron, which
M3: would kind of bolster female hormones, that male hormones would
M3: be a negative and the contraindicated form of therapy. Where
M3: do you stand on that? And what's the state of
M3: the art relative to testosterone and.
M12: The story is, is the male hormone, the androgen, what
M12: makes us men is this hormone testosterone and testosterone is
M12: as it helps the prostate grow up to be a
M12: mature prostate and actually acts as a differentiating agent. It
M12: helps it function. So there's no question that it also
M12: drives prostate cancer cells to grow. And if you have
M12: prostate cancer that's fully developed and is a true cancer,
M12: then testosterone is helping that cancer to grow. And if
M12: it spreads beyond the prostate and we can't treat it locally,
M12: the mainstay of therapy, the first line therapy is to
M12: medically castrate you, meaning that we give you a shot
M12: of this medicine called Lupron. It tells the brain to
M12: stop sending signals to the testicles to make testosterone that
M12: causes the cancer to regress, go to sleep.
M10: It doesn't cure men with prostate cancer, but it puts
M10: them in remission for usually multiple years.
M11: But men who have true hypogonadism as they age and
M11: you replace them to a normal level of testosterone for
M11: their age, they are no higher increased risk of developing
M11: prostate cancer. That's been well established.
M2: I'm curious for either one of you. If you get
M2: tested at age 59 and you're negative when you're 60,
M2: do you still have a 60 percent chance of having it?
M2: Or at that point, is it much lower now?
M6: So, again, we're getting into a little bit of apples
M6: and oranges here. So when you talk about that 60
M6: percent of guys age 60 who have prostate cancer, you're
M6: really talking about that indolent form that's never going to
M6: raise its ugly head.
M10: And that's the same no matter what, whether you're fifty
M10: nine or 60, that amount is going to be there.
M10: And those men what we're really screening for is we're
M10: trying to find the men who are going to have
M10: their cancer growing and developing. So the guy who's fifty nine,
M10: let's say is PSA is one and he's one of
M10: those guys that has that low grade prostate cancer. Well,
M10: when we look at 60, he may be one point
M10: two or one point three, but a guy who has
M10: a higher grade cancer will go from one to one
M10: point seven or one point eight.
M11: And that change over time in a year. We know
M11: if your PSA goes up by more than point seven,
M11: five nanograms per male, no matter what your PSA is,
M11: you probably need a biopsy. We don't wait till somebody
M11: has a PSA of four can.
M2: When people tune into this show, first thing is they're
M2: going to be shocked that they're going to listen to
M2: a show that isn't about covid. Yeah, that's right. I
M2: have to admit, we're guilty as charged. It's been our
M2: focus now for quite a while. But I've got to ask,
M2: how depressed are the numbers of people who are getting
M2: themselves properly checked and screened? And during this time of covid,
M2: when people seem to be avoiding just about everything, but
M2: unless they suddenly find themselves with Kofod, Bill, it's so scary.
M10: There have been many estimates out there about all the
M10: excess deaths that are occurring in the United States and
M10: around the world because people couldn't get care initially when
M10: it first hit, but now are too afraid to go
M10: out and be seen at the hospital. And that's been
M10: estimated to be in the hundreds of thousands.
M12: And we're going to see those numbers spike for a
M12: while because all the people that didn't get their colon
M12: cancer screening, all the people that didn't have their mammograms,
M12: all the people that didn't get their prostates checked, they're
M12: going to end up with more advanced disease. That's not curable.
M12: So we're going to see this downstream effects of this
M12: horrible pandemic for multiple years yet.
M14: Dr. Kenneth Pianta from Johns Hopkins. I want to thank
M14: you for joining us today. This was a dynamic conversation,
M14: of course, Dr. Steven Tayback. Can how can people follow you?
F1: They can follow me on Twitter at Pianta. Underscore Brady,
F1: my website.
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