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Program Notes
- Dr. Jim C. Hu on the Weill Cornell Medicine website
- Dr. Jim C. Hu on Twitter: @jimhumd
- STUDY: Reconsidering the Trade-offs of Prostate Cancer Screening
- ON OUR WEBSITE: Information about PSA screenings
- LeFrak Center for Robotic Surgery
- Fred Hutchinson Cancer Research Center
- US Preventative Services Task Force
Episode Transcript
Welcome to Stay in the Game: Conversations about prostate Cancer with Ed Randall. Here we’ll chat with doctors, researchers, medical professionals, survivors, and others to share and connect. This show was produced and shared by Fans for the Cure, a non-profit dedicated to serving men on their journeys through prostate cancer.
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Ed: Hi, everybody, and welcome. I’m Ed Randall, and this is the Stay in the Game podcast, brought to you by Fans for the Cure. Our guest is Dr. Jim Hu, and we’re so happy to have him. He is a professor of Urology at Weill Cornell Medicine and an attending urologist at NewYork–Presbyterian Hospital, as well as serving the hospital’s Director of the LeFrak Center for Robotic Surgery, all based here in New York City. What an honor it is for us to have him with us. He has been a great supporter of this charity, I’m proud to say. Doctor, it’s wonderful to have you.
Before we get into the nuts and bolts of medicine, let’s talk about you. Tell us about where you grew up. Tell us about when you aspired to become a doctor.
Jim: Sure, and it’s always a pleasure to catch up with you. I’m so grateful to spend this 30, 45 minutes with you today. As to your first question, probably the easiest one for me to answer for the day. I was born in Taiwan and immigrated to this country at the age of 5. Fortunately, in the 70s, my mother had an opportunity to come to the United States because she was a nurse and there was a nursing shortage. So she chose Tyler, Texas of all places because that’s where she had a distant relative that worked at Texas Instruments.
Tyler, Texas is a town of about…back then it was 75,000 people. So I lived there until age 18. Then went off to college in Baltimore, back to Texas for medical school in Houston, and then training out west in Los Angeles. So then I’ve subsequently had positions at Brigham and Women’s Hospital in Boston, then back to UCLA for three years. Now I’ve been out to the Big Apple for a little over five years.
Ed: When did you first have a thought you wanted to devote your life to medicine?
Jim: That’s right. That’s the two-parter. So, basically, from a very early age, I think, as an immigrant, in particular, maybe as an Asian immigrant, in a lot of families, there’s a lot of respect and reverence for physicians. So that was the impetus for I think my parents wanting me to go into medicine. In college, I actually had a bit of identity crisis and decided that I would try to go into economics. Then truth be told, I got these calls on a weekly basis starting in junior saying, “Hey, look, we came to this country because we thought you’d have better opportunities here. We really think you should go into medicine.” So it was kind of a repeating dialogue of “we think you should go into medicine” I suppose. I think it finally rubbed off on me, so I corrected the course and went back into medicine.
Ed: They had to say it more than once.
Jim: Exactly, exactly. But I think having said that, listen, I think they knew me well. And I’m so grateful that they had the wisdom to steer me in that direction. Medicine has been tremendously rewarding. These challenges of trying to figure out what the best to do for patients as relates to what we do, and in particular, for men with prostate cancer, at the risk of prostate cancer, you know, things are not clear. So it’s been a lot of fun and very challenging, exciting work to try to work through those questions.
Ed: What would you say is the most rewarding aspect of what you do?
Jim: Well, I think that on a day to day basis there’s gratification in curing patients of prostate cancer. Because, as a physician, it is a very individualized one on one interaction that gives you a lot of energy and gives you a lot of excitement when you’re able to offer good news to a lot of men. Unfortunately, as we’ll talk about later, there’s more and more PSA screening. And this is a cancer that we can find early and cure in many cases.
On a broader scale, and what I mean by that is to make an impact, I mean, certainly it’s great to have impact one on one with patients, but it’s also refreshing at times to try to provide evidence or answer questions that may help our medical field and others to better understand what we should be doing in terms of treating prostate cancer. Whether we should be screened for it. So I would just characterize that there is the individual gratification of helping patients on a daily basis, but also, I find it gratifying as a researcher to try and answer some of these important questions.
Ed: Where are we now as opposed to where we were when you started?
Jim: It’s interesting. I think when I started and when I went into Medicine and specifically urology, at that time, this was the late 1990s. PSA came around in the early 1990s. So I think that there was still a lot of use of PSA. There was the height of men dying, annual incidences in terms of men being diagnosed with prostate cancer. Then there was a lot of questions about whether or not we were harming men. And probably in some cases, we were. We were probably over treating and over-diagnosing them now with 20/20 hindsight. The pendulum I think may have swung too far the other way.
Starting in really 2009, there were two research studies that came out. One from the US that questioned whether or not there’s any benefit to PSA testing because they did a randomized trial. The highest level of evidence that we have where they flip a coin, and if it’s heads, you do nothing. You just monitor. If you do tails, you do PSA testing. Then in that US study, that’s commonly referred to as the Prostate, Lung, Colorectal, and Ovarian study or the PLCO, that study didn’t show a benefit in terms of PSA testing. Those who were randomized to PSA testing did not have a lower likelihood of dying of prostate cancer.
Our team unearth the fact that the way that they defined contamination or men in the controller, that shouldn’t have gotten PSA, well, up to 90% of those men actually had a PSA test at some point during the study unbeknownst to investigators originally. So when we figured out the contamination was really higher than it was originally reported, then it really called into question this pillar of evidence that a lot of policymakers had turned to. I think that reversed course and got more of a swing back to say, well, if men want a PSA, they can get one. Prior to that, what’s called the United States Preventive Services Task Force recommended against PSA in all ages.
Ed: I know. We’re going to talk about that a little while. Most recently, you and your team into Weill Cornell, you are listed as a co-investigator of a New England Journal of Medicine article that associates PSA screenings with a greater prostate cancer survival benefit than previously indicated. Congratulations on that. Tells us, Jim, more about this new study and why the results represent such good news for those of us who continue to spend our days encouraging men to go get PSA tests.
Jim: Absolutely. I’ll start with your question, and I’ll also, if I can walk it back to an example, a daily example because I think sometimes it makes it more concrete. As far as this research, first, I have to credit…You know, I mentioned there were two pillars of evidence. The second pillar came from The Europeans. They also did a randomized trial. In that study, which was almost two and a half times bigger than the US study, there was a prostate cancer survival benefit in men who had randomized screening and there was less contamination.
So what we did, really, and we worked with the top people at the Fred Hutchinson Cancer Institute out in Seattle. So, really I looked at some of the information that the Preventive Services Task Force, well-intentioned, was sending out there to men to try to tell them “this is the risk and this is the benefit of PSA testing.” And really, I felt that the PSA testing benefit was being underestimated. What I mean by that is that that study is still being followed long term. And with each coming year, results are available. And with longer follow up, we’re going to see that PSA testing becomes more favorable.
Why? Because in many men, prostate cancer grows very slowly. So it takes at least 10, 15, sometimes 20 years to see the true benefit of screening. So what we did was basically we modeled with, again the top people in the field at the Fred Hutch, we looked at the evidence that’s available from Europe, and we used very conservative modeling. Meaning that we didn’t try to overestimate the benefit of PSA testing. We found that if you looked at 25 years down the road from when a man got a PSA—so obviously the greatest benefit is in younger men—well, when you looked at this, 25 years down the road, you needed to screen 385 men to prevent one death from prostate cancer. And also that you would be in excess diagnosing 11 men to save one man for prostate cancer.
Those numbers are relative to the original publication, which was about 10 years after the studies started. Back then you had the screen 1440 men. So you can see the drastic reduction in the number of men who were exposed or did underwent screening but didn’t benefit from it whittles down from 1440 down to 385.
Now, some of you may say, “Wow, well, that’s still such a big number to screen that many man men secure one person from prostate cancer. Well, you can look at the example of breast cancer, for instance, in women, which this National Task Force, the Preventive Services Task Force, still gives a bead recommendation for that. They say there’s moderate certainty that screening helps, whereas PSA moved from a D to a C. But yet for breast cancer screening, depending on the age of the woman being screened, the number needed to screen to prevent one death from breast cancer ranges anywhere from 1250 women to 476. As I mentioned earlier, that 385 number for men, now granted this is 25 years later, is more favorable than…
Ed: It’s the same range. Yeah.
Jim: Yeah, exactly. Part of this I think is that men and you deal with a lot of men, and men like to watch sports and be left alone on the couch when they’re watching sports. I think there’s a tendency, perhaps that men aren’t as vocal and we aren’t as proactive in supporting health initiatives that are increasingly recognized to have more benefits.
Ed: You have referenced US Preventive Services Task Force, and I want to talk about that. As you know with this charity, we have a tough enough time trying to convince men to just go to the doctors. Tough enough time trying to convince men to go to the doctors without the government discouraging PSA screenings. Can you give us the abridged version of how the PSA test wound up originally with a grade of D from the US Preventive Services Task Force, I believe in 2012? It’s been upgraded to a C in 2017.
Jim: Absolutely. I think one has to look at the perspective of overall what’s going on in US healthcare. The first trend is there’s a greater emphasis on value-based care. That is, when you define value as what are the good outcomes that we’re deriving from medical care over the expensive care. So value is outcomes over cost. As we’ve seen every year, the US, unfortunately, leads every economy in the world in terms of the proportion of the economy of the GDP that’s spent on health care. So policymakers have said, “Look, we need to cut health care costs.” So I think there’s certainly the needs look at it from that standpoint.
Number two, it is true that we over-diagnosed men with prostate cancer. Again, this was 5, 6, 7 years ago, every man with prostate cancer, they were told, “Hey, you need to get surgery. You need to get radiation.” But again, with longer term evidence, we found that now a lot of men diagnosed with prostate cancer can just watch and monitor or do what’s called active surveillance. When the original guidelines were made or that taskforce, in 2012 said there shouldn’t be PSA testing, it is true that we were over-treating prostate cancer. I think better adherence to guidelines that is putting men on active surveillance when they should get it, those with low risk cancer, has led to the recognition that, hey, urologist is, a specialty or not, over-treating men with prostate cancer.
The other aspects of have prostate cancer treatment go into when someone undergoes surgery or radiation, there are side effects. I mentioned that the benefits of screening may not happen until 25 years down the road to prevent that. So if someone gets treated right away and they don’t have a good outcome in terms of, let’s say Erectile dysfunction or urinary incontinence, unfortunately, they’re living with that for up to 25 years or more. I think it’s not as black and white.
I don’t want to make it sound like there’s a lot of people on the task force that just didn’t know what they’re doing. These are complex questions. But at the same time, the task force also looks at things like, should vaccines be recommended? Should women have pap smears? When should you do colonoscopies? So, in order to have that broad expertise, they may not focus as much on prostate cancer. So part of our challenge, both yours and mine, is to educate the public and educate men and point out some of the fine details about where PSA testing and getting treated for prostate cancer is beneficial.
Ed: My information about the US Preventive Services Task Force is it was born in 1984 during the Reagan administration. And on it were 16 doctors, not a urologist, not a radiologist, not an oncologist. That’s my information. I saw that you took on the task force for offering up information about screenings that was unbelievably based on obsolete data. It did not represent the current standard of medical care. Could you care to elaborate?
Jim: Yes. Thanks for walking it back to that issue about contamination. As I mentioned previously, when we uncovered the fact that contamination wasn’t really being defined in an accurate way, we actually…and at the time, one of the task force members was actually at a neighboring institution, Mount Sinai in the city. He was kind enough to meet with us. We showed him what we had found. Hopefully that ran up the chain. Certainly, there are people like Patrick Walsh, who is a former chair of Urology at Johns Hopkins…
Ed: One of the fathers of the PSA.
Jim: That’s right. He was kind enough to say, “Jim, your research is the reason why the task force changed the recommendation.” I think it contributes to it, but like I said, I think a lot of it is that we started recognizing that not every man need to be treated for prostate cancer with surgery or radiation, and that decreasing overtreatment makes screening more palatable. And kind of the philosophical debate here is that, in the United States, in the Western society, and nothing actually epitomizes this better, perhaps, than what we’re seeing across the country with COVID. And I know we’re not talking about Coronavirus or COVID, but you can see how individual choice is so important to our culture. The choice of do you want to wear a mask or not? Unfortunately, maybe in some places, some parts of the country, some would argue that that has a deleterious effect, that individual choice.
The point that I’m trying to make is individual choice is important, but yet you had an organization that was looking at data that was somewhat obsolete and coming to the conclusion that no man should get a PSA. And the downstream ramifications of that would be that potentially there would be some health care organizations that would look at a primary care doctor. If they offered a PSA test, they would somehow be penalized for that because they weren’t following guidelines. So I’m glad that we were able to walk that back a little bit. This more recent work in the New England Journal of Medicine, I think, is again in line with the fact that we’re trying to show the benefit of screening, particularly in younger men who have a long life expectancy, is considerable relative to other tests such as mammography.
Ed: It is astonishing to me that a governmental body with all of the assets at hand would come up with this finding based on obsolete information when they can get whatever it is that they need. I find that amazing. And at the time in which these findings were made public, they offered truly no alternative to the PSA.
Jim: I mean, I think some of that is, unfortunately, the momentum. When the committee met, and the meeting is over, you have to have someone that continuously wants to ask questions to kind of undo some of the momentum I think that’s going on. Again, I think these are well-intentioned people.
I would just go back to the first study that we did, that question, well, what is the true contaminant rate? I think if the original authors had defined contamination as we felt it should be defined, that as if someone had a PSA test at any point during the study and they had it for a prostate reason or some other reason, I mean, those are all legitimate reasons to get PSA testing, and they should have been captured as contamination. So some of it is that I think the way that contamination was previously defined was underrepresented. This led that New England Journal paper from the PLCO, The Prostate, Lung, Colorectal and Ovarian study to be overemphasized in terms of its relative importance.
If we knew that 90% of men had a PSA when they shouldn’t have during the study, then you would say look, this randomized trial doesn’t compare apples to oranges. That is, men who were screened versus those who aren’t. It’s comparing apples to apples, it’s comparing moderate screen to a lot of screen that is every year. I wouldn’t put the onus of blame on the taskforce just because they weren’t necessarily aware that contamination wasn’t accurately defined.
I was going to quickly just add. The other thing that we were actually able to show is there are national statistics on cancer death and incidence. The National Cancer Institute invests in tumor registries all over the country. For instance, the state of Connecticut is represented in what’s called the SEER Tumor Registry, Los Angeles County, New Jersey, amongst other places, capturing men and women of diverse backgrounds.
The point that I was trying to make is that after the task force, and then the original recommendation was in 2008, for men aged over 75, it was said that they shouldn’t get PSA testing. To a certain degree, I think that recommendation is valid because a lot of men who are older than 75 are going to live another 25 years. But that being said, that recommendation had a downstream effect on younger men not getting a PSA. So we found that really in 2012, 2013, when you looked at nationally representative tumor registry data, that the incidence of metastatic prostate cancer, that is, men are being diagnosed with cancer that’s already spread, when they found out, that likelihood was going up. The numbers were going up.
And for years, the number of men diagnosed with metastatic prostate cancer had gone down in the United States after the early 1990s when PSA came out as a test. So, again, that’s another way to look at the problem that by decreasing the amount of PSA testing, we saw that number of men diagnosed with metastatic prostate cancer was slowly going back up again. And we see that as well. More recently in the last three years, when you look at the number of men who’ve died from prostate cancer nationally in the United States, that number is also crept up as well. So I think these are downstream effects of, unfortunately, the guidelines and or the disseminating the information that, hey, PSA testing isn’t beneficial.
Ed: For organizations such as ours dedicated to awareness and education, whereas men in their DNA apparently are not designed to go to the doctors, the findings of the task force, if our mountain is this steep, now it becomes even more steep because now they have another excuse not to go to the doctors. We’re with Dr. Jim Hu, the esteemed Dr. Jim Hu, a professor of Urology at Weill Cornell Medicine here in New York. For those of us who were statheads, if you will, it’s difficult to ignore what you just spoke about, which is the incidence of metastatic prostate cancer, which has begun rising in recent years after so many years of decline.
I had an evening at a New York theater with five doctors about five or six years ago, who were commenting on the original grade that the task force gave the PSA exam. They said that within five to seven years if men paid attention to that and stayed away from the doctors, we would have a rise in prostate cancer cases. So the question is, is this a direct result of the decline in screenings following the 2012 Task Force guidelines, or do you think there were other factors at play?
Jim: Sure. I don’t think that one can 100% associate the causality of the decrease or the task force recommendations. But certainly, we do with the increased incidence of metastatic diagnosis. But certainly, we do know that the number of men getting PSA testing went down. Primary care doctors were less likely to offer it. So those facts remain.
We also looked at state of New York data that shows that the number of biopsies went down as a result. So I would say that, now on the other hand, certainly lifestyle factors may also cause an increase in the likelihood of finding a prostate or someone developing prostate cancer. That is, we know that obesity is associated with more risk for aggressive prostate cancer. So perhaps as the men in the United States, the body mass index on average goes up, then that could also lead to a situation where someone may be more likely to be diagnosed with prostate cancer.
But I would say that I think it’s pretty commonly recognized now epidemiologically. It’s interesting, there was an expert in not necessarily prostate cancer but screening for other cancers. This is someone from Harvard. And of course, if it comes from Boston, and in that group, it must be true. But he came out and said, “Look, prostate cancer is an example where we have a pretty good test, but we stopped using it.” He attributed as well, the increased incidence of metastasis diagnosis as well as the increased prostate cancer mortality that we’ve seen in recent years to the fact that there was less use of PSA testing.
Ed: Besides live saved, aren’t there ancillary benefits to PSA tests. Beyond the obvious benefit of lowering the risk of death, isn’t it a way to find and treating cases while there’s still time to prevent it from becoming metastatic disease?
Jim: Absolutely. Death is a pretty hard endpoint, right? When you say PSA prevents prostate cancer deaths, well, there’s also a lot of unfortunate and undesirable things that can happen before death. There’s the development of metastasis. So when you look at how is metastatic prostate cancer treated? Well, current evidence is that if you have metastatic prostate cancer or diagnosis to develop it, then you start what’s called androgen deprivation therapy.
Androgen deprivation therapy said in another way is medical castration. You’re getting an injection or taking pills that stop the body’s production of testosterone. That in and of itself has very bothersome side effects for men. Men get hot flashes; it’s like menopause for men. They lose muscle mass. You get some more body fat in your gut, in your belly. There’s also studies that show that the androgen deprivation therapy increases your risk for diabetes, coronary artery disease, dementia, depression. And you stay on that therapy for life. So avoidance of metastasis also means avoidance of androgen deprivation therapy.
Now, what are the symptoms of prostate cancer metastasis as it progresses? Well, prostate cancer very commonly goes to the bones. So it can cause bone pain, it can cause pathologic fractures. I think everyone knows of other downstream effects of cancer such as weight loss, decreased energy. In fact, you could get spinal cord compression because of prostate cancer involving the spine, and all sudden losing the ability to use your lower extremities. So there are a lot of other undesirable things that happen when you develop aggressive prostate cancer that preceded death as an endpoint.
There is a long, natural history as we’re talking about. Someone could be diagnosed with metastatic prostate cancer where you could live 10 years. And that could be 10 years that you’re on a nutrition deprivation therapy, which may worsen your quality of life.
Ed: For those in the audience who aren’t familiar when we talk about low risk, localized prostate cancer, and metastatic disease, tell us the difference and how treatments for metastatic cases can lead to impaired quality of life.
Jim: Absolutely. So just to define the different spectrums of risk, if you will, what we look at when we say risk is, is a composite of three different measures. First, there’s your PSA. So low risk is men who are diagnosed with prostate cancer with a PSA less than 10. There’s the clinical stage. That is, when you’re diagnosed, is the cancer confined to the prostate? Has it spread outside of the capsule? Has it spread into the seminal vesicles? Has a spread into the lymph nodes? Has it spread into the bones? So there’s the clinical stage.
Then the final thing is the grade. When the pathologist looks at cancer under the microscope, does the cells appear highly abnormal or do they appear more like normal prostate cells? So the combination of those three things gives us the risk stratification. And because in the US, there is still considerable PSA testing as compared to let’s say before the early 1990s, I’d say most men are diagnosed with low-risk cancer or intermediate-risk cancer. So it’s about three-quarters of men that fit into those two buckets. And those are both treatable men in which there’s a high chance if you get treated at that time point that they will not develop metastasis in the future.
Now, when we talk about metastatic prostate cancer, that is cancer that’s already gotten beyond the prostate. There’s evidence on imaging and the most common X-rays or imaging that you get are bone scans or CAT scans. So on those imaging of the body, you can see that cancer has spread into the lymph nodes or it has spread into the bones or some other organs. Unfortunately, once you have metastatic prostate cancer, it is incurable. Again, we talked about earlier, the current standard of care is to go on lifelong, instant deprivation therapy, which in and of itself has significant side effects.
Ed: Let’s talk about the list a few months when our world was turned upside down due to the Coronavirus. My guess is the number of PSA screenings this year in this country is way down.
Jim: I think you’re absolutely right. There’s going to be a market decline, not only for prostate cancers. The National Cancer Institute is estimating that the number of people that will, unfortunately, succumbed to cancer, not just prostate but others, and missed the window of cure abilities, unfortunately, is in the thousands. At least during our lifetimes, this is a public health crisis unlike any that we’ve ever seen. We’re fortunate here in New York that the number of COVID cases has gone down. But we are seeing more and more men coming back and seeing their primary care doctors, getting elevated PSA, and then undergoing the MRI and then a biopsy if needed. So that is slowly coming back.
But to your point, in other parts of the country, like reading the news about Houston, Texas, where there where we were maybe a couple of months ago and they don’t have ICU capacity, then PSA testing prostate cancer and other cancers or elective surgeries are being stopped and taking a backseat to ICU space that’s needed for some of these patients with difficulty breathing.
Ed: In our remaining moments in our Stay in the Game podcast with Dr. Jim Hu, we ask this of all our podcast guests by the way, and just about anybody else who will take our calls. We are a charity that relied on large gatherings to offer screenings, awareness events, and health fairs. Now in a COVID-19 world, we’re limited to online programs like this, which include this podcast, online chat, and our well subscribed and growing online support groups. What else do you feel we can be doing to help men and their families deal with all aspects of their prostate cancer journeys?
Jim: Well, I think that part of it is just understanding that you’re—and maybe you came up with this. I can’t remember it, so pardon me if I’m taking this from you. But part of this is, you may say this, I think when you talk about you joining a club. And it’s not necessarily a club that you want to be a part of.
Ed: That’s exactly right.
Jim: But I think that it’s important for men to recognize that they’re not alone. We joked earlier about men want to stay on their couch but they don’t want to go see the doctors. I mean, part of it may just be that in all the Seinfeld or the TV shows, you have the urologist who snaps on the glove, and it’s time to do the prostate exam. No one looks forward to that. But the truth be told, I mean, we have better ways to image prostate cancer now. More or less people are doing the prostate exams now. The PSA is just a blood test. Part of it is just overcoming that stigma if you will, that I need to go to the doctor and get an uncomfortable prostate exam done.
Also, it’s not uncommon for men to come in and not to know what the prostate is. Or sometimes it’ll be mispronounced the “prostrate.” So, the prostate is just an organ that really the main function is to produce a big component of the ejaculate for reproductive purposes. But it really has no other function in men other than the fact that your urine travels through the prosthetic urethra as it exits the bladder. So I think men just have to be more aware of what the prostate is and the fact that they are at risk for it. One out of nine us men is diagnosed with prostate cancer during their lifetimes.
And understand that there is no shame associated with it, and no stigma. Oftentimes, as I think we both joke about, the wives are the reason that men go see the doctor or follow up on some of these tests. So I think we have to be a little bit more proactive and follow the PSA, just like you follow the batting average or the on-base average and so forth. Right?
Ed: Also, you told me all fair…a while ago – what is it? Three million men are walking around as prostate cancer survivors in this country alone.
Jim: That’s right. The prevalence of prostate cancer is very high. It grows every day. More than 3 million. Again, that gets to the fact that most men, once you’re diagnosed with prostate cancer, you live a long time. So it’s important to understand and learn more about it through podcasts like this, and understand that it’s very treatable, particularly when it’s diagnosed early through PSA screening.
Ed: Besides what we’re doing online trying to compensate as the world was turned upside down, what would you like to see Fans for the Cure do?
Jim: Well, I mean, listen, I take my hat off to you. Gosh, in the five years I’ve been here in New York, we’ve been fortunate to have you really and the Yankees organization do those screenings. I think it increases the visibility of PSA screening. As you said, for a time there’s a little uncertainty given what the task force recommendations were about what is the right thing to do. But you stuck with it. The evidence has come around.
What else from an organizational standpoint should you do? I think you’re being involved with some of the Cornell I think research or the trials to try to get a point of care for PSA. Meaning that there are also men that get PSAs and then they don’t follow up with their doctor. There’s a new technology that we’re working with where you get a finger stick and you get that PSA back very quickly. Almost like what’s called an accu-checker or learning what your sugars are if you have diabetes.
I think these better ways of getting more immediate results to men, education, and ultimately helping to educate men that being part of clinical trials to answer some of the important questions is something that they can do to help others. For instance, we have a clinical trial that we’re starting that is funded by Federal Grants, in which we’re going to look at whether or not we can do a biopsy a safer way. The traditional biopsy is done transrectally. Meaning biopsy needles pass through an ultrasound probe in the rectum through the rectal wall into the prostate.
We’re looking at a percutaneous through the skin, which is cleaner. It should theoretically decrease the risk of infection. So research is important. And if men can participate in some of these trials, not necessarily be a guinea pig, but try to do some of the things to help other men understand more about the potential benefits of new techniques or approaches, it would be tremendously helpful.
Ed: And it would be tremendously helpful if they were more proactive. We’ve spent a lot of this time talking about the US Preventive Services Task Force, who issued their recommendations on a Friday and gave the PSA exam a D grading. At the same time, you’ll recall that they told women that they need not self-examine till the age of 50. This was on a Friday. The charity started getting a lot of emails and communications from men in the wake of these fine things. “I’m so confused. I don’t know what to do with the PSA being degraded as it is.”
The Women put up such an uproar about what they were told with regard to self-examination that the following Monday, the first business day after that, Sebelius who, as you remember was running Health and Human Services in the Obama administration had to call a press conference in which she had to step away from what they had said on Friday. That is the difference between men and women. So we need to be able to bang the guns as loud as we can and tell men about how important it is for them to take possession of their health.
Jim: I agree with you 100%. I think being more proactive, doing more research to understand this. This is something that all men can do. And also being active with local organizations or your representative, your senator to make sure that men’s health initiatives such as PSA are advocated for at the government level.
Now, one thing you reminded me of…I’d mention an antidote if we have time.
Ed: We always do.
Jim: I remember I took care of a very nice gentleman recently, aged 56. Three years ago, he had a PSA. It was 3.7. So at the age of 53, get a PSA of 3.7. His wife, I believe is around the age of 40. They have young children. That 3.7 wasn’t necessarily followed up, a red flag wasn’t triggered. Then he saw one of my partners actually here for a vasectomy and my partner is a very thorough person. He did a prostate exam and found a nodule. And then a PSA was then obtained and that PSA came back now at 6.2, which, again is not terribly high. I mentioned earlier that for low-risk prostate cancer, your PSA should be less than 10.
So this person then goes on to have an MRI-targeted biopsy, has surgery. At the time of surgery, we sample lymph nodes to see if prostate cancer is spread. Unfortunately, he had metastatic prostate cancer. Prostate cancer has spread to two of those lymph nodes at a PSA of again, a little bit over six. So, here he is, 56 years young, how he started hormone therapy. He’s going to get whole pelvis to radiation.
Fortunately, from the surgery itself, within three months, he was dry, not wearing any pads. His sexual function had come back. But that is all. Obviously, when you start hormone therapy, that decreases your libido. It takes away your ability to get erections. So he’s very frustrated that his primary care doctor didn’t follow up on that PSA of 3.7 from three years ago because certainly during the course of the three years, the PSA increased significantly, and no follow up was rendered.
I mentioned to him the work that we’re doing, the task force, and the things that we’ve looked at to look at contamination and help and do the task force recommendations. He said, “Look, you’re spot on.” In fact, he was a speaker back in Ireland at his college, giving at one of the universities there. And he came out and he stopped and said, “Look, I want to tell you a personal story. You need to get your PSA test done.” So he gets it. But I just wanted to also illustrate through that anecdote that there was no family history that if you’re someone who’s relatively young at 56, and because of that delay and following up on a PSA, his life is forever changed. It’s incurable prostate cancer.
Ed: Dr. Jim, you co-wrote a recent paper in the New England Journal of Medicine that challenges the European study, which said that 570 men between the ages of 55 minutes 69 would need to be screened in order to save one life. He contends the European numbers are outdated and don’t incorporate advances in technologies such as MRIs to target biopsies and to identify lesions that can be watched. We thank you for your time. We commend you, sir, for your life-saving work. And we thank you so much for being with us on our Stay in the Game podcast.
Jim: It’s my pleasure, Ed, as always. Thanks for having me on. I look forward to helping the charity any way I can and getting the word out to men that PSA testing is important.
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