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A professor emeritus at Columbia University Medical Center in New York City, Dr. Nicholas A. Romas joined the faculty in 2014. He had previously served as the Chairman of Urology at St. Luke’s-Roosevelt Hospital for three decades, from 1984 to 2014.
A winner of the Albert Nelson Marquis Lifetime Achievement Award for his professional accomplishments, leadership, and prominence in his field, Dr. Romas was also the treating physician of the Stay in the Game host, Ed Randall, when Ed underwent treatment for prostate cancer.
Program Notes
- Columbia University Medical Center
- Press release announcing Dr. Romas’ winning of the Albert Nelson Marquis Lifetime Achievement Award
The Stay in the Game podcast is sponsored by MRIdian by ViewRay, unique in delivering MRI-guided stereotactic body radiation therapy (SBRT) for localized prostate cancer. As reported in JAMA Oncology earlier this year, MRI-guided radiation therapy – delivered with MRIdian – was found in a phase III randomized controlled MIRAGE trial to be superior in reducing the toxic GI and GU side effects of treatment, as well as significantly increasing patient-reported quality-of-life metrics.
For more information about MRIdian MRI-guided radiation therapy, or to see a list of participating healthcare institutions, please visit to viewray.com.
Episode Transcript
Announcer: 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 nonprofit dedicated to serving men on their journeys through prostate cancer.
The Stay in the Game podcast is sponsored by MRIdian, MRI-guided radiation therapy by ViewRay. MRIdian is used to treat a variety of cancers, including localized prostate cancer. As reported in JAMA Oncology, the phase three randomized control MIRAGE trial showed treatment with MRIdian to be superior to standard CT-guided treatment in reducing the toxic side effects. With MRIdian, over 80% of patients can complete treatment in as few as five outpatient sessions with few side effects. Talk to your doctor or to find hospitals where MRIdian is available, visit viewray.com.
Ed Randall: Hi, everybody, and welcome back to our Stay in the Game Podcast. I’m Ed Rendell, the founder and chief advocacy officer for Fans for the Cure. And our very special guest is a professor emeritus at Columbia University Medical Center in New York City, where he joined as a full-time faculty member in 2014. Prior to that, he had served as the chairman of Urology at St. Luke’s Roosevelt Hospital for three decades, from 1984 to 2014.
A graduate of Colgate University and Columbia Medical School, he served in the Air Force for two years following his internship in New York Presbyterian Hospital and has contributed numerous articles in scientific publications based on his many years of both clinical practice and research in the field of urology. A winner of the Albert Nelson Marquis Lifetime Achievement Award for his professional accomplishments, leadership, and prominence in his field, our guest has long been among the bright lights and regular names among the New York area’s best doctors.
And although he may not know it yet, his career will likely be best remembered for being my once-and-always oncologist and urology quarterback starting in 1999. I’m not kidding when I call him one of the best there ever has been. What an honor it is for us to welcome to our Stay in the Game podcast Dr. Nicholas Romas.
Dr. Nicholas A. Romas: Well, thank you.
Ed Randall: Dr. Romas, I can’t tell you how happy we are that you were able to join us as we begin our fourth season of the Stay in the Game podcast. You and I, of course, go way back. And when I take inventory of the people who are responsible for me continuing to walk the earth in 2023, I put you at the top of the list. Thank you so much.
Dr. Nicholas A. Romas: Well, since that time, there has been a lot of developments. First was the prosthetic acid phosphatase was the original tumor marker which I developed with one of the biochemists there at Columbia University. We used that extensively is prosthetic acid phosphatase (PAP). That was a very good agent to diagnose prostate cancer.
And then in the 1990s, they developed PSA which is Prostate Specific Antigen, which is used presently in order to try to make a definite diagnosis in prostate cancer. So that’s the tumor markers that have been developed. And since then, there have been half a dozen other tumor markers that have been developed, but they’re not completely used on a daily basis.
In terms of treatment, a lot of different types of treatment programs. The standard treatment initially was the use of radical prostatectomy, which the entire prostate was removed. There was also the development of radiation therapy, which has shown tremendous amount of development with different types of radiation used and the treatment course has been defined in different terms, so are short-term radiation with high intensity, some are longer, etc.
And then if you develop cancer that spreads to the bones and other parts of the body, there’s been a lot of new chemicals that have been developed to try to control that. So the developments have been pretty extensive since 1974. It seems like every five years there’s been a new drug or something they can utilize.
Ed Randall: You were board certified in urology back in 1974, which is practically 50 years ago. What have been the changes and discoveries in the diagnosis and treatment of prostate cancer over that time that have not only surprised you but astounded you?
Dr. Nicholas A. Romas: Probably it was the development of PSA in 1990. In that era, we needed a good tumor marker. Prostatic acid phosphatase was reasonably good but PSA was even a better marker. That gave us the ability to diagnose prostate cancer at an early phase. Obviously, with that PSA, you’re also supposed to do what they call a digital rectal examination where you examine the prostate with your finger in the rectum to feel is there any hard lumps or bumps. But you need a combination of that plus the PSA blood tests in order to move forward in terms of what has to be done next.
And next is usually if you’ve got very, very suspicious based on the blood tests and the rectal examination, you use different techniques to biopsy the prostate. Originally, we use ultrasound along with the biopsies. Now recently they are using MRI to find the exact area where you have to biopsy. So diagnostically we’ve improved things tremendously. Therapeutically we’ve also made a lot of advances.
Ed Randall: The PSA test was first approved by the FDA in 1986 as a tool to aid in the management of patients already diagnosed with prostate cancer. In 1994 it was approved as a diagnostic tool. In your 20 years of practice until the PSA went mainstream, what were the available tests or symptoms that led to biopsies and diagnoses of prostate cancer?
Dr. Nicholas A. Romas: Well, number one, you had a finding on physical examination of feeling the hard or underrated area of the prostate. They gave you evidence to go ahead with the biopsy. Number two, I told you about the prosthetic acid phosphatase was another test developed way back in the 1940s or 50s. Either one of those if they were abnormal, you would proceed with a biopsy, which can be performed in the offices. And there’s some patients who are anxious, you need general anesthesia, other people that are a little more relaxed, you use local anesthetic.
Ed Randall: How revolutionary was it for the field when Dr. Patrick Walsh performed the first purposeful nerve-sparing prostatectomy in 1982?
Dr. Nicholas A. Romas: Well, that was a major breakthrough from Johns Hopkins. He came up one time and we operated together just to show how effective it was. The major advantage there in this type of operation is the technique that you use, number one to decrease a blood supply and number two, to spare the nerves on either side of the prostate. So, therefore, the combination of that and also to do a good connection between the remaining bladder neck and the urethra to try to control urinary control so you won’t be incontinent or lose urine afterwards.
So two major defects were number one, loss of erectile function, number two, the loss of urinary control. And by doing a good operation developed by the Johns Hopkins Group, if you did it effectively, you would decrease the incidence of those two abnormalities.
Ed Randall: I’m familiar on a firsthand basis with your work as a clinician where the outcome speaks for itself, and we’re having a conversation 24 years later. So let’s leave the clinic for a moment. I’m not as familiar with your career as a researcher. What specific research or published paper or papers are you most proud of as you look back on your career?
Dr. Nicholas A. Romas: Well, first we developed the lab test prosthetic acid phosphatase. One of our biochemists isolated that and showed that it was present in the prostate. If it leaked out in high levels, it indicated there was something going on. Number one, is it prostate cancer? Number two, do you have an infection? These are episodes that would increase the PAP. So that was one of the major breakthroughs.
We did a lot of research in terms of trying to develop new drugs that would be effective to decrease the testosterone in the person’s body. If we found that the cancer had gone beyond the prostate, we had to decrease the testosterone in the male body. And number one, the easy technique was just to remove the testes which removes the testosterone levels. The second method is certain drugs that were developed that would affect a pituitary gland and therefore cause a defect in not allowing the testes to produce testosterone.
The second thing was a medication that would block the testosterone that comes from the adrenal gland. There’s a small amount of testosterone that comes from the adrenal gland, which, if you want to fit a complete loss of testosterone, you need to take that medication, also another medication to prevent testosterone production by the adrenal gland.
Ed Randall: [inaudible 00:10:24] of other guests who are triple threats. Clinicians who see patients, researchers, and classroom teachers training the next generation of physicians. Which aspect of your job brought you the greatest satisfaction?
Dr. Nicholas A. Romas: Well, I think training residents was probably the major thing. Even at St. Luke’s Roosevelt for 30 years, we had urology residents rotating from Columbia down to our hospital. We trained him how to diagnose prostate cancer and how to treat it. And therefore also medical students came down dealing extensively with medical students. We had a high percentage of medical students who went into urology, which was part deficiency and a lack of urologists going forward.
In fact, they’re predicting in the next five, ten years there may be a major loss of urologists and also orthopedic doctors was another loss. So we spent a lot of time training these doctors and getting them enthusiastic about the field.
We also had a major impact on females entering urology, which was an important impact. And a lot of our female medical students elected urology. In fact, 10 years ago, we had three women graduating the same time, which was sort of an unusual thing. The three women hit the New York Times. No other department in the country had three women graduate at the same time.
Ed Randall: You served as chief of Urology at St. Luke’s Roosevelt where you worked for 30 years, as seismic shifts were taking place in the way prostate cancer was being diagnosed and treated. How was it like to manage change and set policy for others during a time when so many long-established protocols were going out the window?
Dr. Nicholas A. Romas: Well, being in a teaching environment and being an academic individual, we were sort of asked and forced to keep up with anything that was coming out new. And we continually got lectures from staff from Columbia coming down to St. Luke’s Roosevelt to keep us abreast of all new developments. And therefore it was fairly easy to stay current because of the connections with Colombia with their large staff. That’s the direction we went. I had so many different conferences every week in order to stay on top of new developments.
Ed Randall: We’ll pause for a moment for a brief word from our sponsor.
Announcer: The Stay in the Game podcast is sponsored by MRIdian, MRI-guided radiation therapy by ViewRay. MRIdian is used to treat a variety of cancers, including localized prostate cancer. As reported in JAMA Oncology, the phase three randomized control MIRAGE trial showed treatment with MRIdian to be superior to standard CT-guided treatment in reducing the toxic side effects. With MRIdian, over 80% of patients can complete treatment in as few as five outpatient sessions with few side effects. Talk to your doctor or to find hospitals where MRIdian is available, visit viewray.com.
Ed Randall: Another example of how things change has been the choice of active surveillance as a man’s first option. In the past 10 to 15 years, the number of men going with active surveillance has gone from about 20% to 60%. The New York Times article from early May argue that even 60% isn’t high enough. What are your thoughts about active surveillance? And what is the disease profile that best lends itself to closely monitoring rather than treating the tumor or tumors, at least as a first step?
Dr. Nicholas A. Romas: Basically number one, you look at the age of the patient. Obviously, if they’re 85 years old, you’re not going to be so aggressive. So age is an important factor. Number two, the other factor is if the patient has multiple other medical issues and is going to get into trouble and die in a very short period of time, you tend to hold back on the treatment of the prostate cancer.
Also, you look at the numbers. Look at the pathology. Number one, does it have a low Gleason number? Does it have a PSA less than 10? So if it’s got PSA less than 10, it’s got a Gleason number below four or five, then you can make a decision. And also you have to talk to the patient about the side effects of doing treatment. And some patients are willing to accept the side effects and go ahead with surgery and not be on active surveillance.
Other people are willing to accept sitting back and waiting and being checked every six months or 12 months. And if there are evidence that the PSA increases or the rectal examination shows more firmness of the prostate, you may have to repeat the biopsy and compare with the biopsy tissue that was taken out initially. And if all these factors go in the direction of showing an increase, you sort of justify the fact that the patient should receive some type of treatment. And the treatments are so extensive. Now you have to have a lengthy discussion with the patient on whether they want surgery or whether they want radiation therapy, or they want some type of drug therapy.
Ed Randall: Next year will mark 50 years that you have been a board-certified urologist. I read an article this past week, which reported that there aren’t enough new physicians choosing to specialize in urology, and this is especially applying to women. So I’ll give you the floor, make the case to med-students, pre-meds, and other health professionals for a career in urology.
Dr. Nicholas A. Romas: We’ve been doing that. We’ve been sensitively talking to the students, getting them organized, enthusiastic. Therefore, when medical school class graduates, we have a reasonable amount of candidates to go into Urology. So Colombia is doing a very good job from that point of view. I’m not sure how the rest of the country is because in the next five or 10 years, there may be a very big decrease of urologists coming up. And with the aging population is going to be a real difficult problem. Because the aging population is increasing while the number of urologists is decreasing. So that’s going to have a major impact on how we go forward.
Ed Randall: Dr. Romas, is there a subject we didn’t get to cover a question you wish that I had asked?
Dr. Nicholas A. Romas: I think you were pretty thorough. Question is, are patients willing to accept the complications…? Therapy for prostate cancer is a big area. And obviously, we’ve improved in terms of decreasing the complication rate, using different parameters, for example, trying to save the nerves, different techniques surgically, and radiation to try to minimize the impact on the nerves. Therefore, going forward, I think we’ll use a lot of techniques to decrease the side effects of the disease. And the cure rates have been increasing and I think the death rate has been decreasing.
Ed Randall: It has been enlightening, and it has been everything I hoped it would be to have a conversation with the doctor whom I entrusted with my cancer treatment 24 years ago, that we were able to have this discussion today says everything you need to know of that outcome for both of us. It’s great to be with you, Dr. Romas. And I hope you can stop by one of our Thursday night support groups to share your wisdom and answer a few questions say.
Dr. Nicholas A. Romas: Me too.
Ed Randall: And thank you again. Dr. Nicholas Romas, award-winning neurologist and Professor Emeritus at the Columbia University Vagelos College of Physicians and Surgeons and the man who guided me through my prostate cancer journey. I’m honored to be with you.
Announcer: The Stay in the Game podcast media partner is Cancer Health—online at cancerhealth.com. Cancer Health empowers people living with prostate cancer and other cancers to actively manage and advocate for their care and improve their overall health. Cancerhealth.com provides accessible information about treatment and quality of life for people with cancer and their loved ones, along with information about cancer prevention, and health policy.
Thanks for listening to the show. You can find program notes and a full transcript at the charity’s website, fansforthecure.org. Be sure to subscribe to our podcast in iTunes, Spotify, Stitcher, in everywhere good podcasts are available. And if you liked what you heard, a positive review on iTunes will help other people also find our show.
Cancer Health empowers people living with prostate cancer and other cancers to actively manage and advocate for their care and improve their overall health. Launched in 2017, cancerhealth.com provides accessible information about treatment and quality of life for people with cancer and their loved ones, along with information about cancer prevention and health policy.
