Dr. Stacy Loeb, a Professor of Urology and Population Health at NYU Grossman School of Medicine, shares her experience and expertise about early detection of prostate cancer, PSA screening, men’s health, and addressing health equity in the treatment of prostate cancer.
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.
Ed: Hey everybody. I’m Ed Randall, the founder, and CEO of Fans for the Cure. We welcome you to our Stay in the Game podcast. Our guest is Dr. Stacy Loeb. She’s an assistant professor of Urology and Population Health at New York University and the Manhattan Veterans Affairs Medical Center, specializing in prostate cancer.
We welcome you to our Stay in the Game podcast. First, tell us about where you grew up and when was your first thought, “You know, I’d love to be a doctor.”
Dr. Loeb: Well, thank you so much for having me. I grew up in Syracuse, New York. So go orange. Big Syracuse fan. It’s really quite a wonderful part of the country up there. I don’t know, I really liked science in school and decided I wanted to try to help people. I did not know that I wanted to go into urology, though until much later. So that was a bit of a surprise. But when I was in medical school, my grandfather died of prostate cancer. So that really changed everything.
I actually didn’t know what urology was until that time or know much about prostate cancer. But that was the pivotal moment for me where I decided that this is what I want to dedicate my future research and clinical practice to.
Ed: So the career that you have carved is in honor of him?
Dr. Loeb: Yes.
Ed: What are the challenges of pursuing a field of medicine that is predominantly male?
Dr. Loeb: That’s a really good question. Urology still really is predominantly male. Actually, among practicing urologists, it’s currently 9% female. So it’s either the lowest or among the lowest of all fields in medicine. So I really did not have any female role models in the field. However, I had some really fantastic male role models. I think that sometimes if we embrace our differences, and use it to your advantage, a lot of people remember my name if I give a presentation because I look different than the other people. So they give it like a hidden weapon. So I think I just persevered because I knew that this is what I want to do. There are just so many unanswered questions in prostate cancer. I saw a personal experience with what it did in my family. I wanted to contribute to other families.
Ed: Did you encounter any difficulties along the way?
Dr. Loeb: I think residency is a tough time for everyone no matter who you are. It’s always challenging to learn a completely new discipline. Learning a surgical field is very challenging. Learning how to do research is challenging. So I’m not sure that any of that is unique. Applying for grants and trying to get funding for your research is another interesting process.
Ed: For nine years or so, you have hosted the Men’s Health Show on Sirius XM Radio. You’re known to so many people across the country. What do you enjoy most, Doctor, about doing the show? And what are the messages you’re hoping to pass along to men and their families each week that you’re on the air?
Dr. Loeb: That’s a great question. It’s been a very interesting journey. I never thought that I would have a radio show or that I would be on one of those for this long, but I think it has really been an important tool for public education. Actually, early in my tenure on Sirius XM is when the whole controversy erupted over prostate cancer screening.
So back in 2011 to 2012, the US Preventive Services Task Force recommended against prostate cancer screening. There was just so much confusion out there among men. Even in unrelated situations, there’s confusion among men who had already been treated for prostate cancer. Should they still have their PSA checked to determine if the cancer is coming back or just SPA, is it no good anymore? Does it not matter? But actually, the recommendations were only referring to screening and were just one set of recommendations, whereas other groups recommended discussing the pros and cons of screening with your doctor.
I think that was the moment in time where I realized how important it is to have a platform to help with public education. I’ve spent 10 years of my career doing research on prostate cancer screening. I understand that PSA screening is not perfect, but it is still the best that we have and has real advantages for a lot of people. So I think it was very important to get across the message at that time that we’re not going to abandon screening, and that this is still a condition that can be lethal and that men need to be aware of and talk to their doctors about.
Ed: And what I found distressing at the time, doctor, was that the task force offered no alternative to the PSA exam that they downgraded.
Dr. Loeb: Yes, that’s a good point. I think we’ve had just so many advances in prostate cancer over the past decade. PSA is still the first test that we do. But now there’s many other options that can be done after that. So even though the test is imperfect, we do not have to make our decisions strictly based on that result. There are other second-line testing options that can be done.
Also, the harms of PSA screening is not really the test. The PSA test is a simple blood test. There’s really no harm associated with getting the PSA test. It’s what happens afterwards that makes a difference. But we’ve improved the technology of prostate biopsy for those who do decide to proceed with a biopsy. We’ve also gotten better at helping men to select a treatment or no treatment that is appropriate to their stage of disease and their preferences. There’s a lot of new treatments that are being investigated, new treatments have been approved.
So it’s a rapidly dynamic situation, and we have a lot more to offer. So as far as I’m concerned, burying your head in the sand does not make the situation go away. So if you do want to know what is going on and then make a choice about whether or not you want to act on it after educating yourself about it, to me, that is the most patient-centered way to go.
Ed: My recollection was that the findings of the task force were made public on a Friday. And over that weekend, I received so many notes from men who were to, use your word, “confused” about how to go forward. Meanwhile, at the same time, the Preventive Services Task Force told women they need not self-examine till the age of 50. There was such an outcry over that weekend that Sebelius, who was running Health and Human Services at the time had to call a press conference on Monday to step away from what they had recommended for women, saying, “We were not correct in doing that.” And that to me highlighted the difference between women and how they are guardians of their health and men who are not.
Dr. Loeb: That’s a very interesting observation. I think these differences persist. today. We’ve done a lot of interesting research looking at the social media activities surrounding breast cancer compared to prostate cancer. The difference is really striking. There’s just so much more public discourse about breast cancer.
We’ve recently been doing some interesting work surrounding BRCA because we’ve now learned a lot more about prostate cancer genetics. Interestingly, some of the same genes such as BRCA that are involved in risk for breast cancer also increase the risk for prostate cancer. Actually, BRCA is also associated with more aggressive prostate cancer. But for some reason, the public does not seem to be aware of the link between BRCA with cancers in men. So that’s something that we’re actually working on in one of our grants right now is trying to raise public awareness and increase the conversation and social networks and digital platforms around prostate cancer and risk factors for men.
Ed: One of my colleagues is a regular listener to your show, and I should mention cruciferous vegetables. Now, that’s not a term I use on the air every day, Doctor. What is the connection between those foods and prostate cancer?
Dr. Loeb: I think diet does not receive enough attention in the conversation about prostate cancer. Some men, in fact, may never discuss their lifestyle with their physician. And that’s very important alongside management. Cruciferous vegetables, so things like broccoli, cauliflower, Brussel sprouts, kale, these are associated with a lower risk of prostate cancer. They’re just very good in general for overall in cardiovascular health.
Something really interesting that I learned over time, I see primarily early-stage prostate cancer. I’ve been involved in a lot of work on active surveillance for men with favorable features to their prostate cancer who decide to watch the cancer. That’s been one of my main areas of focus over the years. It turns out for those men, they’re very unlikely to die from prostate cancer.
Actually, the leading cause of death is cardiovascular disease. So this is a teachable moment, what we call from the medical side or from the patient side, this is an awakening where many men who may have had no symptoms at all or maybe didn’t even see the doctor regularly are now very interested to take better care of their health.
There are actually some guidelines from the American Cancer Society and the National Comprehensive Cancer network for cancer survivors. And emphasis is really a predominantly plant-based diet. So you really want to avoid processed meat. Processed meat is considered carcinogenic by the World Health Organization. So I’m talking about things like pepperoni, and sausage, bacon. In general, saturated fat is bad for prostate cancer. So that is the bad fats. It’s the kind of fat that you would find in ice cream, cheese, beef, pork, chicken skin. So the focus should really be on trying to get your fat sources from healthy fats, plant sources, such as olive oil, nuts, avocado. These are just important tips.
Oh, I should also mention tomatoes. Cook tomatoes. Cooked tomatoes have lycopene, which is also beneficial for the prostate. So I think make a lot of nice vegetable foods, I think it’s a great way to improve your overall health and prostate health. And exercise. Exercise is really important too.
Ed: Doctor, one of the goals of both your radio show and this podcast is to urge men to take charge of their health. What are the one or two knowledge gaps that many men seem to have when it comes to managing their health?
Dr. Loeb: Well, I think one knowledge gap is just that prostate cancer doesn’t have any symptoms at an early stage. I see a lot of people who think that they must be okay because they don’t have any symptoms. Most of the time, if you do have urinary symptoms, that’s not prostate cancer. Usually, that’s actually enlarged prostate, which is a different process. Enlarged prostate is just something that happens where the prostate grows with age. It’s benign, and it’s not related to prostate cancer. So even if you don’t have symptoms, that does not necessarily mean that everything is okay.
Ed: According to the American Cancer Society, one in nine men in this country will be diagnosed with prostate cancer as you know versus one in 41 will die from the disease. And that’s quite a gap. Describe, if you will, the doctor’s balancing act between conservative management of a case and avoiding or delaying life-changing side effects and the risk of possible disease progression.
Dr. Loeb: Really there is just such a big spectrum for prostate cancer. There’s cases that are extremely aggressive and lethal. Some men unfortunately are diagnosed at a later stage where the cancer is already spread. At the other end of the spectrum, there are very indolent prostate cancers that is very slow growing, where it may never cause any harm in the man’s lifetime. So I think that’s another point of confusion is that not all prostate cancer is the same. In fact, there’s really an entirely long spectrum between very low risk, slow growing and very fast growing.
So individualizing, the treatment protocol is great. Recognizing that if you are in the case where you’re diagnosed early and the cancer is low risk, that you may not need immediate treatment at all. In fact, you may be able to surveil the cancer over time or continue following with the doctor and checking up on it and just see what happens and maybe get treatment at a later stage if things start to look worse.
Ed: I sat on Prostate Cancer Awareness panels where the terms “active surveillance” and “watchful waiting” have been used interchangeably. But they’re not the same. Are they?
Dr. Loeb: No. I don’t think a lot of people are aware of that. So these are both options that are part of what we call conservative management. But even that is a spectrum. So how aggressive are we in our watching of the cancer? Watchful waiting is the very least aggressive form of management. Watchful waiting is primarily for men who are older or have a lot of other health issues, where their prostate cancer is unlikely to cause any morbidity during their remaining lifetime. They don’t have any symptoms. It’s not bothering them. So the course of action is just to do nothing. And if it got to the point where the cancer grew, and it started causing symptoms, then we could just treat them symptomatically, but not do any kind of curative intervention. So that’s at one end of the spectrum.
The other end of the spectrum is active surveillance where we are actually doing serial tests on a regular basis. This includes PSA tests at least two times a year. This includes perhaps MRIs, repeat biopsies, lots of testing to really keep a very close watch on the cancer because the goal here is curative. The goal of active surveillance is that you don’t need treatment right now, but you might at a later stage. And we want to know that as soon as something changes so that we can change course. So that one the goal is actually to watch the cancer so closely. That if things change, then that patient has the opportunity to pursue curative treatment. So yes.
There’s a gray area in between. There’s people who do active surveillance for many years, where they are following up, they’re getting all the PSAs, they’re getting MRI, biopsies, but then they’re getting older, and they don’t want to undergo all this testing anymore. So then the intensity of the follow-up protocol can decrease.
This has been a very active area of interest for me. In fact, my first grant that I ever had from the NIH was to look at what is the optimal intensity of testing during surveillance? How much do we gain compared to watchful waiting by doing all of these biopsies? Actually, this whole project was inspired by one of my patients. That patient said to me, “Do I really need another biopsy this year? I’ve already had several biopsies and I don’t want another biopsy.” The truth is, we didn’t have the answer. So this is something that I learned from one of my mentors, Dr. Walsh, who invented the modern radical prostatectomy.
Ed: He’s the Godfather.
Dr. Loeb: That’s right. You learn a lot from your patients. It’s then that you find out what do the patients want to know and what questions do we not know the answer. Because those are the important questions for us to research. So we built a mathematical model to compare the lifetime impact of different intensities of testing during active surveillance. To my surprise, you really do not gain very much by doing a very intense testing protocol. So it made me realize that perhaps we’re doing too many tests, particularly for men who are getting older.
So, bottom line, I think, just like everything else, that this needs to be individualized. If you are somebody with low-risk prostate cancer, definitely speak to your doctor about these conservative approaches, and also what intensity of testing makes sense based on your cancer, your general health, and your preferences.
Ed: Doctor, you headed a study of patients in VA hospitals where national statistics showed a significant reduction in the so-called rush to treatment between 2005. In the end of the study, 10 years later, in 2015, this really got the attention of people in the prostate cancer world, for both the doctors and the public. What are some of the takeaways from that study?
Dr. Loeb: So this was a study in the Veterans Affairs hospitals across the US. We looked at a decade of treatment patterns. Fortunately, we found that while in 2005, most men with low-risk prostate cancer were having treatment like surgery or radiation. By the end of this period in 2015, the vast majority of men with low-risk prostate cancer were going for conservative management. And that’s what the guidelines recommend. The guidelines say that for low-risk prostate cancer, the preferred management is active surveillance. So this is good news. It’s good news that we are reducing over treatment of prostate cancer that is at a favorable stage and hopefully sparing more men from living additional years with side effects from treatment.
Now, that being said, active surveillance is not necessarily a forever process. So many men over the course of a decade, 15 years, end up getting treatment at some point. But I don’t see that as a failure. I see that as a success because those men still gained many additional years with their quality of life preserved that they otherwise may not have had. So I think that if this is something that is on the table based on somebody’s cancer features that it is worth considering. And even a few additional years before getting treated may be worthwhile.
Ed: Wasn’t there also a reduction in the historical racial disparities in diagnosis rates among participants in that same study? And are there larger lessons to be learned here as well?
Dr. Loeb: Actually, in that particular study in the Veterans Administration, black men were more likely to get conservative management. So that’s an interesting finding. And good news that they were getting guideline-concordant care. I think that the VA health care system is a great model. It provides equal access to care. I think there’s a lot of very good prostate cancer management going on in the VA system.
In fact, this paper had much higher rates of conservative management than had been reported in other studies that we’re outside of the Veterans Health Care System. So hopefully all the good research that we’re doing and work that we’re doing on care for the veterans can translate over to the population as a whole.
Ed: For at least 20 years, we’ve been hearing about the next latest and greatest diagnostic tests for prostate cancer that will make the PSA obsolete. And yet the first step in prostate cancer screening for most men remains the PSA. Is there a test or a series of tests we’ll see in the next five years that will give us the best of the PSA? Which can raise flags, of course, about the aggressive cases while also identifying low-risk cases, differentiating them.
Dr. Loeb: I’ve been hearing the same thing.
Ed: Bet you have.
Dr. Loeb: You know, this might increase PSA, that kind of thing. The bottom line is I don’t think PSA is going anywhere anytime soon. There are a lot of other tests. And that’s really great news. However, they’re in a different context. The tests that we have are second-line tests. So for the most part, these other tests have not been studied as a replacement for PSA as a first-line screening test. These other tests have been studied as a reflex test. That means for men who are found to have an elevated PSA… PSA is kind of like the check engine light in your car. When it goes up, you know, if you see there’s an indicator something’s going on, now we’ve got to look under the hood. But the check engine light doesn’t tell you what exactly is broken. It’s just something needs to be fixed and needs to be checked.
So in this case, when the PSA goes up, it could be the prostates grown. It could be inflammation. It could be you have an infection. There could be other things going on. Or it could be there’s a tumor in there that is producing more PSA. We don’t know until we follow up on it. The good news is that now we do have a bunch of other tests that can be used in that context to help us follow up on it.
So, first of all, just basic things. For men who come to see me for an elevated PSA, we check their urine, make sure they don’t have an infection. We check how well they’re emptying their bladder, make sure that they’re not retaining urine, and that that’s causing the PSA to rise. So just doing some basic clinical steps can help to confirm if the PSA might have been confounded by something else. We also repeat the PSA because sometimes there is just a spurious value and after a few weeks, it goes back down.
But for those who have a confirmed elevation, there is a series of other blood tests. There’s urine tests. There’s imaging tests. So there’s lots of other tests now that can be done as a step in between that decision of should I have a biopsy or not, and can help really make that decision more informed than it ever was a decade ago.
Ed: I love your analogy about the check engine light and checking under the hood, because that’s the problem with men. They don’t want to have anybody check under the hood. According to the US Preventive Services Task Force, which we’ve been discussing, men between the ages of 55 and 69, are told to, quoting now, “Discuss the potential benefits and harms of screening with their clinician to incorporate their values and preferences in the decision.” Unquote. What if a man’s primary doctor is not current on both the benefits and the harms of PSA screenings? Should this discussion be taking place with a urologist?
Dr. Loeb: I think that’s absolutely an option. I read some statistics that urologists only order 7% of the PSA tests in this country. So the truth is, as much as I would like to feel like we’re very important as urologists, we are really not on the front lines of this. But that’s not always the case. I definitely have a cadre of patients myself who come in for their wellness exam and to have this conversation about screening with me because they didn’t feel that they were having a full shared decision making conversation about this with their primary doctor. So yes, I definitely think that if you feel like you haven’t been able to get all the information…
And I think it’s very difficult. Primary care doctors have so many guidelines, and so many issues that they need to tackle. Blood pressure, blood sugar, etc. So there’s just so much going on in prostate cancer. I think it’s a challenge to continuously stay up to date on all the latest data, and I don’t have to worry about blood pressure, diabetes, and all of those other conditions. So I think absolutely, just more generally speaking, if you are a patient, and you feel like the doctor that you’re seeing does not have enough information about a really critical decision that you need to make, then I think getting a second opinion or seeing a specialist to make sure that you’re properly informed is always a great idea.
Ed: Another trend over the years since my diagnosis back in 1999 has been the emphasis on men and their doctors reaching a shared decision about a treatment plan. Tell us why that’s so important.
Dr. Loeb: This is important because prostate cancer along with many other medical decisions is what we call preference-sensitive. So actually, how much benefit or how much harm you may get from something like PSA testing or undergoing surgery versus active surveillance actually depends a lot on your own preferences. And people have very different preferences.
For example, some people their entire priority is sexual function. They are willing to accept a shorter lifetime in order to have fully preserved sexual function. Other people may be in a different scenario where they’re not sexually active, or that’s not a priority and the length of life being around at a certain time point. When a grandchild is going to graduate or somebody getting married is the main priority. So there’s just such a spectrum. There’s no right or wrong answer in terms of what is most important. What’s most important is what is most important to that patient. And it’s hard for us to make a good treatment plan without having the patient involved in the decision and really understanding their preferences.
Ed: One can’t help but notice the number of important research and significant writings about prostate cancer that bear your name. Do you still maintain a practice where you see patients? And if so, describe that balance.
Dr. Loeb: Yes, absolutely. I have about half and half. I’m about 50/50 clinical versus research in my current time allocations. I describe it as the circle of life. My clinical practice helps me to stay up to date with what do patients care about, what do we not know? The example I gave you earlier in the podcast, patients asking me about active surveillance protocols and we didn’t really know the answer. So that means that I need to study it.
I’ve had patients ask me questions about prostate biopsies that triggered other studies that we’ve done. And it just feels so gratifying then to go back to the clinic, and then share with the patients the results of the study that you did in response to their question. So I think it’s very complimentary and cyclical where the clinic helps to give me inspiration and always to make sure that the work that I’m doing is relevant to the topics that patients are really needing more information. I really enjoy then taking the results of these studies back to the clinic, printing out the papers for the patients, and going over what we found.
Ed: At Fans for the Cure, Doctor, we’ve gotten a small measure of consolation during COVID from our online support groups, which are more successful than we could have ever imagined. But when the discussion topic one week was “what part of your prostate cancer journey took you by surprise?” nearly all of the guys complained that the possibilities of life-changing side effects and complications weren’t sufficiently or accurately explored. What are your thoughts about communicating quality of life risks and what’s the best way for us to communicate to urologists, surgeons, radiologists what we are hearing in support groups about soft-selling the risks?
Dr. Loeb: I think one key problem is that the clinical encounter just has limited time to explore all of these issues. One thing that we’ve been studying a lot is the impact of online information on decision making by patients. We published a study last year looking at the top 150 YouTube videos about prostate cancer. And by the way, some of these videos have millions of views. And what we found is that more of the videos discuss the benefits and the risks of different treatment options, for example. There is also a fair amount of either biased, misinformative or commercially biased content.
So I think this is a tough scenario because you only have so much time with the doctor. And then if you do go on the internet on your own to try to learn more outside of the clinical encounter, you’re at a high risk of coming across content that is perhaps overly favorably biased or in some way misinformative. I think speaking to other patients in these kinds of groups is very helpful and informative and likely to give a much more in-depth patient perspective on the topic.
In terms of communication back with physicians, one option is to bring a list with you to the doctor visit of topics that other men feel have not been addressed sufficiently. So to ensure that you can specifically hit those topics with your doctor before making a decision. So I think that could be one way to address it.
Also, finding out quality sources of information. If you don’t feel like you’ve gotten as much information as you need from the doctor visit because it just isn’t long enough, asking the doctor or trusted colleagues to recommend high-quality sources of information is always a good idea.
Ed: Here’s a question we’re asking all our guests on our Stay in the Game podcast. What are the best actions that Fans for the Cure can be taking in 2020 and beyond to help men take responsibility for their health and make the most informed decisions during their prostate cancer journeys?
Dr. Loeb: I think what you’re doing now just continuing to get the word out through all different platforms. I think podcasts are great. They’re really increasing in popularity and are a great way to get information out to the public much more. Any kind of digital dissemination strategy is great. Just keeping these conversations going is just so important because the public awareness is just not there.
Also, for men who reach out, I think helping them to navigate the vast sea of information out there is very helpful. What we found is there actually is a lot of great content already online about prostate cancer, but there’s it’s sort of buried amidst a lot of very bad content too. So I think what’s needed even more than having more content is searching through existing content to identify good content. A navigator, if you will.
Ed: We’ve been speaking with Dr. Stacy Loeb, an assistant professor of Urology and Population Health at New York University and the Manhattan Veterans Affairs Medical Center. Dr. Loeb, an honor to have you with us. Thank you so much.
Dr. Loeb: Thank you.
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