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- Dr. James McKiernan
- Urology at NewYork-Presbyterian Hospital
- Columbia University Department of Urology
- Centers for Disease Control (CDC) – COVID-19 Homepage
- Coronavirus (COVID-19): What to Know
- U.S. Preventive Services Task Force – Statement, Prostate Cancer Screening
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 is produced and shared by Fans for the Cure, a non-profit dedicated to serving men on their journeys through prostate cancer.
Ed: Welcome everybody to the first edition of Fans for the Cure Podcast. I’m Ed Randall. Johnny Carson’s first guest, when he took over the Tonight Show on NBC in 1962, was Groucho Marx. We wanted him to be our first guest, but ss Casey Stengel once said “he’s still dead at the present time.” So we went to the bullpen and called in our emergency backup, Dr. Jim McKiernan. Jim is the John K. Lattimer Professor of Urology. He’s the chair of the Department of Urology of the College of Physicians and Surgeons, and Urologist in Chief at New York Presbyterian Columbia University Hospital. That’s a lot to put on a business card. We are so honored to have Dr. McKiernan with us on this first edition of Fans for the Cure podcast. Thank you for being with us. What an honor to have you.
Jim: Thank you, Ed. It is an honor to be here to kick this off and I guess you could have gone with Harpo but it might have been a little bit less interesting of an interview.
Ed: Well it’s the same situation – still dead at the present time. Some personal questions: tell us about where you grew up.
Jim: I grew up in New Jersey in a town called Metuchen, New Jersey. Outside of New Brunswick, maybe half hour outside New York City, and I’ve been kind of a Northeastern New York kid ever since. Went to college down in Baltimore, that’s about as far away as I got.
Ed: And was being a doctor something in your DNA from your earliest times as a child?
Jim: No, it wasn’t actually, I didn’t really get interested in medicine until about half way through college, which would be considered a relatively late bloomer at the time particularly. I was an engineering major and started to drift over towards biology, and got a little more interested in medicine as college went on.
Ed: Engineering didn’t do it for you?
Jim: No, just didn’t seem to be as directly impactful on the people around me. It was science, but it wasn’t science where you could see results right away, and as I got into the second half of college, a little further along, I started to get involved in some of the volunteer work that was available there. Got to work at the hospital at Johns Hopkins, and really started to get excited about the challenges that medicine sort of presented.
Ed: That’s pretty, that’s a pretty dramatic shift though, isn’t it? Going from one to the other?
Jim: It is. Although, there’s a lot of overlap the first couple of years of the training in college for both medical school and engineering is pretty similar. A lot of physics, chemistry, math, so I didn’t really miss a beat.
Ed: That’s all stuff I failed, by the way, or was close to failing.
Jim: It helps to do reasonably well in that. Although, ironically, you never use any of that stuff as a doctor, but you got to get through it all in college to show that you can process information. The last time I used a physics equation in the operating room was never.
Ed: It’s so many years since high school for me but I still have nightmares about the time I dissected a worm in biology my sophomore year in high school. From that shift from engineering into medicine, then take us through the decision that you wanted to devote your life to curing cancer.
Jim: Yeah, that also happened kind of late in medical school. I went from Hopkins up to Columbia University. In 1989, I started at the medical center, and really didn’t know what kind of doctor I wanted to be, honestly at all, and took an open mind into the whole four years of medical school, relatively late in the game, decided to settle in on surgery and specifically on urologic cancer surgery, and then went into residency which is a six year training program after you graduate from medical school.
Ed: Did you love it from the very beginning?
Jim: I did. Yeah, I was kinda addicted to it. Couldn’t get enough of it. One of those 10,000 hour type people that kept doing it in their free time. And learning, and again you come to med school and to early training, you have so little knowledge and everybody around you is so proficient at what they are doing, that you just have to soak it up and if you don’t have that kind of open faucet passion to suck it all up right away, it’s difficult to be successful. So if it’s something you love to do, as they say, you never work a day in your life and that’s the way I feel.
Ed: Yeah, Ernie Harwell, was a dear friend of mine, the hall of fame broadcaster for the Detroit Tigers, who once said to me “Lucky is the man to whom God gives a job that he loves” and you’re one of those guys and, thank God, so am I.
Jim: Yeah, it’s a great honor and privilege to have that kind of a career and I love doing it.
Ed: Who were your mentors, who inspired you as a kid, when you were starting out?
Jim: Wow, believe it or not, not so much medical. I wasn’t really that interested in medicine or science growing up. I was a sports fan, and played a bit of sports myself so a lot of my early career people were professional athletes. I was a big Giants fan growing up, New York Football Giants that is. And soccer was my thing, I played a lot of soccer in high school and I played in college as well. I was a Cosmos guy, followed Pelé, Franz Beckenbauer, Giorgio Chinaglia. Went to all the games. I was at Pelé’s last game. I mean, all the passion of the late mid 70’s in New Jersey and New York sports – that was a lot of it. My family and parents were a huge inspiration to me. I was the first doctor in the family, so I didn’t have anybody that was a doctor to aspire to, but just the challenge to succeed and to be able to do what you want to do with your life and look to the next generation. So it’s been fantastic.
Ed: Who has inspired you in the medical field?
Jim: I’ve been lucky since I’ve been at Columbia to be around a lot of the giants in our field both in medical and surgical disciplines. The person who ran our department at the time when I first started training was a fellow named Carl Olsen who’s still around the New York area. He’s retired now, but he is just a master surgeon and academic leader in terms of research. He was one of the early influences on my career and somebody that I aspired to emulate as I grew up in the field.
Uh, then had a chance to go to Sloane Kettering and worked with a great team of doctors and surgeons who also were great role models for me to shape my career afterwards. It’s always great to be able to stand on the shoulders of giants and people who have preceded you to be able to establish yourself in the field and then give it back frankly. And that’s what we enjoy now, honestly, a lot of us just paying it back to the people who come after us, and kind of pave the way for the doctors who are going to care for us as we get a little older.
Ed: From the time that you started out till now, there have been so many advances in the field of detecting prostate cancer. From my own experience, at the time I was diagnosed, Jim, I was told by the man who saved my life, Dr. Nicholas Romas, at that time the chair of Urology Department at Columbia, excuse me, at St. Luke’s Roosevelt Hospital in Manhattan. Later, you have now brought him on board at Columbia Presbertyrian Hospital. At the time of my diagnosis, more than 39,000 men a year were losing their lives to prostate cancer. We’ve made significant progress since then.
Jim: For sure, for sure. If you look back over the last 25-30 years, we have a couple of different sort of waves of prostate cancer. The first one was right around that time when I arrived at Columbia, was the, we call pre-PSA era, when the blood test PSA, which stands for Prostate Specific Antigen, didn’t exist and that was basically through the 70s and 80s we were finding people with prostate cancer mostly who either had symptoms or an abnormal physical exam and in general those patients were in a worst state, they had more advanced disease higher volume of disease and oftentimes even had stage 4 or metastatic cancer in their bones. And then, right around the late 80s early 90s this blood test came out which really shook up our world and suddenly you were able to detect prostate cancer via bloodmarker, probably a year or sometimes even decades before a patient knew that they had it and of course that was a big breakthrough. It led to a lot of diagnosis and a lot of earlier treatments and then we moved through thatPSA era of the 1990s early 2000s and then people started to question whether or not we were maybe overdetecting prostate cancer by finding too many cases too early and treating people too radically who perhaps weren’t destined to go on to have any abnormalities or problems from the disease. And then we started to look back and say how can we use that test more intelligently, how can we be more cautious about who we treat and how can we get smarter at detecting patients early who need to be detected but leaving those folks alone who don’t need to be detected. And that’s kind of where we are now, it’s challenging but that’s our goal today.
Ed: we are going to talk a lot more about prostate cancer in a few minutes. But you and I find ourselves in a lockdown. We’ve all been on lockdown for the past two months. What has the average day been like for you over that time, or is there no such thing as an average day?
Jim: Well, it has been very different, there’s no question. Starting about in early March, here in New York City, at our medical center which is a combination of Columbia University and Presbyterian Hospital, we got some early warning signs that something was going on in the community when we first started to see patients come into the hospital with these atypical symptoms of cough, fever and severe pneumonia and of course now we all understand it’s driven by what’s called COVID-19 disease or the coronavirus, or sometimes referred to as SARS-COV2, it’s got a lot of names but everybody’s pretty familiar with it. And then New York City, as we all know, became the epicenter of the country and really of the world and we’ve had an explosive change in everything we do. The hospital really shut down normal operations very rapidly, rallied a huge number of our health care workers: doctors, nurses, emergency medical technicians, respiratory therapists and went in to kind of a crisis mode and a lot of our patients early on were frustrated because they said “well doc, why I can’t get an appointment to see you tomorrow” and “how come the clinic’s closed” and “Why is my surgery being cancelled” and we’re now in our 9th week of that kind of emergency operation and whatI’ve tried to explain to people is that on September 11, 2001 I was working at the hospital that day and we closed that hospital to normal operations that day for about 10 hours and then we re-opened to normal business. We are now in our 9th week of shutdown at the hospital doing nothing but emergency management of COVID-19 so if compare it from a hospital healthcare perspective to September 11th I think that’s a little sobering. We never shut our hospital down for anything other than a catastrophe and even in that catastrophe was less than a day. And we are now in basic complete lock down dedicating every possible resource to the management of patients with this kind of pneumonia and we’re ending up taking care of thousands and thousands of patients in our health care system and across New York, every borough, Queens, Brooklyn, the Bronx, Staten Island, and Manhattan have all been affected. We are just now, here in mid May, starting to see a decrease in the number of new diagnoses and a decrease in the number of people dying from COVID-19 and starting to get back to thinking about some normal operations, like doing cancer surgery or doing surgery on patients who deferred a lot of their decisions during the crisis mode. It’s unprecedented, every day has been different but by and large it has been humbling, we have seen a degree of heroism and fearlessness from everybody: from the doctors to the nurses to the technicians, to the janitors, to the food services people. They are walking into the building where they know there risk of catching this virus and there’s potential of dying from it and they’ve just run into it like a burning building like a NY, New York Fire Department officer, put a mask on, put a hat on and go in to work. It really has been a humbling experience.
Ed: We’re here with Dr. Jim McKiernan who is the urologist in chief at New York Presbyterian Columbia University Medical Center on this first outing of Fans for the Cure Podcast. What aspect of the coronavirus has surprised you and your colleagues the most?
Jim: There’s a couple things. The first one which has been talked about a lot in the news, is that the patients who get this have surprisingly few symptoms despite being very very sick. When we measure people who have pneumonia we oftentimes measure the oxygen level in their blood, if you’ve ever been in the hospital or had surgery they put a little monitor on your finger and it beeps and it shows your heart tracing and shows how much oxygen you have in your blood. And a normal reading might be 99% or 100% of normal and if you really start to get sick that number might drift down to the low 90s maybe high 80s you might need oxygen. We’ve seen people with this condition with oxygen levels in the 50s and 60s yet they’re talking on a cell phone, or sitting in front of you without really looking like they’re having a difficult time breathing. And that’s really not something we see with regular pneumonia and that took a lot of people by surprise because you can walk by a patient and they look reasonable well then you put the monitors on and you say ‘my goodness this guy should be on a ventilator” “This guy should be in the operating room, or the intensive care unit” so that took about a few weeks for everyone to understand and that’s been the case in really all the hospitals in America and around the world. Not entirely clear why that is happening but it has to do with the way the inflammation of the blood vessels in the lungs is affecting the lung function. So that’s been a surprise. The other one is how quickly people get sick. So patients are coming in and 4/5 hours into the hospitalization everything looks great and then you come back and check on them 5 hours later and they are on a ventilator and they are deteriorating rapidly and so that’s what led to a lot of the stress about the capacity of the healthcare system, and you read this in the papers in mid-april where everyone was worried we would run out of ventilators, run out of hospital beds and it was close. New York City definitely came very close to having that happen and that is really when things would get terrible, because when that happens then people who could potentially be saved can’t be, because you just don’t have a physical place to put them, or a machine to put them on. And that did happen to a pretty large effect in a lot of countries in Europe, including Italy and Spain but in the US by and large, that did not happen because we were able to rally and kind of respond quickly to ever changing needs of this pandemic and thank God that that’s more or less over know and we just pray that it doesn’t come back later in the summer or in the fall.
Ed: You have some breaking news for us though about there’s evidence to suggest the way in which corona virus is affecting the sexes differently.
Jim: Yeah, so there’s an interesting story that kind of links the coronavirus to prostate cancer in a backhanded and odd way. So, it turns out, that more of the patients who are getting this are men than women and unfortunately more of the people dying from coronavirus are men than women, inordinately more, probably 60% of the patients in New York who got this virus are male and 40% female and there’s been some scientific research done on the way the virus gets into cells and it looks like that is mediated by a gene that’s called TMPRSS2, which is actually a gene that is turned on by testosterone, which is the male hormone. So it’s not coincidental that more men are getting it than women. It’s actually led to some research to suggest that if a man has his testosterone level lowered his risk of getting the virus might potentially go down. There have been a few studies, one that came out just 3 or 4 days ago from Italy that suggested that men who were getting treated for prostate cancer with a medicine that lowers their testerone actually had a very low rate of getting Coronavirus infections. Which means the prostate cancer treatment was protecting them from coronavirus. We’re analyzing that in America, in the US, and there’s actually a trial, a research study starting this week in the veterans hospital system that is coming out of UCLA that will look at treating men with hormone lowering medications, normally reserved for prostate cancer patients, but treating men who have coronavirus with that medications to try and get them off the ventilators and get them out of the hospital and cure them because the evidence is so convincing that it’s a hormone mediated infection.
Ed: There’s so much you could talk to us right now with regard to vaccines and antibodies and testing and new drugs to try and break the back of this thing.
Jim: Yeah there are. All those categories that are in the daily press conferences of the governor and the president and anybody you tune in to. I like to kind of break it down a couple different ways. One is the testing, so everyone probably realizes now there’s two kinds of testing. There’s one testing for the virus, which is oftentimes called PCR test or a DNA test. That’s the one that involves a very large q-tip going way up your nose and down your throat. The one that no one wants to have because it’s very uncomfortable and makes you gag. That’s actually a test to determine if you have the virus currently. In other words, if you’re infected with it. And that one was not widely available early, it was hard to find. But now it’s pretty universally available to anyone who wants to get checked for the infection. It really only makes sense to test people who are sick, with that test. You can test anyone, just walking down the street, but most of the time we try to reserve that test for people who have symptoms like a fever or sore throat. The other big category test which are in the news a lot now are the antibody tests. And that is testing your blood to determine if your body has built up antibodies to the coronavirus and that really is an indication that you were previously exposed to it that you fought it off and now you’ve developed antibodies which implies, possibly, possibly that is key you may be immune to it or resistant to getting reinfected. We don’t yet know if those antibodies are in fact an indication that you cannot get it again, but we’re pretty convinced that it is an indication that you were exposed to the virus. These antibody tests are now available one thing that is important is that there are many many different forms of that antibody test and some of them are more accurate than others. So just like a lot of things, they kinda hit the market and very quickly the FDA approved a lot of them, but the performance characteristics of them vary. So it is important for people to check with their doctor to find out how that test that they are going to get is performing and they should not change their behavior if they find out they have the antibody because it doesn’t mean they should take their masks off, or start to mingle in crowds of people or ride the subway because we just don’t know how protective the antibodies are
Ed: As you and I discuss this, many states are in the first stages of reopening but at the same time there are portions of this country still with a lot of bad stats: diagnosis, hospitalizations and deaths that are still on the rise nationally. What are the science metrics that would tell you that it is time to reopen?
Jim: Well first of all I want to say that I’m not an expert in this field. I’m no Tony Fauci that’s for sure but I do enjoy watching him on TV and I listen to everything he says. Um, the stats generally, you have to look at the population as a whole and look at things like the new diagnosis rates, the number of people in the hospital in the community, and which way those things are going and if you see that your hospitalization is declining, the number of new cases are declining, the death rate is declining and each state is supposed to be doing that. And when they get down to relatively low levels then ease off a little bit on some of those restrictions. The key is the restrictions are lifted slowly and you test and re-measure what’s happening. For instance, you open up the restaurants, you wait a couple of weeks and you see what did that do? Did the number of cases go up? Okay, nothing happened, let’s open up the schools, or the parks or the next level of things. What concerns me a little bit and this is something that is not getting talked about is that when you look at the possibility of getting infections on the rise it is dependent upon how prevalent the infection was in the first place. I’ll give you an example: New York got hit hard because we didn’t know what was coming, we have a lot of international travel from Europe and Chin,a and we’re a very densely populated city. Across the rest of the country, people reacted quickly. So, Atlanta, Baltimore, Chicao, Houston, the Midwest they all had warning and they all locked down more rapidly. So it is likely that those populations in those areas have lower immunity and a much lower exposure rate so their risk on reopening is higher than for instance, reopening the Bronx because 25-30% of people in the Bronx have gotten it already so they probably can’t get it again. Whereas if you go to a small town where only 1 person got it, and you reopen everybody is at risk. So you might see these little spikes in different areas of the country because they were really good at closing quickly before they had an outbreak, but without a vaccine, that outbreak could happen in August or September of July.
Ed: Any advice to those of us staying home on how best to stay healthy?
Jim: Well, yeah, follow the simple rules that everybody is describing which is: stay more than 6 feet away, wash your hands 3-5 times a day, and wear a mask whenever you are outside or in contact with non-family members. That’s really the best thing you can do right now. Not a lot of evidence to suggest that taking vitamins or eating certain things, or any kind of natural supplements has any big effect. There has been lots discussed about taking medications including things like hydroxychloroquinewhich by and large has not been proved effective in treating the virus. There are a few studies going on about whether or not you can take that as a preventative agent and try to keep yourself from getting the virus but those results aren’t in yet. But it’s really staying out of dense areas, washing your hands and staying with a mask on when in public.
Ed: Let’s pivot to prostate cancer for a moment because it is the major focus of your department and your practice and your life. With on-site physical examinations and bloodwork replaced by video appointments I’d imagine that PSA screenings are at historical lows. What do you say now to convince men not to pass on their annual health screenings this year.
Jim: Yeah, that’s a great question. So, the good thing about prostate cancer is that a lot of the value of screening is blood test based and you can do blood tests at outpatient laboratories like Quest, LabsCorp, or commercial labs without entering a hospital. So we have encouraged people to get their blood work done and then have a tele-health or telemedicine visit remotely without necessarily entering a crowded waiting room or hospital. The other good thing about prostate cancer is that with 2-3 month delays which is what the duration of this has been so far, usually you’re not going to lose out on detecting a patient with prostate cancer. So the screening component of it has not concerned us that much. It is true that most interactions with doctors in the New York Area are being done by telemedicine. Our department in general would see about 1% of our patients through a video call in February of this year. We now see 65% of our patients through a video call.
Jim: So in 3 weeks we just completely changed the way we practice and that’s a side story that is going to come out of this that involved a lot of technology advances. It also involved suspending a rule that was in place that did not allow a doctor to practice medicine across state lines prior to Corona. So, for instance, if you were in Connecticut and I was in New York and you wanted to do a tele-health check up, I wasn’t allowed to do that unless I went up to Connecticut and set up an office and got a license to practice.
Ed: Do you think that is going to be a permanent option?
Jim: I hope so.
Ed: When this is over?
Jim: I hope so, the federal government actually waived all these kind of border disputes between states some time in late March early April which opened up the ability for a person for instance in Arizona or Florida to call in and say” Doc I’m not coming back to New York right now, I’m gonna get a PSA done and set up a tele-visit with you and stay right here in Scottsdale.” “No problem, stay right there. Don’t move, you know? Don’t get on an airplane, don’t have to come back to a dense area.” So, I personally hope that stays in place forever. It may not, but right now that’s been one of the sort-of silver linings of this: that it is much easier to do telemedicine now in the era of the Corona than it was before.
Ed: This is going to change how you do business.
Jim: It is. It is. I think it is going to change a lot of professions and industries around the country. Obviously between airplane travel and various degrees of in-person business visits. But for medicine, which has always been an in-person profession, I would suspect that we are going to settle into at least a third of what we do long term being done from a telemedicine perspective which has lots of implications on physical space, bricks and mortar; staff; how big does your hospital have to be? How many seats do you have in your waiting room and the whole industry is going to have to pivot in a way that we never predicted, or at least not predicted to happen this fast.
Ed: In the realm of prostate cancer, and I know you can talk about this for hours, if not days, talk if you will, about diagnosis and early detection advances recently that have you excited.
Jim: Yeah, so I was saying before at the end of “PSA Era” with the famous 2012 preventative task force, which I know you’re a big fan of.
Jim: When they came out with their recommendation, their whole system pivoted on smarter detection, as opposed to mass detection. So there are multiple different assays, both bloodwork and urine tests that can be done to look at a patient’s risk of having prostate cancer in different ways. Some of the more common ones include things like: 4KScore or the Epi Score. These are kind of secondary tests. So you get a PSA, it’s borderline, it’s a little bit high, you don’t want to go through the whole rigmarole of a biopsy. So you go for a secondary test to see if it is really significant. Do I really have a problem? Do I have to get to the next level? And that’s been like the last 5-7 years, and we have really gotten better at telling a person if their PSA score is concerning and worthy of further investigation or not, and that has helped reduce the risk of “over-diagnosis” which sounds like a strange term but there is a way to over-diagnosed people with prostate cancer. The other big thing in that category is imaging. I am sure a lot of your listeners have heard about the advances in MRI scanning. When MRI scanning of the prostate came out probably the mid 1990s, it was a pretty crude instrument. It didn’t have a lot of accuracy. But based on some advances in the power of the magnet of the MRI and the features of the way the MRI is done, today it is actually very accurate. You can find tiny prostate cancers and pinpoint them with a biopsy when it used to be sort of like a shot in the dark when you did that biopsy. So that’s improved our ability to detect significant cancers.
Ed: I hear about things like a new urine test that might be able to detect prostate cancer. One of the other doctors on our Medical Advisory Board at Fans for the Cure talked about a steam test that might be able to detect prostate cancer. This is a really exciting time.
Jim: Yeah, it really is. The concept of liquid biopsy. That’s the buzzword you’ll hear a lot about. So one day being able to give a drop of blood or a half an ounce of your urine, and have it run through a test, and they come back and tell you you do or don’t have X, Y, or Z-condition, as opposed to a needle biopsy where they actually take a piece of your prostate or whatever organ of interest. And that’s really the goal. The goal is to get less invasive and more accurate at the same time. So whether you take a blood sample or a urine sample and you can profile it in a way that you couldn’t do before and say “Wow! There’s a 97% chance you have a serious problem.” Okay, now I’m going to let you take a piece of my prostate out” or a piece of my liver or whatever organ you are interested in. And that’s really what these fall under the liquid biopsy realm for urine or blood tests.
Ed: I’m sure you get questions like this all the time “I don’t know what’s wrong with me, Dr. McKiernan, but I’d sure like to find out.” So what does the general population, Jim, need to know about getting checked?
Jim: Well the first message I would like to get out there is that it is worth getting checked for prostate cancer. So 2012-2015 period where the message was kind of, I think …
Jim: Convoluted. But there were a few sides to it. So one side said don’t worry about your prostate and the other side said you better worry about your prostate and there was a lot of debate. As the tests have gotten more accurate, and that includes the blood and urine test as well as the MRI, the process of going in for checking has become safer. There is a lower chance of misdiagnosis and a lower chance of over-diagnosis. So we really want people to come back and say okay. It’s okay to get checked for prostate cancer. It’s not dangerous, you’re not going to get harmed by it because the check up process is more accurate and people understand better to figure out if you have the kind of cancer that needs treatment or not. And that’s probably the best message I can think of. There are still a fair amount of controversy and there are differing guidelines as to who should be checked but certainly people with family history of prostate cancer or breast cancer and African Americans should be checked and depending on which society you ask that should start some time between ages 45 and 55 depending on their risk profile As you get older, there is some controversy about when to stop getting checked. That’s always a favorite topic of conversation. Do you tell a 70 year old, “Okay, that’s it, we don’t need to check you any more because you are too old.”? But that really has to do with the life expectancy of the person. So if a 70 year old patient looks like they have a 20 or 25 year future life expectancy they should continue to get checked for everything including: colon cancer, high blood pressure, cholesterol, etc. But if they have a lot of other medical conditions and are very sick and it looks like they aren’t going to live another five years then it doesn’t make any sense to check them for something like prostate cancer.
Ed: I am sure you get this question all the time from men who have been diagnosed previously to consulting with you and they say “Dr. McKiernan, I have prostate cancer, how do I know how bad it is? How do I know what’s wrong with me after I get diagnosed?” So if you will, talk about that risk-assessment, as you call it.
Jim: Sure, yeah. So that’s kind of the second phase of things. You’ve been through the checkups, you were told you had a problem, you went to biopsy, you got diagnosed. And you got the phone call or that face-to-face conversation, and the doctor told you “Unfortunately, you have prostate cancer.” So then immediately the “c” word is on the table, and your head is spinning, and you decide that you need to have it removed. Well, the real thing is to figure out what kind of prostate cancer you have. And there are a range of ways of doing that: the MRI is one, the blood work is one, and there are even molecular tests now where the tissue itself, the piece of your prostate that has the cancer, can be analyzed and the DNA can be analyzed to try and determine what is the actual potential of this cancer to hurt you in the future. Because the biggest first decision you have to make is “Do I do any kind of treatment?” or “Should I just keep an eye on this?”, and we call this active surveillance. That’s the first decision that has to be made. The best way to do that is to get with one or two different experts in the field, have them look at all of your numbers, including the Gleason score, which is really the most important driver of how aggressive the cancer is, your PSA, and your MRI findings, and say “Okay, I think to the best of my ability it’s likely that this cancer will lay dormant for many many years, and I think in your case it might be safe to watch it”, or “I think you need treatment.” And there’s a process that we referred to there, which is sort of an interesting term, called shared decision making which means the doctor has to empower the patient and educate them so that they can have a vote in what to do. And it is difficult because most patients don’t know a lot about prostate cancer, so it takes some time to bring them up to speed on all the factors that go into a decision. Then they get to say, “Understanding all these things, I think I want to be treated. I know there are some side effects and some down sides but let me see what the treatment options are.” And then you move into the whole tertiary controversy of what kind of treatment should I do: Should it be a form of surgery a form of radiation, should it be something else, and that’s sort of the last piece of what to do is exactly who where and what you should have done for your treatment.
Ed: And there is such an array of treatments that are out there. Time marches on. At the time which I was diagnosed it was basically two options: have the radical prostatectomy to have it removed or have the implantation of radioactive seeds which had been a relatively new process developed in Europe And I chose to have the radioactive seeds. And what was not told to me was one of the side effects of having the radioactive seeds is that when I walked down the street I get cable TV. So somebody could come up to me and say “How are the San Francisco Giants doing?” And I go well it’s 2-2 in the seventh inning but they got second and third and nobody out.” So that’s one of the side effects. I digress but the point is there are now so many different options out there for doctors and their patients.
Jim: You just have to be careful, Ed, because Time Warner will charge you a monthly subscription fee for that so don’t advertise that. There are a lot. That’s still an option: brachytherapy therapy or seed implantation. It’s probably not as common as it was when you were diagnosed. But there have been a lot of advances, mostly in the surgical side around minimally invasive treatments and robotic prostatectomy which is now relatively standard treatment and that decreases the time the patient has to spend in the hospital.
Radiation has gone through a lot of evolution. There have been multiple new forms of radiation including proton beam which is a popularly advertised form of radiation that essentially uses positively charged radiation particles versus traditional radiation which uses negatively charged particles, or electrons. Even within traditional radiation you have the brachytherapy option you mentioned. And then you have forms of decreasing numbers of external treatments which we sometimes will call hypofractionation or stereotactic body radiation therapy so that you can go through radiation in less than 8 weeks which is the traditional time frame. And even complete it in sometimes 4 weeks, or even as few as 1 or 2 weeks. So the field of radiation has developed and progressed and the field of surgery has developed and progressed. And then you have the sort of alternative energy sources including things like kryo-surgery which is essentially freezing the cancer and something called high intensity focused ultrasound; which is using sound waves to destroy the cancer. That’s abbreviated hifu, H-I-F-U.
Ed: The title of the charity is Fans for the Cure. Tell me about how far you think we are away for a cure for prostate cancer.
Jim: Wow, that’s a great question. I mean in some ways we’re here because we cure most people with prostate cancer. That’s the good news. Probably 75-80% of people diagnosed today will be cured long-term and die of something else. Which is the actual definition of being cured. But there are still a fairly large number of people who die from prostate cancer each year, it’s ranging somewhere between 20-25 thousand each year. So we haven’t cured everyone with prostate cancer and that speaks more to the advanced stage. So we walked through the process of being diagnosed, risk assessment, early treatment. What happens if the treatment you chose doesn’t work or if the cancer comes back or if it spreads and now you are facing the imminent risk of stage 4 prostate cancer. Thankfully there have been a series of different improvements in treatment there that all, or predominantly all involved advances in hormone therapy. So I mentioned earlier that lowering testosterone is a common treatment of prostate cancer. Unfortunately that rarely cures a man and usually after 2 to sometimes 5 years the cancer will come back again, even though they had their testosterone level lowered. And there have been about 3 or 4 different FDA approved new treatments in the past 3years that have come out that have found ways to block hormone receptors in the cancer cell to further increase survival and extend the life and extend the quality of life for patients with advanced prostate cancer. None of them are really “cured” stage 4 prostate cancer but oftentimes have extended life by 2 years or more beyond where patients were living in the 1990s and 2000s. So we look at those as major advancements.
Ed: It’s never been better for you .
Jim: That’s true. It’s never been better. The one sort of sidetracked was that when that PSA testing issue happened we started to see more people with advanced cancers briefly. So between 2012 and 2015 in the United States the incidence of prostate cancers being diagnosed in the bones went up a little bit, the incidence of prostate cancer in the lymph nodes went up a little bit, and thankfully a lot of those screening policies retracted back to yes you should get checked and yes you should talk to your doctor about prostate cancer. So that was a scary moment there for a couple of years where it looked like we were going to repeat the 1980s all over again and thankfully we were able to revert that back to some intelligent screening policies.
Ed: I can’t imagine what your initial reaction was when you heard the news.
Jim: We were disappointed but most of us weren’t surprised because it is pretty easy to tell what happens when you stop testing. In 2013, there was 30% decrease in the use of PSA testing in the United States – that’s a check-up. So for those of us who were around when PSA didn’t exist, we could just do the math. Okay, if you do 30% less test then it is going to look like 30% of 1989. If you do 70% less tests, it is going to look like 70% of 1989, and it just takes a number of years for that to play out. Thankfully we reacted to it and some of the policy makers decided to say let’s go a little more neutral on this and tell patients you should at least talk to your doctor about whether it makes sense to get checked, as opposed to saying you should not get checked.
Ed: Because the government was basically saying exactly that.
Jim: Yeah, technically it wasn’t the government.
Ed: And offering no alternative.
Jim: You’re leading the witness now, Mr. Randall ,and I object.
Ed: Strike that from the record, will you please?
Jim: Technically, it wasn’t the government, it was a spin-off agency that’s sponsored by the government. There were some experts on that panel and there was some truth to the idea that we were detecting and treating too many people for low-grade prostate cancer. So we all agreed that that was not right and a lot of people were suffering side effects that didn’t need to. But the question was “Do you throw the baby out with the bath water?” so to speak. Or do you just stop testing everybody because some people were getting over treated? And I think we are getting closer now to figuring out who needs to be treated and who doesn’t, and treating the people who need to be treated and not treating the people who don’t.
Ed: I’ll ask you the question I will ask each guest who comes on to be interviewed on our Fans for the Cure podcast. Our charity has always relied on large gatherings, whether they be health fairs, panel discussions, theater events, or sports arenas or stadiums. You and I have worked together with the New York Yankees for the past five years offering their fans a free prostate cancer screening. We have large gatherings of people to hold our screenings and awareness events. Now that charity is pivoting to online programs like this, and to support groups via Zoom, do you have other ideas of what we can be doing to keep men mindful of their overall health?
Jim: That’s a great question. You certainly have to be creative. I work at Columbia University and we had our medical school graduation last week. Probably one of the most solom events that occur throughout the year. We have family and parents that are going to see their children become doctors and it was conducted via Zoom. The kids were all over the country. The parents were in little boxes like Hollywood Squares, and we have the speakers and speeches and awards. It wasn’t quite the same but it was actually pretty well done, believe it or not. I think the students appreciated it and everyone who watched it was very touched by it. They swore the Hippocratic Oath at the conclusion of it. It was done very well. There are some upsides when you talk about large gatherings. Frequently people say things like “Oh, I can’t make it into the city for that event.” Well, now there’s no excuse. You can sit on the couch and participate in the next big event for Fans for the Cure. So there are ways to use it to your advantage. But I agree it is not the same, you can’t fill a room and have an entertainer or a speaker or an awards ceremony. It is not quite the same energy in the room when it is on Zoom but I think for this summer, and probably deep into the fall the large gatherings of people who don’t have some serious purpose to be together are probably not going to be safe to do.
Ed: Do you have any ideas about what we should be doing to keep prostate cancer awareness and men’s health in front of men during this time as we go forward.
Jim: I think this is the right medium. I think if you can get a draw, and I think present company excluded, sports figures or people that will fill a Zoom room, and get them to tune in has been effective. We’ve had a lot of celebrities and sports people appear through messages to the hospital, to sort of cheer on the nurses or cheer on the staff. Anywhere from Eli Manning to baseball players.
Ed: Hey, you got Reggie Jackson, you got your good friend Reggie Jackson to come up to our screening at Yankee Stadium.
Jim: Right, so a couple minutes with somebody like that, in a medium where you can get a thousand or ten thousand people to tune in. You can fill a bigger room faster and people can tune in or tune out. You can put it in the can and re-run it the next day. There’s some advantages to it, but it’s not quite the same as filling a room in person.
Ed: What an honor it is to have you on our launch of the Fans for the Cure Podcast. Thank you so much. Be sure to look out for the lovely parting gifts. We didn’t spare any expense with that. And thank you and best wishes to you and to your staff, and for doing God’s work and for joining us on this podcast. Thank you so much.
Jim: Thank you, Ed. Thank you so much for having me. Stay safe everybody.
Ed: Thanks, everybody, for listening to our Fans for the Cure podcast. I’m the founder and CEO of Fans for the Cure, Ed Randall. Thank you for your time.
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, and everywhere good podcasts are available. And if you liked what you heard, a positive review of iTunes will help other people also find our show.