Dealing with anxiety; explaining prostate cancer: Upstate Medical University's HealthLink on Air for Sunday, Nov. 13, 2022
Psychiatric nurse practitioner Thomas Ringwood addresses anxiety screening and what to do for people who have anxiety. Pathologist Gustavo de la Roza, MD, tells how prostate cancers are graded and staged.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a nurse practitioner talks about screening for anxiety, the difference between anxiety and an anxiety disorder, and the common ways anxiety disorders are treated.
Thomas Ringwood, NP: ... We all feel anxious, and we can choose to focus on the symptom, or we might consider what it might be about. ...
Host Amber Smith: And a pathologist goes over what's important to know about the staging and grading of prostate cancer.
Gustavo de la Roza, MD: ... What we're looking for is a proliferation of abnormal glands. So they're glands of the prostate that resemble the normal glands, but they're different under the microscope. ...
Host Amber Smith: All that, plus some advice about what to do when your baby has RSV, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll learn about staging and grading of prostate cancers from an experienced pathologist. But first, when do you need treatment for anxiety?
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
The U.S. Preventive Services Task Force recommended that all adults under the age of 65 be screened for anxiety. It's a disorder that often goes undetected in primary care. Today, I'm talking about this with Thomas Ringwood. He's a nurse practitioner of psychiatry and behavioral Sciences at Upstate.
Welcome to "HealthLink on Air," Mr. Ringwood.
Thomas Ringwood, NP: Hi, Amber. Thank you so much for having me today.
Host Amber Smith: This recommendation comes at a time when it seems like many people have been more anxious than usual because of the pandemic, but anxiety was an issue even before COVID-19.
Is that right?
Thomas Ringwood, NP: Well, Amber, I'm glad that you've framed the question in this way for several reasons. What I want to point out is that if we screen adults for anxiety, we are going to find that 100% of adults have anxiety.
It's an absolutely normal human emotion that a hundred percent of us will experience at one time or another, so I think language is important here. When we say, are we screening for anxiety? it's a common thing that we're going to pick up in everybody. And this is different, of course, and the difference does come up in the language of the recommendation. This is a different thing than an anxiety disorder, so I don't want to trivialize an anxiety disorder, but I want to point out that language, saying that we're screening for anxiety, we're going to turn up a lot of anxiety.
The second thing is, you put it in the context of the COVID-19 pandemic. And this is something I think is important, too. I read an article in The New York Times not too long ago that I thought really was pertinent here. And the author talked about a term -- they call it reification. And they talk about coming up for a scientific explanation or an objective explanation for a political or power arrangement. The COVID-19 pandemic, I think, illustrates this, and so does this so-called mental health crisis or anxiety crisis that we're in the middle of right now. And you said this when you asked the question: This was a problem before COVID-19. Sure, of course.
So, in reification, the effects of a political arrangement are seen or framed as an objective reality about the world. If we look at the way things are today, I would say that there's a reason that people are anxious, instead of "Are we in the middle of an anxiety crisis?" Are we looking at something else here?
So, one way to think about it is, if it's an anxiety crisis, then it's the responsibility of individuals or health care providers or therapists to figure out a solution to the problem. Whereas if the anxiety might be a symptom of some other problem, well, that's a different story, isn't it?
One way to think about this is we live in a time where the two major political parties in the United States can't agree on anything. We're in the middle of drastic changes in our climate. We are in the middle of a vast distribution of wealth to a very small percentage of our population. Formerly secure Industries that led people to a reasonable quality of life have evaporated. And there's an erosion of our social safety net. And then we can think about another path to a secure lifestyle, a college degree, that's not even a reality for most people anymore. It's a ticket to debt, that's for sure. but it's not a ticket to maybe a middle-class or reasonably comfortable way of life. And these are all political and power arrangements here in the United States. And for me, I would say, well, no wonder people are feeling so anxious.
And then, of course, we throw on a global pandemic on top of all of this, which is frightening in and of itself. Here's an illness that we don't understand that well, that spreads very quickly, killed lots of people, is still a problem, but it also exposes a lot of these other sort of power arrangements that we have here in the United States and around the world.
And then to turn around and say, "Oh, it's a mental health crisis. You know, everybody's so anxious. We need to figure out a solution to this," it sort of obscures the problem. So, going back to what I was saying about anxiety being a normal human emotion, it's a signal that there's something wrong.
And that's why we all feel anxious, and we can choose to focus on the symptom, or we might consider what it might be about. So that's sort of a long way of answering the question. I would say yes, that it was here before the pandemic, and the pandemic has certainly exposed more of it, but at the same time, it's important to pay attention to the difference between an anxiety disorder and anxiety as a normal human experience.
Host Amber Smith: So when does anxiety turn into or become a disorder? Because if I understand you correctly, a lot of this is normal, what we're feeling ...
Thomas Ringwood, NP: Sure.
Host Amber Smith: ... the anxiety ... because there's a lot to be anxious about. When does it become a problem?
Thomas Ringwood, NP: I mean, if we look at the DSM (Diagnostic and Statistical Manual of Mental Disorders), which is the classification of mental health disorders, if you will, what the main criteria in all the anxiety disorders are, is it has to cause impairment in your function, right? We all get anxious. I was anxious about this interview, but did I not come to work today because I was anxious about the interview? No. So, you know, my anxiety about the interview isn't preventing me from coming here and doing my job and taking a break and talking to you. So an anxiety disorder, there really does have to be impairment in your social, occupational life.
Again, this goes back to if we're screening everybody for anxiety, we're going to find a whole lot of anxiety, but if we screen for impairment, we're looking at something different.
Host Amber Smith: Does anxiety or anxiety disorders impact a person's physical health?
Thomas Ringwood, NP: Yes. Long-term anxiety can make us sick in many ways. So one thing to think about is an increase in stress hormones like cortisol, and this can have all sorts of negative health impacts. We can gain weight, it can cause coronary artery disease, insomnia, things like that. It can absolutely take a toll on our physical health.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Upstate nurse practitioner Thomas Ringwood about anxiety.
Let's go over the symptoms of anxiety disorders. How would one be diagnosed?
Thomas Ringwood, NP: It would be a careful interview about symptoms, and again, there would have to be impairment. So that's the main diagnostic criteria. Some symptoms, like if we're thinking about something like generalized anxiety disorder, we're thinking about a lot of worry, you're worrying all the time. It occurs most of the time across lots of different situations, and it has to be present for at least six months, so it does have to be going on for a long time. The person has to have a difficulty controlling the worry. Nothing you do seems to make it any better. And then the worry or the anxiety has to be associated with other symptoms, so feeling restless, keyed up, getting really tired all the time because you're just worried so much, having a hard time concentrating on things, feeling like your mind's going blank, like you just can't function or get the right answer to something, feeling irritable or tense and insomnia, having a hard time sleeping.
So those are symptoms of a generalized anxiety disorder. And then some of the other ones you would see. like a panic disorder: You have a panic attack, and then you're worried about having a panic attack, and that would be a panic disorder. Or a social anxiety disorder, where there's a lot of the same sort of apprehension, irritability, worry, things like that. But it really occurs specific to social situations.
Host Amber Smith: How are general anxiety disorders treated?
Thomas Ringwood, NP: The treatments with the most evidence for a generalized anxiety disorder is a combination of antidepressant medications and psychotherapy. So again, I would go back to, if somebody's having anxiety, it's a symptom that there's something wrong.
So think about it like your house is burning down, and the smoke alarm is going off, and the smoke alarm could be thought of as anxiety, and there's approaches here. We could just say, "Well, we just need to address the symptom, which is the anxiety. We just need to turn that symptom off." And, of course, you can try to do that with medications, but I would really liken that to I'm laying there, trying to go to sleep, and my smoke alarm's going off, and I'm thinking, "I just need to shut that off so I can get some sleep."
So when thinking about treating anxiety, what's wrong? Why is the anxiety here? What is it trying to tell us? Do we just want to turn it off? Or would we want to explore what it might be about?
So that's my practice, is I try to work along with people to figure out why are they so anxious, what it is about, because it's a signal that's built into all of us, to try to tell us something about ourselves, our relationships, our environment: There's something wrong.
Host Amber Smith: Have you had patients who successfully managed their anxiety, and if so, can you tell us how they did it?
Thomas Ringwood, NP: Yeah, lots of patients, patients that are curious about what it might be about and make an effort to discover what is wrong and then to address whatever they discover is wrong, tend to get better.
One thing that I find frequently is, anxiety is the signal that we feel like we're all alone, and I guess this is another function of what I was talking about with reification, is a lot of us live in an awful lonely society, and the more distant we get from people, the more anxious we get, because we're social creatures.
And if it was, I don't know, 10,000 years ago, and we were out in the woods, and we got separated, we'd be anxious because we know we need our group to survive. And I think that that is still built into us. If anxiety wasn't there to tell us something, it would've been selected out by evolution a long time ago.
One thing that people find is being in good, healthy relationships or having friends or doing things, that helps with anxiety. Other people, they have trauma that they need to address in therapy, and that helps with their anxiety. Other people need to take better care of themselves, and they figure this out, and they start to eat better, sleep better, things like that.
So, yes, I would say it's very treatable, and it's a condition that people can absolutely recover from, like an anxiety disorder, if they're willing to be curious and work on what they discover is going on.
Host Amber Smith: I'm wondering, you mentioned antidepressants. Can those be effective for someone if they don't have a relationship with an established therapist?
Thomas Ringwood, NP: I mean, antidepressant medications are only so effective. There was a big trial of antidepressants called the Star*D trial (Sequenced Treatment Alternatives to Relieve Depression Study), and it shows that antidepressants have about a 30% effect rate, so they're just not very effective medications.
It's not to say that they don't help, because they absolutely do, but I would say antidepressants alone, we're addressing the signal, and this is with, again, with any medicine that we're going to think about. It can address the signal, so it can absolutely help with the maybe overwhelming feeling of anxiety or the mood that might come along with it.
It can help your mood, but is it really going to help you get to why you might be so anxious? No, a pill isn't going to do that. Antidepressants and other medicines that are prescribed for anxiety can help the signal, but again, I think this goes back to the idea of reification is you can think of, OK, now we've addressed the symptom, but the symptom's there to explain that there really is something wrong, and a pill just is not going to help with that.
As far as therapists being in short supply, that's true. And there are long waiting lists. One thing to consider is there's other resources, I guess, in the community, and things that come to mind are 12-step groups or things like 12-step groups.
So these are groups of people with some common trouble, and they get together, and they share, in their words, their experience, strength and hope with each other, in order to address what's wrong.
This functions in two ways. One, it gets a group of people together, which is often a nice feeling and does help with feeling anxious. And two, it gives people. a platform or a space to talk about what's wrong. So, of course there's 12-step groups for substance-use disorders, but there's also 12-step groups for people that come from dysfunctional families and things like that. There's other groups in the community here that are a little more general, so they're like sort of trauma-based groups or just groups for somebody that they just need to come and talk to somebody. So there's a sort of free or accessible resources in the community for people that maybe can't or don't want to go talk to a therapist.
Host Amber Smith: Do you think primary care providers in general are equipped to screen for anxiety?
Thomas Ringwood, NP: I think, primary care providers are equipped to screen for it, but I know that primary care providers are just so busy, and I think this is true of lots of people in health care. You're just so busy, and it is hard to do all the screening as a primary care provider that you have to do and address what the patient's there for in five minutes. I guess this goes back to the power structure or the culture structure here, is that a lot of providers are seeing a lot of patients and not a lot of time.
And they have to now screen for anxiety, which of course they're equipped to do. We can all ask basic, interview-type questions, but are they screened to really delve into what might be wrong? No, they're not. They don't have that time.
And then this comes back to are they equipped to prescribe an antidepressant? Well, of course they are. Are they really set up to successfully monitor how effective that medication is over time? No, probably not. They can screen, they can maybe prescribe, but with everything else they have to do, how effective is that going to be? I really don't know the answer to that question.
Host Amber Smith: That Preventive Services Task Force recommendation was for adults up to age 65. Why are adults over the age of 65 not recommended to be screened for anxiety?
Thomas Ringwood, NP: What I read in the document was that they just didn't find any evidence that there was going to be any benefit from that. So I don't know if this says anything about people over 65. Maybe it does, maybe that generation handled things differently or has closer social connections or something, and they're less anxious. From my day to day practice, I would say that's not true because I treat many older adults who are terribly anxious and depressed.
Host Amber Smith: This same Preventive Services Task Force recommended earlier that adults of all ages undergo routine screening for depression.
How often do you see depression present in someone with an anxiety disorder?
Thomas Ringwood, NP: So in my practice, I tend to mostly think about them as a related condition. If we look in the DSM at the symptoms of a major depressive disorder, anxiety is a symptom of being depressed. And the treatment is the same, it's the antidepressants and therapy. That's the gold standard for treating a depressive disorder. I tend not to split them into two separate disorders. I tend to mostly just see it as depression. And I also am a big believer in some thinking that was developed by a lot of different people, my mentor Brian Johnson (Upstate psychiatrist and pain medicine specialist) is one.
But there's an animal researcher, Jaak Panksepp. There's anotherneuropsychoanalyst, Mark Solms. And they talk about "affective neuroscience." So Jaak Panksepp, one of his concepts about anxiety is that it's an instinctual system that's built into us and that it's there to cause us to feel anxious and worried when we're cut off from other people.
But it's not sustainable. It's not sustainable to be anxious and in that heightened state for very long. If we go back to you and I being in the woods, and we get separated, it's not going to do me a bit of good to just freak out, freak out, freak out. I need to conserve energy. So we can think about depression. Depression is a shutdown, so it's not going to do me any good to be anxious, anxious, anxious, anxious. I can do that for so long, and then I fall into a depression. So I think of these sort of as a continuum. I treat them the same because really the treatment is the same, and I just say that they are definitely related.
Host Amber Smith: Well, Mr. Ringwood, thank you so much for making time to tell us about anxiety.
Thomas Ringwood, NP: Thank you, Amber. I appreciate you having me on.
Host Amber Smith: My guest has been nurse practitioner Thomas Ringwood from Upstate's department of psychiatry and behavioral sciences.
I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air," a pathologist explains the laboratory assessment of prostate cancer.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Once a man learns he has prostate cancer, before he and his doctor can decide on treatment, they'll need information about the growth or spread of the cancer. That's where laboratory pathologists come in.
Today I'm talking with pathologist Gustavo de la Roza, a professor and vice chair of pathology at Upstate, and also the director of anatomic pathology. Welcome back to "HealthLink on Air," Dr. de la Roza.
Gustavo de la Roza, MD: Thank you. I'm glad to be here.
Host Amber Smith: The American Cancer Society recommends screening for prostate cancer using the prostate specific antigen, or PSA, starting in a man's 40s or 50s, depending on his individual risk.
This is the blood test, but can you explain to us what the test is looking for?
Gustavo de la Roza, MD: Prostate specific antigen, it's normal in the body, so It's an enzyme it's in the prostate, but it gets released into the bloodstream as well. So, when there's pathology in the prostate gland, this antigen could be increased in the serum, and that's what we measure.
Host Amber Smith: So what does the number mean then? Because a man would get a number back from the lab, right?
Gustavo de la Roza, MD: It depends a little bit on the patient's age, but in general, I would say, for practical purposes, any level greater than 4 is considered abnormal. So it's 4 -- it's nanograms per milliliter -- but basically 4. If you say that, people would understand.
Host Amber Smith: Is it normal for the number to fluctuate up and down from one PSA test to another?
Gustavo de la Roza, MD: Yes. And also, it's important to mention that the PSA is not specific of cancer, so it's elevated in a lot of processes that happen in the prostate. The most common one is what people know as BPH, or benign prostatic hyperplasia. It's almost, if you will, a physiological change because all men get it. It enlarges the prostate and so forth. And so that increases also the level of serum PSA. And so does prostatitis, so infections or inflammation of the prostate.
Host Amber Smith: So just because you have a high number, higher than 4, doesn't at all mean that it's ...
Gustavo de la Roza, MD: Exactly. No, no. In fact, it's been questioned, a little bit, it's use as a screening test. And the reason why is because it was used so much and patients were biopsied and diagnosed with cancer that probably doesn't need to be treated, it resulted in a lot of overdiagnosis and overtreatment. But that's kind of another subject.
Advanced prostatic cancer is uncommon, uncommonly diagnosed. So in other words, if we didn't have prostatic specific antigen, we'd be missing a lot of early cancers, and we would only detect those that are already advanced.
Host Amber Smith: Well, let's talk more about a biopsy, and that's where you would, get a tissue sample from the prostate. Is that the only way to get a definitive diagnosis of prostate cancer?
Gustavo de la Roza, MD: Yes. Yes, it is. Clinically, it's required for any treatment. The truth is, if you have a widespread metastatic disease in the bones and the PSA is super high, the likelihood that that is cancer is very, very high.
Regardless of that, confirmation by a tissue sample is needed.
Host Amber Smith: In the lab, what are you looking for in those tissue samples?
Gustavo de la Roza, MD: What we're looking for is a proliferation of abnormal glands. So they're glands of the prostate that resemble the normal glands, but they're different under the microscope.
Host Amber Smith: What do cancer cells look like?
Gustavo de la Roza, MD: In prostate cancer, basically, the cells are larger and they grow in a disordered way, so in a kind of haphazard pattern. So that, and there're also very cytological features, meaning precise features of the gland, the cells itself. All the cells have a nucleus and a cytoplasm, so features of that nature that would make us, diagnose cancer.
And they're different from the normal glands. And there're also ways of doing some markers that we can use, immunocytochemistry, which is a form of tumor markers that will be present in benign tissue and not in cancer.
Host Amber Smith: Are you able to tell, based on the biopsy sample, how advanced the cancer is, or can you tell whether it has likely spread?
Gustavo de la Roza, MD: Not really. There is a component of that, but it's very uncommon that if you see in a biopsy that there's a little bit of adipose tissue, or fat, and there's tumor in it, we know it's spread out, but that's very uncommon. So in general, no. What you can use the biopsy (for) in general, is a way of predicting which cancers could be already outside of the prostate.
Meaning if you have a very high-grade tumor, the likelihood of the cancer have been already out of the prostate is much higher.
Host Amber Smith: How common are false negative results in biopsies, where a patient learns that they do not have cancer, but actually it turns out that they do. Does that ever happen?
Gustavo de la Roza, MD: Yeah. There is roughly, about probably 2 to 2.5% with today's protocols. That was not an uncommon event a couple of decades ago, or even a decade ago, maybe, where the biopsy sample was more restricted, and the number of biopsies were lower, and so we really missed a lot of cancers.
But today, that's a lot lower possibility.
Host Amber Smith: What are the possible reasons for a false negative at this point in time?
Gustavo de la Roza, MD: In general, the concept is that more biopsies lead to a higher detection rate. So it's a think, it's a matter of sampling. Did we get it all? Do we have all the areas sampled?
So, just to give you an example and put this in perspective, decades ago, the typical protocol for urologists to perform a biopsy was doing six biopsies,so we call it sextant biopsy. It was a classic for decades and decades, and so usually we divided the prostate in the apex, the mid-prostate and the base of the prostate, and they would do one biopsy from each side, right and left.
Today, the protocols at least include what we call extended protocols, 12 biopsies, which include the periphery of the prostate. That was not included in the previous ones. And the cancers tend to be in the periphery of the gland, so there's a higher likelihood that it will be detected.
In addition to that, in some places they do something that's called saturation biopsies, many of them, actually much more 20 or 30. but that's not used very often. What people may be start seeing now. it's done Upstate, but not in every medical center, is image guided biopsies, also known as fusion biopsies. And they're called fusion because it's a way of targeting a lesion rather than just sampling blindly a lesion. And that's fusion because it's the fusion between ultrasound and MRI testing. So they do an MRI and ultrasound and detect the more likely areas of a lesion. And that is sampled, and that yields a much higher detection of prostate cancer.
It is also worth mentioning that in the past there were some patients that, because of their age, maybe their life expectancy is not that low, or the cancer involvement is very minimal, they will be put in (the category of) basically deciding not to treat, and they called it "watchful waiting." That was probably about 10 years ago, they started changing that to something called "active surveillance." It means the same a little bit, but it's not just waiting for something to happen. You are actually more active in watching the PSA and then deciding to biopsy again. And that is critical. For instance, at Upstate, and in many medical centers around the country, people are not put in active surveillance until this type of biopsies are done. So if they're done this way, the likelihood of missing cancer is much lower, so they feel confident. Whereas if somebody comes with a classic (case), 12 biopsies are negative, and the PSA is really high, it makes you wonder whether there's cancer that could have been missed. And so it's safer to put him in active surveillance this way.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Gustavo de la Roza. He's a professor and vice chair of pathology at Upstate and the director of anatomic pathology, and today we're focused on prostate cancer.
What can you tell us about how prostate cancers are graded using the Gleason scale?
Gustavo de la Roza, MD: It seems, kind of complicated, but relatively speaking, it's rather simple. So Gleason grading is a form of histologic grading, meaning the least aggressive to more aggressive types, depending on a score. And the truth is, Gleason grading is actually called, in reality, score. So it's a combination. What we're looking at is basically whether the glands are well-formed glands, there're glands that they're not so well formed, and they're coalescing together, or they're infiltrated in a single file, different things that we use. And the division grade actually has a very good reputation because it's one of the best, probably, grading systems that exists I would say the most reliable.
It was created in the 1960s by a Dr. Gleason. He was in Minnesota at a VA (hospital) in Minnesota. So the grading has been changed a lot. There have been a lot of updates. So what is used in the Gleason grading for people to understand is that we divide it in five different histologic patterns.
And so in the Gleason grading, we use the most predominant pattern. Followed by the second most predominant pattern. So that means if you have a Gleason score of 6, and usually patients will see it says Gleason score 6, in parenthesis, 3 plus 3. Or sometimes it says Gleason 3 plus 3 equals 6, which seems kind of silly, because it's basic math, but that's the idea.
So if you have a Gleason 7, you could have a Gleason 7, 3 plus 4, , or at Gleason 7, 4 plus 3,, meaning that the 4 is more predominant, which is actually, a more aggressive form. That's how we create it.
So the lower the Gleason, the better. And the higher is obviously more aggressive. But there's been some very important changes since that, and I think it has helped researchers, technicians and also patients, probably. It would be easier to understand. So the problem with the Gleason system is, like I mentioned, we have five different patterns.
The truth is that the patterns, for instance, what is called pattern 1 and pattern 2, they're almost nonexistent in real practice. This was the 1960s, the new methods. So we know that those probably are not really cancer. So the reality is that the minimum Gleason pattern that we can see is 3.
So if you have a tumor that is all 3, that means it's going to be 6, 3 plus 3. So if one person looks at that, a patient looks at that and know that the scores, the Gleason score, or Gleason grading, goes from 1 to 10. If you're in 6, well,, you have a pretty significant cancer, right? You're not 1, you're not 2, and you're 6. And the reality is that Gleason score 6 is the lowest possible Gleason grading.
So research studies actually looked at what is called chemical recurrence. So basically after the prostate is taken out, the PSA starts to rise. So that's called a chemical recurrence because the PSA should be normal by then, when they took the prostate out, with all the tumor. So based on that, it has been divided in five different groups and combinations of Gleason grades.
So that's what patients will start to see and maybe possibly Gleason per se, with that name may be actually not used anymore. What we call this is great grouping, and it's five different groups of combinations. So the group 1, for instance, is a Gleason 6, 3 plus 3, and a Gleason 5, it's a Gleason 9 or 10.
So it's a combination of pattern 4 and 5, 5 and 4 or just 5 and 5. So those are the highest Gleason grading. So this is more accurate because it really reflects more, exactly what's happening and the likelihood of that tumor to spread or to be more aggressive.
And better understood.
So today, you will see a biopsy, for instance, I will diagnose a Gleason adenocarcinoma and say Gleason 6. And then he will say how much of the biopsy was involved in cancer? And then that's followed by a great group. And I say great group 1 of 5.
If you have a very high Gleason grade, so for instance, you have a Gleason grade of 8, you would say Gleason score 8, in parenthesis we'll put 4 plus 4 or 3 plus 5. And in parenthesis then we will say great group 4 of 5. So that's easier to understand it that way.
And also this separation is not totally arbitrary. It's based on risk of having a recurrence or, cancer coming back after surgery.
Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more prostate cancer information from Upstate pathologist Dr. Gustavo de la Roza.
Welcome back to Upstate's "HealthLink on Air." I'm your host, Amber Smith, and I'm talking with Dr. Gustavo de la Roza. He's a professor and vice chair of pathology at Upstate and the director of anatomic pathology, and today we're focused on prostate cancer.
I understand the grading system has evolved since the 1960s. Does it still rely mostly on the pathologist's impression of what the sample looks like under the microscope?
Gustavo de la Roza, MD: Yeah, absolutely. I'm glad you mentioned that, because actually urologists trust the Gleason grading, a lot and it is a very good system, but there is some sensitivity to it, and there's some inter-observer variability, so it's not perfect, but it's pretty good. So the way we grade things has not changed as much, it's how we report it. And today, cancer protocols, and they talk about great groups rather than Gleason grade. It's a lot easier because it's a combination of different gradings and possibilities.
Host Amber Smith: But if I understand correctly, the grading only tells part of the story, because you also do something called staging. Can you explain what that is?
Gustavo de la Roza, MD: Right. So staging is different. It's a way of judging how much the tumor has spread, how much of the prostate is involved by cancer. Has it gone outside of the prostate? Has it gone to the lymph node? Has it going to other organs, to the bone? And so forth.
So there's two ways of TNM staging, two different types. One is the clinical, which is what the clinicians do in base of imaging analysis, and. X-rays and MRIs and CT scans and so forth.
And then there's the pathologic staging. So the pathologic staging can only happen after the prostate has been taken out. So we see how much of the prostate has been involved, mostly. Just to put it simply, a very low tumor is usually, let's say, T2. Basically (that) means that it's confined to the prostate; 3 and 4, meaning that they went outside of the prostate into the surrounding tissues, the fat, or It could go into the rectum and things of that nature.
The staging that you're referring to is how do we determine, the most accurate and the one all centers all around the world uses, called TNM. So T for tumor, N for nodes, and M for metastases.
So, the tumor will be what I just mentioned. Is it confined to the prostate? Is just outside of the prostate? How far did it go? And then, are the lymph nodes involved? How many of them are involved? Are they involved or not? And then, are there any metastases outside of the lymph nodes or the prostate? So, distant metastasis or distant spread.
Host Amber Smith: Under the T designation, does the actual physical size of the tumor matter?
Gustavo de la Roza, MD: Not in prostate. In many tumors it does, but in prostate it's actually like what I mentioned to you. T1 is reserved only for those diagnosed and the needle biopsy and their pathologic grading. T2 is the lowest possible one, and that means it's confined to the prostate. T3 is when the tumor has spread either to the fat around it, so outside of the prostate or into the seminal vesicles -- that is another component of the prostate. And then, at 4, it's like I mentioned, it goes into other organs, such as, for instance, the rectum, which is very advanced then.
Host Amber Smith: So TNM staging is not a prediction, it's actually what is going on currently.
Gustavo de la Roza, MD: Exactly, exactly. So it's the involvement of cancer in the body, how far has the spreading occurred, or has it occurred at all?
Host Amber Smith: So the urologist takes this information, the grade and the stage, and that's how they recommend treatment?
Gustavo de la Roza, MD: Absolutely. Yeah. So it's a risk assessment that I'm not going to get into. It's quite complicated, but it actually takes into account to show a very low risk, low risk, intermediate risk, high risk and very high risk. And it's a combination of staging, grading and level of PSA in the serum. So a combination of those puts a patient in a category which is easy to decide how to treat or what to offer the patient in terms of treatment.
Host Amber Smith: When is molecular testing of the tumor recommended?
Gustavo de la Roza, MD: It's very early on that now we have several ways of trying different tests to try to predict aggressiveness of the tumor that go beyond the grading. But the truth is this has not been adopted or has not been really tried well enough to have a universal, use of them.
So the truth is there are many commercially available molecular testing that the companies have developed, and there's been some studies, and that's what they're trying to predict. So, for instance, a patient with a Gleason 6 for the most part will be told that probably doesn't need to be treated.
The question is, at some times, obviously because we are sampling, we can get a 6, but the truth is maybe somewhere in the gland -- we can't sample it all -- it might be a higher pattern or higher grade. So these molecular tests that target different genes in a combination of genes, difference in each one, may be able to predict which patients with that kind of grading will be progressing.
But in a nutshell, there are many of them, and none of them have universal use recommended for now. There haven't been any significant randomized trials for it.
Host Amber Smith: So it would be very patient specific if the doctor felt like it would be useful or not.
Gustavo de la Roza, MD: Right. and it doesn't hurt to get some of those tests.
But the truth is, actually, at Upstate, mostly we're not using them.
Host Amber Smith: What are the most common places where prostate cancer may spread? You mentioned the rectum. Is that just because of its proximity?
Gustavo de la Roza, MD: Right, right. So, in staging, we're talking about local spread or involvement and then distant spread. So one is, like you mentioned, going into the rectum, which is pretty close to it. So it goes Into that, that's direct extension, and that's what we call a T4 tumor. But if the tumor goes to the lymph node, meaning that it has left the prostate already, it's not just in the confines of the prostate, goes to the lymph node, and then after that it will be going to different, more distant sites.
The most relevant and most typical is the bone -- bone lesions. And, lung also. It could be other organs. It just becomes really serious level of metastasis when it goes to the visceral, organs, like the lung and so forth. But the most common is the bone. Once the tumor has spread to the bones, basically we're dealing with a disease that is not curable at that point. Doesn't mean that it's lethal. It could be treated, but it's not curable.
Host Amber Smith: When you find cancer in the prostate, is there ever a concern that it's a cancer that's spread to the prostate from somewhere else in the body? Does it ever happen that way?
Gustavo de la Roza, MD: Yeah. But it is very, very uncommon. So yes, we can have certain types of tumor that could actually go to the prostate, like lung cancer and so forth, but it's very uncommon.
Host Amber Smith: Aside from the biopsy, are there other tests that might be ordered which would end up in the pathologist's lab?
Gustavo de la Roza, MD: Not really, no, other than PSA and the prostate biopsies and then surgical specimens, if the prostatectomy has been performed. We talk about molecular testing, but we don't have any accepted form of molecular testing at this time.
Host Amber Smith: Do you have any idea how common it is for men to live with prostate cancer, even for years? I mean, we talked about active surveillance. Does that happen? Are there a lot of men that are actively ...?
Gustavo de la Roza, MD: Yeah. Yeah, it is. It is. Some of the great developments that happened have been based on this.
So. I cannot be precise in terms of timing. It could have been probably about two decades or maybe 15 years ago. There'd been studies done originally in Europe. The Swedish were the most reliable studies, but then they were done elsewhere in Europe and the United States.
People, realized that the prostatectomies were overtreating patients because no one was progressing into any disease, and the disease had spread already. It was the same whether they had a prostatectomy or not. So there wasn't a lot of value.
So the truth is, we're probably overtreating cancer, for the same reasons that I explained at the beginning, that you have a Gleason 6, so it's an intermediate grade, it's cancer. Today, we know that Gleason grade 6, for instance, has very low potential for spread. So patients, yes, they can live with cancer and not be operated on and followed for it.
There is a saying that some people die with cancer and others die of cancer. Still, prostate cancer is the most frequently diagnosed tumor in men, and the second cause of mortality. So, it is important, butthere are more cases diagnosed. So for instance, if you consider prostate, the estimated new cases, maybe 20% of all the cancers, whereas lung could be 14%, which is less.
But when you're talking about death, lung causes almost 25 to 30% of mortality and prostate, being more common, only causes 9%, so it's less lethal.
Host Amber Smith: Can you tell me about the use of artificial intelligence in pathology?
Gustavo de la Roza, MD: Yes. This is a very modern thing, and it's based on computer imaging of the same images that we looked at under the microscope, but it's scanned perfectly all around the sample.
These computers are basically taught how to detect things, right? And so, it's a very complex process, but the idea can be applied to the prostate very easily, and in fact, it already exists, being approved for FDA approval for use in the prostate. To make it easy and simple, diagnosing cancer of the prostate is not that complicated. We talked about grading, which could be variable, so that the artificial intelligence targeting of all these biopsies that we mentioned, at times all are negative. Sometimes one or two are positive, so that means that we're looking at 15 biopsies with no tumor in them. And so it's very easy to teach a computer how to detect that. So we will concentrate on the ones that we need to concentrate (on). It doesn't mean that a pathologist doesn't look at it, it just is selecting the areas of concern. And the computers are actually much better than humans for this because they don't get distracted, they don't get biased or interrupted by a telephone call and so forth.
The second thing is the histologic grading that we were discussing. A lot of these, I didn't want to, overwhelm people with details, but it's a percentage of a pattern and the other pattern and how we make decisions. So if you teach a computer how to do this based on information, and these computers have a network that actually allows it to learn a system, the grading will probably be more objective and possibly more accurate. But then again, it won't be a computer diagnosing you and grading your cancer. It will be a pathologist doing it with the help of the computer.
Host Amber Smith: Well, Dr. de la Roza, thank you so much for helping us understand more about prostate cancer.
Gustavo de la Roza, MD: Oh, you're very welcome. My pleasure.
Host Amber Smith: My guest has been pathologist, Dr. Gustavo de Roza, Upstate's vice chair of pathology and director of anatomic pathology. I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from Dr. Joe Domachowske from Upstate Golisano Children's Hospital. What do parents need to know if their pediatrician says their baby has RSV (respiratory syncytial virus)?
Joe Domachowske, MD: Just watch carefully for signs and symptoms of inability to feed effectively, depending on the baby's age, if they're nursing, or if they're taking a bottle. You want to make sure that they're not struggling to feed because they're trying to breathe instead, right? So if that starts to happen, we would bring those babies into the hospital, and we support them the best we can. We keep their nose and their upper respiratory tract as clear as we can using suctioning techniques and a saltwater syringe with a bulb syringe to clean out their nose.
But there really isn't anything else that we can offer them as an outpatient because nothing works. Things have been tried, and they just do not change the natural course of this infection. When we bring them in the hospital, that's also true, but we have IVs. We can put IVs into babies, and hydrate them up. We can have a nurse at the bedside keeping their nose as clean and as clear as possible and supplemental oxygen or more invasive types of respiratory support, as needed. So when those events start to be considered, that's when we bring the babies in, and the younger they are, the more inclined we are to hospitalize them.
Host Amber Smith: You've been listening to Dr. Joe Domachowske from Upstate Golisano Children's Hospital.
And now, Deirdre Neilen, editor of Upstate's Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Cathy Kodra, an independent editor in Knoxville, Tennessee, is the author of a collection of poetry called "Under the Adirondack Moon." She published that in 2017. Her love of nature pulses throughout the beautiful elegiac poem she sent us, "Birdie Leaves This World":
Bees arrive and gently lift you up
to a bed of honeycomb that hangs
a wing shy of the nursing home cot
before they bear you high and higher
to weightless light where honey and jam,
sheep and yarn and song, encircle you
in benediction, where you taste snow
on your tongue again, where shocks of hay
shine in the sun like thick strands of hair,
and you soar above the world you knew
to a pure state of satiation
you hadn't believed in, hadn't seen
in the tea leaves you brewed each morning,
not noticing your soul's reflection.
Astride the humming carpet, you turn
back once, see your children crying for
how they've disappointed you, lovers
suffering for how they've done you wrong.
You urge them all, Go easy to your
futures. Never underestimate
the forgiveness of a soul in flight.
Below you they stoop low in sorrow,
cling to each other, seeking solace,
not remembering to gaze skyward
where the bees bear you high and higher,
where the new honeyed light encircles
your hair like a halo, where snow falls
past your smiling lips, and on you soar.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," an update on Alzheimer's research. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at HealthLinkonAir.org. Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Bill Broeckel. This is your host Amber Smith, thanking you for listening