Explaining regular screening, advanced-stage disease

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Routine screening helps detect prostate cancers, but there's been a troubling uptick in advanced stage diagnoses. At the same time, more kidney cancers are being found incidentally and treated successfully. Here to talk about each of these cancers is Dr. Gennady Bratslavsky. He's professor and chair of the department of urology at Upstate, and he and his colleagues care for patients with both of these types of cancer. Welcome back to "The Informed Patient," Dr. Bratslavsky.

[00:00:52] Gennady Bratslavsky, MD: Thank you, Amber. Great to be here.

[00:00:55] Host Amber Smith: How is kidney cancer typically discovered? Are there symptoms?

[00:00:59] Gennady Bratslavsky, MD: Unfortunately, kidney cancer is something that is often not discovered until very late. If there are symptoms, by the time people have symptoms, the disease is usually quite advanced or at least has a stage when it had either grown in size to be felt, cause local symptoms or cause blood in the urine. And all these are usual signs of something a bit more advanced than a small renal mass.

The vast majority of kidney cancers nowadays are still diagnosed with an incidental screening done for other causes. Somebody may have an abdominal pain, a back pain. They are seen in the emergency room. And because kidneys are in the area of body that is often being scanned, the small renal tumors are usually found.

The only time when we continually screen for kidney cancer are in patients that have hereditary disorders, which means that these people are at risk to develop kidney cancers because of a family history of kidney cancer, or a known problem with the gene code that is known to predispose to later, or at some point in life, develop kidney cancer.

So in summary, you have three groups. You have patients that are diagnosed with kind of a more advanced kidney cancer, usually when they have symptoms from the tumor itself, whether it's, again, blood in the urine, pain in the abdomen, swelling of the legs, loss of the weight. Most of the cancers in the second category are diagnosed incidentally, from scans done somewhere else. And the third, much smaller group of patients are diagnosed because of a very meticulous screening in a very specific proportion of patients at risk for developing kidney cancer when we know who these people are.

[00:03:26] Host Amber Smith: If you suspect that someone might have kidney cancer, how do you go about diagnosing that?

[00:03:34] Gennady Bratslavsky, MD: Certainly we do a specific scan that is either a CAT (computerized tomography) scan or an MRI (magnetic resonance imaging) that just gives you a very simple answer: Is the tumor of the kidney present, or not? And, is this tumor likely to be cancerous, or not? Never can we guarantee that something is a cancer, because even among some large renal tumors, a small percentage of tumors may turn out to be non-malignant, also known as non-cancerous or benign.

But the most common type today is diagnosed via a classic scan known as CAT scan or MRI. Sometimes ultrasound can be used, but usually the definition or the information about anatomic and some specific things that we see when evaluating kidney tumors are better seen with, again, CAT scan or MRI.

Do we have additional scans that help us further with trying to predict or guess what kind of kidney cancer or kidney tumor this is? Yes. But that is a much more specific type of both scans as well as research that is ongoing that, very soon -- it's already FDA approved. It's not yet in the mainstream -- but we have now some PET scans coming for our use where we will be able to not only say, "yep, the tumor is there," but we will be able to say with high certainty what kind of tumor is this, not only that it's malignant. But even among malignant tumors, there are different types of tumors, so we will be able to even pinpoint what type of histology or what kind of cells these tumors consist of. But that's a bit down the line, probably a year, and then we will have many more breakthroughs coming our way.

[00:05:56] Host Amber Smith: If you do find a tumor on one of the kidneys, how likely is it that there would be a tumor on the other kidney as well?

[00:06:05] Gennady Bratslavsky, MD: Oh, that is a great question, to be asked by somebody who is not in medicine or urology. So you are asking a question about something known as bilaterality -- bilateral meaning of both sites.

The presence of bilateral tumors is about six or so percent, on the average. And then these bilateral tumors are often seen, again, in patients that are predisposed

to form kidney tumors, to be numerous in quantities and on both sides of the kidneys. Again, in these patients with what I mentioned earlier, hereditary cancers, those with known family history of kidney cancer, those with known genetic syndromes where specific genetic mutation or a change, small change in the D N A is likely the course, what is known as bilateral kidney tumors.

But overall, it is not a common scenario, and most patients that we see and that exist with kidney cancers are not presenting and are unlikely to have tumors to develop on both sides, the right and left kidney.

[00:07:40] Host Amber Smith: Is surgery usually the treatment for kidney cancer?

[00:07:44] Gennady Bratslavsky, MD: Just like with any disease, the earlier stages are often treated with surgery. Later stages are treated with medications, whether it is immunotherapy or targeted therapy. In kidney cancer, we use surgery typically for certainly stage 1 and 2. We often use it for stage 3, which is a bit more advanced cancer, and we occasionally use it -- or I should say often enough, but not all the time -- use it for stage 4, which is a metastatic kidney cancer.

There are many things that go into decision making: how far the kidney cancer has spread? Has it spread? Is the tumor only located in the kidney, or somewhere else? What is the burden or amount of disease outside of the kidney, for stage 4? And that is what is the performance status of the patient? So there are many predictors that we put in together to calculate certain scores, to put patients into certain risk categories that later allow us to decide whether or not the surgery is the right next step.

But for the earlier stage disease, when the tumors are small, surgery is usually the most type of treatment. Although, small renal tumors, even when they are cancers, can be safely observed and can be followed. And we utilize something known as active surveillance for small renal masses. It has been not only accepted, but it is in guidelines for treatment of patients with kidney tumors. And of course there is something known as ablation, which is either freezing or frying the tumor. And those are also some of the therapeutic or treatment options for patients that are made together with the patient and the family.

[00:10:12] Host Amber Smith: Well, before I talk to you about prostate cancer, let's talk about survival rates for kidney cancer. Why have they improved in recent years?

[00:10:21] Gennady Bratslavsky, MD: It's a great question. We, of course, are trying to, I want to say not only attribute this improved survival to new treatments, but indeed we are finding more and more renal tumors. So more and more tumors now are diagnosed at an earlier stage.

With the earlier stage in diagnosis, you have a denominator for the number of total renal tumors growing pretty high or pretty large. And while the denominator is growing and the rate of kidney cancer death is still close to 15,000 a year, the ratio of the patients dying from the disease -- so the number of patients diagnosed with the disease -- is smaller. And we certainly have much improved therapies today. There was an era of targeted therapy that has now been mostly surpassed by era of something known as immunotherapy, where the medications administered to patients allow the immune cells to get activated. Or, to be more specific, they allow immune cells to not be inactivated by cancer cells. A lot of immunotherapy are now focused on allowing these cancer cells to stay active and to prevent tumor cells to turn those immune cells off.

So overall, we still have close to 80,000 new diagnosis expected this year, and there will probably be close to 200,000 people living with kidney cancer in the United States alone, with about 15,000 of patients with kidney cancer dying from the disease.

So it still is a major healthcare problem. It still is one of the top 10 cancers in humans. And, understanding of everything from diagnosis to time to intervene, to when to intervene, to to intervene or not to intervene, and the treatment options, this is a long continuum of many issues that we're facing today.

And, I'm happy to say that at Upstate we do all the modern imaging. We're doing all the modern trials and therapeutics, and we also have a very strong basic science lab that is funded by the government and donors to find new potential cures for the kidney cancer.

[00:13:40] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Gennady Bratslavsky. He's professor and chair of urology at Upstate. We've talked about kidney cancer. Now we're going to turn to prostate cancer.

The American Cancer Society says the incidence of prostate cancer increased by 3% from 2014 to 2019. Dr. Bratslavsky, is this a statistical blip or is it a concerning trend?

[00:14:10] Gennady Bratslavsky, MD: Well, one of the reasons for relatively small increase that is unlikely to be just a statistical blip is because these were the years of controversial recommendations by United States Preventative Task Force, when prostate cancer screening was discouraged. And this was using the PSA (prostate specific antigen test), which is a blood test drawn in the doctor's office. So there were a few years when the blood test known as PSA was not recommended to be done. So these are the interesting years of 2014 to 2019. Unfortunately, as a field, we're dealing with these recommendations because we're noticing a run of higher risk disease patients with more advanced prostate cancers that are now coming to us because of a lack of screening.

And of course, let us not forget implications of Covid that followed these recommendations by United States Preventative Task Force. So I would say that perhaps the epidemiology and numbers have been influenced by both recommendations of preventative task force and by relative lack of access of care to many of the offices during a year and a half or two with Covid, when many patients were not looking or able to see their primary care doctors or urologists. So I think we're going to see effects of these two things in the next few years.

[00:16:06] Host Amber Smith: I want to ask you about how prostate cancer is typically diagnosed and what the common treatments are like. Is it usually found after a PSA screening?

[00:16:16] Gennady Bratslavsky, MD: Correct. So PSA, while controversial, if used appropriately, is one of the most common used markers to screen for prostate cancer. There is no question that it has numerous drawbacks from identifying men with just large prostates or inflammation of prostates. Nevertheless, several studies have shown that baseline PSA levels are very good, especially at the younger age, that potentially predict a possibility of men dying from prostate cancer at a later age.

Just an example is a PSA greater than 1 at the age of 50 correlates with about eight fold higher chance of dying from prostate cancer later in life. But prostate cancer obviously is not a disease that is diagnosed by one modality. There are numerous other biomarkers.

There are several companies that have advocated to fusion their screening tests for prostate cancer in specific scenarios. One are those with elevated PSA and negative biopsy. Others with elevated PSA alone. Others with elevated PSA, no prior negative biopsy, but negative MRI. So the screening is quite heterogeneous, pSA being, still, the most common I would say red flag or first threshold that many physicians need.

Certainly digital rectal exam, when the physician just examined somebody's prostate, is still part of the screening. We must admit that nowadays less than 10% of cancers are diagnosed on physical examination, even less than 10% of prostate cancer, because most of the prostate cancers will have a perfectly normal exam of the prostate. Over 90% of men with prostate cancer do have absolutely normal exam. And of course we do have, as I mentioned, other than modalities that I mentioned earlier, offered by different companies. We also have MRIs that has been a good adjunct and a tool to identify not only suspicion for presence of prostate cancer, but also help urologists guide the biopsy as the prostate MRI, if suspicious, not only gives a degree of suspicion, but also gives kind of a localization of an area of suspicion, so the biopsy can be done targeting that one specific area, in addition to sampling of the prostate traditionally.

[00:19:18] Host Amber Smith: Well, I know that treatment depends on the man's condition and what else is going on. It's very individualized. But in general, what are the more popular methods of treatment these days?

[00:19:31] Gennady Bratslavsky, MD: Just like we discussed with kidney cancer, not all prostate cancers are created equally. In more advanced cases, again, the treatment will be very different from treatment for a more localized disease. And, treatment for localized disease is very different based on the aggressiveness of the cells that we see under the microscope. It's different based on the starting PSA level because just because we may not be able to see anything outside of the prostate.

I mean in most modern imaging, we always have to keep a good degree of suspicion that some cells may have escaped and are just not picked by our modern imaging. For localized disease that urologists typically see and diagnose, the three most common types of treatment include active surveillance for patients that have a very low risk disease that is highly unlikely to progress and highly unlikely to hurt patient. And it is important that urologists are not only comfortable offering it, but know who to offer and are able to follow these patients appropriately.

Of course, surgery, removal of the prostate, which now in well over 90%, 95% of the places in the United States and westernized world, is done using a robot. And it doesn't matter whether you make one tiny hole or you make four or five tiny holes. Patients now, after their surgeries go home the same day essentially. Sometimes stay overnight.

And of course, radiation is another very important option for patients that has been proven to be as effective as surgery for many of the patients. And again, the field of prostate cancer is so wide and broad that to just say, "yep, you can either do surgery, radiation, or active surveillance," that would be a very incomplete answer.

There are some men that may have one little area of cancer they wish to not risk with any of the side effects associated with the surgery, or radiation or even anxiety associated with active surveillance. So focal therapy sometimes is an option as well, where patients are given an option of treating just one small area within the prostate using newer technologies.

And of course, in more advanced cases, at least in cases when we suspect that the disease may be advanced, not only we here at Upstate offer traditional therapies, we also offer patients to have an opportunity to participate in clinical trials, which are very important, based on either genetic makeup of the tumor, genetic makeup of the patient based on some of the knowledge of the literature. We have been extremely active in clinical trials, just moving the needle forward in terms of options that we can offer for patients.

[00:23:02] Host Amber Smith: Well, as a urologist, is there anything that you're telling your patients that they can do to try to prevent the development of prostate cancer?

[00:23:10] Gennady Bratslavsky, MD: There have been several studies that have looked at prostate cancer prevention. Unfortunately, none of these studies have been either clear that the prevention is safe, as some medications tested have, for example, resulted in fewer number of cancers diagnosed, but among those that had diagnosis of prostate cancer, there have been observation that more angry cancers were present.

So medications so far are truly not approved by the FDA for the prevention of prostate cancer, despite many years of research. There have been studies that have looked at specific diets, and as of right now, no advantage of one or the other diet has been shown to be the case. There have been studies that looked at specific vitamins or minerals, vitamin E, selenium, for various reasons I will not go into now. And interesting, men that were taking more Vitamin E and selenium than needed to be taken, even though there was a hope that they will prevent prostate cancer, those men were more likely to develop prostate cancer if they were being given these supplements.

So I often discourage patients from doubling down on one or the other specific type of food. One thing that we can state is that healthy balanced diet, avoidance of large amounts of red meat that have been shown to be carcinogenic, are probably the best thing. Exercise. There has have even been studies that have shown that increased sexual activity may be preventative for prostate cancer, and people can look up those studies as well, that the number of ejaculations have correlated with the decreased risk of prostate cancer. So as of today, no one specific diet, just healthy, normal balanced food, and as of right now, we have no evidence to push one specific medication or mineral or ion to be able to prevent prostate cancer development.

[00:25:52] Host Amber Smith: Well, Dr. Bratslavsky, thank you so much for making time for this interview.

[00:25:56] Gennady Bratslavsky, MD: You're welcome, and thank you for having me.

[00:25:58] Host Amber Smith: My guest has been Dr. Gennady Bratslavsky. He's professor and chair of the urology department at Upstate University Hospital. "The Informed Patient" is a podcast covering health, science, and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.