Team of specialists helps patients find best treatment

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with a podcast that features experts from Central New York's only academic medical center. I'm your host Amber Smith. Many prostate cancers are slow growing confined to the prostate gland and cause no serious harm, but some types are aggressive and can spread quickly. We'll sort out what's important to know about a prostate cancer diagnosis with Dr. Alina Basnet. She's a medical oncologist and assistant professor of medicine at Upstate. Welcome to "The Informed Patient," Dr. Basnet.

Alina Basnet, MD: Thank you, Amber. Thank you for having me.

Host Amber Smith: Now, when you see a patient with a new diagnosis of prostate cancer, what sorts of information do you need before you can talk about next steps?

Alina Basnet, MD: That's a very good question, Amber. So, whenever I see a prostate cancer patient -- I'm a junior medical oncologist -- so my role is to deal with the prostate cancer in the front of the medical oncology. What that really means is that I deal with the drug part of the cancer treatment, right? Prostate cancer is a cancer that is treated by multiple disciplines, like, many of the doctors come together to treat a cancer. Like, you have a surgeon, you have a radiation oncologist, you have a medical oncologist. And when everybody comes together to treat that patient in the center, everybody has a predefined role and a very distinct role.

My role as a medical oncologist is to talk about the drugs, the oral drugs, the injections, the chemotherapies, the hormone therapies and so on and so forth. So, when I see prostate cancer, usually (it's at the) metastatic stage, meaning when the cancer has spread out of the prostate gland is when I mostly see my prostate cancer patient. And when I see that, I say, "OK, where is the cancer? Is it only in the prostate? Has it just gone to the lymph node around the prostate? Has it gone to the lymph node a little bit far off from the prostate? Has it gone into the bones? Has it gone into the organs?" Right?

That is the first thing I look at. So what I look at, where do I get that information from? I get that information from scan, so I look for the scans and we can talk about more in detail of what scans and what not in further talks. But that's where I look at.

Moreso with the development in the last couple of years, medical oncologists are getting involved in the prostate cancer treatment, even when they are not metastatic, even when they are not outside of the prostate gland. And those patients, we call it, quote, unquote, "high risk" or "very high risk" prostate cancer, meaning they have the chance, or they can invade the prostate and can metastasize, meaning spread, into the lymph nodes or the bones or the organs.

Or, in a sense, maybe they have already, like what we call it as "micro metastatic," meaning those small cells are kind of sneaky and they kind of sneaked out into the bloodstream already. We haven't seen the cells yet in the scans, but it might be there. So with that principle in mind, medical oncologists sometimes -- most of the times at 2023 -- get involved in the treatment of high risk and very high risk prostate cancer to deliver an aggressive standard of the care treatment where you aim to cure this patient that is in front of you for a very long period of time and give them the best quality of life.

So that's how a medical oncologist's role historically was sort of only in the metastatic setting. But at current time is also there in the non metastatic setting. And if I'm looking at metastatic patient, I'm looking at the scans, I'm looking at, "OK, what all organs are involved?"

If I'm looking at a non-metastatic patient, then I'm kind of looking at, "OK, what is their PSA (prostate-specific antigen test)? What is their Gleason score?" meaning that is a very particular term called Gleason, which is a term that a pathologist gives in the prostate cancer, it kind of gives you the grading of prostate cancer from low grade to high grade. And I look at those numbers to make a determination of where is this patient that is in front of me fall into which risk category? So those are the things I look at.

Host Amber Smith: So, by the time a man makes it to your office, does whether or not he has a family history of cancer, does it matter at that point?

Alina Basnet, MD: It matters, if I'm seeing a really young male. Back in the time when I was in my medical school -- that was not a long time ago, maybe 20 years ago -- we used to be taught that people don't die FROM prostate cancer; people die WITH prostate cancer. But unfortunately, that sentiment has changed. People now die from prostate cancer, unfortunately, because for some people, it's a very aggressive disease. And if you see that in a very young patient, then it becomes even more aggressive. And in that situation, the family history becomes very important.

Like, did your dad had prostate cancer? Did your uncle have prostate cancer? Should your son worry, right? Those things that matters. And that's where the family history plays a role. If you are seeing an elderly gentleman in their 80s and 90s with the prostate cancer, probably not so much. You know, that is probably what the biology of the prostate cancer was naturally tend to be that way.

So family history matters, but not in everyone. If I'm seeing an African American gentleman with the prostate cancer and then, in a younger side, then yes, then that matters, because our African American men tend to suffer from an aggressive variant of prostate cancer than their counter, a Caucasian male. So that kind of goes into the equation of when we kind of talk about the family history, and genetic testing and whatnot.

Host Amber Smith: So are there symptoms that you ask about? Or do most men with prostate cancer not have symptoms?

Alina Basnet, MD: That's that's a very interesting question, Amber. So most of the time, by the time they see a doctor like me, right, they usually have some sorts of thing going on. Either their bones are hurting, or they're having urinary symptoms, or they're bleeding from their urine by the time they see me. But, you know, when we talk about a step before me, when they're seeing a urologist, or they're seeing a primary care physician, where they're doing their PSA screening, PSA check, they might not have any symptom. Like the screening PSA is high, and then they are just fine. I mean, they don't like, "why my PSA is high?" That happens many, many, many, many times, very frequently.

By the time they get to see a urologist, it is either because their PSA is high or because they're having some urinary obstructive features, right? More and more we are seeing patient without symptom, because the screening PSA is something that is very, fortunately, widely accepted and widely available. And our primary care doctors are very good about doing those. So that's why we get to see patients without having any symptoms, by the value of the PSA is high. So not necessarily you have to have symptoms to have prostate cancer.

Host Amber Smith: When might you seek a genetic analysis of the tumor?

Alina Basnet, MD: So the genetic analysis of the tumor kind of goes in two folds, right? One of them is if I am treating a metastatic patient and they have failed the first line therapy, we call it, and then we want to see what is driving this tumor. We call that a driver mutation, meaning, OK, is this really just driven by the testosterone, or is it driven by some sort of an inherited genetic mutations like BRCA 1, BRCA 2? We call them driver mutations. And those driver mutations can be found if we at times look into the tumor, or if we at times look into the blood. That is the time I use those testing, to help me guide the treatment. That's one part of it.

The second part of it is if I'm, again, if I'm seeing a really young people in their 40s and younger people, like, 50s and 60s with the prostate cancer, and they have a family history, or if I'm seeing an African American male in the younger side, then I tend to do genetic testing even upfront to make sure that they don't have anything genetically inherited so that we can alert them. We can screen at times. We can cure patients out of the prostate cancer. We can put them in remission from prostate cancer.

But because if they have certain mutations, do they really have to worry about another cancer screening? Like, let's say if you have BRCA 2 mutation, right? You have a prostate cancer, but you're cured of prostate cancer, but do you now have to worry about the pancreatic cancer? Are you going to pass that BRCA 2 to your daughter, who is going to now worry about the breast cancer, ovarian cancer? And then is your son going to have to worry about the prostate cancer? So, all those, there are so many things that comes into the equation that we kind of think through when we order this genetic testing. And those are the people that I would be requesting up front for.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with Dr. Alina Basnet. She's a medical oncologist and assistant professor of medicine at Upstate, and we're talking about prostate cancer.

Now, some men see a urologist who treats prostate cancer and others may see a medical oncologist like yourself. What is the difference?

Alina Basnet, MD: I will go back to the first sentence that I started with: The prostate cancer is a multidisciplinary disease, right? You need all disciplines to treat this cancer. You need your surgeon. You need your radiation oncologist. You need your medical oncologist. And we all come together to treat this disease.

So, even though you are seeing a primary, like a urologist is driving your cancer treatment, you have to make sure that the radiation oncologist has weighed in in your case, a medical oncologist has weighed in in your case. And even if a medical oncologist is driving your case, is on the driver's seat to move it forward to move your treatment forward, you have to make sure that a urologist has weighed in in your case, (and) a radiation oncologist has weighed in in your case. It's not really about who is driving the treatment. It's really about what other disciplines have to say about your cancer treatment and what are the things that can be incorporated from this disciplines in your cancer treatment so that you get the best treatment and with the most effective treatment to control your disease for the longest time period ever, and giving you the best quality of life. So I think that's what's important.

Host Amber Smith: Well, let's talk about treatment options. And I know there are many for men with prostate cancer. When would you recommend active surveillance, and can you describe what that is?

Alina Basnet, MD: So, active surveillance really meaning that we're going to be actively surveilling, meaning actively observing your cancer. You still have cancer in your prostate, but we think not doing a treatment for it at this time is OK. But you might need treatment in future. That's why you have to be monitored, or surveilled, in other words. And you can't be just left alone. That's why you're going to have to have a certain follow ups, your laboratory workup, your prostate exam, your MRI, your biopsies. You know, there is a scheduled time frame for that. And that's why it's called active because you're not left alone.

You're going to have to find a doctor who is going to do that. And this is mostly done by urologist. You know, urologist brings you to the office and do it. It's not usually done by medical oncologist. And usually done in a patient who has a very low PSA, usually PSA of less than 10, and has a very low Gleason score, meaning Gleason of 6. And there are certain criteria that we have to fill through, like how many cores are involved, how much of a prostate gland is involved, and what is the general health of that patient in front of you. Is it a really healthy person? Is it a really sick person? Does he have other comorbidities, you know, which are more concerning than a prostate cancer?

So those kind of things come into play, and we kind of make a determination of OK, prostate cancer is not, at this time, risky to this person's life, is not going to cause his demise, but rather these other things can, or rather we can save this person from a toxicity of the treatment. And if we can save him another five years, 10 years from the toxicity of the treatment, knowing maybe five or 10 years, maybe 15 years from now, we still might need treatment, but we are saving you that 15 years of toxicity. So that's where the active surveillance principle comes from -- watching the disease actively, saving you off of the toxicity if we really can avoid. Because understand that if you're a 60-year old male or a 50-year old male, and you go through the prostate cancer treatment, some of the things are irreversible. Some of the damages are irreversible. And you have another 40 years ahead of you to live with a very poor quality of life. So you don't want that. I mean, you want longevity, but you also want a decent quality of life. So that's where the active surveillance principle comes from.

Host Amber Smith: Now, that PSA screening test you talk about, that's a blood test?

Alina Basnet, MD: That's correct.

Host Amber Smith: Is a man that tests positive and is found to have prostate cancer through that, is he liable to have other PSA tests all along the way just does that monitor the growth of the cancer?

Alina Basnet, MD: So, every male who has prostate within their body always is going to have a PSA, right? That's a normal. What is PSA? PSA is a blood test that tells you that it's a prostate specific antigen, meaning it is an antigen that is just made by prostate glands. So we females would never make a PSA because we don't have prostate, right? So that gland is making a normal enzyme. That is, we can measure it in the blood. So, that is PSA.

And you will have such a value, like, depending on how big your prostate is. Some people have it in a higher side. Some people have it on the lower side. And given that it's a lab value, it has a range. So when you exceed that normal range, then you kind of get a concern about, oh, why are you exceeding a normal range? Then that person needs to have another follow up either with another PSA or a biopsy or a referral to a urologist. That's how it works. But you just don't keep following PSA without seeing a specialist. If your PSA is high enough for your PCP, your primary care to be concerned about, you do need a referral to urologist to talk about the next steps.

Host Amber Smith: When would you recommend removal of the prostate?

Alina Basnet, MD: The removal of the prostate, of course, is one of the option. We call it a radical prostatectomy. And then there is something also called lymph node dissection, meaning you remove the lymph nodes around it. That is one form of the treatment for a localized prostate cancer, meaning when it has not spread outside of the prostate. So that is one form of the treatment that you can do.

There is an alternative to it, which is considered an equivalent approach. But for a general understanding, surgery is one of the form of the treatment that can be employed for a localized treatment of the prostate cancer.

Host Amber Smith: What are the non-surgical options that you might suggest?

Alina Basnet, MD: So, the equivalent approach is considered to be an external beam radiation therapy, or some other kind of a radiation therapy like brachytherapy, IMRT (Intensity-Modulated Radiation Therapy.) There are certain ways of radiation therapy delivered to the prostate and nearby lymph nodes, and there are seeds that can be placed in the prostate gland, which delivers radiation to the prostate gland and the lymph node where you can kill the prostate cancer within the prostate gland, but still have the prostate gland within your body. So it's a non surgical, equally effective treatment for the cancer in the prostate, without removing the prostate. And that is mostly, except for some low risk and very low risk situation, are done with hormone therapies in conjunction with the testosterone-depriving medication.

Host Amber Smith: Do all of your patients end up with hormone therapy?

Alina Basnet, MD: All of my patients end up with a hormone therapy called androgen deprivation therapy. Most of them, most of them, I would say, not all of them, but most -- like, almost 98% of them. And what it does is -- because male have testosterone in their body, their testes makes the testosterone, and that's what drives the prostate cancer -- so, the first thing you're going to do is take the testosterone away. Meaning take the food away, and you're going to starve the cancer to death. So on that principle, everybody gets a medication either in the form of an injection or pill to lower the testosterone or to deprive the body off of the testosterone. Hence, it is called androgen, which is testosterone deprivation therapy.

Host Amber Smith: So, how do you go about helping a man decide what is the best treatment for him?

Alina Basnet, MD: So I will come back to my previous point as you are going to have to meet with all the disciplines, right? You have a localized prostate cancer. You're going to meet with the surgeon. You're going to hear the pros and cons of that option. You're going to meet with the radiation oncologist. You're going to hear the pros and cons of about that option.

And then you're going to meet a doctor like me, a medical oncologist, and you're going to hear the pros and cons of the options that I have to offer. And then you're going to make your decision. That's what I would recommend.

Host Amber Smith: So it may depend on the person's age, and their stage of life, and their activity level, and their other medical conditions. It sounds like it's very individualized.

Alina Basnet, MD: That's correct. That's correct. And you have to look at the patient in front of you. You have to look at their comorbidities. You have to look at what is important for them, right? You have to look at their age, their other lifestyle activities, and even the fact that some patients are not even in a good health to undergo surgery, right? Can you even undergo an invasive procedure, or not? And then some patients have A lot of bowel issues, bladder issues. They may not be able to get radiation, right? So those are the things, there are so many things that comes into play. But rather than making a decision by just meeting one discipline, I encourage everyone to meet with multiple discipline before they make that decision so that they at least know what are their options? What are their disadvantage? What are their advantages? And what is the right path to take?

Host Amber Smith: Do you have any advice for the women in the man's life, in terms of being a support person for the man when he's a patient?

Alina Basnet, MD: Absolutely. 100%. You know, as much as the patient is the center of the treatment, right? He's in the center of this treatment, and he's the person who's going through this. Caregivers play a huge role in the success and of failure of the treatment. And most of the time that caregiver for that male could be the wife, could be the partner, could be the daughter, could be the daughter-in-law, sister, sister-in-law, so many things I've seen, right?

So, I would say that because males are males, because of the testosterone that they have been built with, and they have lived their life with, when you take that away, it's not easy. They're not going to feel like they're male anymore. They're going to go through a lot of emotions and a lot of mood changes, a lot of body changes, a lot of health changes, right? So we, as a family to them, have to understand that and have to support them in the way we can do. They need to go for exercise. Do they need motivation for that? Do we need to go with them? Do we need to push for that? Are they eating healthy? Are they maintaining their lifestyle? Are they going for the regular blood work? Are they going for this regular checkups?

And, you know, more importantly, just being there for them and understanding the detailed intricacies of the treatment and what could affect them and their, and his, lifestyle and ultimately their lifestyle is, I think, a lot has to do with who that person is with.

Host Amber Smith: Well, Dr. Basnet, thank you so much. I appreciate you making time for this interview.

Alina Basnet, MD: Absolutely. Anytime. And I'm very happy that I could talk, and that this is going to get out in the community and people can know about a very common disease like prostate cancer. And we, I just want to say one thing, that we at Upstate have an excellent, phenomenal multidisciplinary team. So any of the prostate cancer patients that gets to see a urologist or radiation oncologist or a medical oncologist at Upstate will be seeing a multidisciplinary team, and I want to say that.

Host Amber Smith: That's very good to know. My guest has been Dr. Alina Basnet. She's a medical oncologist and assistant professor of medicine at Upstate. "

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.