Supposed brain boosters; cancer survivorship; treating prostate cancer: Upstate Medical University's HealthLink on Air for Sunday, Sept. 3, 2023
Scientist and ADHD researcher Stephen Faraone, PhD, discusses whether drugs or supplements can boost concentration. Oncology nurse Susan Tiffany talks about transitioning from cancer treatment to cancer survivorship. Medical oncologist Alina Basnet, MD, goes over concerns about prostate cancer treatment.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a neuroscientist discusses products that say they can help us boost our concentration.
Stephen Faraone, PhD: ... actually, the kids that use stimulants to help them through college end up doing worse overall in terms of grade point averages than other kids. ...
Host Amber Smith: A nurse talks about the transition from cancer care into survivorship.
Susan Tiffany, RN: ... not only should they be screened for their cancer, but there's also routine screening, such as colonoscopies, Pap smears, mammograms, bone density ...
Host Amber Smith: And a medical oncologist goes over some of the concerns related to treatment of prostate cancer.
Alina Basnet, MD: ... We used to be taught that people don't die FROM prostate cancer; people die WITH prostate cancer. But that sentiment has changed. People now die from prostate cancer, unfortunately, because for some people, it's a very aggressive disease. ...
Host Amber Smith: All that, 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, an oncology nurse talks about survivorship. Then, a medical oncologist addresses treatment options for prostate cancer. But first, a neuroscientist discusses products that say they can help boost our concentration. Can they really?
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Can drugs that improve concentration in people with attention-deficit/hyperactivity disorder also help people who do not have ADHD?
We're exploring that with Dr. Stephen Faraone. He's a Distinguished Professor and vice chair of research of psychiatry and behavioral sciences at Upstate.
Welcome back to "HealthLink on Air," Dr. Faraone.
Stephen Faraone, PhD: Thank you, Amber. Great to be here again.
Host Amber Smith: College campuses and various workplaces are full of people who may turn to stimulants to help them stay awake and perform well on exams or during important deadline projects. Some of the stimulants they use are prescribed for helping people with ADHD to improve their concentration.
Do these medications work in people who don't have ADHD?
Stephen Faraone, PhD: Well, what I would tell you is that the medications will have an effect on these people, but they won't help them in the same domains as they help people with ADHD.
So, for people with ADHD, they improve concentration, they reduce hyperactivity and impulsivity, but for a person without those problems, it's not helpful.
It's almost like saying, I'm nearsighted, so I need glasses, but if I give my glasses to somebody who has perfect vision, it's not going to help them. In fact, it could make their life worse; it would make their life worse, from wearing glasses.
The college kids that use the stimulants think that because it helps people with ADHD, that somehow it's going to make them into super students and do better. And it doesn't. I mean, we know from studies that clearly show that actually the kids that use stimulants to help them through college end up doing worse overall in terms of grade point averages than other kids.
And we know from a recent study by some colleagues of mine in Australia that when you look at adults performing neuropsychological tasks, adults who don't have ADHD, having stimulants on board does not help them at all. It's not useful.
Host Amber Smith: Well, how do these things work?
Like Ritalin and dextroamphetamine, how do they work? What do they do in the body?
Stephen Faraone, PhD: Well, we know about those two medications, the class is called stimulants. People know them as Ritalin or Concerta for methylphenidate, or Adderall or Vyvanse for amphetamine, and there are many different variants of that.
What they do is that they target proteins in the brain, actually one specific protein called the dopamine transporter, which is -- I'll have to explain this, because it does get a little technical, but in the brain is a collection of cells called neurons. These neurons talk to each other. They're not physically connected. They're separated by small gaps. We call those gaps a synapse. And for one neuron to talk to another, it has to send chemicals across the synapse to propagate the message. To give a clear message, you have to have each of these neurons sending a chemical message to the subsequent neuron.
If there's not enough chemical in the synapse, the message gets garbled, gets confused, and is not as effective as it is in controlling the type of behavior or mental activity that these neurons regulate.
In the case of ADHD, the medicines literally block the activity of a protein called the dopamine transporter. And it prevents the dopamine transporter from removing a chemical called dopamine from the synapse. Because we think what happens is that, with people with ADHD, there's too many dopamine transporters that are removing the dopamine from the synapse too quickly, so the message isn't getting through.
So by blocking the transporter, you enable more message to get through and a less garbled and a clearer message to get through.
Host Amber Smith: So, the role of dopamine: We do need it, but not too much of it?
Stephen Faraone, PhD: Everybody needs dopamine. Dopamine is a very important neurochemical in the brain, among many others, and we need dopamine, for sure.
I should point out other medications for ADHD, which are not stimulants, medications like atomoxetine, viloxazine, clonidine and guanfacine. And these all work in another system called the norepinephrine system.
Essentially, the effect is similar. They try to improve the communication between neurons that use norepinephrine as the communicating neurochemical, as opposed to dopamine.
Host Amber Smith: And these are medications that we know work in people with ADHD. They've been studied.
Stephen Faraone, PhD: These have all been studied. All FDA approved and indicated for treating ADHD.
Host Amber Smith: Can you tell us about research from the University of Cambridge that looked into this?
Stephen Faraone, PhD: Well, this was a study where they literally had adults do some psychological tests, mental calculations, things of that sort. The goal of the study was to see if you were to give them a dose of stimulants, the kind that you would give to a person with ADHD, does it improve their performance on these tests?
And the answer is it didn't help them at all, which is something that makes perfect sense to me because they don't have the problem that the medication is supposed to improve. So, giving them the medication is not going to help them.
Host Amber Smith: Well, if stimulants don't improve concentration, is there a benefit to someone taking them if they just are trying to stay awake, either to drive or to study?
Stephen Faraone, PhD: There's no question that if you take a stimulant, it will keep you awake. I mean, the U.S. Air Force will give stimulants to pilots; they have to fly long, long missions, for sure. We know that stimulants keep people awake. College students will sometimes, therefore, use them to stay awake and study, so they can cram for a test, but we know that's a very bad way to study for tests, and it actually hurts them because if they think, "Oh, I don't have to study until the night before because I'm going to stay up all night studying, because I'm going to take Adderall or Concerta, and then I'll be wide awake in the morning, and I will be able to take the test," they're totally wrong, because the method of cramming for tests does not work, in general.
And taking the medication to help you do that probably worsens your performance on the test, because you may get side effects from the medication, such as feeling jittery because you took too much or having headaches, having other side effects from the medication that would put you in a situation where you're not going to test as well as you might otherwise.
I should also point out that many of the people who misuse these medications, they think, "Well, I'm not abusing a drug, because this isn't a street drug. This is a drug that was approved by the FDA, it was, given by a doctor to my friend for his ADHD, so therefore it's safe."
And the answer is, well, yes, the drug is safe, but there's a qualifier there. It's safe when it's prescribed by a physician for appropriate use, and the person has been cleared for that appropriate use. So, for example, there are some cases where you wouldn't prescribe the medication if somebody had a pre-existing cardiac condition, because it could kill them. People who misuse it, they haven't been screened for conditions that might hurt them if they take the medication, and that can lead to problems.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. My guest is professor Stephen Faraone.
Much of his research focuses on attention-deficit/hyperactivity disorder. And today we're talking about whether medications that improve concentration in people with ADHD can also provide a mental boost to people who don't have ADHD.
So if ADHD medications don't boost concentration for people who don't have ADHD, let me ask you about the supplements -- Prevagen, Neuriva -- these are advertised as brain boosters to improve memory or give you a sharper mind and clearer thinking. How do they work?
Stephen Faraone, PhD: Well, the answer is they don't work. So, I think we can start and stop there.
I always urge people, when they hear something like "this supplement will help you with a certain mental activity, mental trait or physical trait," just go to PubMed.gov (a government cite for scientific research) and do a search, and can you find publications that actually show that? And usually the answer is no.
Occasionally you can find something might help you for a certain indication. But none of these so-called brain boosters have ever been shown to be dramatically effective or effective at all for helping people. Mostly, it's just a waste of money. Frequently, we don't even know the mechanisms of action, because they haven't really been studied, because most of these supplements are not useful. People haven't bothered to study the mechanism.
And one exception is the omega-3 fatty acids. These have been shown to have a small effect in improving the symptoms of ADHD, but they haven't been shown to help people who don't have ADHD.
And the effect on ADHD is small. For some people it may do very well, but it's a very small subgroup of people. I do mention that a little because continually the field is trying to explore for new ways to treat ADHD that don't involve drugs. And, honestly, my colleagues have searched far and wide. They haven't found a diet, and they haven't found much in terms of supplements besides omega-3. And even omega-3, if you try it, don't try it for too long. And if it's not working, because if it's not working after a month or two, it's probably not going to work, and you should switch to something more effective.
Host Amber Smith: Prevagen, the advertising says that it contains an ingredient from jellyfish. Why jellyfish? Are they known to be sharp?
Stephen Faraone, PhD: No, (laughs) certainly not sharp thinkers. It's conceivable that there's some compound in the jellyfish that has some psychoactive effect. But frequently, these supplements will link on to something; there's some very tenuous association, like they might say in jellyfish we found this compound, and this compound has been found to help rats do better in a certain task, or something like that, and then all of a sudden say, "therefore it's going to help you," and it's usually the most tenuous of links.
The ones I would trust the most, if I were to say to someone, if you have to, if you're somebody who just has to use supplements, and you refuse to use standard treatments, I would go with those that have been used for centuries.
So, for example, my colleagues in China still use traditional Chinese medicines to treat ADHD. They have a whole variety of herbs and things of that sort, acupuncture, and they have some interesting data that I would say it's intriguing, but not compelling. And it's not compelling because they haven't done the right kinds of controlled trials to convince me. But the actual data themselves are intriguing enough to say this is worth consideration, and the fact that they've been used for a few thousand years suggests that there is something to it.
But for the most part, I will tell people, "Don't spend a lot of time chasing down these treatments." I can tell you a personal story of a friend of mine who said, "Hey, Steve, I know you're an ADHD expert. Could you talk to my daughter? I'm sure that my grandson has ADHD. She keeps taking him to all these alternative-medicine doctors and practitioners, and it's been two years, and nothing's happened. Could you just tell her what you think is the facts?"
And I did. And, I'll tell her what I'll tell the rest of the people out there looking for alternative medicine, and that's very simple: "Look, if you're afraid of drugs, just do this. Ask your pediatrician for a prescription of what he or she thinks is an appropriate medication. It'll most often be a stimulant drug. And then just try it for a day. If you don't like it after a day, if you think it's horrible, then you can stop. One day it's not going to harm anybody, but I'd suggest you try it for at least a week or two. And then, if you don't see anything you like, you can just stop right away."
Well, this daughter of the friend of mine, she called me back in a week after she got the prescription, and she said, "Oh, my God, I wish I had talked to you two years ago, because he is so much better, and I've just wasted so much of my time with these other, so-called, doctors."
In some ways, they're really quacks, because anybody who does not treat people based upon the evidence base is really not doing appropriate medicine or appropriate clinical work, including my psychology colleagues. I'm a clinical psychologist, and psychologists who like to treat ADHD psychologically are doing their patients harm, because they're denying them medical treatment that we know is much better than any psychological treatment that we have.
Host Amber Smith: Now, a lot of these supplements, though, that are on the market saying that they promote cognitive improvement or alertness or clarity, memory recall, those sorts of things, these are supplements that don't have the oversight of the FDA (Food and Drug Administration) for approval, right?
Stephen Faraone, PhD: Oh, that's right. None of them have been approved by the FDA at all. Their rules for advertising are, I guess, fairly lax, because they're allowed to make these claims. And if you read the fine print, the fine print on many of these supplements will tell you that basically they haven't been approved for what they're claiming that they're useful for.
Host Amber Smith: So has science found anything that can actually help people focus? Anything to eat or avoid eating or any sort of lifestyle modification?
Stephen Faraone, PhD: Well, in general, I always encourage people to, say, to start with the obvious things, get a good night's sleep, have a well-rounded diet, exercise regularly, don't become overweight, take care of yourself medically. If you do those basics, that's going to help everybody concentrate better and do better. Those things are far more important.
You know, the problem with us Americans is we're looking for a quick fix. Is there a quick fix, so I can eat as much as I want, I don't have to exercise, and I can still be super sharp and effective?
And the answer is you can't, basically. Most of us can't. We have to take care of ourselves. A lot of people take care of their cars better than they take care of themselves. It's bizarre.
Host Amber Smith: Well, Dr. Faraone, I appreciate you making time for this interview. Thank you.
Stephen Faraone, PhD: Happy to do it. Thank you.
Host Amber Smith: My guest has been Dr. Stephen Faraone. He's a Distinguished Professor and vice chair of research of psychiatry and behavioral sciences at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Transitioning from cancer treatment into survivorship -- next, on Upstate's "Health link on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
What happens when cancer treatment wraps up? Today I'm talking about that with Susan Tiffany. She's a registered nurse certified in oncology nursing who works at the Upstate Cancer Center.
Welcome back to "HealthLink on Air," Ms. Tiffany.
Susan Tiffany, RN: Thanks, Amber. It's nice to be here.
Host Amber Smith: Depending on many factors, cancer treatment may require intensive care where patients are seeing the same doctors and nurses and technicians for weeks or even months. I imagine some patients develop strong bonds with their care team, and I wonder, does that bond help with healing?
Susan Tiffany, RN: It does. It gives the patient an outlet. They are often coming into the cancer center biweekly or weekly, and they get to see the staff, and they get to share their feelings. And they're scared, they're vulnerable. And it's hard to share with their family, with their loved ones. Oftentimes it's just too close. It's hard for both. It's hard for the caregiver to hear the fear in the patient's voice, whereas the staff at the cancer center are familiar with it. We're trained. We have each other. We do have meetings to discuss it. We have services for us. Spiritual care (the chaplain service) is there for us to share our concerns.
Host Amber Smith: So, patients really depend on the emotional support that comes along with the medical care?
Susan Tiffany, RN: Oh, definitely. Definitely. And it's surprising. It's not just the nurses. It's the administrative staff. It's the front end staff. It is the nurses. It's the medical technicians. We're all there for the patients. And it's an important role. These patients are coming in at such a vulnerable time.
Oftentimes, people will say to me, that must be a really hard job. It's so sad. Well, it's also very rewarding. And I think that the staff, when you're an oncology professional, that's what we do. We help our patients get through these very intimate times. And it's very rewarding.
Host Amber Smith: So, how involved is a patient's primary care provider? When they're going through cancer treatment, if they sprain their ankle or something, do they go to their primary care provider, or does the cancer team handle everything that happens?
Susan Tiffany, RN: We like to handle everything that happens. When a cancer patient is receiving treatment, it depends on the treatment, it depends on the cancer, so, if there is an infection, we would want to know about that. So, during active treatment, the oncology team, the specialist, IS the primary care doctor.
Host Amber Smith: And then what happens when the patient's cancer treatment concludes?
Susan Tiffany, RN: Well, it's noted that primary care doctors have much respect for the oncology doctors, during the treatment phase, and oftentimes it's a difficult transaction to return back to the primary care doctor. So collaboration with primary care is very important. It's very important to the patient because not only are we transitioning back to primary care, but the patient is also transitioning back to primary care. And that can feel threatening. That can feel as though they're lost, that they're out there, and no one's going to watch their cancer.
And so we make sure that the primary care team is well aware of all the treatment that the patient received. And late and long-term side effects and surveillance, and that's really important. During cancer treatment, oftentimes routine screening can be put aside. So, not only should they be screened for their cancer, but there's also routine screening, such as colonoscopies, Pap smears, mammograms, bone density. And so that's one of the things that we make sure that doesn't go missed, by communicating with the primary care.
Host Amber Smith: Please tell us about the letter that you presented at a conference recently.
Susan Tiffany, RN: The letter that I presented was aimed at all primary care doctors. It's a template form that tells the primary care doctor that the patient was -- it's very brief -- that they were diagnosed with cancer, a little bit about the treatment, but also what side effects that they can watch for.
In sharing this information with the primary care doctor, we are being sure that they're aware of all the side effects that could happen with their cancer treatment, such as cardiac problems, pulmonary problems, skin problems. There's so many different kinds of treatments. So we do share that with the primary care doctor.
But also one of the most important things to share with the primary care doctor is the surveillance grid: Who's responsible for the mammogram? Who's going to the colonoscopy? Were there polyps before? So it's a communication about cancer surveillance and cancer screening, as well as making mention of what their treatment was.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with oncology nurse Susan Tiffany from the Upstate Cancer Center.
There are professional caregivers at the cancer center, or the hospital, but many patients also rely on family or friends to provide care at home. Let's talk about what that's like. Do you see this strengthening or fracturing relationships?
Susan Tiffany, RN: I see it strengthening. There's a lot of support. I hear that more than not, about how supportive my husband was, my wife, family, my job. Employers have been very supportive. But there is times it's, again, talking to your significant other, your close family members, about something that's going on with you can be very intimidating to both sides. The roles change. The provider is no longer the provider. The rulemaker is no longer the rulemaker. So things change. Roles change. And we do have, at Upstate, we have a psychologist that deals with oncology.
And so we can make referrals to them. Integrative medicine can be very helpful, looking at contentment and peace. And we have spiritual care that does the same. So, we do have resources, and it can be both ways. It can strengthen a relationship, and it can hurt.
Host Amber Smith: How do you counsel patients who are used to being the ones who are independent, but now they're requiring assistance, and maybe they don't like their partner or their family members seeing them feeling so bad?
Susan Tiffany, RN: Well, again, we do have, we can suggest the psychologist. But also, it's a normal feeling, talking to them about how normal it is, and how it's good to let go and let people care for you.
Host Amber Smith: What do you find yourself telling family and friends about how they might be able to assist their loved one?
Susan Tiffany, RN: By asking about their fears. Oftentimes, that's something that we don't discuss. And so being able to ask somebody what they're afraid of opens that up to that conversation. Again, we have social workers, we have psychologists that are trained in this area. And we do have in-services, so the nurses and the staff are all trained or educated, I should say, in how to respond to our patients. We know that this is a very vulnerable and stressful time.
Host Amber Smith: Well, you and I have talked before about cancer survivorship and how that actually begins at the time of diagnosis. I imagine there can be some shock wrapped up in a cancer diagnosis. How do you help patients understand what's happening and what lies ahead at the moment that they find out they have cancer?
Susan Tiffany, RN: Education, communication, checking in with them. It's hard. Oftentimes they don't hear what is being said, so we try and set it up, ask them to bring in loved ones so that -- or a support person, I should say -- to come in and sit with them and take notes. Talking to them about the normalcy of fears. And then making the referrals if we feel that it's something that needs intervention. We're all trained as that, to recognize when an intervention is required or needed.
Host Amber Smith: Do you see a patient's anxiety level get a little bit more manageable once they have a plan in place for when they're going to have, if it's chemo or radiation or surgery. Does that help, to know what's going to happen?
Susan Tiffany, RN: It definitely helps. Knowledge is power. At first, they just have a diagnosis in the waiting period of "What do I need?' Do I need radiation? Chemo?" And then once you hear the word "chemo," that can take you back years and years, and that means death to a lot of people. So once they understand what exactly they're in for, and that's very important on the staff, on the oncologist, on the nurses, to make sure that there is no questions, and to explain to the best that we can, because that's what's going to calm their anxiety.
Host Amber Smith: People who survive cancer can have anxiety about whether it's going to come back. What are some strategies you recommend for coping with that?
Susan Tiffany, RN: That is very true. There's a word for that: "Scan-xiety." They call it scan-xiety. And we do, again, the psychologist at Upstate is wonderful. That's a very common occurrence for cancer patients having to go back and get their scans. Acknowledging that, acknowledging that it is fearful, can help. And again, if it's interrupting with their activities of daily life, or preventing them to come in to get the scan, then we would suggest that they talk to the psychologist.
Host Amber Smith: Does having a history of cancer treatment, does that impact everything medical for that person going forward?
Susan Tiffany, RN: It can, because of the anxiety. So if you feel a bump, a bruise, tired, you lost a pound, you know, it can always be that reference of, "Is my cancer coming back?"
Host Amber Smith: And so once a patient is done with their cancer treatment, and they go back to their primary care provider, do they ever come back and see the cancer team for stuff after that?
Susan Tiffany, RN: Sure, but that's one of the best parts about the survivorship program. When they're first diagnosed, they are treated by, of course, the oncologist, and that may go on for three to five years, depending on what the surveillance plan is.
When it is time to leave the specialist and go back to their primary care, they have the survivorship navigator that is keeping tabs on them, talking about their treatment, talking about whatever concerns are coming up, talking about surveillance. And then we touch upon wellness, living your best life going forward. This is an opportune time to make changes with your health, lifestyle.
Host Amber Smith: Susan Tiffany, thank you so much for making time for this interview.
Susan Tiffany, RN: Thank you very much.
Host Amber Smith: My guest has been Susan Tiffany from the Upstate Cancer Center. She's a registered nurse certified in oncology nursing. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air" -- options for prostate cancer treatment.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
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 "HealthLink on Air," 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 "micrometastatic," 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 time 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 nonmetastatic 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 nonmetastatic 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 does 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 matter. 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 tending 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 (more) than their counterparts, 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 a very interesting question, Amber. So most of the time, by the time they see a doctor like me, right, they usually have some sort 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 patients 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 testings, 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 "HealthLink on Air" with your host, Amber Smith.
I'm 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 (caregiver), 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 these 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 certain follow-ups, your laboratory work-up, 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 urologists. 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? 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 provider, 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 options. 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 forms of the treatment that can be employed for a localized treatment of the prostate cancer.
Host Amber Smith: What are the nonsurgical 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 nonsurgical, 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 situations 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 males have testosterone in their body, their testes make 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 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 come 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 check-ups?
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 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. I'm Amber Smith for Upstate's "HealthLink on Air."
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Maggie Bowyer is a poet and author of the poetry collection "Ungodly." Her poem "Funeral Juxtaposition" shows us a young daughter's perspective on her mother's untimely death.
We stand far too close,
Baby hairs on forearms brushing,
Leaving prickles on our necks.
Everyone leans in,
Feasting on the words
Of a preacher who'd
Never even met her.
The pews weren't as stiff
As my words were
Reciting the Lord's Prayer
In my mother's name.
There was no burial,
As the only wish honored
Was her incineration.
After hugs full of
Too much perfume,
Stiff, freshly pressed suits,
And tears from relatives
Who meant relatively nothing to me,
We went home.
Laid out on the counters
Were ham biscuits
And cold cuts.
The room was filled
With the smell of meat
I refused to eat,
And the chatter of wrinkled lips
Between bites of
Too sweet brownies.
No one noticed
Me slip off my heels
And out the door.
I couldn't be there,
Where no one seemed to recall
How we just stared at
A seemingly plastic corpse,
My mom's hair completely wrong,
In her least favorite outfit.
And so I sat outside,
In the grass,
Feeling the sting
Of a late December rain.
I bet I ruined that dress,
The black one with
Small purple flowers,
The one I was supposed to
Wear to her wedding.
The rain seemed fitting;
She only liked to leave the beach
On rainy days.
My grandparents sat inside,
Forgetting storms of their own,
While I shared malice
With the clouds above.
I don't know how
You end a poem
About your mother's death
Much like I don't know how God
Ends a mother's life
When she was only 36.
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," work on a dengue virus is taking place at Upstate.
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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.