Dementia factors; genes and COPD; prostate cancer treatment: Upstate's HealthLink on Air for Sunday, May 5, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a public health researcher explains how your neighborhood may impact your risk of dementia.

Roger Wong, PhD: ... I found that in this 10-year period from 2011 until 2020, those that were foreign born, so born outside the United States, they had a 51% higher risk for dementia. ...

Host Amber Smith: A pulmonologist tells about research into the role genes may play in chronic obstructive pulmonary disease.

Auyon Ghosh, MD: ... A significant portion of folks who are at risk, people who have smoked, don't develop COPD. And the question here is, what makes those folks different? ...

Host Amber Smith: And a medical oncologist discusses prostate cancer treatment considerations.

Alina Basnet, MD: ... 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: 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, do your genes increase your resilience or your risk of developing chronic obstructive pulmonary disease, or COPD? Then, an oncologist discusses what to consider about prostate cancer treatment.

But first, we'll hear how neighborhoods may influence your risk of dementia.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Researchers are looking at what factors influence a person's risk for dementia. Today, I am talking with a public health and geriatrics researcher from Upstate who has examined how neighborhoods may impact dementia risk.

Dr. Roger Wong is an assistant professor of public health and preventive medicine, and he also has an appointment in the department of geriatrics.

Welcome back to "HealthLink on Air," Dr. Wong.

Roger Wong, PhD: Thank you for having me back, Amber.

Host Amber Smith: Before we get into the study itself, help us understand the measurements you used.

What does "nativity" mean, and why does that matter?

Roger Wong, PhD: For the context of the study, nativity is pretty straightforward. I think it's just whether or not you were born in the United States, and I think it's a really important topic right now because I think we all see the news. Immigration is a pretty hot topic, and it seems like many of these immigrants will be staying in the United States for the foreseeable future.

Host Amber Smith: What is meant by "neighborhood disadvantage"?

Roger Wong, PhD: Neighborhood disadvantage is, I think, a pretty loaded term. A lot of researchers have different definitions of neighborhood disadvantage. Typically, I see in previous research that neighborhood disadvantage is often measured as the percent of people in a specific community that has less than a high school degree, (and) what is the median income of the people in this certain ZIP code?

I think those are valid measures of maybe neighborhood disadvantage, but I mean, from a public health standpoint, I think it's pretty difficult to intervene and enforcing people to get a higher education, get higher incomes, when realistically, this is probably not possible.

So I measure neighborhood disadvantage a little bit differently. I look at it from more of the physical and social side of a neighborhood. I'm looking at things like neighborhood physical disorder, which in this study I define as whether or not the neighborhood has high levels of graffiti, litter and also vacant buildings. So that's the first component of neighborhood disadvantage I look at specifically for physical disorder. And then the second component is, I was looking at neighborhood social cohesion. This is whether or not you know, trust and help people in your neighborhood.

Host Amber Smith: So you really have to be familiar with the neighborhood that you're studying.

Roger Wong, PhD: Yes, and some people often ask me how objective are these measures for physical disorder and social cohesion, which I think is a fair question.

Starting with the physical disorder, I think that's pretty objective, because you have the researcher that goes directly to the community, and they have a pretty standardized questionnaire. They're looking around to see if there's litter, graffiti and also vacant buildings. So it's not from the person that's being interviewed, it's actually the researcher that is assessing this. So I think that's pretty objective.

Whereas, I would admit, obviously the researcher's not going to know how socially cohesive a neighborhood is, so we ask this to the person that's being interviewed.

Host Amber Smith: So tell us about your sample. How many people, and where were they from, that you were looking at?

Roger Wong, PhD: This study, it's funded by the National Institutes of Health, the NIH, and this sample that I was looking at, they're all older adults, 65 years and older. This is all of the United States, except for Hawaii and Alaska. And also, to be eligible for the study, you had to be a Medicare beneficiary, so this is like 99.9% of all people 65 years and older, on Medicare. And I was looking at a sample of 5,000 people. So that's the starting sample size.

And I was looking at 10 years of this dataset, so the first time that this data was collected was in 2011, and then they interviewed these same older adults every single year, so the end cutoff that I used was 2020, and the main reason for that is because there was a pandemic in 2020, so we didn't have a researcher that could go to the community at that year and measure physical disorder because there was a lockdown for many communities.

So in this 10 years of data for 65 years and older, and even though it's 5,000 people in the 48 states, I did something in statistics we call "weighting," where we try to adjust the results to be a little bit more representative of the whole U.S. population, because typically, in these datasets, they don't really interview enough racial and ethnic minorities, and they don't interview enough people in the oldest age groups.

So after I weighted these 5,000 people, these results are actually representing 27 million older adults in the United States, 65 years and older.

Host Amber Smith: Well, one of the things you were looking at is how nativity status is associated with dementia risk.

So what do we already know about this?

Roger Wong, PhD: It's a very complex literature on this topic, and, thankfully, I had a really great student. Daniel (Soong) is my co-author on this paper. He's in his second year in the MD program here at Upstate, and based on his review of the literature, he found that it's really convoluted, because there's kind of half of the literature that says that nativity is not associated with our risk for dementia. And then there's like kind of the other half that's shown that maybe nativity might be protective.

So I'll talk about the first half first. There's one paper that I can think of, I believe it's published from a group in California, and they found that there's basically no association between nativity and dementia. But the California population, when they were looking at non-native, so this is foreign-born older adults, pretty much everyone in that demographic group were Asian older adults. So they were comparing Asian older adults to white older adults. And so they found no association with nativity.

And then the other half, which finds that nativity might be protective, the best example that I can think of is a group in Texas. They found that there's something known as the "healthy immigrant effect," where people with more resources, they're more likely to immigrate into the United States, and as a result, they tend to be a whole lot healthier, and they protect their cognition later on in life because of that.

So this was the case that was talked about in the Texas group, where they found that for their non-native population, which was predominantly Hispanic, they had a protective effect for dementia.

Roger Wong, PhD: As you might be noticing, a huge problem is that the foreign-born older adults in these different studies, it's with just like one single racial/ethnic group. There's so many different racial/ethnic groups within "foreign born." So that's kind of the problem that Daniel and I tried to fix with this study -- or not fix, but contribute, with this study. We want to include multiple racial/ethnic groups for those that were both native and also non-native to the United States.

Host Amber Smith: So if there are papers that show that being foreign born increases your risk of dementia, and other papers that show that it decreases, what did your work show?

Roger Wong, PhD: I had three research questions for the paper that I'm talking about right now. My first research question is, I wanted to see, like, the answer to your question, Amber: What is the association between nativity and dementia risk? So I found that in this 10-year period from 2011 until 2020, those that were foreign born, so born outside the United States, they had a 51% higher risk for dementia by the end of the 2020 period.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with assistant professor of public health and preventive medicine at Upstate Dr. Roger Wong.

You also looked at differences in neighborhoods in their physical disorder and social cohesion. How does this vary based on nativity status?

Roger Wong, PhD: Last year I talked about the preceding study for this, where I was looking at the association between neighborhood physical disorder and social cohesion, how that's linked to dementia risk. The paper that I published a few years ago, I found that those older adults that were living in neighborhoods with more physical disorder, they had an 11% increased risk for dementia later on in life. And this was same dataset, but different years; it was 2011 until 2019. So, nine years of data for that. And then I didn't find a significant association between social cohesion and dementia risk.

Host Amber Smith: Do we know why living in a disadvantaged neighborhood with graffiti and vacant buildings, why does that increase someone's dementia risk?

Roger Wong, PhD: In my 2020 paper, I talked about how the most likely reason is because a lot of these older adults, they don't really feel safe exercising outdoors, and exercise is probably one of the best preventive approaches we can do today to protect our risk for dementia. So that is the main mechanism we talked about in our paper, about how we think living in these neighborhoods with very high levels of physical disorder is increasing our risk for dementia later on in life.

Host Amber Smith: There's got to be stress that goes along with that. If you're living in a place that you're so fearful of, you can't exercise outdoors, what is that stress doing?

Roger Wong, PhD: Yeah, for sure. And there's been quite a few studies also looking at neighborhood levels of stress and how that's been linked to dementia, and I totally agree. I think they go hand in hand with the safety in the neighborhood, the stress and how that's linked with dementia. And so there definitely have been papers that have talked about that mechanism as well.

Host Amber Smith: Well, looking from the other direction, even in a disadvantaged neighborhood, if there's an ethnic enclave of people who really are cohesive, have you seen that that makes a difference in dementia risk?

Roger Wong, PhD: Yeah. And ethnic enclaves is really fascinating to me. I am of Chinese descent, and most of my relatives live in ethic enclaves, so I have a few of my relatives that are living in Chinatown in Manhattan. And then the vast majority of my relatives are living in Flushing, in Queens. And I myself have lived in an ethic enclave. So I lived in Chinatown for at least a year between undergrad and grad school. I was teaching in the Bronx.

I thought it was so cool how it was a really socially cohesive neighborhood in Chinatown, but also it was just like high levels of physical disorder. There's just, like every day, graffiti on my apartment; it got painted over, and then, fresh graffiti the next day. And the sidewalks were really just not great as well. And so, it was really interesting for me to think about how does living in this type of neighborhood impact your health later on in life?

So that was another motivation for this paper I was also writing on nativity and neighborhood and dementia. Like, how does this all come together?

So for this paper that I'm talking about right now, unfortunately, we don't really have any measures of ethnic enclave; this was more of the motivator for the reason why we looked at this. But our theory was that, OK, so even though these immigrants are living in these ethnic enclaves, (with) high levels of physical disorder, the social cohesion, as you noted, Amber, it might protect their cognition later on in life. So that was kind of the original intention of the study, but we didn't answer that question.

So I think that might be the next direction that we want to answer: How does that all come together? Even though you have high levels of physical disorder, but maybe that's balanced with high levels of social cohesion, how does that kind of all fit into this relationship with nativity and dementia?

Host Amber Smith: For this paper, did you look at how a neighborhood could moderate the relationship between nativity status and dementia risk?

Roger Wong, PhD: Yes. I will answer that question, Amber. Maybe I'll talk about my second research question first, and then that moderation is my third research question.

So my second research question is, I wanted to see if there are any differences in physical disorder and social cohesion by whether or not you were born in the United States. I found from my second research question that those that were immigrants had significantly higher levels of physical disorder and also significantly lower levels of social cohesion in their neighborhoods. So this is throughout the whole 10-year period, from 2011 until 2020. So this is like their entire life. It's high levels of physical disorder, high levels and low levels of social cohesion for those that were immigrants, which is really concerning to me.

So that kind of led to my third research question. I found from my first research question that immigrants have a 51% significantly higher risk for dementia. And then I also found from my second research question, we're finding that immigrants are living in these neighborhoods that are more disadvantaged.

So that led to my third research question. OK, so basically, in lay terms, we know that dementia risk is higher for those that are immigrants. How does neighborhood play into this?

So immigrants, if they're living in neighborhoods with maybe high levels of social cohesion, so this is tying it back to, again, the whole ethnic enclave, maybe if they're living in these neighborhoods with high levels of social cohesion, is this protecting their cognition then, later in life?

And likewise, it's the same thing with physical disorder. Maybe if they're immigrants living in neighborhoods with higher physical disorder, maybe it might be further increasing their risk for dementia. So that's kind of what I tried to answer with my third research question.

Unfortunately, I didn't find anything in this third research question. Basically, it didn't seem like neighborhood was kind of explaining the reason why immigrants have a higher risk for dementia. I talk about, in the paper, that the theory that it's probably more due to discrimination that immigrants face on a frequent basis.

And I can see this as well from my parents. They're both immigrants. There's pretty high levels of, unfortunately, high levels of discrimination in the United States, especially when you're interacting with the health care system. So I think that might be part of the reason why immigrants have a higher risk of dementia later in life. It's probably partially due to discrimination and also partially due to stress, being an immigrant and trying to like, navigate this whole U.S. system as well.

Host Amber Smith: Well, let's go over some of the takeaways from your study. What would you like health care workers or health care professionals to be aware of?

Roger Wong, PhD: I think, as we talked about earlier, immigration is a huge issue right now because there's just a lot of folks that are trying to escape countries with sociopolitical unrest, and I think this will continue to be a huge problem in public health. So I think health care professionals should just be cognizant that my findings indicate that foreign-born older adults, they appear to have a significantly higher risk for dementia later in life.

And I think that's something we really need to address early and try to address as soon as possible, because right now, we don't have a cure for dementia. We don't have any definitive approaches to prevent dementia. And once you get dementia, it's really hard to treat it. Your memories won't come back. But with the current treatment methods we have, it's only able to kind of help the condition not get worse -- it's the best way that I can explain it.

So I think we really need to figure out right now and focus on these foreign-born older adults and how we can reduce the risk for dementia.

Host Amber Smith: Is there anything that you would suggest city planners could do regarding neighborhoods? Is there any way to design them or plan for them that would be more beneficial?

Roger Wong, PhD: I wish that we could include more green spaces within these neighborhoods for city planners, but I mean, realistically, I get it. I don't think that is always feasible. I think these findings are more related to have implications for maybe policy makers rather than city planners. Like in the paper I talked about, published in 2020, I was finding that racial/ethnic minorities are significantly more likely to also live in these disadvantaged neighborhoods with high levels of physical disorder, low levels of social cohesion. And then with this paper I'm talking about right now, with immigrants, they're also living in these same conditions of high levels of physical disorder, low social cohesion. So I wish that we could, from a policy standpoint, invest more in these neighborhoods because regardless of these demographic differences, it's clear from many studies, including mine, that these neighborhoods that are not really ideal to, and conducive to, physical activity, it increases their risk for dementia later in life. It's shown from many research studies. So I wish we could invest more in these neighborhoods from a policy standpoint.

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

Roger Wong, PhD: Yes. Thank you so much for having me.

Host Amber Smith: My guest has been Roger Wong. He's an assistant professor of public health and preventive medicine at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," looking into the role of genes in chronic obstructive pulmonary disease.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

A lung disease that affects more than 11 million Americans is called COPD, for chronic obstructive pulmonary disease. A researcher from Upstate wonders whether there are genetic factors that can contribute to the disease or that protect people from developing COPD.

Dr. Auyon Ghosh, an assistant professor of medicine at Upstate, recently was awarded a $1 million grant from the National Institutes of Health to investigate, and he's here to talk about his work.

Welcome to "HealthLink on Air," Dr. Ghosh.

Auyon Ghosh, MD: Thank you for having me.

Host Amber Smith: I'd like to start by asking you to tell us what we know about COPD.

Is this a disease that smokers get?

Auyon Ghosh, MD: Yeah, that's exactly right. Smokers are at higher risk of COPD than the general population, but there are a lot of other things that can affect a person's risk for COPD.

Host Amber Smith: What are some of those other things?

Auyon Ghosh, MD: In the U.S., the predominant risk factor is cigarette smoking.

But in developing countries and low- and middle-income countries, a growing number of people are at risk for COPD based on their exposure to air pollution.

Host Amber Smith: In America then, what percent of COPD cases are because of smoking? Is that the majority of them?

Auyon Ghosh, MD: It depends on how you look at it.

About 40% of smokers develop COPD, but of folks who have COPD, about 70% of those folks are smokers.

Host Amber Smith: So what are the symptoms?

Auyon Ghosh, MD: The symptoms of COPD kind of have this classic triad, as we call it: three cardinal symptoms of COPD. First is a cough that doesn't go away; excess sputum production -- making, coughing up, a lot of phlegm; and then feeling short of breath.

Host Amber Smith: So how does a person typically discover or get diagnosed with COPD?

Auyon Ghosh, MD: The usual way that this happens is that a person will have these types of symptoms, whether it's the cough, or the shortness of breath at rest, or when they're exerting themselves, and that'll bring them to see a doctor.

Once they see a doctor, usually they'll get referred to a pulmonologist, someone like myself, who will perform what are called pulmonary function tests, and that's kind of what we use to diagnose COPD.

Host Amber Smith: Are most of the people with COPD older people?

Auyon Ghosh, MD: Generally speaking, yes. The average age of diagnosis is in the early 60s, but in certain individuals, it can be a little bit earlier.

Host Amber Smith: And does it affect men and women the same?

Auyon Ghosh, MD: So part of the disparity or the difference in, the number of men and women that were affected by COPD, came down to differences in the rates of smoking that have changed over time. Fifty, 60 years ago, it was predominantly a disease in men, but as smoking rates increased in women, the number of women with COPD also increased.

Host Amber Smith: Now, does a person who is diagnosed with COPD, does it keep getting worse as they age?

Auyon Ghosh, MD: So for some, lung function can get worse as they age. For others, the lung function can kind of get bad and then stay at the same level. So the trajectory, or the rate at which lung function changes, can vary from person to person.

Host Amber Smith: Now, you mentioned the pulmonary function test to help diagnose. Do you use that to track where they are and if it's gotten better or worse, too?

Auyon Ghosh, MD: Yeah, certainly. At different periods of time for different folks, we'll repeat those pulmonary function tests to see what a person's lung function is doing over time.

Host Amber Smith: Are there effective treatments?

Auyon Ghosh, MD: There are great treatments that are out there to help with symptoms, but there really isn't a medication or some other treatment that can reverse the damage to the lungs or sometimes even slow the lung function decline. The best treatment that's out there is quitting smoking.

Host Amber Smith: Well, I'm anxious to hear about the project that received the grant. Now, this is from the NIH's National Heart, Lung and Blood Institute. What will you be looking at?

Auyon Ghosh, MD: The idea here is, and what we touched on a little bit earlier, is that really only a minority of smokers, about 40% of smokers, get COPD. So a significant portion of folks who are at risk, people who have smoked, don't develop COPD. And the question here is, what makes those folks different? We have done a lot of work in trying to better understand who's at risk, but we don't have a great understanding about the folks who are resistant, or as we call it, resilient, to developing COPD.

Host Amber Smith: Do you have ideas about why only 40% of smokers get COPD?

Auyon Ghosh, MD: We do, and some of the results that we've already seen are what we're going to be exploring further in this grant. Specifically, we know that there are certain genetic variants, or specific genes, that a person can have that puts them at higher risk.

What we want to know is, are there other genes, or other genetic variants, out there that reduce that high risk? So for folks who are at high risk because they smoke, or if they are at high risk because of the specific genes that they have, are there other genes that can mitigate those effects? Are there other genes that can kind of tamp down on the genes that cause a higher risk?

Host Amber Smith: So there might be a genetic reason that 60% of smokers seem to be protected from developing COPD. Is that what you're saying?

Auyon Ghosh, MD: Yeah, that's exactly right. and we are going to try to look for the genes, or the groups of genes, that can be protective.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with Upstate pulmonologist and assistant professor of medicine Dr. Auyon Ghosh. We're talking about COPD and a research project Dr. Ghosh recently received grant funding to conduct.

Well, I understand you'll be working with studies that involve more than 60,000 people. They're not all from Syracuse, right?

Auyon Ghosh, MD: No, no, no. The individuals who are a part of this study belong to studies that already exist. The NIH over many decades has developed and funded many different studies across the country that have recruited folks from different geographic areas, folks who belong to different demographic groups, and, over time, have collected the DNA samples and other molecular samples that are now available to the research community.

And so the idea here is that we're going to be able to use these 60,000 samples that have been collected over a long period of time to get additional insights from these samples that have already been collected.

Host Amber Smith: So some of them will be from people who have COPD, and some of them will be from people who don't? Is there a mix like that, or are you looking just at people with COPD?

Auyon Ghosh, MD: For the purposes of this project, we actually need, specifically, folks who don't have COPD, and we need to understand the folks who either have smoked or have high genetic risk of COPD but don't actually develop COPD.

What makes those folks different?

Host Amber Smith: I see. So how will your work be done?

Auyon Ghosh, MD: The project comes down to three different arms, or, as we call them, aims.

The first aim, we're trying to identify a set of genes that are protective, that contribute to what we're calling genetic resilience. So the idea here is that we're going to, first, identify the folks who are at high risk by looking at what's called a polygenic risk score, and I'll take a minute to talk about the polygenic risk score now. The idea is that each individual gene there has a variable amount of effect on a person's risk of developing COPD, for instance, but over the entire genome, which is millions and millions of these genetic variants, about seven and a half million, to be exact, about 2.5 million of these genes contribute to the genetic risk. And these contributions are very small, but when you add it up, over 2.5 million genes, that's when you can kind of figure out, OK, it's this person because their, 2.5 million genetic variants are at X amount of risk. And the next person, because of their 2.55 million genetic variants, are at Y amount of risk. And the idea here is that there are 5 million other genetic variants; how do these affect that risk?

Our goal is to take the folks who have the high polygenic risk score, meaning we've summed up the effects over those 2.5 million genes, and then we're going to look for differences in the other 5 million genetic variants to see how those 5 million variants affect that higher risk.

And so the polygenic risk score, again, basically puts together the information from millions and millions of variants, and then the polygenic resilience score, similarly, will be putting together the effects of another large set to see how those two things work together.

So going back to your question, the first part of what we're going to try to do is identify these genetic variants that reduce, or can help mitigate the effects of, folks who are at high risk.

The second part is to identify what are some other factors, like nongenetic factors, whether it's demographics or medical history or things like that, that can contribute to what we're calling resilience.

And then the third is to see how we can find molecular signals in the lung that are related to this resilience idea.

Host Amber Smith: So this polygenic risk or resilience score that you mentioned, has this been used in research previously?

Auyon Ghosh, MD: One of my collaborators actually developed the first polygenic resilience score for COPD, and that's what we're going to be using to identify these folks who are at high genetic risk.

And the concept of polygenic risk scores has been developed in a bunch of other diseases, namely, heart disease and heart attacks, diabetes and so forth, to identify folks who are at high genetic risk for these things to happen. Now, this type of research is still in the early stages; it hasn't really been deployed outside of the research context. But the hope is that by identifying folks who are at high genetic risk, that we can find ways to intervene before the disease really gets going.

Host Amber Smith: That's a little ways off though, right?

Auyon Ghosh, MD: Many, many, many years off, but that's the hope.

Host Amber Smith: But if your project does show that there's a gene or a collection of genes involved in either the risk or the resilience, then you can build on that and hopefully come up with some information that would help people.

Auyon Ghosh, MD: Absolutely. That's the goal.

Host Amber Smith: Well, Dr. Ghosh, thank you so much for making time to tell us about your work. I appreciate it.

Auyon Ghosh, MD: Thanks. It was a pleasure.

Host Amber Smith: My guest has been Upstate pulmonologist and assistant professor of medicine Dr. Auyon Ghosh. I'm Amber Smith for Upstate's "HealthLink on Air."

Prostate cancer treatment considerations. Next, on Upstate's "HealthLink on Air."

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, right -- 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 patients. 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?"

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 scans, so I look for the scans, and we can talk about more in detail of scans and what not in further talks, but that's where I look.

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 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 get involved in the treatment of high-risk and very high-risk prostate cancer to deliver an aggressive standard of care treatment, where you aim to cure this patient 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 patients, 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 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? 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. 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 a (more) aggressive variant of prostate cancer than their counterpart, 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: 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. But, 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 (say), 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 symptoms, 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 "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, 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 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 (conditions) 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. 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 provider to be concerned about, you do need a referral to a 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 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 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 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. 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 disadvantages? 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, 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. They need to go for exercise. Do they need motivation for that? Do we need to go with them? Are they eating healthy? Are they maintaining their lifestyle?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.

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: Physician and poet Tai Wei Guo gives us a portrait of a young girl in the hospital, reflecting on the sounds and sights all around her, as she tries to be brave.

Here is "Brave":

Machines in the hospital can cry, but brave little girls do not.

Little girls who cry startle doctors who ask "what's wrong?"

Doctors feel like they have to fix everything.

When your bones are broken, they fix your bones;

and when your bones are dislocated, they locate them.

When your pancreas is broken, they excise the tumor;

when your spirit is broken, they try to exorcise the fear.

Meanwhile, machines in the hospital sing all day of apocalypse:

Air in line, occlusion downstream, air in line, infusion complete.

Machines in the hospital are actually metronomes

because they count every lonely second with you.

Lub-dub pa-chik lub-dub pa-chik lub-dub pa-chik lub-dub --

Brave little girls whittle away at time watching Van Helsing.

Brave little girls read books like Dawkins and know there is

no use crying over statistics: someone had to be unlucky.

Brave little girls know refusing morphine is a sign

of strength and refusing faith is a sign of science because

refusing pity is the highest sign. Bravery is being content

watching ships outside the window barging downstream.

Except it doesn't feel brave to watch your mother crying.

Here is the secret: brave little girls are just

little girls because they never chose to be brave.

What else is there to be, with half a pancreas

and a line of staples holding their guts together.

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," how you can participate in a study focused on balance and mobility.

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.