August 6, 2024 • 41 mins
About 1 in 8 men will be diagnosed with prostate cancer during their lifetime. Join Lauren Bright Pacheco at the 2024 ASCO Annual Meeting in Chicago, as she investigates the advancements in prostate cancer care. Dr. Mohammad Atiq shares ways innovative treatments are paving the way for better outcomes.
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Speaker 1 (00:34):
Welcome to Symptomatic.
Speaker 2 (00:35):
Today, we are tackling prostate cancer, the most common cancer
men face, something one in eight men will navigate during
the course of their lifetime, which also has a ripple
effect on their friends and family. And we're recording this
episode from the twenty twenty four Asco American Society of
Clinical Oncology Annual Meeting. I am joined by a gentleman today,
(00:57):
ideally suited.
Speaker 1 (00:57):
For this complicated conversation.
Speaker 2 (01:00):
Doctor Mohammad Attique is an assistant professor in the Department
of Medicine at University of Chicago Medicine, where he specializes
in hematology and oncology, with a focus on genitorinary cancers.
His research has appeared in leading publications and has earned
him recognition as an American College of Physicians Young Achiever
(01:20):
and a Prostate Cancer Foundation Young Investigator.
Speaker 1 (01:24):
Welcome, Doctor Atique.
Speaker 3 (01:26):
Thank you, thank you. Happy to be here now.
Speaker 1 (01:28):
Right out of the gate, What drew you to this specialty?
Speaker 4 (01:31):
Yeah, so it really kind of started out my father's
medical oncologist, and so when I was younger, my siblings
and I would kind of go into the clinic maybe
help out there, and we grew up in a small
town in Arkansas. We really got to see the development
of the relations that he had with his patients, and
so that development of relations was something that we always
(01:53):
kind of grew to admire, But for myself it was
really I began to learn more about molecular biology and
genetics and getting into that, I became fascinated with the
science behind cancer, and so as I went through medical school,
I knew that I wanted to do something with it.
Speaker 3 (02:10):
I just didn't know in what shape, and so.
Speaker 4 (02:13):
I just kind of found myself gravitating more and more
towards medical oncology as I finished residency and I was
kind of looking at next steps. I was fortunate enough
to have great mentors at University of Arkansas who advised
me on considering joining a lab based in oncology or
oncologic work that could then help me further delineate my pathway,
(02:35):
whether that be in terms of a lab based physician, scientist,
or clinical investigator. And I connected with Philip Kantoff at
Memorial Sloan Kettering joined his lab and began the work
in prostate cancer at that bench side, and that kind
of was basically the start of getting into this area.
Speaker 2 (02:51):
And medicine is a passion shared by your siblings as well.
Speaker 4 (02:55):
Yeah, yeah, So I have a elder brother who is
a oncology resident at Lo Melinda. I have a younger
brother who's actually presenting a poster right now. He is
a medical oncology fellow at the National Cancer Institute, works
in bladder cancer. And then I have a sister who's
a first year resident at Cleveland Clinic and interestingly enough,
(03:18):
has already kind of gravitated towards one of the gu
oncology attendings there and is looking at doing research with her.
Speaker 1 (03:26):
Wow, that's amazing.
Speaker 2 (03:28):
If I ever get bad news, I'm going to come
to your next family reunion. Now, in terms of breaking
down prostate cancer, let's just start at a basic definition,
because a lot of people don't even understand what a
prostate is, right.
Speaker 4 (03:43):
So, this is a glendon, and it's anatomical position tends
to be you could think more kind of behind the
bladder and sort of encompassing a twobe that leads from
the bladder that drains out urine. The pro state itself
produces a protein, and so this kind of is something
we'll probably talk about a little bit more. But prostate
specific antigen. This then is a protein that comprises seminal fluid,
(04:09):
and so it produces that protein that then becomes a
component of that.
Speaker 1 (04:14):
Do we know why it is such a common cancer, So.
Speaker 4 (04:18):
We don't really have a clear understanding of why we know.
You know, different risk factors we obviously understand for the
development of it. So one of the most common things
is age, So about seventy percent of the cases diagnosed
in men are in men over age sixty five. We
know that family history plays a role in this, so
(04:39):
those with the first degree relative who have prostate cancer
have a two fold risk of developing disease, whereas those
with two first three relatives have a.
Speaker 3 (04:47):
Five fold risk of developing disease.
Speaker 4 (04:50):
We know that race also plays a role, so there
is a much higher incidence of the disease in the
United States and African American men. There's not clear evidence
that diet is causal, but we know that there are
some associations where having a higher red meat consumption the
diet can be associated with an increased risk, but nothing
(05:11):
that's clearly causal there.
Speaker 2 (05:13):
It's so interesting to me in how many ways prostate
cancer for men almost mirror statistically breast cancer for women.
Speaker 4 (05:22):
Yeah, you know, we look at both of these cancers,
and so even though they are obviously separate cancers, but
then in terms of a commonality, you kind of describe
it as an indocrine cancer, right, just something that's kind
of a gland sort of cancer in that sense, obviously
being very common in each individual sex, but also sharing
that kind of general category.
Speaker 2 (05:43):
What is the typical timeline in terms of symptom onset
to prostate cancer diagnosis?
Speaker 4 (05:51):
So this is something that you know is actually kind
of where the screening and prostate cancer also comes into
play and why there's been a lot of debate and
discussion there in the percent decade or so as well.
So in terms of the timeline to diagnosis and symptom onset,
the way that I kind of look at prostate cancers,
we have a lot of diagnosis that happens in the
(06:12):
asymptomatic stage, which is through screen, but in the symptomatic
stage that can be pretty variable. So symptoms could be
anything from what are those associated would say, just an
enlarged prostate BPH and so that can just be issues
with urinating, There can be some trouble with maybe weak
streams et cetera.
Speaker 3 (06:33):
But then symptoms.
Speaker 4 (06:34):
Kind of as a sort of spectrum, because it can
be as mild as that versus a gentlemen presenting to
an emergency room with.
Speaker 3 (06:41):
Severe back pain or difficulty walking.
Speaker 4 (06:44):
At that point, the prostate cancer is typically very, very advanced.
So it's a bit variable there in terms of that
timeline to diagnosis.
Speaker 2 (06:53):
And then what key role does timing play in terms
of fighting prostate cancer and what are the hurdles many
patients face in terms of recognizing early symptoms.
Speaker 4 (07:05):
Yeah, so in prostate cancer, early detection is very important,
so you're able to kind of keep an eye on
the disease going forward. You want to detect before the
cancer has spread or is causing severe symptoms. Now I
say severe because there's different kinds of symptoms you can have.
Speaker 3 (07:21):
When I say.
Speaker 4 (07:22):
Severe, meaning back pain and ability to walk, or pain
in the bone specifically that the prostate cancer is spread there,
but also the less severe forms of symptoms, which include
urinary hesitancy or weaker streams. And so the ideal timing
is obviously going to be before that you have severe
(07:42):
pain in the bones. Absolutely, But yes, in that earlier
part where maybe it's just in difficulty with urinating or
even before that. But we have to differentiate that early
detection does not equate early treatment, okay, And the reason
for this is that prostate cancer is risk stratified based
on some of its components. And so what we look
at here are the PSA level, which is a level
(08:06):
that's detected from the blood. So this is a protein
made by the prostate. If you have prostate cancer, then
it tends to be made in higher amounts.
Speaker 3 (08:15):
So that's one.
Speaker 4 (08:16):
Thing that we look at in terms of risk stratifying.
The other would be how the prostate cancer looks underneath
the microscope. This comes out to what's called a gleic
In score. And then we also look at what the
prostate cancer its extent of involvement is on exam or
on imaging, so that's called a clinical stage. So these
things help risk stratify prostate cancer. Now, when we have
(08:38):
prostate cancer that's detected early.
Speaker 3 (08:41):
And it falls in the low risk.
Speaker 4 (08:43):
Categories, these are the ones that are really managed with
active surveillance. And what I mean by that is that
active surveillance doesn't mean you're not doing anything, but it
means you're not going to surgery or radiation. What you're
actually doing is having PSA's check, digital rectal exams, repeat
biopsies on a periodic basis. And the rationale behind this
(09:06):
is that these low risk cancers, it's estimated about fifty
to sixty eight percent of the patients who have these
when it need treatment within ten years of diagnosis. And
so some will say, Okay, well, if I don't need
it within ten years, but i'll need it later, why
don't I just get it now? And that's because there
are side effects and there are issues when you have
(09:27):
surgery or radiation, just as within any medical treatment, and
so delaying the time to which you would need that
treatment and focusing on quality of life for a patient
is something that I think is very important. Just because
we can do something doesn't happen exactly.
Speaker 2 (09:42):
So it's not even just a wait and see, it
is strategize and observe.
Speaker 4 (09:48):
Oh absolutely absolutely so. Yeah, it's not just you know,
oh you have prostate cancer. I'll see you when I
see you, right, it's you have prostate cancer. But we
have a plan for this, and our plan is to
monitor this in conjunction with you, and we're going to
do this together. But like when do you do something right.
Let's say it's not ten years. I'm one of the guys.
Within ten years. Well, that's based on say the PSA,
(10:09):
so if it starts to increase rapidly, if on a
repeat biopsy so these are done periodically. If on that
say the gleas and score chains or the prostate cancer upgrades,
then that would be another trigger to then intervene. So yes,
it's not sit and wait, but it's actively watch and
make sure nothing's going on.
Speaker 1 (10:29):
Interesting.
Speaker 2 (10:30):
What do you think are the biggest misconceptions that people
have about prostate cancer in general?
Speaker 4 (10:36):
One of the biggest things is that you hear the
word cancer and you think I need to treat this now, right,
And I think that's one of the things that we
have to really make sure people understand is that you
may not have to immediately proceed to treatment. I think
the other thing is that there's a lot of misconceptions
about what the treatments mean for a person, and I
(11:00):
think it really requires a discussion with a physician about
what your treatment options are and where there's ability to
do something different than say just what one recommendation may be.
Speaker 2 (11:14):
That is interesting because you're right when people hear cancer,
they want to be as aggressive as possible, and perhaps
the best strategy is much more nuanced and measured.
Speaker 4 (11:24):
Yeah, yeah, you hear cancer and you think I have
to fight this. And it's not that you're not fighting this,
it's that you are fighting it appropriately in a way
that really helps you enjoy life to the best of
your ability.
Speaker 2 (11:36):
It can't be easy delivering that news to anybody. As
a doctor, how do you emotionally prepare for that conversation?
Speaker 4 (11:45):
Right, So, when we've become physicians, we take our hippocratic oath,
and as physicians we understand that it truly is a
privilege to be caring for someone. When someone comes to
you and you're two strangers and you walk in through
that patient or the clinic door, all of a sudden,
you're the most important person in that room and the
(12:05):
connection that you make with that person is very sacred.
And so you understand that, yes, this is an honor
to be able to take care of someone a major
responsibility as well. And so what that means is that
you have to focus on your training and preparation for
understanding of how to be able to be pragmatic with
(12:27):
someone but still balancing that with being too blunt. It's
kind of a mix of things that you sort of
have experienced during all your training that allows you to
be able to walk in that room and be able
to share with them the news that's going to be important,
but letting them know that we have an idea, we
have a plan of what we're going to do.
Speaker 2 (12:47):
For those and I should imagine anybody in that situation
receiving that news is going to immediately go to a
place of shock, fear, anxiety. How do you help the
patient navigate the information overload but also detach themselves emotionally
(13:08):
enough to be able to wrap their head around treatment.
Speaker 3 (13:11):
That's a great question.
Speaker 4 (13:13):
Some advice that you know, I generally have for patients
is if you have someone who can come with you
to an appointment that you you know, involve in these decisions,
it's great to bring them along because, as you rightly
mentioned there, you know the moment that someone hears about
what's going on with them, Sometimes they just shut down
and you can be talking and you think they're receiving
(13:33):
what you're saying, and at the end they may have
no clue. If you ask them to repeat back what
you talked about or what their understanding is. It may
just be blank stares. And so it's a matter of
sort of going through the visit where you've set the
stage and you're kind of doing it in increments, so
it's not just an information dump all at once, right,
you kind.
Speaker 3 (13:53):
Of work through things.
Speaker 4 (13:54):
You're frequently checking in with the patient to see, Okay,
do you have any questions about that? Are there things
is that you know you're wondering about there? I think
it's also important for patients. So what I frequently advise
is after our initial visit that whenever a random question
comes into your head about your disease, you're able to
write it down because that way, when you come to
(14:16):
see me the next time, we can talk about these
things and you're not scrambling, Oh what was it I
wanted to ask? So I think it's a matter of
just giving information and increments, checking with the patient to
see how they're understanding that, and also understanding, you know,
how you build on your visits with a patient. So
you know, a new patient visit, there's some very important
(14:37):
things that need to come across and decisions to be made,
and then there are other things that we add in
that maybe won't affect the patient's immediate care plan, but
would have a role as time goes on.
Speaker 2 (14:50):
We talked about, you know, the similarities and the parallels
between breast cancer for women and crosstate cancer for men.
But in terms of the emotional impact and the fear
that men have when they get that diagnosis, how do
you help them process that in terms of being so
attached to their masculinity and other fears.
Speaker 4 (15:15):
Right, it's through kind of having a very open and
honest discussion with them about what it looks like with
and without treatment, what things may look like for them.
How making the decision to undergo treatment is something that
you know, is obviously a very difficult decision, We understand that,
(15:36):
but at the same time, you know, is something that
they have to balance what kind of priorities are important
for them.
Speaker 2 (15:43):
There are there common misconceptions that patients have about the
likely outcome.
Speaker 4 (15:51):
So I think one of the common misconceptions is that
when they are diagnosed with this, that instantly they're like,
spend has now just become within a matter of months.
And I think that's something that's not necessarily unique to that.
I would say in general, patients when they hear the
word cancer. There's a lot of images and thoughts that
(16:12):
are evoked from just maybe things they've seen in movies
or TV shows, et cetera. You know, when patients come
to see me, sometimes they say, so it's just a
couple of months, like, you know, this is it right?
And you know you have to kind of temper that
and really let them know that not all cancers are
the same things behave differently and kind of let them
(16:32):
know where their cases are in terms of the spectrum disease.
Speaker 2 (16:36):
And so that is probably how you have to individually
tailor treatment to each specific patient.
Speaker 1 (16:43):
Can you just walk me through the stages of doing that.
Speaker 4 (16:46):
Yeah, So we're talking a little bit about risk stratification,
and what I'm referring to here is the National Comprehensive
Cancer Network Risk Sertification so NCCN guidelines.
Speaker 3 (16:54):
So that's something we commonly use.
Speaker 4 (16:56):
And so that risk traffication goes from very low risk
to very high risk, and it depends on PSA Gleason
score and then kind of the clinical staging meaning what
the prostate cancers and atomic involvement is based on digital
rectal examine imaging and so basically when a patient is
first diagnosed with prostate cancer. So this, you know, is
(17:17):
confirmed on a biopsy, so then that gives us a
Gleason score to start, we have a PSA value that
we'll get with that. Sometimes there's some imaging indicated there
as well, or maybe it's just a digital rectal exam,
but that will kind of put the patient in one
of these categories. Now, the risk categories are the risk
of the patient's cancer progressing or spreading. Essentially, it is
(17:38):
kind of what those fall into, and so based on
those risk categories, then we kind of look at life
expectancy as well. Sometimes you can have men who are
diagnosed with a prostate cancer, but they are much later
in life, and so at that point whether or not
to even pursue the surveillance can be a question simply
(18:02):
because there may be other things, natural causes that may
shorten one's life versus the prostate cancer itself. So after
you do kind of risk traification, life expectancy is a
big important part of that. Some patients may have severe
other medical issues that are affecting their life expectancy, so
those are kind of the initial sort of factors we
(18:24):
weigh when trying to decide which sort of treatment route
we're going to go with a patient after kind of
determining that. So let's say, you know, we have a
patient life expectancy, age, etc. Everything is within the range
that makes sense to pursue treatment. Then the discussion on
what treatment is more appropriate kind of comes down to
what the patient's tolerance for particular side effects may be.
(18:48):
Sometimes there are medical comorbilities that know they don't necessarily
limit someone's life significantly to where treating the prostate cancer
is inappropriate, but they still may mean that, say, radiation
may be more appropriate than surgery or something along those lines.
Speaker 2 (19:05):
Assessing a variety of risk factors is just the starting
point for creating a personalized treatment plan.
Speaker 1 (19:12):
Balancing each person's.
Speaker 2 (19:13):
Unique symptoms and treatment tolerance paves the road to recovery.
After the break, we'll continue our conversation with doctor Atique,
delving into the advancements made in prostate cancer therapies over
the past few decades and how they are reshaping patient outcomes.
(19:42):
Now back to my conversation with doctor Atique. Let's talk
about advancements and treatment, because obviously there's no good time
to receive a diagnosis of cancer, but there's probably been
no better time. Right now, tell me about the weapons
(20:03):
you would have had in your arsenal thirty years ago
as opposed to what you have now.
Speaker 4 (20:08):
So thirty years ago, we didn't have the radio ligands
that we have today. There's a lot of immune therapies
that although prostate cancer itself, you know, the disclaimer there
is it hasn't been traditionally one where immune therapy has
been as successful as compared to say, other gu cancers
like renal cancer for example, But we.
Speaker 3 (20:28):
Didn't have that.
Speaker 4 (20:29):
Even chemotherapy had really just come about into usage in
prostate cancer more in the late nineties. If we go
back thirty years, we're talking right about the time that
that came in there. Really what we had was hormone injections,
androgen approvation therapy and basically steroids, and then there was
also an agent called mitoxantrone, but that was really meant
(20:50):
to be one that was shown to help with palliation
for symptoms, so not really treating the disease. So you know,
you're talking about basically a handful of things that really
one was using at the time.
Speaker 2 (21:04):
And why are technological advancements so important in terms of
treating cross a cancer.
Speaker 4 (21:11):
Yeah, So in general, when you look at the population
we have, people are living longer, so there are more
people who are being diagnosed with prostate cancer. And so
while a large number of those people have localized cancers,
even out of the localized cancer, so this is about
a little bit over our quarter million men are diagnosed
every year, and out of that, around thirty to forty
(21:33):
percent who have treatment will have recurrence of disease and
then that eventually can progress to metastatic disease. And so
this is metastatic disease currently is an incurable state of disease.
But incurable doesn't mean that we can't control or manage it,
and that's where having these treatment options is vitally important.
And so what we've seen is that while we've been
(21:56):
able to add newer treatments in the past decade or
so to improve on the survival of men in these states,
cancer has been able to develop mutations or mechanisms of
resistance to get around those treatments. And that's where subsequent
treatments are important to be able to have in our
arsenal Wow.
Speaker 2 (22:15):
So for patients, it's important to find a doctor who
is evolving their arsenal as these new advancements come out.
Speaker 4 (22:26):
Right, there's a lot of advancements and options that are
available widely available, whether that's a physician in the community
or at a tertiary academic center. But then there are
options that you know, include clinical trials, and those tend
to be more isolated to kind of the larger groups
or larger centers, and so those are important things that
(22:48):
you know, we have to have available for patients as options.
Speaker 2 (22:53):
It's very interesting in terms of cancer trying to outsmart
the treatments.
Speaker 1 (22:58):
Yeah, what are radiopharmaceuticals?
Speaker 4 (23:01):
So basically you're thinking about a therapy that uses a
radioactive particle for treatment. So that's kind of the short
way of thinking about that. We've had that in prostate
cancer some time. But we've also had kind of a
newer particle added within the last couple of years getting
FDA approval in the form of lutetium. So this is
a beta emitter.
Speaker 2 (23:20):
We touched upon it a little bit, but why should
healthcare providers discuss innovative treatments early with metastatic castration resistant
prostate cancer patients?
Speaker 4 (23:33):
So in terms of discussing these early, so patients should
be able to know what their options are. I think,
you know, when patient's here they have metastatic cancer, their
mind just goes to how much time do I have?
And you have to also let them know that just
because you've heard this diagnosis doesn't mean there's nothing we
can do.
Speaker 3 (23:52):
So letting a patient.
Speaker 4 (23:53):
Know about their options upfront, I think kind of frames
things for them and gives them a sense that while
this is not what we wanted to hear, and this
is not what we would have desired, we are here together,
we're going to do this together, and we have a
plan for you.
Speaker 2 (24:08):
Are there certain patients that are better candidates for innovative treatments?
Speaker 3 (24:14):
Yeah?
Speaker 4 (24:14):
Absolutely so having a number of treatments and metastatic castration
resistant proces state cancer is great or in metastatic prostate
cancer in general. But what we're having to learn and
discover in the current field is the sequencing of these treatments.
So which one should go first?
Speaker 3 (24:31):
Right?
Speaker 4 (24:31):
We know based on some data, you know, okay, well yeah,
and we might start with X treatment and go.
Speaker 3 (24:37):
To the next one.
Speaker 4 (24:38):
But then there's just kind of a mix of options
which can all be appropriate, and so which one going
next and which one is the best to continue and
linked in to survival is kind of a big poin.
Speaker 2 (24:50):
Discussion do you have a favorite success story that illustrates that.
Speaker 4 (24:55):
So we had, you know, a great success story, and
this was at my prior program when I was in
training and I was working under the guidance of doctor
Robbie Maddens, one of my mentors and friends. We had
a patient and this was on a clinical trial that
we had there using aminocytokine when that was in combination
with androgen deprivation therapy, so the subcutaneous injections and then
(25:17):
dose tax which is chemotherapy. And I really like this
example because this was a much elderly gentleman. He had
just gone into his early eighties. And you know, when
you get here and you have a multitude of options,
choosing one most appropriate for you is always a big question.
And so there weren't particular mutations or things that would
have said he should have one treatment versus another. So
(25:39):
he was a great candidate for this study, and on
the study he was able to have over year and
a half two years on the same treatment in metastatic
castration resistant prostate cancer, which the overall survival for this
tends to be around years, but he was still on
one treatment in that area. And the reason that that
story really stood out to me was, you know, he
(26:01):
was a big hockey fan. The patient was able to
go to games frequently, he was able to attend his
daughter's wedding cross country. He had a very meaningful quality
of life without having to undergo different or other treatments,
whereas sometimes certain treatments may be particularly tough for a
patient tolerate. It may really limit what they're able to
(26:23):
do on a day to day basis.
Speaker 2 (26:25):
What are you most excited about in terms of the
advancements in terms of treating pasta cancer.
Speaker 4 (26:35):
There's a couple of different advancements coming into play, some
with phase one and phase two study data, so meaning
that you know, they're being shown to have safety and
or some efficacy in the disease state in the last
just couple of years here. So we kind of talked
about radio pharmaceuticals and I use the example of a
lutetium based radio pharmaceutical you know, and mentioned as that
(26:58):
was a beta emitterr there, but we also have alpha
emitters coming into the play, and so a different kind
of form of a radioactive particle, so phase one study
ongoing with that. So actinium is one that kind of
comes to mind currently, another kind of radio pharmaceutical coming
into play. The other things that you know are pretty
exciting to me include antibody drug conjugates and so what
(27:21):
these are are basically molecules here treatments that use a
targeting moniiclonal antibody. So it's kind of a portion of
this treatment is designed to target say a protein that's
expressed on protestate cancer cells. And then the other part
of the treatment is what's considered to be a payload
(27:42):
of a cytotoxic particle, and so these have approval and
other cancers, and so bringing it to prostate cancer is
something that's pretty exciting. And then another thing that actually
comes to mind as well. So those are the antibody
drug conjugates. But then we also have a form of
immune therapy called bispecific T cell engagers, and so basically
(28:04):
again has one part of it that targets a certain
protein and another part of it that brings in a
T cell. So basically brings a part of your immune
system to a cancer cell and kind of has it
recognize it to get a therapeutic event. So basically overall
kind of summarizing it is all comes back to targeted therapies, right,
(28:26):
So whether that's in the form of an antibody drug conjugate,
a BUI specific T cell engager, or in a radio
pharmaceutical that's you know, targeting psma.
Speaker 2 (28:36):
As somebody who is so on the cusp of advancements
as they're happening, do you find a hesitancy with more
traditional or old school providers and patients even to embrace
these advancements.
Speaker 4 (28:55):
So I think that you know, my interactions with fellow
physicians and you know call leagues around the country has
been pretty open to clinical trials because part of your
training is exposing you to understanding clinical research and trials
and the importance of these and developing the treatments that
we currently have. So, especially being at University of Chicago,
(29:15):
we do get a large number of referrals from physicians
in the community who have been practicing for a number
of years because you know, they kind of recognize when
the standard options may not be appropriate for patients. There
can be obviously some skepticism and this isn't I don't
think unique necessarily to physicians in the field for longer
durations versus you know, some who are just out of
(29:37):
kind of training. But you know, there can be some
skepticism about a trial, but that tends to be more
on scientific merit, So there can be debates about these things, right,
That's why we're doing trials. We don't know that X
treatment is really going to change the world. That's why
we're obviously trying to learn about it. I think for
patients there can be some hesitancy as well. You know,
(30:00):
when you use the word clinical trial, sometimes you know
just kind of flat out responses. You know, Doc, I
don't want to be a guinea pig.
Speaker 1 (30:07):
I was going to say guinea pig is right.
Speaker 4 (30:09):
And obviously, you know, in past years, with recent climate
in questions about some treatments that were around during the
pandemic and all, you know, from patients side, and a
lot of misinformation that have kind of bempeld around, there's
a higher sense of sort of maybe a garden nature
at times from patients that you may meet. But it's
really on physicians to explain kind of what we're doing
(30:31):
and why we're doing it. And you know, I think
through that when you're able to kind of let the
patient know first you are there to establish a relation
with the patient. When you are there and they know
that you're there to care for them and you're on
the same team with them, then I think that makes
it easier to bring up these subjects of you know,
some unknown therapy and when it may or may not
(30:53):
be appropriate for them.
Speaker 1 (30:54):
You just answered it.
Speaker 2 (30:55):
But I was going to touch upon the challenges that
healthcare providers in terms of new treatment plans.
Speaker 4 (31:03):
Absolutely, I mean again it comes back to while looking
up and trying to understand as much about your disease
as possible is great, there can be a lot of
less reliable sources out there that you know, make it
difficult for people to understand their care to the level
that's needed to make a well informed decision. So that,
you know, is kind of I think one of the
(31:24):
bigger challenges.
Speaker 2 (31:25):
In terms of well informed decision how do you navigate
the topic of risk in terms of treatment with your patients.
Speaker 4 (31:34):
In terms of that, we have adverse effects of treatments
which are important for patients to understand. So what those
possibly are now, as you can imagine that list of
adverse effects and be pretty long anything from things that yes, okay,
we're more likely to see this too, this was reported
and I don't know that in treating you know, three
hundred and four hundred patients, I've ever seen this happen,
(31:54):
and so I think you know, you obviously relay the risk,
you provide information in written form as you can, and
then obviously letting them know of any sort of important
additional potential adverse risk. So there's some very uncommon things
but can be particularly severe that you make sure patients
are aware of.
Speaker 2 (32:14):
So you're constantly monitoring and adjusting.
Speaker 4 (32:18):
Oh, absolutely, absolutely, So if you initiate a patient on treatment,
then ultimately you are the one who's making sure that
if there's any issues or problems that come up, that
those are being managed and as best as you can,
being cut off before they become major issues.
Speaker 2 (32:34):
How much is avoiding recycling existing therapies a factor when
you are creating a treatment plan.
Speaker 4 (32:42):
Yeah, so that's something we definitely look at in terms
of especially in the metastatic prostate cancer. So you're essentially
trying to get as much mileage as you can out
of every treatment option, right, and you want to be
able to go through and use it until the point
which maybe the cancer develops a sort of resist mechanism
to that. There are scenarios in which reusing therapies that
(33:04):
have been used before are reasonable. But the way that
I kind of look at it is more if a
patient has progressed on so and what I'm thinking about
here is one of the chemotherapy options in mind, but
also one of the oral second generation androgen receptor pathway inhibitors.
So these are two common drugs used in messin prostate cancer,
and so there is some sense of, well, if someone
(33:27):
progresses on say one of the ARPIS for short or
one form of the chemotherapy, then maybe you could come
back to that same chemotherapy or the ARPI. Now that
concept is there, but in the field we understand that,
especially in particular when it comes to arpis, if one
has progressed on them, coming back to a different form
(33:48):
of it is unlikely to produce a meaningful benefit. And
so that's where having all these other treatment options, including
the radio pharmaceuticals and clinical trials come into play.
Speaker 2 (33:57):
We've talked a lot about treatment options and also the
importance of having a support person for someone who receives
a diagnosis in terms of processing the information and helping
navigate treatment. But on your end, I know with breast
cancer there is very much a team approach. Is there
(34:19):
a medical team approach to prostate cancer?
Speaker 1 (34:21):
And ideally who would be on your team?
Speaker 3 (34:23):
Yeah?
Speaker 4 (34:23):
Absolutely, So there are some patient interfacing team members and
there are some who work more directly with the physicians
involved in this case and the other clinical staff involved
in this case. So in terms of patient facing members,
so there can be a urologist, a radiation oncologist, a
medical oncologist. Obviously our nurses who are a major backbone
(34:47):
and really do a lot of interactions and care with
our patients, so they're a big part of the patient
facing team approach. We also have members of the team
who don't necessarily have patient facing roles, but have critical
roles in the treatment of this patient. So that includes
pathologists and then radiologists as well. There's also nuclear medicine
(35:07):
physicians that can be involved depending on the treatment, so
it can be a pretty broad group of people working
together to take care of you.
Speaker 2 (35:14):
Is there also an emotional psychological component that you find
certain patients need.
Speaker 4 (35:22):
Yes, absolutely, I mean we do have psychological support and
all through our center, and there's other resources available for
patients for that, because it is critically important for patients.
It's sometimes hard to wrap your head around the diagnosis,
you know, it's hard to just get that first step in.
But also even with the treatment options or understanding what
that looks like, having the support of people who have
(35:46):
gone through the same situation or from a psychologist or
in some cases psychiatrists of their issues with emotional adjustment
to this can be very helpful.
Speaker 1 (35:57):
Yeah, because I should think that you know.
Speaker 2 (35:59):
For men it's as equally loaded and complicated and emotional
journey to process.
Speaker 5 (36:06):
Yeah.
Speaker 4 (36:06):
Absolutely, just cancer in general carries that right. And then
also because you know, there is a lot of thought
about the treatment we're using, does lower the men's testosterone
can affect things on a very emotional and personal level
for them, And so these are things that do require,
you know, more support than just from the medical side
(36:29):
of things.
Speaker 2 (36:30):
How has your specialty changed you personally in terms of
your relationships with patients and just looking back, how has
it shaped you as a doctor.
Speaker 4 (36:44):
So I think going into being a physician and kind
of gravitating more into medical oncology, I think personally You've
really had to exercise a much greater degree of empathy
than I probably possessed before. To be very frank, I
treat stay cancer all the time. I may be able to,
you know, sit there and I'm not worried at all
(37:05):
about something, but that's because of what I see and
what I do every day. And so I think personally,
you know, it's kind of made it to where you
really have to sit there and really put yourself in
the other person's shoes a lot more so and really
kind of think, Okay, if this is someone coming in
who has little to no understanding or doesn't have this training,
doesn't see this all the time, then how are they
(37:27):
going to feel about this?
Speaker 3 (37:28):
What could be going through their head?
Speaker 4 (37:30):
And I think that's probably one of the biggest things
that you know, I always try to keep in mind
with my patience.
Speaker 1 (37:36):
I love that.
Speaker 2 (37:37):
I love that your empathy has evolved, you know, and progressed,
as have the treatments.
Speaker 4 (37:44):
You know.
Speaker 1 (37:44):
What would you like listeners to take away?
Speaker 4 (37:47):
So a couple of key things. One is that when
you have prostate cancer, not treating it in some cases
is a reasonable option, and that comes down to how
it may affect your life and how the disease evolves.
There's you know, hundreds of men who you know, would
undergo procedures and things when they could very well have
just been monitoring and watched for several years. So I
(38:09):
think that's one key thing. The other is that there
are a lot of new technologies coming into play in
prostate cancer, and we're learning the best ways to utilize those.
But I think it's important to understand that while these
are there, some of these are not appropriate for every scenario,
and so it's good for patients to read and do
(38:31):
their own research and learn about what's out there, but
also to understand that having every test done, or every
procedure or every treatment is not necessarily the ideal way
to go about treating something. To managing a disease, you know,
you can lead to a lot of overdiagnosis, overtreatment and
issues there. I think the other thing is is that
(38:52):
just because you have prostate cancer doesn't mean you don't
have options, and so I think that's you know, kind
of a key thing.
Speaker 3 (38:59):
I think all the people mind.
Speaker 4 (39:00):
I obviously encourage patients to do their own research, but
in doing so, you know, talk to your physician, see
what they might recommend as an appropriate resource and you know, go.
Speaker 2 (39:10):
From there, and then on the flip side of that coin,
what do you want healthcare providers to take away?
Speaker 4 (39:16):
So I think that it actually kind of comes down
to almost similar advice. So in terms of when we're
advising patients, we need to make sure that we're doing
a good job of informing them about the risk of
the disease that they have, about the risk of the
treatments associated with it. But we also, you know, have
to be keeping up with kind of the latest advancements
(39:37):
in our area so that we understand when it's appropriate
to use something or not. There can be over diagnosis
or over treatment, you know, with all the new technologies
and things are available, and so it's on us to
kind of be understanding when it's appropriate to use something
or not.
Speaker 1 (39:55):
Is there anything else you'd like to add?
Speaker 4 (39:57):
No, I'm just really thankful for the opportunity to be
on today and to talk with you all, and obviously
for any patients out there who are being faced with
this diagnosis. There's teams of people across the country working
on this, trying to come up with advancements and there
to support you.
Speaker 1 (40:13):
Excellent answer thank you doctor for speaking with us.
Speaker 3 (40:17):
No, thank you very much for having me. I really
appreciate it.
Speaker 2 (40:23):
Thanks for listening to this special episode of Symptomatic. Be
on the lookout for all new episodes of Symptomatic in
the coming months, and if you haven't already, be sure
to go back and check out our two part episode
on doctor David Fagenbaum. Seemingly in the prime of his life.
David went from determined medical student to dying in the
(40:44):
ICU in a matter of days.
Speaker 5 (40:46):
I'll never forget my doctor walking into the room and saying, David,
your liver, your kidneys, your bone marrow, your heart, and
your lungs are shutting down.
Speaker 3 (40:58):
I was just treating Pa down the hall.
Speaker 2 (41:01):
Follow David's race against the clock for a diagnosis as
his efforts towards finding life saving treatment for himself quickly
become the first piece of an even larger puzzle. As always,
we would love to hear from you. Send us your
thoughts on this episode or share a medical mystery of
your own at Symptomatic at iHeartMedia dot com, and please
(41:23):
don't forget to rate and review Symptomatic wherever you get
your podcasts. We'll see you next time. Until then be
well
Welcome to Symptomatic.
Speaker 2 (00:35):
Today, we are tackling prostate cancer, the most common cancer
men face, something one in eight men will navigate during
the course of their lifetime, which also has a ripple
effect on their friends and family. And we're recording this
episode from the twenty twenty four Asco American Society of
Clinical Oncology Annual Meeting. I am joined by a gentleman today,
(00:57):
ideally suited.
Speaker 1 (00:57):
For this complicated conversation.
Speaker 2 (01:00):
Doctor Mohammad Attique is an assistant professor in the Department
of Medicine at University of Chicago Medicine, where he specializes
in hematology and oncology, with a focus on genitorinary cancers.
His research has appeared in leading publications and has earned
him recognition as an American College of Physicians Young Achiever
(01:20):
and a Prostate Cancer Foundation Young Investigator.
Speaker 1 (01:24):
Welcome, Doctor Atique.
Speaker 3 (01:26):
Thank you, thank you. Happy to be here now.
Speaker 1 (01:28):
Right out of the gate, What drew you to this specialty?
Speaker 4 (01:31):
Yeah, so it really kind of started out my father's
medical oncologist, and so when I was younger, my siblings
and I would kind of go into the clinic maybe
help out there, and we grew up in a small
town in Arkansas. We really got to see the development
of the relations that he had with his patients, and
so that development of relations was something that we always
(01:53):
kind of grew to admire, But for myself it was
really I began to learn more about molecular biology and
genetics and getting into that, I became fascinated with the
science behind cancer, and so as I went through medical school,
I knew that I wanted to do something with it.
Speaker 3 (02:10):
I just didn't know in what shape, and so.
Speaker 4 (02:13):
I just kind of found myself gravitating more and more
towards medical oncology as I finished residency and I was
kind of looking at next steps. I was fortunate enough
to have great mentors at University of Arkansas who advised
me on considering joining a lab based in oncology or
oncologic work that could then help me further delineate my pathway,
(02:35):
whether that be in terms of a lab based physician, scientist,
or clinical investigator. And I connected with Philip Kantoff at
Memorial Sloan Kettering joined his lab and began the work
in prostate cancer at that bench side, and that kind
of was basically the start of getting into this area.
Speaker 2 (02:51):
And medicine is a passion shared by your siblings as well.
Speaker 4 (02:55):
Yeah, yeah, So I have a elder brother who is
a oncology resident at Lo Melinda. I have a younger
brother who's actually presenting a poster right now. He is
a medical oncology fellow at the National Cancer Institute, works
in bladder cancer. And then I have a sister who's
a first year resident at Cleveland Clinic and interestingly enough,
(03:18):
has already kind of gravitated towards one of the gu
oncology attendings there and is looking at doing research with her.
Speaker 1 (03:26):
Wow, that's amazing.
Speaker 2 (03:28):
If I ever get bad news, I'm going to come
to your next family reunion. Now, in terms of breaking
down prostate cancer, let's just start at a basic definition,
because a lot of people don't even understand what a
prostate is, right.
Speaker 4 (03:43):
So, this is a glendon, and it's anatomical position tends
to be you could think more kind of behind the
bladder and sort of encompassing a twobe that leads from
the bladder that drains out urine. The pro state itself
produces a protein, and so this kind of is something
we'll probably talk about a little bit more. But prostate
specific antigen. This then is a protein that comprises seminal fluid,
(04:09):
and so it produces that protein that then becomes a
component of that.
Speaker 1 (04:14):
Do we know why it is such a common cancer, So.
Speaker 4 (04:18):
We don't really have a clear understanding of why we know.
You know, different risk factors we obviously understand for the
development of it. So one of the most common things
is age, So about seventy percent of the cases diagnosed
in men are in men over age sixty five. We
know that family history plays a role in this, so
(04:39):
those with the first degree relative who have prostate cancer
have a two fold risk of developing disease, whereas those
with two first three relatives have a.
Speaker 3 (04:47):
Five fold risk of developing disease.
Speaker 4 (04:50):
We know that race also plays a role, so there
is a much higher incidence of the disease in the
United States and African American men. There's not clear evidence
that diet is causal, but we know that there are
some associations where having a higher red meat consumption the
diet can be associated with an increased risk, but nothing
(05:11):
that's clearly causal there.
Speaker 2 (05:13):
It's so interesting to me in how many ways prostate
cancer for men almost mirror statistically breast cancer for women.
Speaker 4 (05:22):
Yeah, you know, we look at both of these cancers,
and so even though they are obviously separate cancers, but
then in terms of a commonality, you kind of describe
it as an indocrine cancer, right, just something that's kind
of a gland sort of cancer in that sense, obviously
being very common in each individual sex, but also sharing
that kind of general category.
Speaker 2 (05:43):
What is the typical timeline in terms of symptom onset
to prostate cancer diagnosis?
Speaker 4 (05:51):
So this is something that you know is actually kind
of where the screening and prostate cancer also comes into
play and why there's been a lot of debate and
discussion there in the percent decade or so as well.
So in terms of the timeline to diagnosis and symptom onset,
the way that I kind of look at prostate cancers,
we have a lot of diagnosis that happens in the
(06:12):
asymptomatic stage, which is through screen, but in the symptomatic
stage that can be pretty variable. So symptoms could be
anything from what are those associated would say, just an
enlarged prostate BPH and so that can just be issues
with urinating, There can be some trouble with maybe weak
streams et cetera.
Speaker 3 (06:33):
But then symptoms.
Speaker 4 (06:34):
Kind of as a sort of spectrum, because it can
be as mild as that versus a gentlemen presenting to
an emergency room with.
Speaker 3 (06:41):
Severe back pain or difficulty walking.
Speaker 4 (06:44):
At that point, the prostate cancer is typically very, very advanced.
So it's a bit variable there in terms of that
timeline to diagnosis.
Speaker 2 (06:53):
And then what key role does timing play in terms
of fighting prostate cancer and what are the hurdles many
patients face in terms of recognizing early symptoms.
Speaker 4 (07:05):
Yeah, so in prostate cancer, early detection is very important,
so you're able to kind of keep an eye on
the disease going forward. You want to detect before the
cancer has spread or is causing severe symptoms. Now I
say severe because there's different kinds of symptoms you can have.
Speaker 3 (07:21):
When I say.
Speaker 4 (07:22):
Severe, meaning back pain and ability to walk, or pain
in the bone specifically that the prostate cancer is spread there,
but also the less severe forms of symptoms, which include
urinary hesitancy or weaker streams. And so the ideal timing
is obviously going to be before that you have severe
(07:42):
pain in the bones. Absolutely, But yes, in that earlier
part where maybe it's just in difficulty with urinating or
even before that. But we have to differentiate that early
detection does not equate early treatment, okay, And the reason
for this is that prostate cancer is risk stratified based
on some of its components. And so what we look
at here are the PSA level, which is a level
(08:06):
that's detected from the blood. So this is a protein
made by the prostate. If you have prostate cancer, then
it tends to be made in higher amounts.
Speaker 3 (08:15):
So that's one.
Speaker 4 (08:16):
Thing that we look at in terms of risk stratifying.
The other would be how the prostate cancer looks underneath
the microscope. This comes out to what's called a gleic
In score. And then we also look at what the
prostate cancer its extent of involvement is on exam or
on imaging, so that's called a clinical stage. So these
things help risk stratify prostate cancer. Now, when we have
(08:38):
prostate cancer that's detected early.
Speaker 3 (08:41):
And it falls in the low risk.
Speaker 4 (08:43):
Categories, these are the ones that are really managed with
active surveillance. And what I mean by that is that
active surveillance doesn't mean you're not doing anything, but it
means you're not going to surgery or radiation. What you're
actually doing is having PSA's check, digital rectal exams, repeat
biopsies on a periodic basis. And the rationale behind this
(09:06):
is that these low risk cancers, it's estimated about fifty
to sixty eight percent of the patients who have these
when it need treatment within ten years of diagnosis. And
so some will say, Okay, well, if I don't need
it within ten years, but i'll need it later, why
don't I just get it now? And that's because there
are side effects and there are issues when you have
(09:27):
surgery or radiation, just as within any medical treatment, and
so delaying the time to which you would need that
treatment and focusing on quality of life for a patient
is something that I think is very important. Just because
we can do something doesn't happen exactly.
Speaker 2 (09:42):
So it's not even just a wait and see, it
is strategize and observe.
Speaker 4 (09:48):
Oh absolutely absolutely so. Yeah, it's not just you know,
oh you have prostate cancer. I'll see you when I
see you, right, it's you have prostate cancer. But we
have a plan for this, and our plan is to
monitor this in conjunction with you, and we're going to
do this together. But like when do you do something right.
Let's say it's not ten years. I'm one of the guys.
Within ten years. Well, that's based on say the PSA,
(10:09):
so if it starts to increase rapidly, if on a
repeat biopsy so these are done periodically. If on that
say the gleas and score chains or the prostate cancer upgrades,
then that would be another trigger to then intervene. So yes,
it's not sit and wait, but it's actively watch and
make sure nothing's going on.
Speaker 1 (10:29):
Interesting.
Speaker 2 (10:30):
What do you think are the biggest misconceptions that people
have about prostate cancer in general?
Speaker 4 (10:36):
One of the biggest things is that you hear the
word cancer and you think I need to treat this now, right,
And I think that's one of the things that we
have to really make sure people understand is that you
may not have to immediately proceed to treatment. I think
the other thing is that there's a lot of misconceptions
about what the treatments mean for a person, and I
(11:00):
think it really requires a discussion with a physician about
what your treatment options are and where there's ability to
do something different than say just what one recommendation may be.
Speaker 2 (11:14):
That is interesting because you're right when people hear cancer,
they want to be as aggressive as possible, and perhaps
the best strategy is much more nuanced and measured.
Speaker 4 (11:24):
Yeah, yeah, you hear cancer and you think I have
to fight this. And it's not that you're not fighting this,
it's that you are fighting it appropriately in a way
that really helps you enjoy life to the best of
your ability.
Speaker 2 (11:36):
It can't be easy delivering that news to anybody. As
a doctor, how do you emotionally prepare for that conversation?
Speaker 4 (11:45):
Right, So, when we've become physicians, we take our hippocratic oath,
and as physicians we understand that it truly is a
privilege to be caring for someone. When someone comes to
you and you're two strangers and you walk in through
that patient or the clinic door, all of a sudden,
you're the most important person in that room and the
(12:05):
connection that you make with that person is very sacred.
And so you understand that, yes, this is an honor
to be able to take care of someone a major
responsibility as well. And so what that means is that
you have to focus on your training and preparation for
understanding of how to be able to be pragmatic with
(12:27):
someone but still balancing that with being too blunt. It's
kind of a mix of things that you sort of
have experienced during all your training that allows you to
be able to walk in that room and be able
to share with them the news that's going to be important,
but letting them know that we have an idea, we
have a plan of what we're going to do.
Speaker 2 (12:47):
For those and I should imagine anybody in that situation
receiving that news is going to immediately go to a
place of shock, fear, anxiety. How do you help the
patient navigate the information overload but also detach themselves emotionally
(13:08):
enough to be able to wrap their head around treatment.
Speaker 3 (13:11):
That's a great question.
Speaker 4 (13:13):
Some advice that you know, I generally have for patients
is if you have someone who can come with you
to an appointment that you you know, involve in these decisions,
it's great to bring them along because, as you rightly
mentioned there, you know the moment that someone hears about
what's going on with them, Sometimes they just shut down
and you can be talking and you think they're receiving
(13:33):
what you're saying, and at the end they may have
no clue. If you ask them to repeat back what
you talked about or what their understanding is. It may
just be blank stares. And so it's a matter of
sort of going through the visit where you've set the
stage and you're kind of doing it in increments, so
it's not just an information dump all at once, right,
you kind.
Speaker 3 (13:53):
Of work through things.
Speaker 4 (13:54):
You're frequently checking in with the patient to see, Okay,
do you have any questions about that? Are there things
is that you know you're wondering about there? I think
it's also important for patients. So what I frequently advise
is after our initial visit that whenever a random question
comes into your head about your disease, you're able to
write it down because that way, when you come to
(14:16):
see me the next time, we can talk about these
things and you're not scrambling, Oh what was it I
wanted to ask? So I think it's a matter of
just giving information and increments, checking with the patient to
see how they're understanding that, and also understanding, you know,
how you build on your visits with a patient. So
you know, a new patient visit, there's some very important
(14:37):
things that need to come across and decisions to be made,
and then there are other things that we add in
that maybe won't affect the patient's immediate care plan, but
would have a role as time goes on.
Speaker 2 (14:50):
We talked about, you know, the similarities and the parallels
between breast cancer for women and crosstate cancer for men.
But in terms of the emotional impact and the fear
that men have when they get that diagnosis, how do
you help them process that in terms of being so
attached to their masculinity and other fears.
Speaker 4 (15:15):
Right, it's through kind of having a very open and
honest discussion with them about what it looks like with
and without treatment, what things may look like for them.
How making the decision to undergo treatment is something that
you know, is obviously a very difficult decision, We understand that,
(15:36):
but at the same time, you know, is something that
they have to balance what kind of priorities are important
for them.
Speaker 2 (15:43):
There are there common misconceptions that patients have about the
likely outcome.
Speaker 4 (15:51):
So I think one of the common misconceptions is that
when they are diagnosed with this, that instantly they're like,
spend has now just become within a matter of months.
And I think that's something that's not necessarily unique to that.
I would say in general, patients when they hear the
word cancer. There's a lot of images and thoughts that
(16:12):
are evoked from just maybe things they've seen in movies
or TV shows, et cetera. You know, when patients come
to see me, sometimes they say, so it's just a
couple of months, like, you know, this is it right?
And you know you have to kind of temper that
and really let them know that not all cancers are
the same things behave differently and kind of let them
(16:32):
know where their cases are in terms of the spectrum disease.
Speaker 2 (16:36):
And so that is probably how you have to individually
tailor treatment to each specific patient.
Speaker 1 (16:43):
Can you just walk me through the stages of doing that.
Speaker 4 (16:46):
Yeah, So we're talking a little bit about risk stratification,
and what I'm referring to here is the National Comprehensive
Cancer Network Risk Sertification so NCCN guidelines.
Speaker 3 (16:54):
So that's something we commonly use.
Speaker 4 (16:56):
And so that risk traffication goes from very low risk
to very high risk, and it depends on PSA Gleason
score and then kind of the clinical staging meaning what
the prostate cancers and atomic involvement is based on digital
rectal examine imaging and so basically when a patient is
first diagnosed with prostate cancer. So this, you know, is
(17:17):
confirmed on a biopsy, so then that gives us a
Gleason score to start, we have a PSA value that
we'll get with that. Sometimes there's some imaging indicated there
as well, or maybe it's just a digital rectal exam,
but that will kind of put the patient in one
of these categories. Now, the risk categories are the risk
of the patient's cancer progressing or spreading. Essentially, it is
(17:38):
kind of what those fall into, and so based on
those risk categories, then we kind of look at life
expectancy as well. Sometimes you can have men who are
diagnosed with a prostate cancer, but they are much later
in life, and so at that point whether or not
to even pursue the surveillance can be a question simply
(18:02):
because there may be other things, natural causes that may
shorten one's life versus the prostate cancer itself. So after
you do kind of risk traification, life expectancy is a
big important part of that. Some patients may have severe
other medical issues that are affecting their life expectancy, so
those are kind of the initial sort of factors we
(18:24):
weigh when trying to decide which sort of treatment route
we're going to go with a patient after kind of
determining that. So let's say, you know, we have a
patient life expectancy, age, etc. Everything is within the range
that makes sense to pursue treatment. Then the discussion on
what treatment is more appropriate kind of comes down to
what the patient's tolerance for particular side effects may be.
(18:48):
Sometimes there are medical comorbilities that know they don't necessarily
limit someone's life significantly to where treating the prostate cancer
is inappropriate, but they still may mean that, say, radiation
may be more appropriate than surgery or something along those lines.
Speaker 2 (19:05):
Assessing a variety of risk factors is just the starting
point for creating a personalized treatment plan.
Speaker 1 (19:12):
Balancing each person's.
Speaker 2 (19:13):
Unique symptoms and treatment tolerance paves the road to recovery.
After the break, we'll continue our conversation with doctor Atique,
delving into the advancements made in prostate cancer therapies over
the past few decades and how they are reshaping patient outcomes.
(19:42):
Now back to my conversation with doctor Atique. Let's talk
about advancements and treatment, because obviously there's no good time
to receive a diagnosis of cancer, but there's probably been
no better time. Right now, tell me about the weapons
(20:03):
you would have had in your arsenal thirty years ago
as opposed to what you have now.
Speaker 4 (20:08):
So thirty years ago, we didn't have the radio ligands
that we have today. There's a lot of immune therapies
that although prostate cancer itself, you know, the disclaimer there
is it hasn't been traditionally one where immune therapy has
been as successful as compared to say, other gu cancers
like renal cancer for example, But we.
Speaker 3 (20:28):
Didn't have that.
Speaker 4 (20:29):
Even chemotherapy had really just come about into usage in
prostate cancer more in the late nineties. If we go
back thirty years, we're talking right about the time that
that came in there. Really what we had was hormone injections,
androgen approvation therapy and basically steroids, and then there was
also an agent called mitoxantrone, but that was really meant
(20:50):
to be one that was shown to help with palliation
for symptoms, so not really treating the disease. So you know,
you're talking about basically a handful of things that really
one was using at the time.
Speaker 2 (21:04):
And why are technological advancements so important in terms of
treating cross a cancer.
Speaker 4 (21:11):
Yeah, So in general, when you look at the population
we have, people are living longer, so there are more
people who are being diagnosed with prostate cancer. And so
while a large number of those people have localized cancers,
even out of the localized cancer, so this is about
a little bit over our quarter million men are diagnosed
every year, and out of that, around thirty to forty
(21:33):
percent who have treatment will have recurrence of disease and
then that eventually can progress to metastatic disease. And so
this is metastatic disease currently is an incurable state of disease.
But incurable doesn't mean that we can't control or manage it,
and that's where having these treatment options is vitally important.
And so what we've seen is that while we've been
(21:56):
able to add newer treatments in the past decade or
so to improve on the survival of men in these states,
cancer has been able to develop mutations or mechanisms of
resistance to get around those treatments. And that's where subsequent
treatments are important to be able to have in our
arsenal Wow.
Speaker 2 (22:15):
So for patients, it's important to find a doctor who
is evolving their arsenal as these new advancements come out.
Speaker 4 (22:26):
Right, there's a lot of advancements and options that are
available widely available, whether that's a physician in the community
or at a tertiary academic center. But then there are
options that you know, include clinical trials, and those tend
to be more isolated to kind of the larger groups
or larger centers, and so those are important things that
(22:48):
you know, we have to have available for patients as options.
Speaker 2 (22:53):
It's very interesting in terms of cancer trying to outsmart
the treatments.
Speaker 1 (22:58):
Yeah, what are radiopharmaceuticals?
Speaker 4 (23:01):
So basically you're thinking about a therapy that uses a
radioactive particle for treatment. So that's kind of the short
way of thinking about that. We've had that in prostate
cancer some time. But we've also had kind of a
newer particle added within the last couple of years getting
FDA approval in the form of lutetium. So this is
a beta emitter.
Speaker 2 (23:20):
We touched upon it a little bit, but why should
healthcare providers discuss innovative treatments early with metastatic castration resistant
prostate cancer patients?
Speaker 4 (23:33):
So in terms of discussing these early, so patients should
be able to know what their options are. I think,
you know, when patient's here they have metastatic cancer, their
mind just goes to how much time do I have?
And you have to also let them know that just
because you've heard this diagnosis doesn't mean there's nothing we
can do.
Speaker 3 (23:52):
So letting a patient.
Speaker 4 (23:53):
Know about their options upfront, I think kind of frames
things for them and gives them a sense that while
this is not what we wanted to hear, and this
is not what we would have desired, we are here together,
we're going to do this together, and we have a
plan for you.
Speaker 2 (24:08):
Are there certain patients that are better candidates for innovative treatments?
Speaker 3 (24:14):
Yeah?
Speaker 4 (24:14):
Absolutely so having a number of treatments and metastatic castration
resistant proces state cancer is great or in metastatic prostate
cancer in general. But what we're having to learn and
discover in the current field is the sequencing of these treatments.
So which one should go first?
Speaker 3 (24:31):
Right?
Speaker 4 (24:31):
We know based on some data, you know, okay, well yeah,
and we might start with X treatment and go.
Speaker 3 (24:37):
To the next one.
Speaker 4 (24:38):
But then there's just kind of a mix of options
which can all be appropriate, and so which one going
next and which one is the best to continue and
linked in to survival is kind of a big poin.
Speaker 2 (24:50):
Discussion do you have a favorite success story that illustrates that.
Speaker 4 (24:55):
So we had, you know, a great success story, and
this was at my prior program when I was in
training and I was working under the guidance of doctor
Robbie Maddens, one of my mentors and friends. We had
a patient and this was on a clinical trial that
we had there using aminocytokine when that was in combination
with androgen deprivation therapy, so the subcutaneous injections and then
(25:17):
dose tax which is chemotherapy. And I really like this
example because this was a much elderly gentleman. He had
just gone into his early eighties. And you know, when
you get here and you have a multitude of options,
choosing one most appropriate for you is always a big question.
And so there weren't particular mutations or things that would
have said he should have one treatment versus another. So
(25:39):
he was a great candidate for this study, and on
the study he was able to have over year and
a half two years on the same treatment in metastatic
castration resistant prostate cancer, which the overall survival for this
tends to be around years, but he was still on
one treatment in that area. And the reason that that
story really stood out to me was, you know, he
(26:01):
was a big hockey fan. The patient was able to
go to games frequently, he was able to attend his
daughter's wedding cross country. He had a very meaningful quality
of life without having to undergo different or other treatments,
whereas sometimes certain treatments may be particularly tough for a
patient tolerate. It may really limit what they're able to
(26:23):
do on a day to day basis.
Speaker 2 (26:25):
What are you most excited about in terms of the
advancements in terms of treating pasta cancer.
Speaker 4 (26:35):
There's a couple of different advancements coming into play, some
with phase one and phase two study data, so meaning
that you know, they're being shown to have safety and
or some efficacy in the disease state in the last
just couple of years here. So we kind of talked
about radio pharmaceuticals and I use the example of a
lutetium based radio pharmaceutical you know, and mentioned as that
(26:58):
was a beta emitterr there, but we also have alpha
emitters coming into the play, and so a different kind
of form of a radioactive particle, so phase one study
ongoing with that. So actinium is one that kind of
comes to mind currently, another kind of radio pharmaceutical coming
into play. The other things that you know are pretty
exciting to me include antibody drug conjugates and so what
(27:21):
these are are basically molecules here treatments that use a
targeting moniiclonal antibody. So it's kind of a portion of
this treatment is designed to target say a protein that's
expressed on protestate cancer cells. And then the other part
of the treatment is what's considered to be a payload
(27:42):
of a cytotoxic particle, and so these have approval and
other cancers, and so bringing it to prostate cancer is
something that's pretty exciting. And then another thing that actually
comes to mind as well. So those are the antibody
drug conjugates. But then we also have a form of
immune therapy called bispecific T cell engagers, and so basically
(28:04):
again has one part of it that targets a certain
protein and another part of it that brings in a
T cell. So basically brings a part of your immune
system to a cancer cell and kind of has it
recognize it to get a therapeutic event. So basically overall
kind of summarizing it is all comes back to targeted therapies, right,
(28:26):
So whether that's in the form of an antibody drug conjugate,
a BUI specific T cell engager, or in a radio
pharmaceutical that's you know, targeting psma.
Speaker 2 (28:36):
As somebody who is so on the cusp of advancements
as they're happening, do you find a hesitancy with more
traditional or old school providers and patients even to embrace
these advancements.
Speaker 4 (28:55):
So I think that you know, my interactions with fellow
physicians and you know call leagues around the country has
been pretty open to clinical trials because part of your
training is exposing you to understanding clinical research and trials
and the importance of these and developing the treatments that
we currently have. So, especially being at University of Chicago,
(29:15):
we do get a large number of referrals from physicians
in the community who have been practicing for a number
of years because you know, they kind of recognize when
the standard options may not be appropriate for patients. There
can be obviously some skepticism and this isn't I don't
think unique necessarily to physicians in the field for longer
durations versus you know, some who are just out of
(29:37):
kind of training. But you know, there can be some
skepticism about a trial, but that tends to be more
on scientific merit, So there can be debates about these things, right,
That's why we're doing trials. We don't know that X
treatment is really going to change the world. That's why
we're obviously trying to learn about it. I think for
patients there can be some hesitancy as well. You know,
(30:00):
when you use the word clinical trial, sometimes you know
just kind of flat out responses. You know, Doc, I
don't want to be a guinea pig.
Speaker 1 (30:07):
I was going to say guinea pig is right.
Speaker 4 (30:09):
And obviously, you know, in past years, with recent climate
in questions about some treatments that were around during the
pandemic and all, you know, from patients side, and a
lot of misinformation that have kind of bempeld around, there's
a higher sense of sort of maybe a garden nature
at times from patients that you may meet. But it's
really on physicians to explain kind of what we're doing
(30:31):
and why we're doing it. And you know, I think
through that when you're able to kind of let the
patient know first you are there to establish a relation
with the patient. When you are there and they know
that you're there to care for them and you're on
the same team with them, then I think that makes
it easier to bring up these subjects of you know,
some unknown therapy and when it may or may not
(30:53):
be appropriate for them.
Speaker 1 (30:54):
You just answered it.
Speaker 2 (30:55):
But I was going to touch upon the challenges that
healthcare providers in terms of new treatment plans.
Speaker 4 (31:03):
Absolutely, I mean again it comes back to while looking
up and trying to understand as much about your disease
as possible is great, there can be a lot of
less reliable sources out there that you know, make it
difficult for people to understand their care to the level
that's needed to make a well informed decision. So that,
you know, is kind of I think one of the
(31:24):
bigger challenges.
Speaker 2 (31:25):
In terms of well informed decision how do you navigate
the topic of risk in terms of treatment with your patients.
Speaker 4 (31:34):
In terms of that, we have adverse effects of treatments
which are important for patients to understand. So what those
possibly are now, as you can imagine that list of
adverse effects and be pretty long anything from things that yes, okay,
we're more likely to see this too, this was reported
and I don't know that in treating you know, three
hundred and four hundred patients, I've ever seen this happen,
(31:54):
and so I think you know, you obviously relay the risk,
you provide information in written form as you can, and
then obviously letting them know of any sort of important
additional potential adverse risk. So there's some very uncommon things
but can be particularly severe that you make sure patients
are aware of.
Speaker 2 (32:14):
So you're constantly monitoring and adjusting.
Speaker 4 (32:18):
Oh, absolutely, absolutely, So if you initiate a patient on treatment,
then ultimately you are the one who's making sure that
if there's any issues or problems that come up, that
those are being managed and as best as you can,
being cut off before they become major issues.
Speaker 2 (32:34):
How much is avoiding recycling existing therapies a factor when
you are creating a treatment plan.
Speaker 4 (32:42):
Yeah, so that's something we definitely look at in terms
of especially in the metastatic prostate cancer. So you're essentially
trying to get as much mileage as you can out
of every treatment option, right, and you want to be
able to go through and use it until the point
which maybe the cancer develops a sort of resist mechanism
to that. There are scenarios in which reusing therapies that
(33:04):
have been used before are reasonable. But the way that
I kind of look at it is more if a
patient has progressed on so and what I'm thinking about
here is one of the chemotherapy options in mind, but
also one of the oral second generation androgen receptor pathway inhibitors.
So these are two common drugs used in messin prostate cancer,
and so there is some sense of, well, if someone
(33:27):
progresses on say one of the ARPIS for short or
one form of the chemotherapy, then maybe you could come
back to that same chemotherapy or the ARPI. Now that
concept is there, but in the field we understand that,
especially in particular when it comes to arpis, if one
has progressed on them, coming back to a different form
(33:48):
of it is unlikely to produce a meaningful benefit. And
so that's where having all these other treatment options, including
the radio pharmaceuticals and clinical trials come into play.
Speaker 2 (33:57):
We've talked a lot about treatment options and also the
importance of having a support person for someone who receives
a diagnosis in terms of processing the information and helping
navigate treatment. But on your end, I know with breast
cancer there is very much a team approach. Is there
(34:19):
a medical team approach to prostate cancer?
Speaker 1 (34:21):
And ideally who would be on your team?
Speaker 3 (34:23):
Yeah?
Speaker 4 (34:23):
Absolutely, So there are some patient interfacing team members and
there are some who work more directly with the physicians
involved in this case and the other clinical staff involved
in this case. So in terms of patient facing members,
so there can be a urologist, a radiation oncologist, a
medical oncologist. Obviously our nurses who are a major backbone
(34:47):
and really do a lot of interactions and care with
our patients, so they're a big part of the patient
facing team approach. We also have members of the team
who don't necessarily have patient facing roles, but have critical
roles in the treatment of this patient. So that includes
pathologists and then radiologists as well. There's also nuclear medicine
(35:07):
physicians that can be involved depending on the treatment, so
it can be a pretty broad group of people working
together to take care of you.
Speaker 2 (35:14):
Is there also an emotional psychological component that you find
certain patients need.
Speaker 4 (35:22):
Yes, absolutely, I mean we do have psychological support and
all through our center, and there's other resources available for
patients for that, because it is critically important for patients.
It's sometimes hard to wrap your head around the diagnosis,
you know, it's hard to just get that first step in.
But also even with the treatment options or understanding what
that looks like, having the support of people who have
(35:46):
gone through the same situation or from a psychologist or
in some cases psychiatrists of their issues with emotional adjustment
to this can be very helpful.
Speaker 1 (35:57):
Yeah, because I should think that you know.
Speaker 2 (35:59):
For men it's as equally loaded and complicated and emotional
journey to process.
Speaker 5 (36:06):
Yeah.
Speaker 4 (36:06):
Absolutely, just cancer in general carries that right. And then
also because you know, there is a lot of thought
about the treatment we're using, does lower the men's testosterone
can affect things on a very emotional and personal level
for them, And so these are things that do require,
you know, more support than just from the medical side
(36:29):
of things.
Speaker 2 (36:30):
How has your specialty changed you personally in terms of
your relationships with patients and just looking back, how has
it shaped you as a doctor.
Speaker 4 (36:44):
So I think going into being a physician and kind
of gravitating more into medical oncology, I think personally You've
really had to exercise a much greater degree of empathy
than I probably possessed before. To be very frank, I
treat stay cancer all the time. I may be able to,
you know, sit there and I'm not worried at all
(37:05):
about something, but that's because of what I see and
what I do every day. And so I think personally,
you know, it's kind of made it to where you
really have to sit there and really put yourself in
the other person's shoes a lot more so and really
kind of think, Okay, if this is someone coming in
who has little to no understanding or doesn't have this training,
doesn't see this all the time, then how are they
(37:27):
going to feel about this?
Speaker 3 (37:28):
What could be going through their head?
Speaker 4 (37:30):
And I think that's probably one of the biggest things
that you know, I always try to keep in mind
with my patience.
Speaker 1 (37:36):
I love that.
Speaker 2 (37:37):
I love that your empathy has evolved, you know, and progressed,
as have the treatments.
Speaker 4 (37:44):
You know.
Speaker 1 (37:44):
What would you like listeners to take away?
Speaker 4 (37:47):
So a couple of key things. One is that when
you have prostate cancer, not treating it in some cases
is a reasonable option, and that comes down to how
it may affect your life and how the disease evolves.
There's you know, hundreds of men who you know, would
undergo procedures and things when they could very well have
just been monitoring and watched for several years. So I
(38:09):
think that's one key thing. The other is that there
are a lot of new technologies coming into play in
prostate cancer, and we're learning the best ways to utilize those.
But I think it's important to understand that while these
are there, some of these are not appropriate for every scenario,
and so it's good for patients to read and do
(38:31):
their own research and learn about what's out there, but
also to understand that having every test done, or every
procedure or every treatment is not necessarily the ideal way
to go about treating something. To managing a disease, you know,
you can lead to a lot of overdiagnosis, overtreatment and
issues there. I think the other thing is is that
(38:52):
just because you have prostate cancer doesn't mean you don't
have options, and so I think that's you know, kind
of a key thing.
Speaker 3 (38:59):
I think all the people mind.
Speaker 4 (39:00):
I obviously encourage patients to do their own research, but
in doing so, you know, talk to your physician, see
what they might recommend as an appropriate resource and you know, go.
Speaker 2 (39:10):
From there, and then on the flip side of that coin,
what do you want healthcare providers to take away?
Speaker 4 (39:16):
So I think that it actually kind of comes down
to almost similar advice. So in terms of when we're
advising patients, we need to make sure that we're doing
a good job of informing them about the risk of
the disease that they have, about the risk of the
treatments associated with it. But we also, you know, have
to be keeping up with kind of the latest advancements
(39:37):
in our area so that we understand when it's appropriate
to use something or not. There can be over diagnosis
or over treatment, you know, with all the new technologies
and things are available, and so it's on us to
kind of be understanding when it's appropriate to use something
or not.
Speaker 1 (39:55):
Is there anything else you'd like to add?
Speaker 4 (39:57):
No, I'm just really thankful for the opportunity to be
on today and to talk with you all, and obviously
for any patients out there who are being faced with
this diagnosis. There's teams of people across the country working
on this, trying to come up with advancements and there
to support you.
Speaker 1 (40:13):
Excellent answer thank you doctor for speaking with us.
Speaker 3 (40:17):
No, thank you very much for having me. I really
appreciate it.
Speaker 2 (40:23):
Thanks for listening to this special episode of Symptomatic. Be
on the lookout for all new episodes of Symptomatic in
the coming months, and if you haven't already, be sure
to go back and check out our two part episode
on doctor David Fagenbaum. Seemingly in the prime of his life.
David went from determined medical student to dying in the
(40:44):
ICU in a matter of days.
Speaker 5 (40:46):
I'll never forget my doctor walking into the room and saying, David,
your liver, your kidneys, your bone marrow, your heart, and
your lungs are shutting down.
Speaker 3 (40:58):
I was just treating Pa down the hall.
Speaker 2 (41:01):
Follow David's race against the clock for a diagnosis as
his efforts towards finding life saving treatment for himself quickly
become the first piece of an even larger puzzle. As always,
we would love to hear from you. Send us your
thoughts on this episode or share a medical mystery of
your own at Symptomatic at iHeartMedia dot com, and please
(41:23):
don't forget to rate and review Symptomatic wherever you get
your podcasts. We'll see you next time. Until then be
well
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