May 7, 2025 • 18 mins
Urologist and president of the Duval County Medical Society Dr. Ali Kasraeian joins Dr. Michael Koren to update us on recent advances in Urology. In Part 2 of this series, Dr. Koren and Dr. Kasraeian explore into the controversial history of PSA testing. Dr. Kasraeian explains how this simple blood test revolutionized prostate cancer detection while creating challenges around overdiagnosis and overtreatment. The doctors also talk about how modern approaches to prostate screening have evolved to balance finding dangerous cancers while avoiding unnecessary interventions.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Announcer (00:00):
Welcome to MedEvidence!, where we help you
navigate the truth behindmedical research with unbiased,
evidence-proven facts Hosted bycardiologist and top medical
researcher, Dr.
Michael Koren.
Dr. Michael Koren (00:11):
Hello, I'm Dr .
Michael Koren, the executiveeditor of MedEvidence! I've been
having this fabulous discussionwith Dr.
Ali Kasraeian and we talkedabout your background and some
of the wonderful things thatyou've been doing for our
community.
And now let's jump into acontroversy and you and I have
had this discussion before, butI think it'd be super
interesting for our listenersand viewers to hear it and the
(00:32):
discussion is around the use ofPSAs, or prostate-specific
antigens, to diagnose prostatecancer.
And when I was a resident andearly in practice and was
practicing some internalmedicine, I would routinely get
PSAs on my patients, typicallymen anywhere between mid-30s and
(00:54):
55.
And we would be looking to seeif there are early signs of
prostate cancer.
And then the rules changed alittle bit or the policy did,
and that was no longer looked atas something that we should be
doing on a regular basis.
So why don't you educate ouraudience a little bit about the
history of that and thecontroversies around that and
kind of where you stand?
Dr. Ali Kasraeian (01:14):
So the PSA is a very inexpensive, very simple
to get lab test that we use asa screening test to see what the
risk of having prostate cancermay be.
And the controversies that liearound this is the potential of
over-diagnosing prostate cancersthat may not kill someone,
(01:35):
low-risk, low-volume prostatecancers that people could live
with, versus over-treatment ofthose same cancers.
So that has been, you know the,the albatross that has has
really plagued prostate cancerscreening for a long time, and
(01:55):
since its inception it's beenthis, this discussion of what to
do.
When you know, in the lateeighties, early nineties, PSA
developed.
It was a really wonderful toolthat we had nothing.
People would show up withmetastatic prostate cancer and
you would be lucky to findorgan-confined prostate cancer,
to be able to do a prostatectomy, which Patrick Walsh at Hopkins
did some wonderful studies tofind the anatomy, to do nerve
(02:18):
preservation and betterprostatectomy.
So then everyone that was thendiagnosed with prostate cancer.
We had a sharp increase in thediagnosis of prostate cancer and
a really, really profounddecrease in the mortality from
prostate cancer, which thencontinued for years and decades
to come.
The challenge with that is, thetreatments for prostate cancer
(02:42):
were associated with significantquality of life implications,
such as incontinence or erectilefunction issues that were
really profound.
And so the discussion was ifyou have a potential prostate
cancer that is low risk andpeople could live with and it
was not fatal, is it worth thediagnosis and the anxiety
(03:03):
related to it and the potentialovertreatment with treatment
alternatives that may haveimpact?
And prostate cancer-specificantigen, or PSA, is not prostate
CANCER-specific antigen, it'sone that could be elevated for
other things and enlargeprostate inflammation and those
type of things.
So we're kind of plagued withthe appropriate way of screening
(03:24):
.
So more appropriate, smarterscreening and you know the
counseling and kind of how overthe years have we used better
tools to be more personalizedand precise with our screening
discussions?
Dr. Michael Koren (03:39):
So, just for the audience's knowledge and for
my knowledge, what are thecurrent recommendations about
PSAs?
Never get them.
Get them in certain patients.
Just break that down for us.
Dr. Ali Kasraeian (03:49):
So right now with the AUA, the recommendation
is around 45, begin screeningfor prostate cancer, and that's
been kind of like a thatconstantly changes.
Different organizationsrecommend different things and
if you are at a higher riskpopulation.
Dr. Michael Koren (04:03):
When you say screening, is that a rectal exam
or is that a live test now?
Dr. Ali Kasraeian (04:07):
So you know the PSA is what you talk about.
The rectal exam remainscontroversial, but most of us
that do a lot of prostate cancertend to recommend getting a
rectal exam and a PSA test as ascreening measure.
Dr. Michael Koren (04:18):
So that's still in the books as something
we shall do at age 45.
At 45.
You know the rectal exam byitself there are studies that
show it may not be as impactful.
I personally do a rectal exambecause it gives you a lot of
information.
The size of the prostate is aguesstimation.
It's not as precise as gettingan ultrasound or an MRI scan per
se, but it gives you an idea ofif someone has a huge prostate,
(04:38):
a medium-sized prostate or alarge prostate and you look to
make sure there are no nodules.
You know if someone does have anodule on their prostate you
could still have a low PSA andhave a nodular prostate.
You can make sure there are norectal nodules or rectal masses
and things of that nature.
So I think there's impact andpositivity in doing a rectal
exam.
So I still do rectal exams.
(05:05):
Risk and high-risk populationsinclude a family history of a
prostate cancer, especially abrother, father, first-degree
relative and people of Africanancestry and African-American
populations are a higher risk ofprostate cancer and with the
African-American population theyhad an almost twofold increase
in more aggressive and fatalprostate cancer diagnosis at an
earlier age.
So earlier screening kind ofstarting at 40, is an easy way
(05:26):
to kind of think about that.
So I try to make things simplefor people, if you have no
family history, no increasedrisks 45, and then everyone else
at 40.
And you can kind of at 45,.
You can think about that as thesame timeframe to begin getting
that first colonoscopy.
Okay, and when do you stop screening for
PSA?
This is where the whole conceptthat later in life maybe it's
(05:49):
not going to be particularlyhelpful and just chase you down
a rabbit hole.
So one.
Dr. Ali Kasraeian (05:54):
You know 70 comes up as this age.
That comes up in a lot of theguidelines.
However, you kind of thinkabout that in terms of, you know
, age as chronology but alsolevel of health.
You know there's 70-olds thatare running triathlons and then
there's 70-year-olds that have900 heart stents and are walking
around with an oxygen tank.
So you assess that 10- 15-yearlifespan and possibility of
(06:17):
being alive at 10- 15-year,which is not the easiest thing
to do, but there are a lot ofways you can potentially assess
that and you look at that.
And really one thing that'sreally important to think about
these conversations a lot oftimes are had at urology
meetings and within urologyvenues, but it's important for
this to be had at the primarycare doctor's office because a
lot of times we have theseconversations when the patient
(06:41):
already has had a PSA andthey're like 85 years old and
they show up with an elevatedPSA.
So then you got to figure outdo we want to make sure that we
don't have metastatic diseasenow, because I'm not excited
about getting, you know,prostate biopsies on an
85-year-old for their PSA beingelevated, but you want to make
sure what the reason you'redoing that is from that
(07:01):
standpoint.
So those are the discussions tohave at the primary care level
and that's where we are workingvery hard as urologists to
figure out the best way to comeup with the best screening
aspect at the beginning of theconversation which is there?
Dr. Michael Koren (07:14):
So just for clarity.
So somebody who is consideredlow risk doesn't have any of the
high risk markers.
Do you still recommend primarycare physicians check at 45 and
yearly, or every five years?
Or give us a Good question,yeah.
Dr. Ali Kasraeian (07:28):
So when you talk the guidelines, talk about
a patient-centered discussion,and a lot of times when you talk
to your patient, they havebuy-in on checking it on a
yearly basis and it's aninexpensive test to do If their
PSA is very low, and most of theworld's population's PSAs are
actually less than one then youcan actually come
Dr. Michael Koren (07:50):
And is four still considered above normal?
Dr. Ali Kasraeian (07:53):
So in a lab test, but we're actually looking
at that a bit more.
Four would actually come upwith as a two standard deviation
increase from two, two and ahalf we're actually looking at
could two and a half be the newnormal per se?
A study was actually justpublished that people in their
70s the world's majority of PSAsare actually less than one at
70.
And if your PSA at 70 is lessthan one, your risk of having a
(08:16):
clinically significant prostatecancer is very low.
There was a great study doneout of Malmo, sweden, years ago,
where they went it was anatural history of disease study
and they went back and lookedat blood and looked at PSAs.
That first PSA at 45 to 49 foraverage risk patients was the
most telling of your risk ofprostate cancer.
(08:36):
If your PSA at that age was 1.5, that represented about 44% of
people who had clinicallysignificant prostate cancer in
their lifetime.
If at 60, you had a PSA lessthan one average risk, your risk
of clinically significantprostate cancer was very, very
low.
And that study showed at 70,kind of similar type of thing.
(08:57):
So you can come up with analgorithm of how frequently to
check PSAs based on what thosePSAs are at A.
So if your PSA is less than oneat 45, could you check less
frequently.
If it's two, it is differentfrom that standpoint and that's
what we want to kind of look at.
The other thing is knowing yourfamily history, knowing if
there's any kind of bracket genepositivities, even in the women
(09:18):
in your life.
So that becomes important interms of how often you check
your PSA.
For you personally, the easyanswer is if you're getting labs
anyway and you check a PSAevery year, it's not an
expensive test.
But as a population discussionyou can make decisions based on
what your individual PSA is in aconversation with your primary
care doctor, so if it's less,than one, risks are much lower.
Dr. Michael Koren (09:39):
And, as you alluded to before, the concern
is that there are a lot of falsepositives and I imagine that if
you have prostatitis frominfection or something else,
your PSA goes up.
Dr. Ali Kasraeian (09:50):
Absolutely, and I want a couple of things.
We recommend to people Avoidejaculation for two to three
days.
If you have any kind ofsymptoms you're worried about,
talk to your urologist.
You know a lot of the things.
When people look up, you knowprostate cancer a lot of urinary
symptoms come up which areusually associated with BPH
benign prostatic hyperplasiawhich is a benign entity.
It's not a cancer-based entityfrom that standpoint.
(10:11):
So that's something for peopleto be mindful.
Often, most of the prostatecancers that we diagnose are
really simply from a lab testthat was obtained, often with
patients not knowing that theyhad the lab test done, being
elevated.
So that's why the importance ofscreening is so profound.
And you know, looking at thedata, you know in 2008, there
was an initial screeningrecommendation against prostate
(10:35):
cancer screening by the USPreventative Services Task Force
.
That then was strengthened in2012 with a grade D
recommendation and that reallyled to a significant decrease in
screening, especially at theprimary care level, which we now
see the downstream effect.
And you know, multiple yearslater, that grade D
(10:58):
recommendation, afterre-evaluation of the
Dr. Michael Koren (11:03):
Grade D meaning they did not recommend
it at all.
Dr. Ali Kasraeian (11:04):
Now it became a great C recommendation,
meaning that you can have apatient-centered discussion with
your doctors about the riskbenefits and that has increased
screening.
But we downstream have seen asignificant stage migration more
metastatic disease, morehigh-risk disease.
Dr. Michael Koren (11:23):
Because we're not diagnosing these earlier.
Dr. Ali Kasraeian (11:25):
We're not diagnosing earlier and in
populations like theAfrican-American population.
That's a big deal from thatstandpoint and those are really,
really profound.
So if you have people men intheir 50s not being diagnosed
with high risk disease, theimplication of that is profound.
Dr. Michael Koren (11:41):
So we always like to talk about the fact that
things should be personalizedwhen you're getting medical
information from the internet orfrom Med Evidence!, and so
let's come up with a couple ofscenarios so people can
understand things in a morepersonal way.
48-year-old guy not 100% sureof his family history but thinks
(12:02):
maybe somebody had prostatecancer two generations ago.
He comes in PSA, comes back 2.8.
Do you freak out?
What do you do as a next step?
Dr. Ali Kasraeian (12:12):
No, I mean.
So why always repeat a PSAafter one, you know, unless you
have a trend?
So you kind of go back and lookif they've ever had any kind of
PSAs and things of that nature.
Then we kind of talk aboutrepeating it.
There are studies that showthat even kind of, you know,
giving antibiotics doesn't makea difference unless they have
symptoms.
You know prostatitis.
(12:33):
That's where the rectal examhelps.
If you have a warm, tenderprostate associated with
prostatitis, then you can treatthat.
But repeating, you know, is thisa fluke?
Is it elevated For someone intheir 40s?
You know age-specific PSA.
Your PSA should be less thantwo and a half, you know, from
that standpoint.
So then you kind of look at ifthe PSA is elevated.
I was, you know, I'm a big, bigbeliever in multi-parametric
MRI scan.
This is a very specific MRIscan that looks within the
(12:56):
prostate to see are there anyareas of concern.
Because now we have thetechnologies that if there is,
you can actually merge the MRIand the ultrasound and target
that area.
And if that area is the onlyplace that's concerning, then we
could potentially just treatthat.
Dr. Michael Koren (13:11):
So you repeat the 2.8 before you do imaging,
I imagine.
Dr. Ali Kasraeian (13:14):
Absolutely Okay.
Dr. Michael Koren (13:15):
And then your go-to is ultrasound, or is it
MRI or this?
Dr. Ali Kasraeian (13:18):
Yeah, so ultrasound is not the most
diagnostic tool for "aha.
There's the prostate cancer.
There's a very, very highfrequency ultrasound that can be
used at a time of biopsy thatcan give us more information to
see "aha.
There's a better place to do,but in terms of a diagnostic
(13:40):
tool that helps guide and shapebiopsy decisions and also as a
tool to do a better biopsy themulti-parametric MRI scan.
And if someone can't get thecontrast, the gadolinium, we
could do what's called abi-parametric MRI scan.
But that can give you a target,if one exists, to do a targeted
biopsy.
But also if the MRI is negative, that's great information from
(14:01):
that standpoint to not only helpguide a better, more accurate,
more precise diagnosis, but alsoit could help shape our
discussions of what to do next.
Dr. Michael Koren (14:12):
So the 48-year-old guy 2.8, gets it
again 2.8,.
You're going to do imaging.
Dr. Ali Kasraeian (14:16):
I'm going to do imaging and that helps shape
our diagnosis.
At 48 with a PSA of 2.8, if theMRI scan is negative, you know
we have to be mindful that youcould still have about a you
know, 20 to in two amazingstudies, the PRECISION trial and
the PROMISE trial, which helpedland the impact of MRI scan for
(14:36):
not only finding moreclinically significant disease,
which means intermediate andhigh-risk prostate cancer,
meaning prostate cancer that ifyou found you would treat
Low-risk prostate cancer, whichthere's a thing called the
Gleason score.
It's how you grade the prostatecancer.
Lower-risk prostate cancer isthe Gleason score of six PSA
less than 10, a small nodule orno nodule those you can monitor
(14:57):
with an active surveillance.
We hope not to find those.
If we can, we want to find theones that we would treat and
could impact your lifepotentially in the future If you
find a small targetable lesionlike that.
Now we have technology that youcould potentially just treat
that Interesting.
Dr. Michael Koren (15:11):
So take that same 2.8, but now it's a
70-year-old person.
You just sit on it, or do youstill do the same thing?
Look at their trend.
Dr. Ali Kasraeian (15:18):
If they've been 2.8 for two decades,
especially if they've hadprevious biopsies or things of
that nature, you can see If it'sa change, if they've had an
increase in their PSA velocity.
They've been one their wholelife and now it's 2.8, you
repeat it.
If it's still 2.8, then you cantalk to them.
You know, I would do an MRIscan.
It gives you the size of theprostate.
It can give you some idea ifthere's a targetable lesion.
(15:40):
Because that same pathway Couldyou do a better biopsy and you
can also use biomarkers.
Dr. Michael Koren (15:45):
Right, and the reason I'm creating those
two scenarios is that there is anotion, as I understand it,
that being diagnosed withprostate cancer later in life
tends to have a more benigncourse than somebody that's
diagnosed earlier in life.
Dr. Ali Kasraeian (15:59):
Yeah, and a couple different perspectives.
One the average age for beingdiagnosed with prostate cancer
is 66, 67 years old and theimplications of how to manage
them depend on a few things.
One, the stage and grade of theprostate cancer.
Like I mentioned, there'sGleason score.
Pathologist looks at the cellson the microscope and assigns
(16:21):
two numbers.
The first number is the mostcommon, second is the second
most common.
Adds them together to a totalscore.
As the numbers increase, howdifferent from normal those cell
types are increases and thepossibility of it in the future
at some point getting out of theprostate increases.
So a Gleason score of seven iskind of a fence that divides
aggressive cancers, like eight,nines and tens, from less
(16:42):
aggressive cancers, like six wedon't really see fours and fives
anymore Within the seven familyand 10s from less aggressive
cancers, like 6.
We don't really see 4s and 5sanymore Within the 7 family.
A 3 plus 4 is less aggressivethan a 4 plus 3.
Dr. Michael Koren (16:51):
So you're less worried about over-treating
people with prostate cancerbecause you feel like there's
ways of characterizing thecancer so that you're really
treating the people who are athigher risk over time.
Dr. Ali Kasraeian (17:03):
Yeah.
So I'm a big believer in activesurveillance have been for my
whole career.
So if you have a low volume,low risk or even you know a low
risk prostate cancer in general,you can do what are called
genomics tests.
You can assess the biology ofthat disease to give you a
picture of, you know, the cat inthe bag analogy.
If you have a cat in the bag.
Is that cat going to grow up tobe a small kitten?
Is it going to be a cat that'sa timid cat, or is it going to
(17:25):
grow up to be a ferocious tiger?
You can make decisions, and itcan actually.
We have testnodes that can giveyou predictive information.
What's the likelihood ofpassing away from this cancer,
based on your biology andclinical information, in the
next 10 years?
If we treated it, what's therisk of metastasis in that time?
And then, based on thatinformation, we can counsel.
You're a great candidate foractive surveillance.
(17:46):
Every guideline talks aboutactive surveillance for low-risk
disease.
If we have intermediate disease, what's the volume?
Is it localized?
We can do artificialintelligence technology.
Dr. Michael Koren (17:56):
Well, let's get to that.
I'm going to take a quick breakhere, but this is fascinating.
So we talked about thecontroversy about PSAs and gave
a little bit of informationabout how you would customize
that for different patientpopulations.
But let's talk about the futurein our next segment.
Dr. Ali Kasraeian (18:11):
Absolutely
Announcer (18:11):
To continue watching this podcast episode head over
to MedEvidence.
com.
Welcome to MedEvidence!, where we help you
navigate the truth behindmedical research with unbiased,
evidence-proven facts Hosted bycardiologist and top medical
researcher, Dr.
Michael Koren.
Dr. Michael Koren (00:11):
Hello, I'm Dr .
Michael Koren, the executiveeditor of MedEvidence! I've been
having this fabulous discussionwith Dr.
Ali Kasraeian and we talkedabout your background and some
of the wonderful things thatyou've been doing for our
community.
And now let's jump into acontroversy and you and I have
had this discussion before, butI think it'd be super
interesting for our listenersand viewers to hear it and the
(00:32):
discussion is around the use ofPSAs, or prostate-specific
antigens, to diagnose prostatecancer.
And when I was a resident andearly in practice and was
practicing some internalmedicine, I would routinely get
PSAs on my patients, typicallymen anywhere between mid-30s and
(00:54):
55.
And we would be looking to seeif there are early signs of
prostate cancer.
And then the rules changed alittle bit or the policy did,
and that was no longer looked atas something that we should be
doing on a regular basis.
So why don't you educate ouraudience a little bit about the
history of that and thecontroversies around that and
kind of where you stand?
Dr. Ali Kasraeian (01:14):
So the PSA is a very inexpensive, very simple
to get lab test that we use asa screening test to see what the
risk of having prostate cancermay be.
And the controversies that liearound this is the potential of
over-diagnosing prostate cancersthat may not kill someone,
(01:35):
low-risk, low-volume prostatecancers that people could live
with, versus over-treatment ofthose same cancers.
So that has been, you know the,the albatross that has has
really plagued prostate cancerscreening for a long time, and
(01:55):
since its inception it's beenthis, this discussion of what to
do.
When you know, in the lateeighties, early nineties, PSA
developed.
It was a really wonderful toolthat we had nothing.
People would show up withmetastatic prostate cancer and
you would be lucky to findorgan-confined prostate cancer,
to be able to do a prostatectomy, which Patrick Walsh at Hopkins
did some wonderful studies tofind the anatomy, to do nerve
(02:18):
preservation and betterprostatectomy.
So then everyone that was thendiagnosed with prostate cancer.
We had a sharp increase in thediagnosis of prostate cancer and
a really, really profounddecrease in the mortality from
prostate cancer, which thencontinued for years and decades
to come.
The challenge with that is, thetreatments for prostate cancer
(02:42):
were associated with significantquality of life implications,
such as incontinence or erectilefunction issues that were
really profound.
And so the discussion was ifyou have a potential prostate
cancer that is low risk andpeople could live with and it
was not fatal, is it worth thediagnosis and the anxiety
(03:03):
related to it and the potentialovertreatment with treatment
alternatives that may haveimpact?
And prostate cancer-specificantigen, or PSA, is not prostate
CANCER-specific antigen, it'sone that could be elevated for
other things and enlargeprostate inflammation and those
type of things.
So we're kind of plagued withthe appropriate way of screening
(03:24):
.
So more appropriate, smarterscreening and you know the
counseling and kind of how overthe years have we used better
tools to be more personalizedand precise with our screening
discussions?
Dr. Michael Koren (03:39):
So, just for the audience's knowledge and for
my knowledge, what are thecurrent recommendations about
PSAs?
Never get them.
Get them in certain patients.
Just break that down for us.
Dr. Ali Kasraeian (03:49):
So right now with the AUA, the recommendation
is around 45, begin screeningfor prostate cancer, and that's
been kind of like a thatconstantly changes.
Different organizationsrecommend different things and
if you are at a higher riskpopulation.
Dr. Michael Koren (04:03):
When you say screening, is that a rectal exam
or is that a live test now?
Dr. Ali Kasraeian (04:07):
So you know the PSA is what you talk about.
The rectal exam remainscontroversial, but most of us
that do a lot of prostate cancertend to recommend getting a
rectal exam and a PSA test as ascreening measure.
Dr. Michael Koren (04:18):
So that's still in the books as something
we shall do at age 45.
At 45.
You know the rectal exam byitself there are studies that
show it may not be as impactful.
I personally do a rectal exambecause it gives you a lot of
information.
The size of the prostate is aguesstimation.
It's not as precise as gettingan ultrasound or an MRI scan per
se, but it gives you an idea ofif someone has a huge prostate,
(04:38):
a medium-sized prostate or alarge prostate and you look to
make sure there are no nodules.
You know if someone does have anodule on their prostate you
could still have a low PSA andhave a nodular prostate.
You can make sure there are norectal nodules or rectal masses
and things of that nature.
So I think there's impact andpositivity in doing a rectal
exam.
So I still do rectal exams.
(05:05):
Risk and high-risk populationsinclude a family history of a
prostate cancer, especially abrother, father, first-degree
relative and people of Africanancestry and African-American
populations are a higher risk ofprostate cancer and with the
African-American population theyhad an almost twofold increase
in more aggressive and fatalprostate cancer diagnosis at an
earlier age.
So earlier screening kind ofstarting at 40, is an easy way
(05:26):
to kind of think about that.
So I try to make things simplefor people, if you have no
family history, no increasedrisks 45, and then everyone else
at 40.
And you can kind of at 45,.
You can think about that as thesame timeframe to begin getting
that first colonoscopy.
Okay, and when do you stop screening for
PSA?
This is where the whole conceptthat later in life maybe it's
(05:49):
not going to be particularlyhelpful and just chase you down
a rabbit hole.
So one.
Dr. Ali Kasraeian (05:54):
You know 70 comes up as this age.
That comes up in a lot of theguidelines.
However, you kind of thinkabout that in terms of, you know
, age as chronology but alsolevel of health.
You know there's 70-olds thatare running triathlons and then
there's 70-year-olds that have900 heart stents and are walking
around with an oxygen tank.
So you assess that 10- 15-yearlifespan and possibility of
(06:17):
being alive at 10- 15-year,which is not the easiest thing
to do, but there are a lot ofways you can potentially assess
that and you look at that.
And really one thing that'sreally important to think about
these conversations a lot oftimes are had at urology
meetings and within urologyvenues, but it's important for
this to be had at the primarycare doctor's office because a
lot of times we have theseconversations when the patient
(06:41):
already has had a PSA andthey're like 85 years old and
they show up with an elevatedPSA.
So then you got to figure outdo we want to make sure that we
don't have metastatic diseasenow, because I'm not excited
about getting, you know,prostate biopsies on an
85-year-old for their PSA beingelevated, but you want to make
sure what the reason you'redoing that is from that
(07:01):
standpoint.
So those are the discussions tohave at the primary care level
and that's where we are workingvery hard as urologists to
figure out the best way to comeup with the best screening
aspect at the beginning of theconversation which is there?
Dr. Michael Koren (07:14):
So just for clarity.
So somebody who is consideredlow risk doesn't have any of the
high risk markers.
Do you still recommend primarycare physicians check at 45 and
yearly, or every five years?
Or give us a Good question,yeah.
Dr. Ali Kasraeian (07:28):
So when you talk the guidelines, talk about
a patient-centered discussion,and a lot of times when you talk
to your patient, they havebuy-in on checking it on a
yearly basis and it's aninexpensive test to do If their
PSA is very low, and most of theworld's population's PSAs are
actually less than one then youcan actually come
Dr. Michael Koren (07:50):
And is four still considered above normal?
Dr. Ali Kasraeian (07:53):
So in a lab test, but we're actually looking
at that a bit more.
Four would actually come upwith as a two standard deviation
increase from two, two and ahalf we're actually looking at
could two and a half be the newnormal per se?
A study was actually justpublished that people in their
70s the world's majority of PSAsare actually less than one at
70.
And if your PSA at 70 is lessthan one, your risk of having a
(08:16):
clinically significant prostatecancer is very low.
There was a great study doneout of Malmo, sweden, years ago,
where they went it was anatural history of disease study
and they went back and lookedat blood and looked at PSAs.
That first PSA at 45 to 49 foraverage risk patients was the
most telling of your risk ofprostate cancer.
(08:36):
If your PSA at that age was 1.5, that represented about 44% of
people who had clinicallysignificant prostate cancer in
their lifetime.
If at 60, you had a PSA lessthan one average risk, your risk
of clinically significantprostate cancer was very, very
low.
And that study showed at 70,kind of similar type of thing.
(08:57):
So you can come up with analgorithm of how frequently to
check PSAs based on what thosePSAs are at A.
So if your PSA is less than oneat 45, could you check less
frequently.
If it's two, it is differentfrom that standpoint and that's
what we want to kind of look at.
The other thing is knowing yourfamily history, knowing if
there's any kind of bracket genepositivities, even in the women
(09:18):
in your life.
So that becomes important interms of how often you check
your PSA.
For you personally, the easyanswer is if you're getting labs
anyway and you check a PSAevery year, it's not an
expensive test.
But as a population discussionyou can make decisions based on
what your individual PSA is in aconversation with your primary
care doctor, so if it's less,than one, risks are much lower.
Dr. Michael Koren (09:39):
And, as you alluded to before, the concern
is that there are a lot of falsepositives and I imagine that if
you have prostatitis frominfection or something else,
your PSA goes up.
Dr. Ali Kasraeian (09:50):
Absolutely, and I want a couple of things.
We recommend to people Avoidejaculation for two to three
days.
If you have any kind ofsymptoms you're worried about,
talk to your urologist.
You know a lot of the things.
When people look up, you knowprostate cancer a lot of urinary
symptoms come up which areusually associated with BPH
benign prostatic hyperplasiawhich is a benign entity.
It's not a cancer-based entityfrom that standpoint.
(10:11):
So that's something for peopleto be mindful.
Often, most of the prostatecancers that we diagnose are
really simply from a lab testthat was obtained, often with
patients not knowing that theyhad the lab test done, being
elevated.
So that's why the importance ofscreening is so profound.
And you know, looking at thedata, you know in 2008, there
was an initial screeningrecommendation against prostate
(10:35):
cancer screening by the USPreventative Services Task Force
.
That then was strengthened in2012 with a grade D
recommendation and that reallyled to a significant decrease in
screening, especially at theprimary care level, which we now
see the downstream effect.
And you know, multiple yearslater, that grade D
(10:58):
recommendation, afterre-evaluation of the
Dr. Michael Koren (11:03):
Grade D meaning they did not recommend
it at all.
Dr. Ali Kasraeian (11:04):
Now it became a great C recommendation,
meaning that you can have apatient-centered discussion with
your doctors about the riskbenefits and that has increased
screening.
But we downstream have seen asignificant stage migration more
metastatic disease, morehigh-risk disease.
Dr. Michael Koren (11:23):
Because we're not diagnosing these earlier.
Dr. Ali Kasraeian (11:25):
We're not diagnosing earlier and in
populations like theAfrican-American population.
That's a big deal from thatstandpoint and those are really,
really profound.
So if you have people men intheir 50s not being diagnosed
with high risk disease, theimplication of that is profound.
Dr. Michael Koren (11:41):
So we always like to talk about the fact that
things should be personalizedwhen you're getting medical
information from the internet orfrom Med Evidence!, and so
let's come up with a couple ofscenarios so people can
understand things in a morepersonal way.
48-year-old guy not 100% sureof his family history but thinks
(12:02):
maybe somebody had prostatecancer two generations ago.
He comes in PSA, comes back 2.8.
Do you freak out?
What do you do as a next step?
Dr. Ali Kasraeian (12:12):
No, I mean.
So why always repeat a PSAafter one, you know, unless you
have a trend?
So you kind of go back and lookif they've ever had any kind of
PSAs and things of that nature.
Then we kind of talk aboutrepeating it.
There are studies that showthat even kind of, you know,
giving antibiotics doesn't makea difference unless they have
symptoms.
You know prostatitis.
(12:33):
That's where the rectal examhelps.
If you have a warm, tenderprostate associated with
prostatitis, then you can treatthat.
But repeating, you know, is thisa fluke?
Is it elevated For someone intheir 40s?
You know age-specific PSA.
Your PSA should be less thantwo and a half, you know, from
that standpoint.
So then you kind of look at ifthe PSA is elevated.
I was, you know, I'm a big, bigbeliever in multi-parametric
MRI scan.
This is a very specific MRIscan that looks within the
(12:56):
prostate to see are there anyareas of concern.
Because now we have thetechnologies that if there is,
you can actually merge the MRIand the ultrasound and target
that area.
And if that area is the onlyplace that's concerning, then we
could potentially just treatthat.
Dr. Michael Koren (13:11):
So you repeat the 2.8 before you do imaging,
I imagine.
Dr. Ali Kasraeian (13:14):
Absolutely Okay.
Dr. Michael Koren (13:15):
And then your go-to is ultrasound, or is it
MRI or this?
Dr. Ali Kasraeian (13:18):
Yeah, so ultrasound is not the most
diagnostic tool for "aha.
There's the prostate cancer.
There's a very, very highfrequency ultrasound that can be
used at a time of biopsy thatcan give us more information to
see "aha.
There's a better place to do,but in terms of a diagnostic
(13:40):
tool that helps guide and shapebiopsy decisions and also as a
tool to do a better biopsy themulti-parametric MRI scan.
And if someone can't get thecontrast, the gadolinium, we
could do what's called abi-parametric MRI scan.
But that can give you a target,if one exists, to do a targeted
biopsy.
But also if the MRI is negative, that's great information from
(14:01):
that standpoint to not only helpguide a better, more accurate,
more precise diagnosis, but alsoit could help shape our
discussions of what to do next.
Dr. Michael Koren (14:12):
So the 48-year-old guy 2.8, gets it
again 2.8,.
You're going to do imaging.
Dr. Ali Kasraeian (14:16):
I'm going to do imaging and that helps shape
our diagnosis.
At 48 with a PSA of 2.8, if theMRI scan is negative, you know
we have to be mindful that youcould still have about a you
know, 20 to in two amazingstudies, the PRECISION trial and
the PROMISE trial, which helpedland the impact of MRI scan for
(14:36):
not only finding moreclinically significant disease,
which means intermediate andhigh-risk prostate cancer,
meaning prostate cancer that ifyou found you would treat
Low-risk prostate cancer, whichthere's a thing called the
Gleason score.
It's how you grade the prostatecancer.
Lower-risk prostate cancer isthe Gleason score of six PSA
less than 10, a small nodule orno nodule those you can monitor
(14:57):
with an active surveillance.
We hope not to find those.
If we can, we want to find theones that we would treat and
could impact your lifepotentially in the future If you
find a small targetable lesionlike that.
Now we have technology that youcould potentially just treat
that Interesting.
Dr. Michael Koren (15:11):
So take that same 2.8, but now it's a
70-year-old person.
You just sit on it, or do youstill do the same thing?
Look at their trend.
Dr. Ali Kasraeian (15:18):
If they've been 2.8 for two decades,
especially if they've hadprevious biopsies or things of
that nature, you can see If it'sa change, if they've had an
increase in their PSA velocity.
They've been one their wholelife and now it's 2.8, you
repeat it.
If it's still 2.8, then you cantalk to them.
You know, I would do an MRIscan.
It gives you the size of theprostate.
It can give you some idea ifthere's a targetable lesion.
(15:40):
Because that same pathway Couldyou do a better biopsy and you
can also use biomarkers.
Dr. Michael Koren (15:45):
Right, and the reason I'm creating those
two scenarios is that there is anotion, as I understand it,
that being diagnosed withprostate cancer later in life
tends to have a more benigncourse than somebody that's
diagnosed earlier in life.
Dr. Ali Kasraeian (15:59):
Yeah, and a couple different perspectives.
One the average age for beingdiagnosed with prostate cancer
is 66, 67 years old and theimplications of how to manage
them depend on a few things.
One, the stage and grade of theprostate cancer.
Like I mentioned, there'sGleason score.
Pathologist looks at the cellson the microscope and assigns
(16:21):
two numbers.
The first number is the mostcommon, second is the second
most common.
Adds them together to a totalscore.
As the numbers increase, howdifferent from normal those cell
types are increases and thepossibility of it in the future
at some point getting out of theprostate increases.
So a Gleason score of seven iskind of a fence that divides
aggressive cancers, like eight,nines and tens, from less
(16:42):
aggressive cancers, like six wedon't really see fours and fives
anymore Within the seven familyand 10s from less aggressive
cancers, like 6.
We don't really see 4s and 5sanymore Within the 7 family.
A 3 plus 4 is less aggressivethan a 4 plus 3.
Dr. Michael Koren (16:51):
So you're less worried about over-treating
people with prostate cancerbecause you feel like there's
ways of characterizing thecancer so that you're really
treating the people who are athigher risk over time.
Dr. Ali Kasraeian (17:03):
Yeah.
So I'm a big believer in activesurveillance have been for my
whole career.
So if you have a low volume,low risk or even you know a low
risk prostate cancer in general,you can do what are called
genomics tests.
You can assess the biology ofthat disease to give you a
picture of, you know, the cat inthe bag analogy.
If you have a cat in the bag.
Is that cat going to grow up tobe a small kitten?
Is it going to be a cat that'sa timid cat, or is it going to
(17:25):
grow up to be a ferocious tiger?
You can make decisions, and itcan actually.
We have testnodes that can giveyou predictive information.
What's the likelihood ofpassing away from this cancer,
based on your biology andclinical information, in the
next 10 years?
If we treated it, what's therisk of metastasis in that time?
And then, based on thatinformation, we can counsel.
You're a great candidate foractive surveillance.
(17:46):
Every guideline talks aboutactive surveillance for low-risk
disease.
If we have intermediate disease, what's the volume?
Is it localized?
We can do artificialintelligence technology.
Dr. Michael Koren (17:56):
Well, let's get to that.
I'm going to take a quick breakhere, but this is fascinating.
So we talked about thecontroversy about PSAs and gave
a little bit of informationabout how you would customize
that for different patientpopulations.
But let's talk about the futurein our next segment.
Dr. Ali Kasraeian (18:11):
Absolutely
Announcer (18:11):
To continue watching this podcast episode head over
to MedEvidence.
com.
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