Podcast: Why It's Important to Screen for Prostate Cancer

Dr. Feuerstein: I think that men are dissuaded from screening because of the digital rectal exam. I think that that exam is really not very helpful and that we have much better testing now.

Courtney: Welcome to Health Matters, your weekly dose of the latest in health and wellness from NewYork-Presbyterian. I’m Courtney Allison.

About one in eight men will be diagnosed with prostate cancer in their lifetime. In recognition of Prostate Cancer Awareness Month, we spoke with Dr. Michael Feuerstein, a urologic oncologist at NewYork-Presbyterian The One, a new center for advanced care in Westchester. 

Dr. Feuerstein shares the latest advancements in screening and treatment, the importance of prostate cancer screening, and he debunks common myths about prostate cancer.  

Courtney: Hi, Dr. Feuerstein. Thank you so much for joining us today.

Dr. Feuerstein: Hi. Thank you for having me.

Courtney: And so today we want to share the latest in understanding and treating prostate cancer. So let’s start with the basics. How common is prostate cancer and how treatable is it?

Dr. Feuerstein: Prostate cancer is the number one solid cancer in men. However, it’s very treatable if caught early. And the key to catching it is early detection with prostate cancer screening.

Courtney: Who should be screened and what’s the screening process like?

Dr. Feuerstein: So generally for average risk men, we recommend first PSA screening at some time between the ages of 45 and 50. This is just a simple blood test that can be drawn with your routine, blood work that you would do with your regular doctor.

The prostate exam or digital rectal exam is really fallen out of practice, for many reasons, particularly in young men where we find that it’s really not helpful; that the chance of detecting prostate cancer based on exam is like one in a thousand. Whereas, most of the cases are picked up with a blood test.

For men who have a higher risk, disease. We recommend screening at age 40. The chance of finding cancer in your forties is very rare. However, the PSA level in your forties can help predict what your future risk of prostate cancer might be.

Courtney: So you mentioned PSA level. Could you define what is PSA and how is it monitored?

Dr. Feuerstein: PSA Stands for prostate specific antigen. It’s a protein made by the prostate and it has to do with, semen production. It’s only made by the prostate, and it’s made by the prostate in higher levels when you have prostate cancer or other other prostate illnesses like prostate inflammation or enlarged prostate. A normal PSA, uh, in general terms is less than four, and if it’s elevated between the levels of 4 and 10, the chances are you don’t have prostate cancer, but you do have a higher risk and we have to rule out these other things or evaluate for other things like prostate inflammation or enlarged prostate.

Courtney: Will someone experience symptoms if they have prostate cancer?

Dr. Feuerstein: Generally not. So, you know, prostate cancer often doesn’t present with any symptoms. Prostate cancer is often detected early based on the prostate cancer screening, so a blood test. It only presents with symptoms in very advanced cases. Men who have urinary symptoms that may contribute to an enlarged prostate, things like having difficulty urinating, that’s usually not related to prostate cancer, but can be a sign of an enlarged prostate, which is a totally separate disease.

Courtney: So when a patient comes into your office with concerns what do you say to them?

Dr. Feuerstein: So, first is to distinguish what’s bothering them the most. If they’re having a lot of urinary symptoms, probably from an enlarged prostate, it’s usually a quality of life issue. It’s in rare cases it becomes more of a medical, urgent issue, but in severe cases it can affect the kidneys or result in infections. But for 98% of patients, it’s probably a quality of life issue, which can be managed often with medications, and if medications don’t work, there’s at least a dozen different procedures that can be offered.

Sometimes men have a prostate cancer and enlarged prostate. And we kind of treat these separately as like sort of mutually exclusive. So men who have prostate cancer on active surveillance, we can still offer them treatments for their enlarged prostate without removing their whole prostate or radiating their whole prostate and resulting in worse quality of life outcomes.

Courtney: You mentioned active surveillance. Could you elaborate on what active surveillance is?

Dr. Feuerstein: Sure. This was a concept that came about about 15 to 20 years ago. Another name for it would be deferred treatment. The idea of watching cancer. It used to be that if you had cancer, it had to be removed.

The idea is that you monitor the cancer, and it’s very slow growing. It can be monitored with imaging or repeat biopsies every two to three years because it grows so slowly and it can still be detected at a time when it can be treated without any detriments. And the benefit of active surveillance is that you gain those years of better quality of life without the side effects of cancer treatment and that many men, at least two thirds of men who are on active surveillance, never need treatment.

Courtney: Wow. And so you mentioned that prostate cancer is slow growing. Does it grow more slowly than other cancers?

Dr. Feuerstein: Certainly if you think about other cancers like pancreatic cancer, brain cancers or lung cancers, that can be much more fatal. Prostate cancer, in most cases, grows very slowly and so many times we’re treating prostate cancer, detecting it at least 10 to 15 years before it might harm somebody, 5 to 10 years before they would even know they had cancer, or felt cancer. And that can be a hard thing for patients to grasp the idea that they feel fine, that they don’t feel like they have cancer, and that they can walk out the door and not even know they had cancer for five years.

Courtney: If the cancer is more advanced, can you just talk a little bit more about what that treatment is like?

Dr. Feuerstein: Yeah. So the treatments for advanced prostate cancer have really been revolutionized. It used to be that prostate cancer was treated with one medication at a time, one drug at a time. And now there’s a lot of trials that are combining treatments, chemotherapy and hormone therapy plus or minus radiation therapy. And so the algorithm for treatment has really changed.

Somebody with metastatic prostate cancer, we still offer oftentimes treatment to the prostate, like radiation treatment to the prostate, even if it’s spread to other places, and that’s, that’s a relatively new concept and we’ve seen better outcomes in that case. There’s also been significant advances in hormone therapy blocking the production of testosterone or the testosterone signaling.

Testosterone is the male hormone and is like the fuel to the fire for cancer. There’s been at least a dozen different new treatments that have come out in the last 10 or 15 years, allowing men to live much longer lives and with much better quality of life, and really putting off other toxic treatments like chemotherapy.

In cases of very advanced prostate cancer, sometimes we actually give chemotherapy much earlier on than we used to, and that is also resulting in much better symptom control and, and cancer control, than what we were doing years ago.

Courtney: It sounds like a lot of promising news for prostate cancer treatment.

Dr. Feuerstein: Yeah, it’s a really exciting time to be a doctor in prostate cancer. I’ve been in practice for about 12 years, and I’ll say that when I was a resident in training, that if you were diagnosed with advanced prostate cancer you may have only had a couple of years to live. The treatments were very toxic, and often associated with a lot of pain. And now we’re seeing really drastic changes in quality of life and pain control and life expectancy. Men are really doing much better than they used to.

Courtney: And is anyone more at risk for prostate cancer than other people?

Dr. Feuerstein: There are groups—any one of African American ancestry, men with family history of prostate cancer diagnosed early, so under the age of 60. And when we talk about family history, we’re talking about at least two family members, a father and a brother or two brothers, or any family member who is diagnosed with a fatal prostate cancer.

And then there are certain cancers that go along with prostate cancer. Things like  ovarian cancer and breast cancer. So if you have multiple family members that have those, that can be associated with a higher risk of prostate cancer.

Courtney: So I’d love to do some myth busting. Are there any misconceptions or misunderstandings about prostate cancer?

Dr. Feuerstein: Yeah you know I think that, men are dissuaded from screening because of the digital rectal exam. I think that that  exam is really not very helpful, and that we have much better testing now. And so if men are interested in prostate cancer screening, they should ask for a blood test, a PSA test. And this is often sufficient in most cases.

Other men are concerned about the risks of a prostate biopsy: that a biopsy itself—putting a needle into potential cancer—could spread cancer, or could lead to bad outcomes. It’s incredibly safe. It’s not associated with spreading cancer. And we now have much safer techniques of biopsying where we’re reducing the risk of infection.

Courtney: And so if your PSA level is high, does that mean you have cancer?

Dr. Feuerstein: If your PSA is elevated, if it’s between the levels of 4 and 10, actually the majority of men will not have cancer. At least 60% of men won’t have cancer, but there’s about a 40% chance of cancer. And there’s different types of prostate cancer, and that’s where these other tests, the biomarker tests, the blood tests or the MRIs, can help risk stratify who might have what’s called a clinically significant prostate cancer. That means a prostate cancer that might impact their lives.

Courtney: Is there anything people can do lifestyle wise to protect their prostate health or lower their risk.

Dr. Feuerstein: There’s not a lot we can do to prevent prostate cancer. Early screening is the best way to prevent complications from prostate cancer and, and certainly lifestyle helps with prostate cancer treatments, if you’re gonna have surgery or radiation, you’re gonna have a better outcome with a better lifestyle.

So in general, you know there’s been a number of different vitamin studies, health studies – what I generally say to patients is, whatever’s good for your heart is good for your prostate. You know, low salt diet, not a lot of red meat, lots of fish, fruits and vegetables, and in general, trying to stay fit, lose weight, exercise, these are all good things. We should keep in mind, you know, the number one cause of death is heart disease, even in men with prostate cancer. 

Courtney: Yeah, what’s your message for men to prioritize their health?

Dr. Feuerstein: Preventative care is critical. Men have lower life expectancy than women, and it’s mostly due to these modifiable risk factors that go untreated. We know that there’s a large group of men between the ages of 30 and 50 that don’t go see doctors at all who may have these modifiable risk factors like high blood pressure, smoking, alcohol use, obesity that we can address and we can also discuss with them other cancer screenings, not just prostate cancer, but colon cancer, lung cancer for smokers, mental health screening, and other general health risk factors.

Courtney: And so do you have a takeaway message you’d like to share with listeners, whether it’s about men’s health or prostate cancer or prostate health?

Dr. Feuerstein: We’ve really created a lot of advances over the last few years in terms of determining who might need the next steps of screening, who might need a biopsy, who might need treatment, and it’s really led to great improvements in quality of life for men. And so we’ve seen a lot less overtreatment, a lot less over diagnosis. I’m really excited about New York Presbyterian The One. And what we’ll be able to offer patients in Westchester. We’ve worked really hard to bring, what I think is really the state of the art in treatment for prostate cancer. We have really an outstanding team in medical oncology, radiation oncology, and urology. We have primary care, cardiology, endocrinology, behavioral health, we’re gonna address, sort of a holistic approach to men who might be diagnosed with prostate cancer or other cancers and really bring state of the art care.

Courtney: Dr. Feuerstein, thank you so much for joining us today and sharing all these great tips to reach men for Men’s Health and Prostate Cancer Awareness Month.

Dr. Feuerstein: Thank you very much for having me. It was my pleasure.

Courtney:  Our many thanks to Dr. Michael Feuerstein. I’m Courtney Allison. Health Matters is a production of NewYork-Presbyterian.  The views shared on this podcast solely reflect the expertise and experience of our guests.

To learn more about the care we provide at NewYork-Presbyterian The One, a new center for Advanced Care in Westchester, and how to make an appointment, check out the show notes.

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