Prostate Cancer: Diagnostic Phase
Guest: Dr. Jonathan Picard – Urology Services, MUSC
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: Dr. Jonathan Picard is Assistant Professor of Neurology here at the Medical University of South Carolina. We are so lucky to have him as one of the newer members of our staff, bringing in fresh ideas and training from around the country. Let’s talk about the treatment for your area of specialty, which is prostate cancer, at Hollings Cancer Center. What is the approach that you take at Hollings, and what makes that special?
Dr. Jonathan Picard: What we try to do when we have all new diagnoses come in is to really kind of evaluate everything about the patient. We try to take into account what their background is, what their other medical conditions are and, specifically, what their disease is. In general, this requires getting good knowledge about the patient. It also requires taking this information to what we call the multi-disciplinary review board. Essentially, this is made up of an oncologist, radiation oncologist, medical oncologist, and radiologist.
Every new diagnosis of urologic cancer is brought up for discussion. It’s staged appropriately. Essentially, staging means we go ahead and look at the disease in terms of how aggressive that particular cancer might be, what location it’s in, how advanced it appears to be in terms of its local invasion, or whether it has spread throughout the whole body. Essentially, this allows us to really try to cater the disease and the patient for the proper treatment plan.
Dr. Linda Austin: Now, you mentioned a number of different types of specialists who enter into the discussion. Can you take those one by one and explain who those people are?
Dr. Jonathan Picard: Absolutely. Let’s start with the radiation oncologist, for patients that may benefit from radiation. Frequently, we actually work in combination with them, perhaps placing seeds, or perhaps even working to help with markers. This allows us to really work hand in hand between the surgeon and the radiation oncologist to optimize the patient care.
Dr. Linda Austin: The urologist does, what?
Dr. Jonathan Picard: The urologist, depending on the disease, will, perhaps, do the initial diagnosis. Perhaps they’ll do some of the interventional placement of markers, or things such as seeds. Perhaps they’ll do initial resections if it’s a bladder tumor.
Dr. Linda Austin: A resection meaning, cutting it out?
Dr. Jonathan Picard: Exactly.
Dr. Linda Austin: So, they’re really the surgeon who does the heavy lifting for getting rid of it on the OR table, right?
Dr. Jonathan Picard: Correct.
Dr. Linda Austin: Who else is on the team of the tumor board discussing each patient’s tumor?
Dr. Jonathan: We also have medical oncologists. Generally what they, also, do is work hand in hand with both radiation oncologists and urologists to see if there’s a medical benefit to therapies such as hormonal therapies, or chemotherapies. Frequently what we find is that many diseases require an approach that is multifaceted.
Dr. Linda Austin: So, in other words, a medical oncologist is an internal medicine doctor who has specialty training in cancer, and that training allows them to administer chemotherapy, and those sorts of treatment, hormonal therapy, that might be useful, correct?
Dr. Jonathan Picard: Correct.
Dr. Linda Austin: Anybody else whose role we need to understand?
Dr. Jonathan Picard: We also have radiologists. In general, as a surgeon, we like to go ahead and look at these images. We like to work hand in hand to make sure we have every step of the person’s anatomy understood. That allows us to make a designation on site with everyone being aware of the disease.
Dr. Linda Austin: Now, Dr. Picard, I guarantee that somebody listening to this will be a man, or someone who loves that man, who’s just heard from, perhaps, a primary care doctor that they really need to go and have their prostate examined, and perhaps they have an elevated PSA, and there’s a strong likelihood that they may have cancer, which is a really scary thing, a scary prospect. But let’s make it less scary. Walk me through what that person should expect. They call up, right, or their doctor calls Hollings Cancer? Let’s just take it kind of step-by-step. What happens?
Dr. Jonathan Picard: Sure. This is frequent, just as you’ve said. Essentially, we have someone that comes in with one of two things. One is that they have an abnormal blood test, which is called the PSA test. The second thing might be that there was something abnormal when their doctor did an exam on their prostate, and felt their prostate. Either one of these situations will usually prompt them to be sent to a urologist. My job, as the urologist, is to do a good general evaluation of the patient, looking into their medical history, whether they’ve had anything that could possibly have changed either their physical exam or their blood test.
Dr. Linda Austin: So, on that first evaluation then, probably, the primary care doctor would have initiated the referral, usually, is that right?
Dr. Jonathan Picard: That’s correct.
Dr. Linda Austin: And then they go over to Hollings Cancer Center and see you there, or do they see you in another part of the hospital?
Dr. Jonathan Picard: Actually, they’ll usually see me either in Rutledge Tower, on the 5th floor, or in Mount Pleasant where we have an outreach clinic.
Dr. Linda Austin: And, what does that physical exam consist of? What happens?
Dr. Jonathan Picard: What we do is go ahead and do a digital rectal examination, with our finger, at the time of the evaluation, to see if we can palpate anything that feels abnormal.
Dr. Linda Austin: Ah, the dreaded digital rectal examination. Well, men really do dread that one, but it’s really pretty quick, certainly painless, right?
Dr. Jonathan Picard: Absolutely. And I really try to emphasize that even though it’s uncomfortable, we do find a significant number of cancers that way, with people that have normal blood tests, so it’s a vital part of the examination.
Dr. Linda Austin: And it really feels about like having a bowel movement, is that right?
Dr. Jonathan Picard: Absolutely.
Dr. Linda Austin: What else happens in that physical examination?
Dr. Jonathan Picard: We do just a good general examination, trying to identify where there might be any abnormal lymph nodes, or anything else that would be abnormal in our examination of the male genitalia, or the rest of their body.
Dr. Linda Austin: And what else happens that day?
Dr. Jonathan Picard: Really, there’s a good long discussion about things that could have prompted them to have an abnormal blood test, or any of these abnormal findings. What we know is that PSA can be elevated for many reasons, and that’s one of the most important things to let patients know. It can be elevated because of inflammation, infection, urinary retention, or the thing we’re concerned about; prostate cancer.
Dr. Linda Austin: So, in other words, an elevated PSA isn’t cause for alarm? It certainly is cause, though, for scrutiny?
Dr. Jonathan Picard: Absolutely. It really prompts us to go ahead and try to do another level of examination to make sure that we don’t miss anything that could potentially cause problems in the future.
Dr. Linda Austin: So, on that first day then, I’m sure you order a lot of tests. Will the patient have their blood drawn and have imaging tests that day, or do they come back for that?
Dr. Jonathan Picard: Frequently, we actually just recommend doing a biopsy. That’s, really, the next step. Most of the time, they’ve already had the blood drawn before, and if they bring that result them, there’s really no need to have a repeat draw. Occasionally, we do recommend other tests, but I would say that’s the minority of the time.
Dr. Linda Austin: And, what happens during a biopsy? What does a patient experience?
Dr. Jonathan Picard: What we do is set up a time that’s convenient for them where they can come in, having taken some antibiotics beforehand. We then do an examination with an ultrasound, which does go in the bottom, however, we use numbing medication and numbing medicine next to the prostate. We’ll then do a biopsy where we obtain 10 to 12 cores of the prostate gland, and have those viewed by a pathologist, to tell us if there’s cancer there or not.
Dr. Linda Austin: And you said 10 to 12 cores. These are itty-bitty.
Dr. Jonathan Picard: That’s correct. These are little needle pokes.
Dr. Linda Austin: Right, okay, that the patient doesn’t feel.
Dr. Jonathan Picard: Absolutely. With the numbing medication that we’re using now, most patients tolerate it, really, quite well.
Dr. Linda Austin: And then once you’ve sent those off, how long does it take for the pathologist to give you a report on what they’ve seen?
Dr. Jonathan Picard: Usually, it takes between seven and ten days, especially if they require an additional stain, or something of that sort. I usually have patients come back in about 14 days to discuss the results, to make sure that we do have them [the patient] back.
Dr. Linda Austin: Yeah. That must be a very hard waiting period for men going through that, I’m sure.
Dr. Jonathan Picard: It is. But I do like to emphasize that prostate cancer is really only detected probably about 40 percent of the time when we do these biopsies. So, rest assured, for the most part, frequently, there’s no abnormality. And I try to reassure them about that.
Dr. Linda Austin: And, also, for the most part, prostate cancer is very slow growing. As cancers go, not that anybody wants cancer, it’s a fairly mild, or nonaggressive, form, for most men, is that right?
Dr. Jonathan Picard: Absolutely. I would say the majority of cancers, and we’ve seen this especially in some of the European trials, patients can go two to four years between examinations. And this is not shown to change the course of the disease or your ability to treat the disease.
Dr. Linda Austin: Anything else about what patients should expect in that evaluation and diagnostic phase?
Dr. Jonathan Picard: I think it’s always important to bear in mind that patients will sometimes have a little bit bleeding from the bottom or in their urine after we do the biopsy, and that’s to be expected. In general, if they take an antibiotic, the risks associated with this are quite small. But I definitely like to reinforce that they should expect to have some of these things occur, although it should improve rapidly over the course of a couple days.
Dr. Linda Austin: I guess if there’s anything, maybe, to help a little bit, this is, really, a very common form of cancer. So, if you feel unfortunate for having to go through this process, at least you have a lot of company; there are a lot of other guys there who are going through the same thing.
Dr. Jonathan Picard: That’s true. About 27,000 men in the United States are diagnosed with prostate cancer in a given year. It makes up the second most cancer in men in the United States.
Dr. Linda Austin: In the next podcast, we’ll talk about treatment of prostate cancer. Thank you so much.
Dr. Jonathan Picard: Thank you.
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