One of the serious “side effects” of the pandemic is disruption of other medical care, including screening for prostate, breast and other cancers. Delay in treatment is dangerous and, in the case of prostate, there is evidence the SARS-CoV-2 virus heightens the risk of cancer.
Dr. Ashutosh K. Tewari, chair of Urology at the Icahn School of Medicine at Mount Sinai, spoke to Straus News about the special urgency of prostate cancer awareness month (September) in the time of COVID-19.
There seems to be a special urgency to Prostate Cancer Awareness month this September in the time of COVID-19.
Sometimes because of COVID we kind of got scared and rightfully so. And that led to just kind of not going to a dentist, not going to preventive health, not going to get the PSAs checked.
I mean, not going to indoor dining is one thing. But not taking care of some risk which is working in parallel - that will only result in us finding cancers a little bit more aggressive a little later, because they are not going to take a COVID break.
So it’s a good time to have a refocus back on that. While we have to be protected from COVID, certain very common diseases have not disappeared. In fact, I can say that COVID may be colluding with the prostate cancer to make it even more marked. If COVID led to an inflammation that can make the PSA a little bit haywire [it can] also can make cancer become a little bit more active. So there is a very synergistic story.
Well, that’s very interesting. Not only is there the risk from being distracted from regular checkups, but there actually may be reasons why the pandemic increases the risk of cancer?
That was the work which was done in my lab. Everyone is aware of the COVID virus and they know that the COVID has what they call spike proteins. So spike protein allows COVID to get attached to a body cell. And it attaches to a body cell where there is something known as ACE2. ACE2 is an enzyme, which is involved with the diabetes, hypertension and all other things, but getting attached to a cell is not the end of the story. Because this virus in order to do the bad things has to go inside the cell and inside the cell it has to fool the system to make replications of its own.
So spike gets attached to the ACE2, but it enters the cell through another enzyme known as TMPRSS2. And TMPRSS2 is the same enzyme which causes prostate cancer. So there is a synergy between these two.
Wow. So back up one step and tell us what prostate cancer actually is and what we should be doing to monitor for it.
So almost every man has a gland in the pelvis, which is situated between the bladder and the penis. And it’s known as prostate gland. Basically prostate gland produces certain chemicals, certain enzymes which liquefy the semen, which also protects infection from coming into the urinary system. That gland itself is a little bigger than a small golf ball. One in seven man can have a particular part of this glandular system become out of control. Suddenly one small part of the gland starts making multiple billion cells and they start growing within the glands. And that is what the entire journey of this prostate cancer is.
One cell became a problem, starts dividing, gets out of control, gets a preferential metabolic system that can outsmart the neighboring normal cells so that it survives on the cost of the others not surviving. The good cells are dying and stealing away all the oxygen, all the blood from them, and then it grows and becomes spreading like a metastasis. That meta metastasis manages to kill about 34,000 men every year, just in United States.
Are there signs that men should be watching out for to hopefully spot this?
There are signs. Sings of blood, signs of pain, signs of blocking. But they’re too late. Because this cancer is curable when it is within the prostate. And at that time, it hardly ever produces any sign, but it has a weak spot. It continues to produce that blood test, which is known as PSA. The levels of PSA keep going up and not only levels of PSA keeps going up, there are certain markers which can be studied in the urine also. And if we have an opportunity, we can have a mammogram for prostate, meaning an MRI for prostate, and we can see the bad guys. So that is the time when it is curable, but it will not produce any symptom.
That’s the paradox in order for it to be cured. It needs to be found before it has produced a symptom, but it will produce a symptom later on; the blockage, the infections, the bleeding and bone pains and all those things can happen. But I hope we don’t get to see them.
So what should men be doing to prevent cancer from reaching a dangerous state?
One thing is being aware that it can happen. If I think it can happen to me, I will start a conversation. And that’s the most important thing. That men should have a conversation about what is prostate cancer and who it can impact.
The prevention part is a little bit of an evolving field. Meaning, I have some lifestyle suggestions, which potentially can minimize risk of prostate cancer, but I’m not sure they should be called prevention. People who eat less red meat, less animal fat, less sugar, they may be doing something right for their prostate. [People who eat] a lot of blueberries, a lot of pomegranate seeds, a lot of mushrooms may be doing something good for their prostate. But as a doctor, I cannot say that I made them prevent prostate cancer. Prevention should start with an awareness. Early detection, diet, and lifestyle changes. Exercise is a good thing. Remaining sexually active is a good thing. And managing inflammation. Inflammation in the body and especially on the prostate can later turn into the cancer. So we have to do whatever we can to minimize that.
You mentioned earlier the PSA test, which I guess most men at some point become aware of. Can you explain what a PSA test is and is that the main screening tool that you have now?
PSA is in prostate specific antigen, and it it’s a chemical, which is produced by prostate. And it basically is meant to liquify the semen. Semen initially is a little bit thicker. At some point it becomes more watery - that wateriness happens because of this PSA enzyme kind of liquifies it so that sperms can move freely into the semen. But when there is a cancerous prostate, the PSA being produced by the prostate finds its way back into the blood, rather than all of it being dumped into the semen. That part which goes into the blood is picked up by the blood test.
But there are a lot of buts here, meaning PSA can be high and the patient may not really have cancer. PSA can be high because the patient had a prostatitis. PSA can be high because the patient has a decent, big prostate. Not every PSA means prostate cancer. But if it is elevated, it’s a good idea to talk to an expert.
Are there other steps to screen for prostate cancer, even in people who have a normal PSA?
Normally it should involve the examination of the prostate, which we call a digital rectal exam, and it allows us to feel the consistency, feel the texture, feel any nodularity, feel any hardness, feel any lump in the prostate. An experienced doctor can find that. So that combined with the PSA is a good way to go about it.
So we’ve done the right things. We’ve done the PSA screening. Turns out there is cancer. What then? What’s the treatment?
The treatment doesn’t start with finding the cancer. It’s about what kind of cancer. Prostate cancer is like someone says that I have a car. What kind of a car? So, is it a Gleason six prostate cancer? Or a Gleason nine prostate cancer? Gleason 10? They are going to behave very differently. Gleason six can just lay dormant for decades. Gleason nine will get into the bone within months or years. The first thing for us to know, is what kind of cancer? Everyone would have the same name, prostate cancer. But what grade of the cancer becomes a very important discussion point.
And the second thing is: If it is within the prostate, it’s a different kind of cancer. If the same cancer has invaded through the wall of the prostate, it’s a different kind of cancer. So this part, how far they have spread is known as stage. So the first time I used was a grade of the cancer. And the second part is the stage of the cancer. And sometimes beyond grade and state, we look at certain genomic markers, meaning saying grade same stage cancer in one group may behave differently than in the other group. And that is because at the gene level, they may have some more strong levers in there which will push them to go farther, go faster or go to the bad places. That genomic analysis could also be another way of us to look it what we are dealing with. And once we have in our mind group, the patient into very low risk, low risk, intermediate risk, or at high grade, high risk.
I normally say that very low risk and low risk patients are best suited for what we call active surveillance. Basically they can be observed, watched and intervene if we see something moving. Intermediate risk for cancers usually need a treatment. They can either get it removed, can consider some kind of focal therapy or some kind of radiation. While the very aggressive ones, they can also be removed, but they can sometimes need hormones and they can also need radiation. So treatment depends on what we found, when we found it and what stage we found.
I take it from what you’re saying, that depending on the situation, this is a very curable cancer. In some cases it’s almost doesn’t even require immediate treatment.
Most patients don’t need it, but while I can keep saying that, I cannot ignore that last year we lost 34,000 men. In one important feature, we factor in patient’s own life expectancy to this system. How long are they likely to live? If they never had this cancer, people who have more than 10 years of life expectancy, we tend to want more to protect people who are otherwise very old, very sick. That’s the balance.
Tell us about the new developments in identifying and treating prostate cancer.
One of the new developments is the role of imaging. Men didn’t have what you call a mammogram for prostate. So the MRI became an important tool in a making a decision as to if patient needs a biopsy and B, if we do perform a biopsy, which area of the prostate, we should definitely focus on - what we call a targeted biopsy.
The second thing in the imaging front itself has become very important. It’s known as PSA scan. Recently a new scan has gotten approved by FDA, and that’s known as PSMA - prostate specific membrane antigen. That is a very high fidelity molecular scan. That can tell us if the cancer is trying to escape anywhere else, or has gone anywhere else. Third thing is that the role of genomics has become very important. We have some genomic markers that give us a feel of who is likely to have cancer. And if they have a cancer, whether it’s going to be a more aggressive kind, or an indolent kind.
Then there have been developments in newer kinds of nerve-sparing approaches, or continence-preservation approaches to have an earlier return of urinary control, better chances of sexual recovery. New drugs have become available, even immunotherapy trials have become available. So this is an exciting time for the prostate cancer field. A lot of newer research is coming out and next five years you’ll be seeing even more positive things happening.
Do you have a final message that that you want to make sure men know?
The prostate cancer discussion is all about being aware that this is a cancer which can kill 34,000 men. We should also highlight that not everyone needs to have an intervention. Not everyone needs to have a biopsy. But having a conversation, having a shared decision-making discussion with the doctor is an important tool for us. We should not wait too long for getting to know about it. And in the COVID year, prostate and COVID are not the most friendly things for men. Men can have trouble with both of them and sometimes together. So that is an important discussion for us.
And don’t be shy. I think talk about it, and it may change the outcome. And remember, not every discussion will result in biopsy. They should be aware that they have an option, at least in certain cases, to be watched, not just intervene.
I take it that the ultimate risk of not screening of not talking is a lot worse than most of the outcomes when you do screen or talk.
I totally agree with it. I mean, it’s easier to fight a battle with the enemy which has only 500 troops, and rather than let it go to five billion troops. I would rather fight it when they are smaller than number and not have a spread.
This interview has been edited and condensed.
“This is an exciting time for the prostate cancer field. A lot of newer research is coming out and next five years you’ll be seeing even more positive things happening.” Dr. Ashutosh K. Tewari