From PSA to Personalized Prostate Care

Transcript Generated by AI

Announcer: 0:00

Welcome to MedEvidence! where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren: 0:11

Hello, I'm Dr Michael Koren, the executive editor of MedEvidence!, and I have a really neat guest today, Dr. Ali Kasraeian. Ali and I have known each other for a long time, working as physicians in the community here in Northeast Florida, and we've actually done some media stuff together. But this is a fascinating guy and I want to really introduce him to our MedEvidence! audience and talk about his inspiration to get him involved in clinical medicine, in media, in public health discussions, in scientific research and helping organized medicine stay organized. So, Ali, welcome to MedEvidenc! e and thank you for being here.

Dr. Ali Kasraeian: 0:50

Thank you for having me. It's an honor to be here and congratulations Such a wonderful, wonderful things that you always do and make us all be better at everything that we do.

Dr. Ali Kasraeian: 0:59

So thank you

Dr. Michael Koren: 0:59

Well again, thank you for being here. So tell the audience a little bit about your path. Where'd you grow up, where'd you go to school and then how you got interested in Urology and all these public health issues that you address.

Dr. Ali Kasraeian: 1:10

So I grew up here in Jacksonville, Florida. My parents are actually both originally from Iran and they came here and both trained my mom's a world-renowned breast pathologist, and my dad's a urologist, who I have the real amazing pleasure of working with and operating with. So that's been the greatest.

Dr. Michael Koren: 1:24

It's pretty good genes there.

Dr. Ali Kasraeian: 1:25

Yeah, I mean it's been an amazing highlight of my life and, interestingly, our parents never pushed us to go into medicine.

Dr. Ali Kasraeian: 1:32

But you watch how, what they did, you know, especially when the times of health care were not plagued with all the things that we deal with now, that we talk about in terms of health policy and those things, but you watched how they impacted people's lives, especially in that when I was younger you had no idea what they did, but you saw the appreciation that they had, and my brother and I only knew that my dad took kidney stones out of people and took kidneys out and did things of that nature.

Dr. Ali Kasraeian: 2:03

So there's all these things that my parents joke around. There are pictures of my brother and I drawing kidneys or walking around, cutting our dolls open and throwing things into them and taking them out, and then, as we got older, we kind of always had that in your back of mind as something profound to do, and anytime we had some kind of moment and opportunity to be a part of healthcare, it stuck. And so you know both my brother and I my brother's an orthopedic surgeon we both went in there and you know I went to become a pediatric surgeon.

Dr. Ali Kasraeian: 2:34

I didn't get the rotation, I got urology and you found that it was impactful and I went to Paris, did a robotic surgery, laparoscopic fellowship, and that's where a lot of things we'll talk about today inspired me in terms of a better way of looking at managing prostate cancer.

Dr. Michael Koren: 2:50

So very strong family ties to medicine, which was clearly an inspiration for you.

Dr. Ali Kasraeian: 2:55

Yeah, I mean it's the impact that you have on people's life at the time that they need it most, and that's one thing that I still remember. My parents always said if you can find something else to do that can make you happy, do that. If you can't, then medicine is a wonderful track to go into, although be prepared, it's long and hard. And they don't tell you that when you finish one thing, you expect that it gets easier the next time. It just seems like it gets harder at every step.

Dr. Ali Kasraeian: 3:20

but in a wonderful way,

Dr. Michael Koren: 3:22

Neat. So you went to Paris, you did some special training there and then you came back to work with your dad in practice

Dr. Ali Kasraeian: 3:28

Yep

Dr. Michael Koren: 3:29

Excellent. And so why don't you just fall into the pattern of being a great urologist helping people here in Northeast Florida? Clearly that wasn't enough for you. You needed to do some other things.

Dr. Ali Kasraeian: 3:41

Well, some people say it's an attention span thing, but I mean, you look at other things that you can do. For me, innovation is very interesting and in urology, one thing that's really interesting with urology is we're always you know it's a very cutting edge specialty. You know robotics, endourology, and for me, when I was in Paris, you know I saw some things that in the United States weren't being done the MRI scan. We partnered with a team in London when I was there, with a lot of research collaborations of using the MRI scan to look within the prostate and then look at targeted biopsies. And that blew my mind High-intensity, focus, ultrasound and cryotherapy to do targeted biopsies. So that was really inspirational to me and brought me back to what my mom's career path was with breast cancer. And then I went back and really looked at something I never thought about and realized how instrumental my mom's career path was with that fundamental switch from the lumpectomy or the segmental mastectomy to the big, you know, halstead mastectomy.

Dr. Michael Koren: 4:41

Sure.

Dr. Ali Kasraeian: 4:41

Where they removed everything, the big lymph node dissections,

Dr. Michael Koren: 4:43

much more targeted treatment

Dr. Ali Kasraeian: 4:46

yeah.

Dr. Ali Kasraeian: 4:46

And one of my mentors at the University of Florida was a guy named. Our chairman, was a big breast cancer surgeon who was part of that process as well. So you kind of looked at the similarities between that and where we were at the time with prostate cancer. Where could you be over-treating a lot of disease? And that really inspired me to potentially bring that into a process of my practice. And the wall for that was always, you know, it wasn't done in the United States how do you get it covered? You know, how do you do the research? To be a part of the research as a community physician, to be a part of that. And then I operated on a TV chef, had the opportunity to be part of media and opportunity to have a radio show for some years.

Dr. Michael Koren: 5:38

So you said a TV chef.

Dr. Ali Kasraeian: 5:39

Yeah, I had no idea. He was a TV chef. We're about a week or two before his operation. He was like can you come on my show to talk about prostate cancer? I was like I have no idea what you're talking about, but I'll be happy to, so he cooked some eggs.

Dr. Ali Kasraeian: 5:53

And next thing, you know we're talking about prostate cancer

Dr. Michael Koren: 5:55

That was a local show, yeah, in Northeast Florida.

Dr. Ali Kasraeian: 5:57

Yeah, channel 12.

Dr. Ali Kasraeian: 5:57

And then they asked me to come back and talk about other stuff. And then WOKV asked me to do a radio show and then that kind of stuck and I saw it as an opportunity to not only learn about things that weren't urology but to be able to talk about things, and there's a fun way to talk about healthcare in a different capacity. And then the Affordable Care Act.

Dr. Michael Koren: 6:20

So you did that regular radio show, yeah, and I was a guest a couple of times and we talked about some really neat things in health policy. And then, of course, covid was something that we talked about and I think you really serve the community by getting good information out there.

Dr. Ali Kasraeian: 6:33

I appreciate that it was fun and, for me, where it shaped another part of my career was when I was doing that. The Affordable Care Act was a big part of what's going on and several of my mentors - which for me mentorship seems to have been an underlying theme to a lot of things in terms of my path, where I saw things. I was interested, and I had the right mentors and the hand push me for opportunities. And Joe Tepas who was a prolific pediatric and trauma surgeon at UF, was a right very, very wonderful and strong leader at the American College of Surgeons in many capacities for quality, for health policy, would talk to me and guide me in terms of the positives and negatives of what was going on there. And Carolyn McClanahan, who's a close, dear friend, is very, very knowledgeable about the ins and outs of the Affordable Care Act, and you yourself. We'd have these amazing conversations on the show, so I'd always try to read as much as I could to be at least on par with the conversation with my guests, who are world-renowned experts, who are often on the conversations.

Dr. Michael Koren: 7:38

And you frequently refer to the world's greatest literature, whether it be Lancet or the New England Journal of Medicine and literally pulled it out during the radio broadcast and look at the data and make comments on it, which was fabulous, but it did it in a way that was very approachable even for the average listener.

Dr. Ali Kasraeian: 7:55

I mean, I think, simplifying the importance of data to our decision-making, especially as we see, as that past really 20 years have gone. Data is really impactful for what we do and it's worrisome when it's lost and you make decisions without data, and prostate cancer is something that we've learned over the past 20 years. The importance of data has made us better. Health policy, That becomes very important because a lot of decisions may or may not be made with the total amount of data and you can see how impactful that could potentially be and how dangerous it can be as well. So that got me involved.

Dr. Ali Kasraeian: 8:31

I got on a lot of legislative affairs committees with the AUA and American College of Surgeons and it's a wonderful way to potentially serve and be involved. You know the frustrations of what everyone feels, you see firsthand and you know hopefully it's a way to give back and help, although it is a very frustrating process because the solutions are not fast. But physicians, you know, do need to get more involved and we need to be there because we're all working, we're taking care of patients and the people that are involved and get more wins seem to be there a lot more with deeper pockets, and when we're not there, it impacts our colleagues and, most importantly, it impacts our patients.

Dr. Michael Koren: 9:13

Right, and this is a good segue to the fact that you're now the president of the Duval County Medical Society. So tell us a little bit how you got involved in that and why you decided to take that position, and how's it going so far.

Dr. Ali Kasraeian: 9:26

It's great. Duval County Medical Society is a wonderful organization and for the physicians listening, I would urge you to be involved. You know my big thing this year is to encourage people to think of the Duval County Medical Society as family.

Dr. Ali Kasraeian: 9:41

You know, I'm a big family guy three kids, I have a wonderful wife, I have wonderful parents and an amazing brother and his family and we as physicians historically acted like family our colleagues, our nurses, our patients. It was like family and we're kind of at a danger point where that relationship may be segmented by the way that the way medicine is practiced these days is moving towards potentially a more shift worker mentality. We're having teams that are a little bit more segmented and I think you know the team approach to health care is wonderful. I think it needs to be with physician leadership and I think we need to embrace that because I think it's a better way of taking care of patients. But it needs to be with this concept of family where we all take care of each other and then that's a better way of taking care of our patients.

Dr. Ali Kasraeian: 10:34

And I think the Duval County Medical Society is a great way to potentially do that, both in terms of the networking but also the resources that we can have and the advocacy at first is one of the biggest county medical societies with the Florida Medical Associations.

Dr. Ali Kasraeian: 10:48

We have a lot of passionate, wonderful people that work in that and our staff is amazing and we do a lot of fun things we give back to the medical students. We do a lot of things of that nature and I feel very blessed to be a part of it and honestly, frankly, it's been so many years that I've been involved I don't even know how I got started. My parents have been involved. My mom was in leadership for a long time and there's some really amazing history of profound things that have happened. A lot of you know big, big moves in mass casualty and things like that, where we're inspired by people at UF and trauma surgeons over there. Over the historical time, a lot of amazing other things have been done with surgeons and physicians here in Duval County. We need to celebrate the power of the physician leadership here in Duval County and this is a great organization to help us be great physician leaders for our patients.

Dr. Michael Koren: 11:39

Sounds terrific, very inspiring. Now I know you've also been involved in leadership positions and in committees on a national basis, so why don't you let the audience know a little bit about that work?

Dr. Ali Kasraeian: 11:49

So I've been very fortunate and it seems like all these things happen at the same time and I kind of joke around with my wife I recently got an MHA at UNF.

Dr. Michael Koren: 11:59

Wow.

Dr. Ali Kasraeian: 11:59

And it was really done. Because you go into C-suites with the hospitals to try to bring new technologies and things of that nature and it seems like you and your industry partners think this is the greatest thing since sliced bread and makes money for the hospital. It's great for the patients and they look at you like you've grown horns on and and. So I was like you know, obviously the people on the other side of the fence aren't malintended people, so maybe the conversation is different. So I thought this would be a good way to do it.

Dr. Ali Kasraeian: 12:26

It took a lot of effort and with kids it's difficult to do and you know I thank my wife for her support and patience for doing that. But along doing that, you know, everything seems to kind of work in terms of the ascensions with a lot of organizations. I'm the Legislative Affairs Committee, now called the Federal Advocacy Committee, which we're all chagrined by the anagram for that committee's name at the AUA, at the American Urological Association, a similar legislative committee for the American College of Surgeons. And what's great about that? It allows us to triangulate things locally and with the Florida Urologic Society so that we can potentially make efforts that physicians have a united voice for the things that matter to us, which ultimately help our patients, and I feel very blessed to be in those rooms to see how things are shaped locally, regionally and nationally.

Dr. Michael Koren: 13:16

Yeah Well, that's amazing. Wow, you've done a lot of things and congratulations and thank you on behalf of the physician community for all the stuff you do.

Dr. Ali Kasraeian: 13:24

I appreciate the opportunity.

Dr. Michael Koren: 13:25

So we're going to take a break here, but urologists are very famous for having a good sense of humor. I remember doing surgery and working with urologists and they were cracking each other up. I heard this one recently and you probably heard it, but I'll share it with the rest of the audience is what did the director of the urology program say to the star resident at the time of his acceptance into the urology program?

Dr. Ali Kasraeian: 13:52

I can only imagine.

Dr. Michael Koren: 13:55

He said you're in

Dr. Ali Kasraeian: 13:57

Now urology. It's interesting. Besides the amazing, amazing comedy of this show, one of the things that actually drew me to urology was, in fact, that I actually, like I was saying before I went to be a pediatric surgeon, I would always ask my dad I was like, of all the things you could possibly do, this is what you chose to do, and he'd be like you know, everyone's great the sense of humor. People are all wonderful surgeons and they have great sense of humor. It's a great lifestyle. You treat people or your patients get better.

Dr. Ali Kasraeian: 14:26

And at the University of Florida, when I was there, our third year clerkships where you go from the classroom to seeing patients was on a lottery system and you want the chairman's service so you can get the letter of recommendation for your residency applications, and then I put in to do pediatric surgery. I had a middle of the lot lottery said by the time I got there, all those spots were taking except one chairman spot, so I got that and then the only thing that was left was a urology and some other service that no one wanted. And I'm like, of all the things, it was this and I loved it. Everyone had a great sense of humor. Our chief resident at that time was, and still is, probably one of the funniest people I ever met.

Dr. Ali Kasraeian: 15:06

Every night, you know, back then you could go to drug rep dinners every night. We got all the pens we wanted. You could get pens at that time and our patients did better. We did big surgeries, we did little surgeries, you could shape you know all sorts for your day and it was like a nice mix of clinic and the operating room and everyone was happy. Back then I went to the general surgery side of things. It was a little bit of a different scenario. So I always kept it in the back of my mind. And here we are a million years later and I'm a urologist and couldn't be happier.

Dr. Michael Koren: 15:37

Beautiful. We're going to take a quick break here and then, when we come back, I want to focus on this controversy about prostate-specific antigen, PSAs. Certainly, I know that you've been keenly interested in this and have some views about it, and we'll jump into that discussion in just a moment.

Transcript Generated by AI

Announcer: 0:00

Welcome to MedEvidence!, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts Hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren: 0:11

Hello, I'm Dr. Michael Koren, the executive editor of MedEvidence! I've been having this fabulous discussion with Dr. Ali Kasraeian and we talked about your background and some of the wonderful things that you've been doing for our community. And now let's jump into a controversy and you and I have had this discussion before, but I think it'd be super interesting for our listeners and viewers to hear it and the discussion is around the use of PSAs, or prostate-specific antigens, to diagnose prostate cancer.

Dr. Michael Koren: 0:41

And when I was a resident and early in practice and was practicing some internal medicine, I would routinely get PSAs on my patients, typically men anywhere between mid-30s and 55. And we would be looking to see if there are early signs of prostate cancer. And then the rules changed a little bit or the policy did, and that was no longer looked at as something that we should be doing on a regular basis. So why don't you educate our audience a little bit about the history of that and the controversies around that and kind of where you stand?

Dr. Ali Kasraeian: 1:14

So the PSA is a very inexpensive, very simple to get lab test that we use as a screening test to see what the risk of having prostate cancer may be. And the controversies that lie around this is the potential of over-diagnosing prostate cancers that may not kill someone, low-risk, low-volume prostate cancers that people could live with, versus over-treatment of those same cancers. So that has been, you know the, the albatross that has has really plagued prostate cancer screening for a long time, and since its inception it's been this, this discussion of what to do. When you know, in the late eighties, early nineties, PSA developed. It was a really wonderful tool that we had nothing.

Dr. Ali Kasraeian: 2:04

People would show up with metastatic prostate cancer and you would be lucky to find organ-confined prostate cancer, to be able to do a prostatectomy, which Patrick Walsh at Hopkins did some wonderful studies to find the anatomy, to do nerve preservation and better prostatectomy.

Dr. Ali Kasraeian: 2:21

So then everyone that was then diagnosed with prostate cancer. We had a sharp increase in the diagnosis of prostate cancer and a really, really profound decrease in the mortality from prostate cancer, which then continued for years and decades to come. The challenge with that is, the treatments for prostate cancer were associated with significant quality of life implications, such as incontinence or erectile function issues that were really profound. And so the discussion was if you have a potential prostate cancer that is low risk and people could live with and it was not fatal, is it worth the diagnosis and the anxiety related to it and the potential overtreatment with treatment alternatives that may have impact? And prostate cancer-specific antigen, or PSA, is not prostate CANCER-specific antigen, it's one that could be elevated for other things and enlarge prostate inflammation and those type of things. So we're kind of plagued with the appropriate way of screening. So more appropriate, smarter screening and you know the counseling and kind of how over the years have we used better tools to be more personalized and precise with our screening discussions?

Dr. Michael Koren: 3:39

So, just for the audience's knowledge and for my knowledge, what are the current recommendations about PSAs? Never get them. Get them in certain patients. Just break that down for us.

Dr. Ali Kasraeian: 3:49

So right now with the AUA, the recommendation is around 45, begin screening for prostate cancer, and that's been kind of like a that constantly changes. Different organizations recommend different things and if you are at a higher risk population.

Dr. Michael Koren: 4:03

When you say screening, is that a rectal exam or is that a live test now?

Dr. Ali Kasraeian: 4:07

So you know the PSA is what you talk about. The rectal exam remains controversial, but most of us that do a lot of prostate cancer tend to recommend getting a rectal exam and a PSA test as a screening measure.

Dr. Michael Koren: 4:18

So that's still in the books as something we shall do at age 45.

Dr. Ali Kasraeian: 4:21

At 45.

Dr. Ali Kasraeian: 4:26

You know the rectal exam by itself there are studies that show it may not be as impactful. I personally do a rectal exam because it gives you a lot of information. The size of the prostate is a guesstimation. It's not as precise as getting an ultrasound or an MRI scan per se, but it gives you an idea of if someone has a huge prostate, a medium-sized prostate or a large prostate and you look to make sure there are no nodules. You know if someone does have a nodule on their prostate you could still have a low PSA and have a nodular prostate. You can make sure there are no rectal nodules or rectal masses and things of that nature. So I think there's impact and positivity in doing a rectal exam. So I still do rectal exams.

Dr. Ali Kasraeian: 5:05

Risk and high-risk populations include a family history of a prostate cancer, especially a brother, father, first-degree relative and people of African ancestry and African-American populations are a higher risk of prostate cancer and with the African-American population they had an almost twofold increase in more aggressive and fatal prostate cancer diagnosis at an earlier age. So earlier screening kind of starting at 40, is an easy way to kind of think about that. So I try to make things simple for people, if you have no family history, no increased risks 45, and then everyone else at 40. And you can kind of at 45,. You can think about that as the same timeframe to begin getting that first colonoscopy.

Dr. Michael Koren: 5:41

Okay, and when do you stop screening for PSA? This is where the whole concept that later in life maybe it's not going to be particularly helpful and just chase you down a rabbit hole. So one.

Dr. Ali Kasraeian: 5:54

You know 70 comes up as this age. That comes up in a lot of the guidelines. However, you kind of think about that in terms of, you know, age as chronology but also level of health. You know there's 70-olds that are running triathlons and then there's 70-year-olds that have 900 heart stents and are walking around with an oxygen tank. So you assess that 10- 15-year lifespan and possibility of being alive at 10- 15-year, which is not the easiest thing to do, but there are a lot of ways you can potentially assess that and you look at that.

Dr. Ali Kasraeian: 6:24

And really one thing that's really important to think about these conversations a lot of times are had at urology meetings and within urology venues, but it's important for this to be had at the primary care doctor's office because a lot of times we have these conversations when the patient already has had a PSA and they're like 85 years old and they show up with an elevated PSA. So then you got to figure out do we want to make sure that we don't have metastatic disease now, because I'm not excited about getting, you know, prostate biopsies on an 85-year-old for their PSA being elevated, but you want to make sure what the reason you're doing that is from that standpoint. So those are the discussions to have at the primary care level and that's where we are working very hard as urologists to figure out the best way to come up with the best screening aspect at the beginning of the conversation which is there?

Dr. Michael Koren: 7:14

So just for clarity. So somebody who is considered low risk doesn't have any of the high risk markers. Do you still recommend primary care physicians check at 45 and yearly, or every five years? Or give us a Good question, yeah.

Dr. Ali Kasraeian: 7:28

So when you talk the guidelines, talk about a patient-centered discussion, and a lot of times when you talk to your patient, they have buy-in on checking it on a yearly basis and it's an inexpensive test to do If their PSA is very low, and most of the world's population's PSAs are actually less than one then you can actually come

Dr. Michael Koren: 7:50

And is four still considered above normal?

Dr. Ali Kasraeian: 7:53

So in a lab test, but we're actually looking at that a bit more. Four would actually come up with as a two standard deviation increase from two, two and a half we're actually looking at could two and a half be the new normal per se? A study was actually just published that people in their 70s the world's majority of PSAs are actually less than one at 70.

Dr. Ali Kasraeian: 8:12

And if your PSA at 70 is less than one, your risk of having a clinically significant prostate cancer is very low. There was a great study done out of Malmo, sweden, years ago, where they went it was a natural history of disease study and they went back and looked at blood and looked at PSAs. That first PSA at 45 to 49 for average risk patients was the most telling of your risk of prostate cancer. If your PSA at that age was 1.5, that represented about 44% of people who had clinically significant prostate cancer in their lifetime. If at 60, you had a PSA less than one average risk, your risk of clinically significant prostate cancer was very, very low. And that study showed at 70, kind of similar type of thing.

Dr. Ali Kasraeian: 8:57

So you can come up with an algorithm of how frequently to check PSAs based on what those PSAs are at A. So if your PSA is less than one at 45, could you check less frequently. If it's two, it is different from that standpoint and that's what we want to kind of look at. The other thing is knowing your family history, knowing if there's any kind of bracket gene positivities, even in the women in your life. So that becomes important in terms of how often you check your PSA. For you personally, the easy answer is if you're getting labs anyway and you check a PSA every year, it's not an expensive test. But as a population discussion you can make decisions based on what your individual PSA is in a conversation with your primary care doctor, so if it's less, than one, risks are much lower.

Dr. Michael Koren: 9:39

And, as you alluded to before, the concern is that there are a lot of false positives and I imagine that if you have prostatitis from infection or something else, your PSA goes up.

Dr. Ali Kasraeian: 9:50

Absolutely, and I want a couple of things. We recommend to people Avoid ejaculation for two to three days. If you have any kind of symptoms you're worried about, talk to your urologist. You know a lot of the things. When people look up, you know prostate cancer a lot of urinary symptoms come up which are usually associated with BPH benign prostatic hyperplasia which is a benign entity. It's not a cancer-based entity from that standpoint. So that's something for people to be mindful.

Dr. Ali Kasraeian: 10:13

Often, most of the prostate cancers that we diagnose are really simply from a lab test that was obtained, often with patients not knowing that they had the lab test done, being elevated. So that's why the importance of screening is so profound. And you know, looking at the data, you know in 2008, there was an initial screening recommendation against prostate cancer screening by the US Preventative Services Task Force. That then was strengthened in 2012 with a grade D recommendation and that really led to a significant decrease in screening, especially at the primary care level, which we now see the downstream effect. And you know, multiple years later, that grade D recommendation, after re-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 a patient-centered discussion with your doctors about the risk benefits and that has increased screening. But we downstream have seen a significant stage migration more metastatic disease, more high-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 the African-American population. That's a big deal from that standpoint and those are really, really profound. So if you have people men in their 50s not being diagnosed with high risk disease, the implication of that is profound.

Dr. Michael Koren: 11:41

So we always like to talk about the fact that things should be personalized when you're getting medical information from the internet or from Med Evidence!, and so let's come up with a couple of scenarios so people can understand things in a more personal way. 48-year-old guy not 100% sure of his family history but thinks maybe somebody had prostate cancer 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 PSA after one, you know, unless you have a trend? So you kind of go back and look if they've ever had any kind of PSAs and things of that nature. Then we kind of talk about repeating it. There are studies that show that even kind of, you know, giving antibiotics doesn't make a difference unless they have symptoms. You know prostatitis. That's where the rectal exam helps. If you have a warm, tender prostate associated with prostatitis, then you can treat that.

Dr. Ali Kasraeian: 12:36

But repeating, you know, is this a fluke? Is it elevated For someone in their 40s? You know age-specific PSA. Your PSA should be less than two and a half, you know, from that standpoint. So then you kind of look at if the PSA is elevated. I was, you know, I'm a big, big believer in multi-parametric MRI scan. This is a very specific MRI scan that looks within the prostate to see are there any areas of concern. Because now we have the technologies that if there is, you can actually merge the MRI and the ultrasound and target that area. And if that area is the only place that's concerning, then we could potentially just treat that.

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 high frequency ultrasound that can be used at a time of biopsy that can give us more information to see "aha. There's a better place to do, but in terms of a diagnostic tool that helps guide and shape biopsy decisions and also as a tool to do a better biopsy the multi-parametric MRI scan. And if someone can't get the contrast, the gadolinium, we could do what's called a bi-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 that standpoint to not only help guide a better, more accurate, more precise diagnosis, but also it 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 the MRI scan is negative, you know we have to be mindful that you could still have about a you know, 20 to in two amazing studies, the PRECISION trial and the PROMISE trial, which helped land the impact of MRI scan for not only finding more clinically significant disease, which means intermediate and high-risk prostate cancer, meaning prostate cancer that if you found you would treat Low-risk prostate cancer, which there's a thing called the Gleason score. It's how you grade the prostate cancer. Lower-risk prostate cancer is the Gleason score of six PSA less than 10, a small nodule or no nodule those you can monitor with an active surveillance. We hope not to find those. If we can, we want to find the ones that we would treat and could impact your life potentially in the future If you find a small targetable lesion like that. Now we have technology that you could 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 you still 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 had previous biopsies or things of that nature, you can see If it's a change, if they've had an increase in their PSA velocity. They've been one their whole life and now it's 2.8, you repeat it. If it's still 2.8, then you can talk to them. You know, I would do an MRI scan. It gives you the size of the prostate. It can give you some idea if there's a targetable lesion. Because that same pathway Could you 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 a notion, as I understand it, that being diagnosed with prostate cancer later in life tends to have a more benign course than somebody that's diagnosed earlier in life.

Dr. Ali Kasraeian: 15:59

Yeah, and a couple different perspectives. One the average age for being diagnosed with prostate cancer is 66, 67 years old and the implications of how to manage them depend on a few things. One, the stage and grade of the prostate cancer. Like I mentioned, there's Gleason score. Pathologist looks at the cells on the microscope and assigns two numbers. The first number is the most common, second is the second most common. Adds them together to a total score. As the numbers increase, how different from normal those cell types are increases and the possibility of it in the future at some point getting out of the prostate increases. So a Gleason score of seven is kind of a fence that divides aggressive cancers, like eight, nines and tens, from less aggressive cancers, like six we don't really see fours and fives anymore Within the seven family and 10s from less aggressive cancers, like 6. We don't really see 4s and 5s anymore Within the 7 family. A 3 plus 4 is less aggressive than a 4 plus 3.

Dr. Michael Koren: 16:51

So you're less worried about over-treating people with prostate cancer because you feel like there's ways of characterizing the cancer so that you're really treating the people who are at higher risk over time.

Dr. Ali Kasraeian: 17:03

Yeah. So I'm a big believer in active surveillance 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 of that disease to give you a picture of, you know, the cat in the bag analogy.

Dr. Ali Kasraeian: 17:19

If you have a cat in the bag. Is that cat going to grow up to be a small kitten? Is it going to be a cat that's a timid cat, or is it going to grow up to be a ferocious tiger? You can make decisions, and it can actually. We have testnodes that can give you predictive information. What's the likelihood of passing away from this cancer, based on your biology and clinical information, in the next 10 years? If we treated it, what's the risk of metastasis in that time? And then, based on that information, we can counsel. You're a great candidate for active surveillance. Every guideline talks about active surveillance for low-risk disease. If we have intermediate disease, what's the volume? Is it localized? We can do artificial intelligence technology.

Dr. Michael Koren: 17:56

Well, let's get to that. I'm going to take a quick break here, but this is fascinating. So we talked about the controversy about PSAs and gave a little bit of information about how you would customize that for different patient populations. But let's talk about the future in our next segment.

Dr. Ali Kasraeian: 18:11

Absolutely

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Transcript generated by AI.

Announcer: 0:00

Welcome to MedEvidence!, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts Hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren: 0:11

Hello, I'm Dr. Michael Koren, the executive editor of MedEvidence!, and I've been having this fabulous conversation with Dr. Ali Kasraeian, a urologist and a media person and somebody that's involved in organized medicine. In our last segment we were just talking about the controversy around PSA and how you have to customize that, the number that you get to the specifics of a person. So, higher risk people you're going to be more aggressive If you had a family history, or African-American, for example and lower risk people maybe you watch it for a longer period of time. But interestingly, even when you get to imaging, there's ways of getting a sense for what the prognosis will be over the next 5, 10, 15, 20 years. So that was a fascinating discussion. So let's jump into that point about what you see as the future for getting better at diagnosing prostate cancer and also identifying the people that truly need to be treated aggressively.

Dr. Ali Kasraeian: 1:05

Yeah, you know smarter screening, you know PSA can save your life. Talk to your doctor about PSA screening, know your family history. So if we start with a lab test and it's concerning, then we kind of talk about what to do next. If you show up with a PSA of 10, we recheck it's still elevated, it makes sense to do a biopsy. I think the MRI allows us to do a better biopsy.

Dr. Ali Kasraeian: 1:24

If we're on the fence you've had repeat negative biopsies and things of that nature then you know, can we use biomarkers. Biomarkers are lab and urine-based tests that can help guide us to see what is the probability or the possibility that your elevated PSA is due to not just a prostate cancer but a intermediate or higher risk prostate cancer, meaning a prostate cancer that if we found we would treat A lot of times these tests. If the score is in the lower range, that risk is low. If it's in the intermediate to higher range, it's an incremental higher risk. We can take that with an MRI scan, put them together and give a discussion or initiate a discussion of what is the risk, what is your comfort level, what is our next move, and we can personalize it to you, your history and other medical issues that you're going through in your age.

Dr. Michael Koren: 2:14

So, starting with the diagnosis, are there specific biomarkers other than PSA that you can mention in this podcast?

Dr. Ali Kasraeian: 2:21

Yeah, absolutely so, the three that I use. You know, right now one blood-based test that I use quite a bit is a thing called the 4K score. It looks at PSA with three other cousins intact PSA, total PSA, free PSA, intact PSA and this thing called HK2, a Kallikrein protein 2, which are kind of all in the same family.

Dr. Michael Koren: 2:43

So a doctor has to order that specific panel.

Dr. Ali Kasraeian: 2:45

It's a lab test, yeah.

Dr. Ali Kasraeian: 2:46

And then it comes back with a score and if the score is in the lower risk range, you have a very, very low risk of having an intermediate or higher risk prostate cancer.

Dr. Michael Koren: 2:58

Is that something you should do before just getting a standard PSA? Do you think

Dr. Ali Kasraeian: 3:01

because, honestly, if you have a low PSA, a stable PSA, why would you leap to another test like that? Because what if it comes back with an in-between result? And now you have a low PSA and it's only valid for PSAs that are a little bit increased anyway. From that standpoint, two urine tests that are wonderful and great science with them. One's an exosome DX test, an exosome DS test.

Dr. Ali Kasraeian: 3:23

Beautiful science that they found that exosomes, which we before thought just had mitochondria, actually have messenger RNA in them and so they found it coming off urine. It carries with it messenger RNA and great genetic and DNA information, carbon copies of it coming off urine. That could get prostate information, so that first part of the stream, and they can get predictive information of the risk of prostate cancer off it. Amazing science. So if you're in the low level, the risk of having a prostate cancer that's seven or higher is a little bit higher. If it's in the low range, it's a very low risk of that. So you can do that. And during the COVID pandemic we were very fortunate to be part of the first team using that on an at-home test and it was really really powerful for us to use to be able to guide patients on whether they need to come in and talk about doing a biopsy at a time where people didn't want to leave their house.

Dr. Ali Kasraeian: 4:15

So that was really powerful.

Dr. Michael Koren: 4:18

Again, that's not for people with a low PSA. Those are people that are identified as having higher PSAs and taking the next step.

Dr. Ali Kasraeian: 4:24

Yeah

Dr. Ali Kasraeian: 4:24

So is someone with a PSA change that we want to be mindful of. Do we need to do a biopsy next?

Dr. Ali Kasraeian: 4:30

from that standpoint,

Dr. Michael Koren: 4:32

And would that test, if it was negative, make you feel comfortable that you don't need to do? Imaging of the prostate.

Dr. Ali Kasraeian: 4:39

So that's a very controversial discussion and there are a lot of papers looking at that and we as a as urology have not come up with an absolute answer for that. For some people the MRI scan first makes sense. For some people, doing the biomarker first makes sense. Some people are are. You know, the genetics trump the imaging. Some people, imaging trumps that so so for me it's a very personalized approach, you know from that standpoint. So really, for me personally, it's a patient by patient discussion

Dr. Michael Koren: 5:06

Got it.

Dr. Ali Kasraeian: 5:08

Another test that we use frequently is a My Prostate score. It's a newer of the three. Great test and what I like about this test is a very high negative predictive value. So for someone who's never had a biopsy, they have a 95% negative predictive value.

Dr. Ali Kasraeian: 5:27

If your score is in the low range, you have a 95% likelihood of not having prostate cancer. If you've had a previous negative biopsy, you have almost a 99% negative predictive value. So that's very powerful. So I use it often with people who've had negative biopsies and then we want to think about whether or not to do another biopsy, especially if they have had a negative MRI scan.

Dr. Michael Koren: 5:45

Yeah. So for listeners out there, tests that have a high negative predictive value usually have a very high sensitivity, so they pick up things. So when they're negative, you feel pretty comfortable that you're not dealing with the problem. The flip side is, when they're positive, it doesn't always mean that you have the problem.

Dr. Ali Kasraeian: 6:02

Yeah, it tells you that search further. Right, and that's how I kind of counsel people. You know, if this is a higher, it doesn't mean that we have cancer Absolutely. It just means that we should probably look If it's negative. We feel comfortable that it's negative.

Dr. Michael Koren: 6:14

Any other novel biomarkers that you want to?

Dr. Ali Kasraeian: 6:17

One thing that's really interesting. That's not quite as novel, but something to keep in the back pocket. There's some tests that we actually use when people have had previous biopsies to decide in the next biopsy if their PSA changes. There's a test called the Confirm MDX where you can actually go back and look at the genetics of a previous negative biopsy and it can tell you at any of those cores that you took could there be genetic changes that could heighten the risk of a positive biopsy at that site. So then when you do the next biopsy it can help guide you to take a few more cores at that site. And that's in the diagnostic phase. And then there are what are called genomic tests that you can do after the biopsy. That can then guide you in terms of the therapeutics and the treatment active surveillance versus treatment so you don't again undertreat a cancer that may be able to be monitored versus overtreating a cancer that can be watched and you know, and an undertreating a cancer that should be treated.

Dr. Michael Koren: 7:08

And you mentioning about AI, maybe helping people with decision-making, so I know a big issue of course is, once you're diagnosed with prostate cancer, do you take the prostate out? Do you treat it locally?

Dr. Ali Kasraeian: 7:22

Yeah. So the treatment for prostate cancer is always, you know, very controversial and the thing that often drives a lot of people away from actually screening because they think everyone needs a prostatectomy, everyone needs radiation and unfortunately, with both of those technologies, with the advances in robotics, the advances in radiation therapy, especially in high-volume centers, the side effect profiles are getting better, but they're not perfect. So in doing that we want to see can we offer people things like focal therapies now with high intensity focus, ultrasound, cryotherapy, focal laser ablations, a lot of these technologies where if you have a targetable lesion and that's the only area that we have cancer can we just treat that area and leave the unaffected portions of the prostate untreated, and so the more prostate you preserve, the more function you preserve. Is that safe to do? We're working with a company and we're very fortunate to have been early in the adoption of this technology called Unfold AI by a company called Avenda Health really well-validated technology where you take the MRI scan, the biopsy, and then put all of the information together and it tells you how much of the prostate you have to treat, meaning target plus a margin to give you a very high confidence that you treated all the cancer with a high cure rate probability, and so you can talk to the patient about exactly what we need to do and whether they're a wonderful candidate for focal therapy or we should actually pursue a whole gland treatment.

Dr. Ali Kasraeian: 8:50

And so that's another way you can personalize the treatment so you don't undertreat a cancer that needs a more robust whole gland treatment and then you can very appropriately offer personal focal therapy. And it's a wonderful technology, very smart. And the way from a data standpoint it was monitored, or whether it was studied, is they took the MRI scan compared to a whole mount prostatectomy, meaning they sliced the pathology specimen like an imaging study, had radiologists look at it by itself, had AI look at it by itself and look at it together, and they found the AI actually did better than the radiologists by themselves, but both together did better than each alone, amazingly well validated.

Dr. Michael Koren: 9:30

Are there multiple companies that are pursuing these concepts, or is it

Dr. Ali Kasraeian: 9:33

Absolutely? I mean?

Dr. Ali Kasraeian: 9:34

there are more companies and there are more to come. The big thing for us to be mindful is how they're validated, how the science goes, and AI, like every AI that we look at, we have to be mindful of. AI is only as smart as a teacher, so what goes in it makes what comes out as smart as it can be. And what I really like about this technology it is really smart. The CEO of the company his PhD was in MRI and MRI sciences for the prostate.

Dr. Ali Kasraeian: 10:03

I mean I don't know how much more specific you can get from that in terms of a PhD, but very smart people looked into it and they continue to advance it and put more data into the technology. So it continues to grow, with a very specific focus on having people have better options of treating their prostate cancer and more information to make better choices. Again, it's personalizing it, very similar to breast cancer. So when people get diagnosed with breast cancer, the amount of information they have, a diagnosis to make very wonderful personalized choices for their present and their future and also, you know, for the genetic information for their family's future. And with prostate cancer we're looking to catch up and we're, you know I used to say we're about 20, 20, 30 years behind breast cancer. We're catching up and I think in the next several years we're going to be very, very quick to that, especially in advanced prostate cancer. The amount of medications and the science going into that field is revolutionary and our guidelines keep changing faster than we can keep up, which is a great thing.

Dr. Michael Koren: 11:05

Interesting. We're getting to the end of our time together, but any clinical trials that are ongoing that are particularly fascinating to you.

Dr. Ali Kasraeian: 11:16

Many. We're always trying to push envelopes in terms of better studies for the focal therapy avenue with diagnostics. There are always things going on in the advanced prostate cancer. There are many things. I mean it's not quite related to this, but you know, when people are diagnosed with prostate cancer advanced prostate cancer, metastatic prostate cancer historically we used to give a hormone blockade medication and there's some studies that came out in the past couple of years where you can give a pill by itself and that's similar outcome for people that have recurrent prostate cancer. We're hoping those studies continue so you can potentially treat those patients better.

Dr. Ali Kasraeian: 11:51

We're now, you know, we hope to move and make those kind of diseases, those parts of this disease that used to be uniformly fatal.

Dr. Ali Kasraeian: 11:58

We're approaching where we were having 30 to 60 percent radiographic response rate, where things that used to be on imaging are no longer there. Outcomes are better, medicines are better tolerated and so the hope for people with the more advanced prostate cancer is becoming much, much, much, much better. And you know, organ-confined prostate cancer approaches 100% five-year survival, 98% 10-year survival, and so the idea with prostate cancer is don't be afraid of getting screened, because the implication of what the therapy associated with that diagnosis would mean, because we on this side of that diagnosis are very keenly aware of those fears and we're pushing the envelope of trying to do more precise diagnosis. We're trying to do more precise therapies so that we can be impactfully aware of the quality of life impact of this disease and the science is trying to catch up and be aware of that alongside you as your partner, in terms of the right treatment for the gentleman at the right time so that we can achieve both in a personalized way.

Dr. Michael Koren: 13:12

So it sounds like there's been tremendous progress across the whole spectrum of diagnosis, particularly early diagnosis, identifying risk, identifying intermediate cases, identifying the people that really need to be treated, and then doing as well as possible, even at advanced stages.

Dr. Michael Koren: 13:30

So it's pretty fascinating

Dr. Ali Kasraeian: 13:31

yeah amazing study, new England Journal of Medicine.

Dr. Ali Kasraeian: 13:34

In Europe they do studies like this randomized trial, active observation, surgery, radiation therapy 10-year, 15-year data 97, 98% of men alive and then 15 years, similar, identical, high, 90, I think it was 97, 98% of 10 years, 96, 97% of 15 years. However, in the observation arm more people needed surgery and radiation somewhere along the line and a slight amount of people needed a hormone blockade because of metastatic disease, but it didn't cause them to pass away. Opens up the discussion of the power of active surveillance appropriately and it opens up the discussion of focal therapy appropriately when you find the right disease in the properly selected patient. So what that tells people is people may not die of prostate cancer if you catch it at the right time and you find the right treatment again for the right gentleman at the right time. That starts with screening at the right time.

Dr. Michael Koren: 14:30

Ali, that was an amazing discussion. Thank you for being part of MedEvidence!.

Dr. Ali Kasraeian: 14:34

I appreciate it, and anytime we can have better and smarter conversations, you're the best person to have these conversations with.

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