This episode of PROSTATE PROS reviews and summarizes the year’s advancements in prostate cancer as well as looks forward to future updates. Beyond prostate cancer, the episode examines how COVID-19 has impacted the healthcare landscape and discusses news of the vaccine. Catch up on the latest and stay tuned for an exciting announcement.

Liz:  [00:00] We have an exciting prostate cancer update.  Since recording this episode, the FDA recently approved the PSMA PET scan.  Keep that in mind when listening to the episode.  If you'd like further information, visit fda.gov.

Dr. Scholz:  [00:18] We’re guiding you to treatment success and avoiding prostate cancer pitfalls.  I'm your host, Dr. Mark Scholz. 

Liz:  [00:24] And I'm your cohost, Liz Graves.

Dr. Scholz:  [00:28] Welcome to the PROSTATE PROS podcast.

Liz:  [00:31] A lot has happened this year and we've covered many topics on the podcast.  This episode we wanted to highlight a couple of exciting advancements and talk about some updates. 

Dr. Scholz:  [00:44] The elephant in the living room of course, is the COVID situation.  That's impacted the way we do business.  It's impacted our patients.  It's impacted all of you dramatically.  I thought I'd give a little update on what's happened in our over 2000 clients.  As you know, we serve a population of men between fifty and ninety plus our oldest patient just turned one hundred.  This is a high risk group.  Men are at higher risk for COVID complications and as we get older, particularly over 80, the complication rate goes up and the mortality rate goes up.  We've actually lost one patient to COVID in our whole practice in 2020.  It was an unfortunate individual that was traveling in Egypt in the January, February timeframe and when he came back to the United States he was ill.  This was before people were really clear of what was going on, went to the hospital with pneumonia, and unfortunately passed away.  We've had other patients, perhaps a dozen or so that have caught the COVID.  They're sort of evenly divided between men who really report that it wasn't much of anything at all and others, the other half, they got pretty darn sick, a really bad flu.  None of them fortunately had to go to the hospital. They all recovered.  This is rather remarkable considering our vulnerable demographic.  It shows that if people are careful and they isolate, they wash their hands, keep their hands off their face, most people aren't going to catch this.  Of course, when I talk to patients, I'm impressed by how much isolation is going on out there, how much care they are taking.  Many men have come to the office and said that I am the first out of the house experience that they've had in 2020.  So people are being very careful and clearly being careful does work. 

Liz:  [02:49] Yeah.  I remember early on in the pandemic, our office had way less traffic and was almost empty.  Now it seems like things are picking back up and people are checking back in on their health. 

Dr. Scholz:  [03:01] We've had a bunch of people come to the office who maybe had some cold symptoms, everyone's on edge, and we've tested them for the COVID antibody to see if they did indeed have previous exposure.  These tests are almost always coming back negative.  We're told by the scientists that these tests are probably 80% to 90% accurate.  They're not 100% accurate when you do the antibody test.  That's the test to determine if you've had previous exposure to COVID.  We believe, and some people disagree, that if you've had previous exposure and your antibody test is positive, that it's as if you've had a vaccination and you can't catch COVID and you can't transmit it.  That of course would be good news.  We've tested several hundred people now and almost all of them are negative. The ones that are positive are the ones that told us previously that they knew they had COVID.  These antibody tests confirm it.  This is a different test than the nasal swab, where doctors are trying to determine if you actively have the COVID virus.  Those tests are more accurate, perhaps approaching 99% accurate.  Patients who think that they have symptoms need to find a place to get tested, to rule in or rule out whether they are infectious.  After they've been sick, they want to be tested again, to make sure that the infection risk has gone away. 

Liz:  [4:38] We've had inquiries about where to get tested.  We usually just send whoever across the street to Cedar Sinai, and they'll do it there.  The turnaround on these test is quick enough that people can just wait for their results and they should know within an hour.  All right, Dr. Scholz, I think the biggest information about COVID right now is news of a vaccine.  I think one thing a lot of people are concerned about is how quickly this has developed vaccines usually take years, if not a decade to get developed. This has happened within a year, which is pretty incredible.  Do you think it will be safe? 

Dr. Scholz:  [05:15] So there's been debates, everyone's heard them, that will the vaccine work, will it have durability?  At this point, the preliminary science suggests that it will work and it will have durability.  There's three different companies that are putting forth a new product.  The hope is that by the end of the year we will be having people getting vaccinated.  Of course, there'll be selective preference for the elderly people in healthcare.  How this is all going to roll out is a big question.  But it seems at this point, there's no doubt that by early 2021 a vaccine is to be available and it will be effective. 

Liz:  [06:00] It is changing really quickly.  I know we were just talking about this last week and when I went back to review, I almost had to research it all again.  So it's important to stay up to date on this. 

Dr. Scholz:  [06:14] Yeah everything that we do in the oncology realm and in this realm as well is predicated on what we call a risk-benefit ratio.  We give dangerous medicine sometimes in oncology, but we are treating life-threatening cancers and sometimes rolling the dice and taking a chance with a treatment makes a lot of sense if the disease is much worse and very dangerous.  So it's going to be different for different people, for myself as a physician, meeting people all day long and basically in a high-risk situation, it seems to me that I'll be lining up early for the vaccination.  For those of you out there that are comfortable in your isolated state and are willing to sustain that, 2020 showed us that people can remain pretty safe if they're very careful, but the social isolation is taking a big cost in our patients’ mentalities, their lifestyles, their social lives.  It's been painful and difficult when people have to make a personal choice as to whether the relatively small risk of getting a vaccine is too great to consider as opposed to continuing in their existing lifestyle.  We’ll have more information every month as this vaccine rolls out as to how dangerous or how many risks there'll be associated with it.  That is unknown at this point.  But as a lot of people are going to be getting this vaccine, we should have very good information within a few months.  I think one last thing to emphasize is that we've learned that the COVID virus complication rate goes up astronomically in men over 80. Men over 80 and the elderly are at the very highest risk and mortality rates start to become very significant in this group.  It would seem to me that these elderly men are going to want to try and get a vaccine, even if there are some risks associated with the vaccine, because the virus for them is very dangerous. 

Liz:  [08:22] So another paradigm shift that occurred this year was the shift towards telehealth.  It seems like about half of our visits now are being conducted over the phone or via FaceTime or Skype. 

Dr. Scholz:  [08:36] This has been a really big change.  In trying to understand it and wrap my brain around it, it seems that it's a radical shift in accessibility.  In the past, phone visits were discouraged because the impetus was to get people into the office and be able to bill for your services.  Now, both private and Medicare insurance has essentially mandated insurance coverage for telehealth.  This has rapidly been accepted by patients due to the accessibility, the ease of communication.  It's even been nice to be able to take off my face mask and see the body language of my patients and communicate non-verbally with Skype and FaceTime.  In the office employees, patients alike are all wearing masks and we're making eyes at each other, using our voices and trying to overcome the muffled communication that has become routine now in our lives. 

Liz:  [09:44] I think something else that the telehealth has brought is connection.  Right now people are feeling kind of anxious and separated.  If they are skipping doctor's appointments to avoid waiting rooms and being close to other people, it’s such a great way to catch up on the latest in prostate cancer and catch up with you.  Your face appears in their living rooms and it's like they’re right in your office. 

Dr. Scholz:  [10:10] Yeah it is very personal.  It's as you all have experienced now, your face fills the screen and it's not as disconnected as people might think.  The risk to patients with telehealth is obviously reduced.  But one component of the way we do medicine, of course, is blood tests, injections, and treatments, and certain in office visits are still unavoidable.   If patients go to a remote facility for blood testing, they're still going to have some contact.  But so far as has been demonstrated, the COVID infection rate for our patients has been very low, whatever precautions people are taking seem to be working quite well.  One thing about telehealth is it appears to be here to stay.  I've talked to high-level insurance people about the future of telehealth asking, will it go away once the COVID risk disappears? The general consensus is that there's no going back.  This increased accessibility seems to be the future of medicine. 

Liz:  [11:19] So even big topics that are maybe a little more involved or confusing are easily addressed over Skype or FaceTime or a phone appointment.  Let's start talking about a couple of those that are new developments for 2020. 

Dr. Scholz:  [11:34] We already covered PARP inhibitors but they, being brand new treatments for advanced prostate cancer, merit a quick review.  PARP is an enzyme that helps repair DNA.  About 10% to 15% of men with advanced prostate cancer have a mutation that causes their DNA repaired to work less efficiently.  One application of this mutation, which is called BRCA, is that there's a little higher risk of getting prostate cancer.  The men who get prostate cancer that have BRCA tend to have a more aggressive form.  The PARP inhibitors exploit this mutation and men that have this mutation respond much, much better to PARP inhibitors.  PARP inhibitors are pills that make it even more difficult to replicate or duplicate DNA.  These already impaired cancer cells then die more easily and more quickly than your normal cells of your body.  We’re always looking for a differential effect with cancer treatments, a treatment that focuses more on the cancer, then your cells killing cancer without causing a lot of side effects.  So the medicines we're talking about are Olaparib and Rucaparib two new pills that help men with BRCA mutated cancer and are now FDA approved. 

Liz:  [13:01] These two approvals really highlight how important using genetic testing is.  This will help men with prostate cancer find treatments that may have only been FDA approved for another cancer.  Doing genetic testing is very easy.  It can be accomplished with a mouth swab or a blood test, and it's almost always covered by insurance.  So we briefly covered some updates and genetic testing. Let's review the PSMA PET scan really quick. 

Dr. Scholz:  [13:32] We did a whole podcast on this because it's a big breakthrough.  Most of you have heard of it by now, but for the first time we can accurately locate the prostate cancer wherever it is in the body and the prostate and the lymph nodes in the bones with one single scan.  This scan may be five times more accurate, ten times more accurate than any previous scan that was available.  What a wonderful addition to our diagnostic armamentarium.  This is going to have an impact for people with early stage disease, late stage disease.  Unfortunately, the FDA has not yet approved it, but we're anticipating approval within the next six months or so.  In that situation, it will be covered by insurance and it will be very popular. 

Liz:  [14:18] Some companies are investigating using PSMA as a therapeutic target rather than just a diagnostic target. 

Dr. Scholz:  [14:28] Exactly.  So the diagnostic scanning is incredibly useful reconnaissance for figuring out where the cancer is and helping design a treatment protocol.  But if we're able to accurately locate the cancer with these scans, wouldn't it be possible to use this same target, to make therapies stick to the surface of the cancer cells?  There are two very exciting types of treatment.  One we've talked about before uses an antibody to stick to PSMA and draw a high energy radioactive molecule right next to the cancer cell and kill the cancer cell.  This is called Lutetium- 177.  The phase three trials in prostate cancer have been completed.  We've had patients on trial or outside the country, get this treatment with very nice responses.  We're talking about a treatment for men that have already had chemotherapy, become hormone resistant to Zytiga and Xtandi, and who perhaps have limited treatment options getting nice PSA declines with relatively little, if any, toxicity.  There is a PSMA antibody on the salivary glands, so some people get a little bit of a dry mouth.  Some people with radiation, it can cause some lowering of blood counts, but for the most part, there's practically no side effects with dramatic responses to Lutetium-177.  The phase three trials are completed and they're waiting for them to mature to validate that there is a survival advantage.  Once that happens and the study results are released, the FDA has six months to approve or disapprove the treatment for broad spectrum dispersal amongst the population for therapy and insurance coverage. 

Liz:  [16:14] So it seems like there's a lot to look forward to with PSMA being used as a diagnostic test as well as its role in therapeutics, especially for men with advanced prostate cancer.  There are a couple immunotherapies that are exciting on the horizon.  Can we talk a little bit about those?

Dr. Scholz:  [16:36] Amgen has developed a connector molecule that instead of linking a radioactive moiety to the antibody that clips to PSMA, it's sort of like a pheromone tag that draws in your T-cells.  I don't know how many of you are familiar with how the immune system works, but the soldier cells of the immune system are called the T-cells and the T-cells are the component of your immune system to go in and attack the cancer cells and kill them directly.  Theoretically, if you can get the T-cells in close approximation with the cancer cells, they will attack and kill them.  There is new technology from Amgen, a very large pharmaceutical company, that has developed this and is doing phase two testing in men with advanced prostate cancer and responses are indeed occurring.  So the patients are injected with a substance that clips onto PSMA i.e. the surface of the cancer cells and draws the patient's immune system close to the cancer cells so that it will attack it.

Liz:  [17:49] As you can see, there's so much information about prostate cancer this year alone, we've covered focal therapy, brachytherapy, radiation, immunotherapy, chemotherapy; the list goes on and on.  So looking forward, it's important to always stay in touch and stay up to date and keep sharing and keep listening.  You might find it useful to go back and review old episodes of PROSTATE PROS. You can find us on your favorite player.  So Dr. Scholz, another exciting thing 2020 was the 10th anniversary of your first book Invasion of the Prostate Snatchers.  Something you may not know is that this year, Dr. Scholz and I have been working hard to update his first book Invasion of the Prostate Snatchers.  So about 10 years ago, when the first edition was published, it was really the first introduction to active surveillance.  I think Dr. Scholz received a little flak from that, and now it's more widely accepted, but with that, there's still a lot of the industry that patients need to be careful of.  That includes over-treatment.  That includes dangers of surgery and random biopsies.  So we're really looking to restart the conversation, and get patients to be their own advocates. 

Dr. Scholz:  [19:16] There's a theme in the prostate cancer world that you have to educate yourself.  I hope that both of my books encourage people to do their own research, to take responsibility for their health and to double check the information, rather than just accepting the first pitch you hear from a doctor.  Prostate cancer is big business.  It's a multi-billion dollar world, and people are trying to make a profit.  Ethically, no doubt, there's so many gray areas in the prostate cancer world.  You need to double-check and you need to find the original, basic information that leads you to the truth. 

Liz:  [19:59] So this new completely rewritten second edition of Invasion of the Prostate Snatchers will be out in 2021.  We're really excited to share it with you.  Telehealth has really connected us this year, and we're looking forward to staying connected in 2021.  Remember to tune into the podcast and share with your friends.  If you have any topics you want us to cover in the upcoming year, you can email us at [email protected].