Alicia Morgans:  Hi, this is Alicia Morgans. GU medical oncologist and associate professor of medicine at Northwestern University in Chicago, Illinois. I am so excited to have here with me today a friend and colleague, Dr. Stacy Loeb, who is a professor of urology and population health at NYU Langone and the Manhattan VA. Thank you so much for being here to talk with me today, Stacy, about the importance of Prostate Cancer Awareness Month.

Stacy Loeb:  Thank you so much for having me, always a pleasure.

Alicia Morgans:  Wonderful, well, Stacy, I love in all of our conversations how you focus in so many ways on how we communicate with patients and how we ensure that patients get the right information. I think when I consider Prostate Cancer Awareness Month, it's really a month when I hope that patients are able to learn and to understand the importance of screening for prostate cancer, for treatment or surveillance of prostate cancer.  But as they're doing all of this, how did they think through, "Where do I get my information?" Because you've really pointed out I think, that, in itself, can be a challenge as we try to make sure we understand prostate cancer.

Stacy Loeb:  That is a really good point. I think it is very tough these days because there is just so much information online and it's easy to fall into traps. We did do a study on this last year, looking at YouTube videos about prostate cancer. Actually we looked at the first 150 YouTube videos and it was pretty concerning. You know, we found that about three-quarters of them had some type of bias or potentially misinformative content, either in the video itself or in the user comments underneath the video. So there's a decent chance somebody is just searching online for information that they can come across content that is biased or misinformative. I think there are definitely some strategies to work around this.

First of all, just going to trusted sources. The Prostate Cancer Foundation has a lot of wonderful information about prostate cancer and a patient guide that's vetted by a lot of experts in the field. The Urology Care Foundation has great patient information about all sorts of different urological conditions, including prostate cancer and some videos. There are other patient organizations such as Us TOO and ZERO that are specifically focused on prostate cancer and have information. 

So I think searching out specific sources is very useful. I also think that health consumers need to pay close attention to the date of the information. Things can very quickly get outdated, but usually what happens on the internet is that old stuff may not ever be taken down. So sometimes websites are updated over time, but other times something is posted and it just stays there forever, but that doesn't mean that people won't still see it and maybe the guidelines have changed.  Maybe there's a new treatment option available or maybe something that was done in the past. Now we know that it doesn't work as well. So also very important to look at the date and I recommend discussing everything directly with your doctor because you know, sometimes information that is good and reflects the situation for somebody else may not pertain to your particular case. So it's better not to get overly enthusiastic, or hopeful or on the other side, overly sad or hopeless over some information from other people or other sources without a clear understanding of whether it's relevant to your case.

Alicia Morgans:  Well, I really appreciate that, because I think we talked so much during Prostate Cancer Awareness Month about getting to understand prostate cancer, getting to understand PSA screening, thinking about all of the treatment options that may be available, and getting over the emotional hurdles that can sometimes be a barrier for people as they're thinking about talking to their doctor.

And I just wanted to mention, because I know you've done such great work. That as we're getting over those barriers, and as we're making plans to talk to our doctors, we really have to be very clear and sure that we're going to places to research, and to understand, that are going to be reputable sources. So, thank you, and thank you for the work that you're doing in that area to ensure that people are getting the right information. Now, as you think about Prostate Cancer Awareness Month, and as a urologist, who cares for both the veterans and other patients in Manhattan, what would you want patients to be sure they understand? What should clinicians think about as we're all kind of celebrating this month?

Stacy Loeb:  This a really great question. I think this is an important month for prostate cancer awareness. There's just been so much negative and really confusing publicity about prostate cancer and about prostate cancer screening, more specifically over the years.  It's very easy to feel confused over all the information that's out there. I think it is very important for men, adult men, to talk to their doctors about the pros and the cons of prostate cancer screening, and to learn more about prostate cancer. There are some very specific risk factors that we already know about for prostate cancer. For example, it is more common as men get older. So the average age at diagnosis in the United States is in the mid-60s. However, there are younger men who may be diagnosed. Certainly, genetic factors play a role and men who have a family history of prostate cancer have at least two times the risk of prostate cancer.

Even within that, there are some very specific genetic factors such as BRCA, which have been associated with prostate cancer. Now, for some reason that does not get as much public attention or awareness of the link between the BRCA genes with prostate cancer, as there is with breast cancer. But actually this gene is associated with both and with some other cancers as well. So I think it's important for everyone this month to have awareness of some of these risk factors for prostate cancer. Another important fact about prostate cancer is there is a higher risk of prostate cancer in African American men, but this is also a population where more prostate cancer awareness is very important. So in terms of prostate cancer screening, there is a blood test, it's called PSA or Prostate Specific Antigen. It is really the only way to find prostate cancer early because prostate cancer does not have any symptoms until it's at an advanced stage.

So, this is a really important test. There's also a prostate exam that is not as sensitive of a test as the blood tests. Certainly, both tests can be done together. And that provides even more information. Many men though are afraid or reluctant to have the prostate exam. It's not the most pleasant. It involves the finger in the rectum, but that should not be a deterrent from considering prostate cancer screening at all. Even just the blood test itself, is very worthwhile to consider. And in terms of the blood test, so we are looking for whether the level of PSA is higher. Higher is bad. That being said, the level can go up for more than one reason. So PSA is made in the prostate. If there's more prostate there and the prostate does grow with age, more prostate can make more PSA. If the prostate gets inflamed, more PSA may be released.

And if there's a tumor there that's making PSA, that may cause the PSA to go up. So if the PSA increases or is elevated, that doesn't always mean that it's cancer. However, it's kind of like a light going on in the car, like a check engine. It doesn't really tell you what's going on in the engine, but just that you should be checked. So in this case, I would say it's similar, it's an indicator that something is happening, whether it's that the prostate is growing, inflamed, that there is cancer. The good news is there are many other tests that can be used to follow up on that to help sort out this picture. And for many men, it won't be elevated. And then there's that reassurance that prostate cancer is very unlikely at that time.

Alicia Morgans:  So thank you so much for sorting out those details. And I think, as men think about these screening tests, it's helpful to have some context. And I love the idea of a check engine light. I think that's great, because like you said, it doesn't tell you that the problem is here, it just tells you, you need to check the prostate out, get an evaluation and then get a diagnosis. And that's what's most important. And as we conclude, I want to emphasize once more, just for the listeners, prostate cancer we now know is potentially driven. As Dr. Loeb said by BRCA1 or 2, 2 is more common for prostate cancer. These are genes that have been associated with things like ovarian cancer and breast cancer for years, and women who have had breast cancer, or ovarian cancer are commonly tested for these genetic mutations, which could be drivers in their cancer and could also be targets for therapies.

As we think about prostate cancer care, if you are a man with prostate cancer, if you know someone with prostate cancer, we now know that people with advanced prostate cancer should actually undergo testing to understand if they have these genes in their system that may be leading to the prostate cancer, because it's important for their family then, to also get checked.

So any other comments that you might have on these genes, Stacy? Because I think that really, it's kind of new for our community of prostate cancer patients, but so meaningful for them in terms of treatment options and also important potentially due to the impacts on their family.

Stacy Loeb:  Yes, very, very important point. I think really it's important on both sides of the spectrum. For men who do not have prostate cancer, it is important to know your family history and in particular, family history of other types of cancer. And that is not only a family history of prostate cancer, but also a family history of breast cancer or ovarian cancer in female relatives for example, and the fact that even those may influence the risk of prostate cancer. Then If you are in a situation where you already know about a mutation in your family, or with yourself, that may affect your cancer screening protocols.

On the other side of the spectrum for men out there who are already diagnosed with prostate cancer, you make a very important point that having this knowledge of the genetic information can actually change the treatment protocols for advanced disease. And I think we're going to see more and more of this over time where people will receive a specific treatment based on the specific genetic pathway in their case. And you know, so far we only have a few of these. So I think we're just at the tip of the iceberg, but this is such an active area of investigation that I have no doubt that within the next five or 10 years, we will have others. So also just very important for family members as you mentioned. So this is particularly germane to men who have advanced prostate cancer, where it's more common to see these genetic factors involved. But even some patients who have early prostate cancer who have a strong family history of other cancers or certain cancer features may also be eligible for testing.

Alicia Morgans:  Great. Again, thank you so much for fleshing that out and to all who are listening, I promise you, Dr. Stacy Loeb is absolutely a reliable source. I am always excited and happy to have her here to talk with us on UroToday. And I really appreciate you taking the time to talk about the importance of prostate cancer awareness month with us today, Dr. Loeb.

Stacy Loeb:  Thank you so much for having me.