Conversations With Prostate Cancer Experts

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Imaging Metastatic Prostate Cancer

Dr. Eric Rohren is the chair of the department of radiology at Baylor College of Medicine.

Prostatepedia spoke with him about imaging metastatic prostate cancer.

Subscribe to read Dr. Rohren’s comments on radium therapy + imaging. Members can read the interview in their March 2018 issue of Prostatepedia.

In terms of imaging, what kinds of scans can determine if a man has metastases (mets) anywhere in his body?

Dr. Eric Rohren: X-ray has been around for a long time and still has a role to play. It’s easy to obtain, it’s cheap, and it has low radiation exposure. We still rely on a good old-fashioned chest or bone X-ray, depending on the patient’s symptoms.

These days, most patients with any type of malignancy, and specifically prostate cancer, are managed in a couple of ways.

One way is a CAT scan. CAT scan is a 3-D imaging technique that uses X-rays that can take images of the body, chest, abdomen, and pelvis. Most patients with newly diagnosed prostate cancer or treated prostate carcinoma have undergone a CAT scan at some point in the course of their disease. CAT scans can show us the prostate gland, lymph nodes, liver, and many of the different organs where cancer may be hidden.

To supplement that, patients with prostate cancer often get a bone scan, which is a nuclear medicine technique. In a bone scan, we inject radioactive material that goes to the skeleton, and most strongly so in areas where there’s increased skeletal turnover, where something in the bone is inciting a reaction. It may go to benign things like healing fractures, arthritis, and various areas of injury. But the radioactive material also goes to areas of metastatic disease in the skeleton, and it localizes most particularly in those areas, lighting up on these bone scans.

Rather than just a particular region of the body, a bone scan shows us from the top of the head all the way down to the feet, which is nice. We get a look at the entire skeleton, and we can look for the little spots that are lighting up that may indicate the presence of metastatic disease in the skeleton.

CAT scans and bone scans are very widely used. A bone scan is a little bit better than a CAT scan in looking for these bone metastases, so the two really augment each other in detection of the disease.

Beyond these, we do have some newer imaging techniques coming into play. There’s a way of doing a bone scan with PET scanner. A PET scanner is another nuclear medicine technique that is more sensitive than a standard nuclear medicine camera, and it acquires a CAT scan at the same time. You can look at the images on the nuclear medicine technique overlaid on the CT scan to see where exactly the activity is and what it’s due to.

We can also use some agents with PET scanning to look at the skeleton. A so-called fluoride PET/CT bone scan seems to have many advantages over a conventional bone scan in terms of detecting smaller disease, more sites of disease, and things like that. MRI is also used in some cases.

Traditionally, MRI is used to evaluate specific areas, so if there’s pain in a particular area such as the skeleton,

MRI is a great way to do that. MRI is also used to look directly at the prostate gland and at the prostate bed after prostate surgery or after other therapy in the pelvis. It can be very good at detecting small volumes of disease. The problem with PET scanning and MRI scanning is that they are less accessible, although MRI is in most places now, and most major areas have access to a PET scanner.

Then there’s the issue of cost. Both techniques are costly. We need to determine if the added cost is justified by the additional information that those scans provide.

Beyond these techniques, the exciting thing for nuclear medicine is the new developments on the horizon. As we discover more about the molecular nature of disease, why cancer forms, and what makes and defines a cancer cell, those molecular discoveries can be translated into imaging studies that we can then use with PET scanning to be even more sensitive for detection of disease.

For example, there are several new molecular tracers in the United States that are approved for imaging of prostate cancer. Choline and Axumin (FACBC) are both agents approved in the United States for use with PET/CT.

Internationally, people are moving to a compound called prostate surface membrane antigen (PSMA) that can image prostate carcinoma. It seems to be even better than Choline or Axumin. The data is still a little bit undetermined at this point, but there’s a lot of excitement around these newer agents being able to seek out cancer in very small volumes anywhere it occurs in the body.

Then I guess the question becomes: when do you treat?

Dr. Rohren: Yes. That is very much the question. As we discover more and more sites of disease and smaller sites of disease, the question becomes: do we need to treat those aggressively or conservatively? We’re discovering new things about tumor biology, and we need to understand how that gets translated into the best appropriate therapy for patients.

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Dr. Eric Rohren: Why Radiology?

Dr. Eric Rohren is the chair of the department of radiology at Baylor College of Medicine.

Prostatepedia spoke with him about the path that led him to radiology.

Subscribe to read Dr. Rohren’s comments on radium therapy + imaging.

Why did you become a doctor?

Dr. Eric Rohren: I actually tried my best not to become a doctor initially. My father was a doctor. I grew up in the shadow of the Mayo Clinic up in Minnesota. I knew I was interested in science, but for a long time, I thought I wanted to pursue a career as a research scientist and not a physician.

As I made my way through college and looked at what I really enjoyed and what a career would look like, I wanted to focus on patient care and do things that impacted people. I looked for a career that could combine the science that I enjoyed with the ability to directly interact with people, to hopefully make their lives better. I came full circle, landing back in a career in medicine.

How did you end up in radiology and nuclear medicine?

Dr. Rohren: That was also a little bit indirect. Most medical students aren’t introduced to radiology until very late in their medical training.

A lot of people make the decision to do medicine or surgery well ahead of time, but radiology is often a latecomer. Nuclear medicine is even more so. It’s a subspecialty of imaging, its own medical specialty, but it can also be considered a part of radiology. Medical students often make it through their entire medical training without learning about nuclear medicine at all.

I was fortunate to have a mentor in the radiology department at the Mayo Clinic who taught me what he loved about radiology and how impactful it was on patient care. He got me further plugged in to nuclear medicine.

As I went into my residency and pursued it further, I decided that the science that I loved and the ability to do new things were most focused in radiology, and particularly in nuclear medicine. That’s the career I ended up with.

Many people assume radiology is just imaging. Is that the case? Where does it branch off into nuclear medicine? What kinds of therapies would a radiologist administer?

Dr. Rohren: A big part of being a radiologist is reading images. We also oversee the acquiring of the images, so we monitor the acquisition of the scans and the technologist performing the scans. Many of the people reading this article will have had X-rays, CTs, and MRIs. While technologists and nurses take them into the scanner and get them positioned, ultimately, the radiologists are the ones who oversee the program and make sure that the scans are acquired in the right way. They’re responsible for patient safety, the patient’s experience, and things like that.

At the back end, once the scan is complete, radiologists interpret the scans and look for the findings that may be used to guide medical decisions. Whereas many radiologists can go through their day and not see a patient, they do see the patient’s images. However, there are components of radiology that are directly related to therapy and directly patient-facing.

In interventional radiology, we do biopsies and endovascular procedures, catheter-based procedures, embolizations, administering treatment, and things like that. In women’s imaging such as mammography and breast cancer screenings, those radiologists spend a lot of their time talking to patients and counseling them about their diagnosis and procedures.

One area of radiology where we do meet with a patient face-to-face and interview or talk with them is in nuclear medicine. In that role, we act as “real doctors,” where we walk in, interview the patient, review their labs, go over the plan, do a consent process if it’s for a therapy that has some risks associated with it, and then we administer the therapy directly there in the clinic. When I serve in that role, I feel much more like a patient-facing physician than I do a traditional radiologist. It’s one of the most enjoyable things about it for me.

People tend not to be familiar with specialists until they need them. They might not really understand what you do until they’re at the point where they need your services.

Dr. Rohren: Generally, that is the impression, that the radiologist sits in a dark room, reads scans, and that’s the end of it. The national societies for radiology really encourage us to interface with patients and physicians to make our presence known. Radiologists need to do a better job of that. We have a critical role to play in the management of patients and the diseases that they’re dealing with, so the more we can be out there, share our professional knowledge, act as consultants, and act as physicians for the patients, that’s a positive thing.

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Advanced Imaging + Prostate Cancer

Dr. Phillip Koo is Division Chief of Diagnostic Imaging at the Banner MD Anderson Cancer Center.

Prostatepedia spoke with him about advanced imaging + recurrent prostate cancer.

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Do you have any advice for men considering advanced imaging for prostate cancer?

Dr. Koo: We’ve been talking about better imaging tools for prostate cancer for years. When it comes to other cancers, we moved forward a great deal when FDG PET/CT became available. With prostate cancer, we’ve been stuck with CT and bone scans since the 1970s. They’re great tools. I don’t want to devalue what they’ve done for our patients since then, but we knew we could do better. Urologists and oncologists knew patients had metastatic disease, but our imaging tools limited detection.

We have new tools available to us in 2018. There is no question that costs are going to be higher, but that shouldn’t stop us from exploring and pushing the envelope. The whole purpose is to improve overall survival and treatment for our patients. An ounce of diagnosis could be a pound of cure. If we could identify disease sooner, identify the right patient for these exams, and use them at the right time, then we could probably create treatment plans more appropriate for patients with better outcomes. It’s something that I firmly believe. There is so much potential here.

When radiology is practiced in a vacuum, it’s not as powerful as when it’s integrated into patient histories and treatment plans. Radiology is a very powerful tool. But we often think of it as a commodity, something that does not have any distinguishing value. That is a huge under-estimation of radiology.

When performed correctly in a multidisciplinary setting, with access to the medical record and physicians who are taking care of the patient, radiology unlocks information that can really impact care for patients with prostate cancer. And we are currently only scratching the surface. This will change as analytic tools continue to analyze bigger data sets that include imaging and clinical data. If a urologist determines that their patient needs imaging, they’re going to write a request for imaging that describes what type of test they want and why they need it.

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Patients often go to the closest facility. Convenience is important, but when it comes to certain tests or exams, I urge patients to seek out subspecialized radiology experts and facilities with the experience and expertise in the performance and

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Imaging + Prostate Cancer Recurrence

Dr. Phillip Koo is Division Chief of Diagnostic Imaging at the Banner MD Anderson Cancer Center.

Prostatepedia spoke with him about imaging recurrent prostate cancer.

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Prostatepedi:Some imaging occurs when men are first diagnosed. When, after treatment, do they encounter these newer imaging techniques? After a high PSA reading? Or just a part of routine follow-up?

Dr. Philip Koo: That’s a really tough question because imaging has a role throughout the continuum of care for any prostate cancer patient. Screening currently isn’t done with imaging, but there are a lot of research studies looking at it.

Prostate MRI is most often used for the detection of local disease. Oftentimes, patients with a rising PSA and a negative standard biopsy might get an MRI or an MRI-guided biopsy.

Bone scans and CT scans are used to help detect metastatic disease. There are many different scenarios, but usually after patients are diagnosed with cancer, most will visit radiology if there is a suspicion for metastatic disease. If we refer back to the RADAR 1 paper published in 2014 by Dr. Dave Crawford in Urology (see Urology 2014 Mar; 83(3): 664-9), we talk about imaging patients at initial diagnosis and imaging those who are intermediate or high-risk. In those patients, we recommended a bone scan and a CT scan.

Patients who are biochemically recurrent may also be imaged. Again, MRI will often be used to look for locally recurrent disease. Bone scans and CT scans are used to look for metastatic disease.

What about some of the newer imaging techniques?

Dr. Koo: The newer techniques are exciting. In both the patient community and the scientific community, we’ve heard a lot about these tools over the past decade. They weren’t widely available, especially in the United States. These newer imaging tools are simply better, which is why there is so much excitement. They will pick up more sites of disease at lower PSA levels.

When we do detect sites of disease, they’re more specific. Our confidence that these sites are actually disease is higher than our confidence when we’re using traditional bone and CT scans. These tests perform at a higher level compared to standard imaging.

Another benefit to these new tools is that in one single exam, we’ll be able to detect soft tissue and bony disease.

How do these newer techniques change treatment? If you can pick up the disease at a lower PSA is that going to change how a doctor treats a man?

Dr. Koo: Yes. We will be able to detect disease sooner. Currently, these newer imaging techniques are used mostly in patients with biochemical recurrence. When a patient has biochemical recurrence and we see the PSA rise, our standard imaging techniques are often not good enough to detect metastatic disease. The problem is that the radiation oncologist or the urologist needs to decide how they want to treat the patient.

Using these newer tools, we can provide the urologist or radiation oncologist with better information about whether or not the disease has spread at the time of biochemical recurrence. If it has not, and the urologist can perform salvage cryotherapy or a radiation oncologist does salvage radiotherapy, we could potentially cure the patient.


Dr. Koo: You’re hitting the disease before it spreads, so theoretically yes. These newe imaging techniques do better, but we really need to prove why this is important and how this impacts care. The answers to these questions will solidify the utility and value of these imaging techniques for prostate cancer patients.

If a patient gets the Gallium-68 PSMA or Axumin scans will his local urologist or oncologist know what to do with that information?

Dr. Koo: Maybe. The problem is that all of this sounds great: we have a tool that can detect disease sooner, better, and more accurately. But then the more important question is what to do with that information and does it impact outcomes. If we don’t know, then what is the value of that imaging tool? We operate under the assumption that earlier detection is always better, but we’re learning that in a lot of diseases that is not always true.

We could be over-diagnosing and over-treating certain diseases. Whether it’s imaging, urology, radiation oncology, or oncology, it really is a team effort because we all bring something unique to the table. We really need to work together to make sure we come up with the best plan and the best answers.

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Patients Speak: Anxiety, Depression + Prostate Cancer

Roger G. is an Australian man with prostate cancer.

He spoke with Prostatepedia about how he dealt with anxiety and depression during his prostate cancer journey.

How did you find out that you had prostate cancer?

Roger: My general practitioner had been checking my PSA since 1999. I’d had some issues with urination. He wasn’t too concerned because my PSA hadn’t changed much. In 2003 it had risen to 3.8. In 2004, he said I should get another PSA test but said to leave it until early December, which I did. By that time it was up to 5.6. He referred me to a urologist who said, “We’ll do a biopsy. No hurry. Come back after Christmas.”

I went back to see him in January. The cancer looked pretty well contained. My Gleason score was 3+4=7. He said we’d have to operate, but there was no rush. At that stage, I was a little bit anxious about it all. I thought: Here we go. Just my luck to have cancer, but let’s get on with it. The urologist said, “If it has spread, which I don’t think it has, you can go on hormone treatments. Lots of people get 12 more years with that. Don’t worry.”

I had the bone scan to check if it had spread. Nothing was found in my bones. I had them book me for surgery as soon as they could. The surgery went well. Three months later, I went back to see him. My PSA was 4. He said, “Surgery failed.”

A week later I had another PSA test. It was 5. I started to feel a little bit anxious, but he told me not to worry. He sent me off for a PET scan, which took a little bit of organizing. This was back in 2005 when the PET scan machines were new. They didn’t even know which PET scan to give me. I now know that the PET scans I had were part of a study to determine which was best for prostate cancer. I had one scan and then another. It lit me up like a Christmas tree. There were three big red dots well apart and away from where my prostate was. I was pretty anxious about it all.

How did you deal with that feeling of anxiety?

Roger: I asked, “How long have I got?” They estimated two to five years. I asked about surgery? “No,” they said, “That’s like weeding a garden.” What about radiation? They said they’d have to burn my guts out. I asked what to do. They just told me to “Keep fit and come back in three months.” I was 59. My experience with cancer in my family was pretty grim. My dad was diagnosed with cancer and died three weeks later. It wasn’t prostate cancer, though. My aunt died from lung cancer.

One of my sisters said it was breast cancer, but I didn’t know that at the time. She died pretty soon after her diagnosis. My dad’s brother was 72 when he told us he had lung cancer on Boxing Day in 1995. He was dead by Easter. I was a mess. I would see healthy people and say to myself, “How come you are okay and I have only a few years?” The black dog was giving me a hard time.

But that’s when I organized myself to see the psychologist at the hospital. I had a breakdown. I saw her every week and just talked about how things were going.

She suggested I obtain the Guided Mindfulness Meditation CDs by Jon Kabat-Zinn and start with body scan meditations. I bought the discs. These helped a quite a lot, and I felt as though I was doing something to cure the cancer.

Then, by chance, I went to a support group meeting in one of the Melbourne suburbs—pure chance. I couldn’t find anybody at the meeting who was in the same boat as me. Everybody I met had either had surgery and was all clear, or they were just waiting and watching. But also at that meeting was a motivational speaker. He was fantastic. He talked about how it was mind over matter and about self-talk. He mentioned Lance Armstrong’s book: It’s Not About The Bike.

It’s about turning things around with this self-talk stuff. It all gets to you. I’ve only got a few years to live. I want to really enjoy the rest of my life. Now, I say to myself, “You’re going to be okay.”

Anxiety had me looking at the dark side. Everything on the TV was death. It wouldn’t matter what it was. It was all death to me. It was all why me? A good friend invited me around to his place for a drink and we enjoyed a bottle of red wine. For the first time in two months my nerves settled, and I knew that I could put the black dog in his kennel. Things took a dramatic turn. My boss, who was very understanding, told me of his brush with cancer and how he was given the all clear.

A work colleague told me about his 80-year-old father who had been told he only had a year to live when he was 40. When I took my first PSA test in 3 months, my general practitioner said it might be down. And it was: 3.4!

Cancer is tough. I’m sure most people wonder why me at some point.

Roger: I went through a period when I had a tough time. I was on a hormone-suppressing drug when my PSA went back up to about 20. I got a little bit depressed once

I started on that. I went back to the meditation tapes. There were other issues, too, with loss of libido and putting on a bit of weight. I use the meditation CDs and selftalk. I keep myself fit. I do a good bit of resistance training and stretching.

In June 2016 I had another serious mental breakdown. My general practitioner put me on a mood enhancing drug. Now I’m feeling terrific and energized.

And you lead a support group, don’t you?

Roger: I’m the secretary there. That keeps me busy. I play golf three days a week. I walk around the golf course, dragging my clubs around behind me. Even though I was depressed, I still played golf and worked out at the gym.

Do you have any advice for other men facing similar circumstances?

Roger: Prostate cancer is a chronic disease. If you get a black mood, use self-talk. Talk to yourself inside your ear: “You won’t have any symptoms. They don’t happen. If you do get a bit of pain, well, you can just let them do a bit of radiation.”

You’ve got to keep in touch with your oncologist, just to see if you are eligible for one of the new effective treatments. Work out because your bones degrade when you’re on hormone treatments. Exercise is medicine. Get your heart beating and get your muscles working. This will give you a sense of control over your destiny.

If you are anxious or depressed, see your general practitioner. The medication my general practitioner prescribed sorted that out (and decreased the intensity of the hot flushes).

I enjoy my grandkids. Two of my daughters are married. I’ve got four grandkids. It makes me see the joy. I am really looking forward to all the joys of old age. I had a friend who is about 12 years older than me and he has dementia. I think prostate cancer is a better route.

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Meditation + Active Surveillance

Dr. David E. Victorson is a clinical psychologist and Associate Professor at Northwestern University’s Feinberg School of Medicine in Chicago, Illinois.

Prostatepedia spoke with him about a trial he’s running on mindfulness meditation and active surveillance for prostate cancer.

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Why did you become a clinical psychologist? How did you end up working with cancer patients?

Dr. David E. Victorson: My training was in clinical health psychology and behavioral medicine. A lot of my early training experiences were in cancer, and in some of those, I had the opportunity to work with men with prostate cancer and their spouses in a clinical capacity.

The reasons why I went into this area are multifaceted, but I would say one of the primary reasons is that there is so much that we can do with our own behaviors and lifestyle practices. There is so much good that we can do for our own health by ourselves without needing any heavy equipment or extreme intervention. A lot of times, it just takes a little nudge in a different direction to get people going on a path that will be incrementally better for them.

How do you usually work with patients?

Dr. Victorson: I don’t work with patients in a clinical therapeutic capacity today. I do 100% research. In 85-95% of our research studies, however, we deliver psychosocial and behavioral clinical interventions. Sometimes you might call them self-management interventions. A lot of them are prostate cancer-focused.

Usually, we involve spouses. We help men and their spouses learn skills that can support their health and well-being in different ways.

Most of those studies are group-based, bringing groups of men and their spouses together for classroom skills.

I’m sure that the skills you teach are useful beyond a cancer diagnosis.

Dr. Victorson: They are. A lot of the things we do are applicable across a whole range of different diseases and conditions. People who don’t have a disease can still benefit. But when you get a prostate cancer diagnosis, modifiable health behavior comes into the picture quickly in terms of diet and exercise.

What we’re trying to do with our meditation study is along the lines of mood management, which can be really important in the context of cancer. There’s nothing like a cancer diagnosis to motivate a person to make that kind of lifestyle change. I’ve heard that before, especially when it comes to exercise and prostate cancer.

Dr. Rob Newton told me that cancer patients tend to be more motivated than cardiovascular disease patients, for example. (See Prostatepedia December 2017.)

Dr. Victorson: Right.

What will you be doing in this particular trial? Why mindfulness education in an active surveillance population?

Dr. Victorson: We are comparing our eight-week mindfulness intervention with a matched attention control program. We anticipate that the attention control program is also going to lead to positive health changes, but we hypothesize it will be different than the mindfulness program.

This is a blinded trial, and men and their partners won’t know what group they’ll be put into outside of the fact that it’s a health promotion intervention. This can be challenging for recruitment when you don’t know what you’re signing up for.

All the men will know is that we are testing two different health promotion and wellness interventions that have been shown to be good for men with prostate cancer. That’s about as far as we go.

Most people who sign up really like it, but they don’t even know that they’re signing up for a mindfulness intervention. We’re not trying to deceive anyone, but we need it to be blinded like this to increase the rigor of our results.

Why mindfulness? As we’re doing a better job of prostate cancer screening, we’re finding more indolent or lower grade prostate cancers. Many of these cancers don’t need to be surgically removed or radiated. Active surveillance is becoming a more possible management paradigm. We know that trend is only going to continue.

Many patients are happy with active surveillance. But there are others who, because of how they grew up or because of what cancer means to them, equate cancer with death. When they’re told they have a tumor, they just want it out.

We’re dealing a specific demographic. Older men might be used to the idea of just wanting to get the situation fixed. That’s how they may cope. We’re also dealing with a treatment culture in which active surveillance hasn’t totally caught on. There are still quite a few urologists who recommend what they were trained to recommend: surgery or radiation even for a very low-grade tumor.

There is a certain type of man who will leave active surveillance after one to three years for definitive therapy even when it may not be medically warranted. This shift may be more connected to them wanting peace of mind and just wanting the cancer out.

I always try to say to patients, “If that’s what it’s going to take for you to get peace of mind, more power to you. You know better than me. I don’t have prostate cancer.” But at the same time, as a health psychologist involved in behavioral medicine, I know that there are other ways to help men manage their anxiety than through surgery.

Therefore, we’re exploring which behavioral approaches can be delivered to keep men on active surveillance longer when it is medically warranted. If their physicians say that they can stay on active surveillance longer, we try to support that. You’re hoping that with mindfulness meditation you’ll be able to help men stay on active surveillance longer.

Could mindfulness ultimately be a routine part of active surveillance programs?

Dr. Victorson: Yes. That is the 30-year career goal. We’re not going to be able to answer that question from this five-year trial, though. One of the biggest indicators of peace-of-mind-related departure from active surveillance is uncertainty intolerance and fear of progression. Those two things can form a powerful cocktail that might drive a man to leave active surveillance prematurely. Some men are able to tolerate uncertainty and fear of progression more than others.

We know that mindfulness training can be very useful in helping someone learn to tolerate uncertainty to a greater extent. We can help build that muscle, if you will, in tolerating uncertainties and with sitting with the discomfort of not having your tumor taken out. We are looking at mindfulness training to help reduce fear of progression and increase tolerance to uncertainty. We think those are two important mechanisms toward this goal.

The psycho-educational health promotion group of men and their partners will learn how to integrate positive health behaviors into their lifestyles—things like eating more vegetables, getting more physical activity, and being more aware of their patterns and behaviors. The program doesn’t have anything to do with mindfulness, regulating emotion, or tolerating uncertainty.

Learn more about Dr. Victorson’s clinical trial.

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Cognitive Impairment + Prostate Cancer

Dr. Alicia Morgans is a medical oncologist at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago, Illinois. She specializes in treating advanced prostate cancer and is particularly interested in addressing treatment side effects.

Prostatepedia spoke with her about cognitive impairment, stress, and prostate cancer treatment.

What role do you think medical oncologists traditionally play in anticipating that patients might have these kinds of struggles? What role do you think the medical oncologist should play?

Dr. Alicia Morgans: That is a tricky question. I think, in general, medical oncologists have a lot of things on their plates. They’re trying to balance all of the side effects of therapy, the reason for doing a particular therapy, the complications that a therapy can cause that are medically dangerous, as well as where we go next if this treatment fails. I don’t know that they always take the time to dig deeply into questions about cognitive function, depression, or anxiety unless those things are very clear because a patient is complaining about them himself or a caregiver says it is a huge issue.

Medical oncologists have very short patient visits, especially for followups, and have many things going on that they’re trying to work through with patients. These cognitive changes are not always at the top of their list. However, it’s a critical part of our job and something that I take the time to do because of both my personal experiences and the way that I think medical oncologists should practice. That is not to say anyone else is wrong, but it is a really important part of my practice. This is something that patients are living with day to day. It’s something that needs to be addressed and can negatively impact their quality of life.

A patient’s experience of his quality of life is what really matters at the end of the day. Length of life and quality of life, to me, are both critically important. If you are not thinking clearly or you’re severely depressed or anxious—about your job, financial toxicity, or dying— you can’t live your best life. Helping optimize quality of life during treatment for cancer is a pivotal part of what we do. That being said, I don’t criticize any of my colleagues for missing discussions on this or myself when I’m having a day and running an hour and a half late, but it is something we should strive to do.

Are there ways to circumvent problems with cognitive function, or is it just a matter of identifying them early on and getting patients the help they need?

Dr. Morgans: I don’t know if there’s necessarily a way to completely avoid them, but we might, with some of the research being done, identify patient populations or individual patients who might be most susceptible to some of these side effects based on their genetics or based on the way they metabolize certain drugs.

If we can identify who may be most sensitive, we might be able to steer those men away from certain treatments and toward other treatments or delay treatment if that’s in their best interest and is a clinically reasonable choice.

Our goal is to provide men with a balance of best quality of life and longest length of life.

What we can do now is ask questions of our patients to diagnose these issues. We can ask, “How’s your mood? Are you feeling depressed? Are you feeling down?” We can figure out if they’re depressed or anxious.

If we talk to men and their caregivers about their daily life, we can treat these problems whether it is through pharmacologic therapy or counseling with a social worker, a psychologist, or a psychiatrist.

We can treat depression and anxiety.

Loss in cognitive function is a little more challenging. I have referred patients to behavioral or cognitive therapy (similar to what is recommended for patients post-stroke) to give them strategies for dealing with memory loss or thinking problems. I’ve had some success with that approach, but I would say the standard approach to managing cognitive decline is still being defined. This is the work that I am trying to do, because we still need to confirm which tools are best for measuring cognitive change, and then we need methods to prevent or reverse these issues.

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