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Prostate Cancer and Erectile Dysfunction

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Einstein Healthcare Network in Philadelphia, Pennsylvania presents Doc Talk with Dr. Donee Patterson, a board-certified family physician and our Director of Community Outreach. In each podcast, Dr. Donee sits down with Einstein's medical experts to discuss topics that are important to you. In this podcast Dr. Donee discusses men's health issues. Dr. Donee, take it away.

Donee Patterson, MD: Hi, Dr. Dan Canter, how are you?

Daniel Canter, MD: I am well. Thank you. How are you?

Patterson: I am so great. We are so happy to have you. I just want to give you an official welcome to Einstein because you are new here and we hear you have the new Einstein Urology Center.

Canter: Yes, we are excited to be here and, yes, we are open on the Elkins Park campus, as well as the main campus and a little bit up at Montgomery, so we are really excited about what we are doing and things so far have been going well and there has been great support from the Einstein community. 

Patterson: Awesome. So tell us, your office on Elkins Park, tell us where it is. Do you know the address? 

Canter: Yes, we are at 50 East Township Line Road and essentially what that is is we are in the Medical Arts Building, which is right behind the Elkins Park Moss Rehab Hospital, the physical plant of the hospital. So we are literally a stone's throw from the hospital and we are on the second floor of the Medical Arts Building there. 

Patterson: Awesome. I hear that getting an appointment with you is pretty easy to do. I don’t want to step out of bounds here, but what do you think about that?

Canter: That's one of our goals to make things very easy. From what I have heard so far there have been no problems, but obviously if they are not easy then that's our job to make it easy for the patients and the referring providers so we certainly - so far I think things - we have lived up to that claim. 

Patterson: Awesome. So let's jump in here. For a lot of people they are not really sure what a urologist is and what a urologist does. Can you clarify that for our listeners?

Canter: Yes, I would have put my daughters into that category. They're not sure what I do. They hear a lot of terms, but they are not sure what they mean. A urologist is sort of, it's very similar to a gynecologist without the delivering babies. We take care of the urinary tract from the kidneys down to the bladder and the prostate and the testicles and the male reproductive organs. We deal with those organs and usually the most common issues are older men who have problems with their prostate, among other things, but we see a lot of other ages and genders, but usually it is older men with prostate problems. 

Patterson: Got it. Since we are on the subject of the prostate, September is prostate awareness month so we are perfectly timely with this topic. Can you explain to our listeners exactly what the prostate is and what the prostate does?

Canter: So the prostate does have some function which helps for fertilization when couples are in their reproductive age. Unfortunately, once they get past that age the prostate becomes nothing but sort of a nuisance, and as we know, and I am sure we will talk about it some more, the prostate continues to get larger with age and really all it is is after a certain age it's function really is no longer that important in a man's life. 

Patterson: Right. When I went through training a million years ago…

Canter: But you look so young.

Patterson: Oh, I love you. When I went through training we learned that 50 percent of men by the time they are 50 have enlarged prostate and 70 percent of men by the time they are 70 have enlarged prostate. I just wanted to mention that just to say how common it is and that men don’t have to be upset that it's happening to them. It is just something that goes with the age. What do you say to that?

Canter: Well that's absolutely true and the prostate grows under the influence of testosterone and men will continue to make testosterone throughout their whole life and yes it is a very common problem. Men's prostate will grow bigger with age, but it doesn’t necessarily mean it's going to be a problem. For some men it is not a problem for some other men it is a problem. Because it is getting bigger doesn’t necessarily mean that it's a more increased risk for prostate cancer, which I am sure we will talk about as well. 

Patterson: Absolutely. Absolutely. The technical term for enlarged prostate is benign prostatic hypertrophy. People don’t have to know that, but they may hear their doctor mention that so I just wanted to say that. So can you tell our listeners what are some of the symptoms of an enlarged prostate?

Canter: The first symptom will usually be getting up to go at night. Some men will, it is not uncommon for men as they get into their 40s and 50s to get up at least once a night and as your prostate enlarges some men have to get up four, five times a night. Those are the most - that's usually the first symptom and a very common symptom, but some other symptoms are they have problems when they get to the bathroom they feel an urge to go, but they have a hard time getting their urinary stream started and when it does get started it is a very weak flow or very slow flow. They feel like they don’t really empty their bladder, but they also can have what we call irritative symptoms or non-voiding symptoms where they feel like they have to go a lot. They get these urges to go where they've got to go, go, go, or else they feel like they'll leak and obviously getting up at night is another symptom that is part of the irritative symptoms. 

Patterson: Sure and can you tell people what some of the symptoms might be for prostate cancer? Some of them are probably very similar.

Canter: Well actually, which has become more controversial in the past year or so, most men were actually being diagnosed with prostate cancer asymptomatically, meaning that they were getting yearly PSA blood tests, PSA is just a blood test, and their PSA was elevated and they were getting a prostate needle biopsy and they were being diagnosed with prostate cancer. It is a very interesting dichotomy with prostate because prostate cancer is usually asymptomatic, but prostatic BPH or benign prostatic hypertrophy is really symptomatic and usually the two really don’t cross over that much.

Patterson: Got it. So for our listeners can you explain to them exactly what the PSA is? You mentioned it is a blood test, but how we are picking that up.

Canter: Basically the blood test was invented almost 20 years ago now. The PSA is naturally secreted by the prostate and it gets into the bloodstream and it became part of a routine screening and we were noticing, based on the early studies, they were noticing that men with a PSA of greater then 4 had a higher risk of having prostate cancer. That sort of became the cutoff that we've used for recommending a biopsy. If a man has a PSA of greater then 4, they would get a biopsy, but their risk of having prostate cancer really wasn’t that great. It was 20 to 30 percent. Twenty to thirty men out of 100 had a chance of getting prostate cancer. What we've learned is there is a lot of subtlety to that number and needs to be taken with a grain of salt, but more importantly, it really became an issue of we were detecting men who had prostate cancer, but it was not what we would call a significant prostate cancer, meaning it wasn’t a cancer that would affect their lifespan, but unfortunately a lot of these men got treated and they had side effects from the treatment and they probably got these side effects for a disease that they probably did not necessarily need treatment for. 

Patterson: So what would you recommend for the screening for it?

Canter: I think that a lot of it comes down to patient preference.  Some patients are influenced by friends and family members. I think certainly men, what we consider high risk men and we define those men as African Americans, they tend to have a more aggressive form of prostate cancer that we don’t necessarily understand why and certainly men who have a strong family history of prostate cancer, especially a family history where men have actually died of prostate cancer, those are the men who should get treated.

Patterson: Just for our listeners I want to encourage you, as a family practitioner, please know your family history. It is not okay just to say that my dad died of old age and my grandfather died of something. Ask your family members what did grandpa die of or did dad have any medical problems because you need to know it because as doctors we screen you a little bit differently. I also want to interject that the PSA is still a very important screening test. It's what we have now. It is simply what we have now. Maybe in 2030 we will have something different, but it is a test that we want all men to make sure that they get starting at age 50, but for high risk groups we do start a whole decade earlier. Is that correct?

Canter: For people with a strong family history we start about ten years before the index case, whenever that may be. 

Patterson: That means ten years before, so you need to know when the person in your family had it and you start ten years before that.

Canter: Right, so if you had an uncle who got diagnosed at 48, you could start at 38, and I think it is also important, I want to add, when you are talking about family history, you have to also ask not just about immediate family, you also have to ask about uncles, you said grandparents, but uncles and cousins because a lot of times you will see clusters and for some reason maybe your dad won't have it, but a bunch of his brothers or cousins will have had prostate cancer. We certainly recommend ten years before the first index case. I think 40 to 45 is a reasonable starting point for high risk groups like African Americans. 

Patterson: Got it. You mentioned side effects of the biopsy. What would some of those side effects be?

Canter: The side effects of the biopsy are relatively mild fortunately. It is done via the rectum so it is uncomfortable for men. So they may have some blood in their bowel movements, some blood in their urine and there is a risk of infection that can be not life-threatening, but require hospitalization. Those are the main risks of the biopsy, which are fortunately relatively uncommon. The main risks are really what definitive treatment of prostate cancer, whether it be surgery, whether it be radiation. If you look at pretty much all the studies what most men have is some degree of decrease in their urinary function, quality of life related to their urinary function, some decrease in their sexual function, especially with surgery, and then obviously there can be some bowel dysfunction as well, especially with a radiation treatment. 

Patterson: Okay. I don’t want to scare anybody off. Let's back up a little bit. A lot of my guys say I don’t feel that. I don’t need to have my prostate checked. I feel great.

Canter: Uh huh. Yeah.

Patterson: I just want to hit home. We said it a little bit earlier, I just want to hit home the importance of why they need to get their prostate checked. What do you say to that?

Canter: Well I think the importance of getting the prostate checked I think is related to specifically it's a quality of life issue. I think a lot of men, especially with an enlarged prostate, will have issues related to urinary function, quality of life related to sleep, and a lot of these things are very treated with very minimal invasiveness. Obviously for prostate cancer, the reason it to be checked is especially with people with a strong family history can be a significant cancer that can shorten one's lifespan. 

Patterson: Absolutely. So it's less then a 15 second test. Do you want to explain what the test is like for people that never…

Canter: For the PSA?

Patterson: To check for your prostate.

Canter: It's a quick rectal exam. I tell men it's like when women get a pelvic exam at the gynecologist. It's very similar and it's quick and it's over before they know it and it's usually not as bad as everyone thinks it is. That's what everyone always says to me.

Patterson: It's a very short test, guys, and I always tell my patients it is better to get this very short test then to have prostate cancer. Would you agree to that?

Canter: Yeah, absolutely. I think that's very true.

Patterson: What we are checking for, is the prostate actually sits in side the rectum. So some of my patients say, well, where is this prostate anyway causing problems and they were thinking that it was in their penis area because that's where the urinary symptoms were occurring, but it is actually a gland that sits in the rectum and the doctor can feel for any lumps or bumps. Right?

Canter: Correct.

Patterson: Let's talk a little bit about erectile dysfunction, which is very common. Do you see it in younger and younger men nowadays?

Canter: It depends how you define that number, but certainly it is a very common problem and I think a lot of it has to do with reporting. A lot of people just sort of accept it at a certain age and sort of don’t really seek treatment, but it is very treatable. We do see, especially in younger men, what I worry about is, especially men in their 40s, when they show up with the nuance of erectile dysfunction I worry about heart disease.

Patterson: The reason why we are saying that's related to heart disease, people say, well, it's very separate, but the blood vessels are all connected. We don’t want the heart to be, the arteries in the heart, or the arteries in the brain to be clogged, and it's the same arteries that are in our lower extremities and the penis as well. 

Canter: Right.

Patterson: So I say that just to bring up the point of diabetes. I would assume that you have lots of, like I do, I have lots of patients that have diabetes that have some erectile dysfunction because it is all, if too much sugar is in the blood, that sugar is toxic to the blood vessel, can damage the blood vessel. What other medical conditions do you see that are kind of common with erectile dysfunction?

Canter: Well, I mean I think you hit the nail on the head because essentially anything that can predispose someone to heart disease or a heart attack can cause erectile dysfunction. Diabetes is a big one. High blood pressure is another one. High cholesterol, smoking, and to a certain extent obesity, but the other ones are really the biggest risk factors for erectile dysfunction. Altering them at some point, it may not necessarily reverse the effects of erectile dysfunction, but it certainly will slow the effects and certainly will make the patients more responsive to medications for erectile dysfunction. 

Patterson: Are there some conservative things that people can do like decrease stress and increase exercise? Does any of that help at all with erectile dysfunction?

Canter: Certainly increasing exercise is good for someone's overall health and obese men have higher circulating levels of estrogen and that can affect their desire and certainly affect some of their abilities, affect their erectile dysfunction. So that certainly, exercise will help that. It will help sort of some of the blood flow to the penis, but usually the most conservative measure is trying to reverse the underlying cause, which would be smoking, quitting smoking, and so on and so forth. If those don’t work then the next step would be pills to help with erections.

Patterson: Right. Do you think that stress is directly related to erectile dysfunction in some people?

Canter: Well, you know, yes and no. It certainly can be some part of what we call the psychogenic, or some of the, for lack of better words, psychogenic meaning effects of erections, but erections are really mediated by blood flow. If you have good blood flow you should be okay. Obviously there are other factors. Stress can certainly make people not, decrease their desire and certainly that can decrease their interest in their partner. It certainly does play a role. It is sometimes hard to quantitate though. 

Patterson: Now you had mentioned obesity. Is there a correlation with obesity and prostate cancer, higher level in obese men?

Canter: Well, you know, that's a really good question because there is some research that's been done about obesity and urologic cancers. I think it is a little bit hard to sort of really separate the fact from the fiction, but it does appear that there is a potential that obese men may have a more aggressive form of prostate cancer, but I think that is a little anecdotal at this point to really know for sure.

Patterson: Got it. I can imagine that urology, since it is a surgical profession, that you have, do you have new procedures or is there something that you'd like to make sure you mention today?

Canter: Well, I think everybody likes technology and video games and we have what's very popular now and a lot of patients are asking for is robotic surgery. Essentially it is minimally invasive surgery where we do surgery with the assistance of a robot that helps to improve our magnification, improve our control of the instruments. It has really gotten out in the late press there a lot. Urology is one of the biggest utilizers of the robot, especially for prostate cancer and prostate cancer surgery. 

Patterson: Right. Some of the take home messages here would be, one, to make sure that you are seeing your doctor annually just to make sure that you have your blood pressure, cholesterol, diabetes under control or make sure that you don’t have those things. Two would be if you do need a urologist, if you are having any urinary symptoms, burning when you pee, peeing more frequently, getting up frequently at night, blood in your urine certainly, don’t hesitate to see a urologist. Don’t put those things off. Three would be to know your family history and then if you have some high risk factors to see a urologist. I guess I would say four would be to make sure that you are following up regularly at timely intervals to make sure that you are getting your testing done. Do you have any words of advice or things to tell our men, you know men don’t always like to come to the doctors, just to kind of keep them from being worried about coming to see you?

Canter: Usually they finally end up coming when their significant other makes them come, usually their wife. I think your take home messages are really, are spot on, but I think the main thing that still surprises me to a certain extent is that when men finally do come to see me and with very simple type of interventions we can really improve their quality of life on a number of levels without having to do surgery. In fact, it is very, the amount of men who come to see us and the amount of surgery that we do from the men who see us is relatively low. A lot of times I think people feel like they have to have some major type of procedure done to feel better and it is really just not true. I would say that for all these, especially erectile dysfunction and BPH that we talked today, there's a lot of very conservative or non-invasive treatments that are available that can really improve men's and their partner's quality of life. I would really encourage men to go if they are having any of these symptoms. In fact, just to give you an anecdote, I remember a patient of mine who was 82, who was having terrible urinary symptoms and he just sort of accepted it his whole life. He just lived with it. He finally came to see me and I started him on Flomax and he came back to see me for followup after starting medication and it was like he couldn't believe how much better his quality of life was just by starting that medication. He went probably, I don’t know, ten, fifteen, twenty years, just kind of enduring it when he really didn’t have to. These are very common problems. Men tend to sort of avoid the doctor and they feel like they can just live with it and you know if they want to live with it, they can, but there are a lot of options out there that can really make a positive difference in people's lives.

Patterson: So you hear that, guys? You can feel better. Don't ignore symptoms. Make sure you get things checked out before they get out of hand and definitely just make sure that you are paying attention to your bodies. I can attest. Dr. Canter is not a scary guy. You have to go see him if you need him. Again, they are in Elkins Park and they are in Montgomery. It is Einstein Urology. Welcome, again, Dr. Dan Canter.

Canter: Well, thank you very much and thanks for having me on today.

Patterson: Awesome. Thanks.


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