THE HEART OF THE MATTER
a special program of the National Emergency Medicine Association (NEMA) 

Transcripts: 541-4, 541-5 and 542-1

Week: 541.4 Guest: Dr. Otis Brawley, Dir. Of Special Populations, Nat'l Cancer Institute Topic: Prostate Cancer- Update on studies and treatments, Part One of Three Producer/Host: Steve Girard

NEMA: The Heart of the Matter today revisits the issue of prostate cancer with Doctor Otis Brawley, Director of the Office of Special Populations at the National Cancer Institute near Washington, D.C. Dr. Brawley, tell me about the type of work you do at the National Cancer Institute...one of the branches of the National Institutes on Health.

BRAWLEY: Well, the National Cancer Institute, first off, is the largest research institute in the world. What we do, both at our campus in Bethesda and across the country, is medical research related to cancer. Much of our research involves....in prostate cancer, which is what I do, we're interested, number one, is screening effective in saving lives'?...as well as, how effective are current therapies for prostate cancer'?... and we're also looking at the question, can prostate cancer be prevented'?

NEMA: I don't have very many friends or peers who haven't had a dad or granddad stricken by prostate cancer....

BRAWLEY: Prostate cancer is incredibly common...there's a number that floats around...15 to 20 % of people over the age of 60 who die of heart disease, will generally be found to have some small prostate cancer. Now, some of these cancers are incredibly small, clearly do not lead to death...as well as the problem that there's over 40 thousand men per year who died from prostate cancer. So, while we have a disease that frequently is no problem whatsoever, we have a disease that clearly is a problem for a lot of people, and a lot of reasearch effort is going into trying to find out which kind of a cancer a person has. Our abilities to say, "this person has cancer", while they're alive, right now are actually quite good, the problem is which cancers need to be treated versus which cancers don't need to be treated.

NEMA: With the current technology, are we able yet to determine between the less and more aggressive types of prostate cancer?

BRAWLEY: It is still undetermined, unfortunately. All we can do right now, after we diagnose a man with cancer, is to make an educated guess as to whether its slow growing or fast growing...whether it's the indolent kind, that is unlikely to affect him while he's alive, or it's the aggressive kind...and we're not 100 % good at guessing. A lot of research effort is going into trying to be able to actually make that distinction with a great deal of certainty.

NEMA: I've seen a recent magazine article that features a study that shows at least 85% of men who undergo surgery for prostate cancer, are doing well ten years down the road. Those statistics sound staggeringly in favor of surgery, but that may not be a really clear conclusion...is it?

BRAWLEY: That's exactly right...what we've figured out is that a large proportion of men who get surgery are cured of their disease. What we don't know is how many of those men actually needed to be cured. That's the distinction. There's a...certainly a group of those men, and how large a proportion, is certainly open to argument...but there's certainly a group of those men who are cured, but they never needed to be treated whatsoever. They'd have done quite well if they had not been treated. and this is especially a problem because the treatment does have a number of side effects.

NEMA: Dr. Otis Brawley of the National Cancer Institute will be back with us to discuss the problems associated with prostate cancer surgery... growing awareness of prostate cancer, the controversy over whether a man should be screened for the disease, and other problems men fear as cancer that aren't...and can be treated. I'm Steve Girard.

Transcripts:

Week: 541.5 Guest: Dr. Otis Brawley, Dir. Of Special Populations, Nat'l Cancer Institute Topic: Prostate Cancer- Treatments and goals, Part Two of Three Producer/Host: Steve Girard

NEMA: We're with Dr. Otis Brawley, a researcher at the National Cancer Institute...the largest research institute in the world..and one of the branches of the National Institutes on Health in Washington. He's told us that prostate cancer researchers are faced with a disease that can result in death for some patients, but for others the cancer is so slow developing that treament may not be necessary. The main problem is to determine which cancer is which. Doctor Brawley, I understand there are several complications connected with having prostate surgery...

BRAWLEY: Well, uh, surgery...and we should point out that surgery is not the only treatment for localized prostate cancer, and we're really talking about cancer that is confined to the prostate here. Surgery has certainly been associated with impotence, men who can no longer perform sexually. It has been associated with incontinence, that is the inability to control the urinary stream. It's been associated with, in a very small number of people, certainly less than one percent, death from the operation itself. So, there are some definite risks associated with radical prostatectomy, I should say. And I should also note that a number of men undergo radical prostatectomy and do just fine without any of these side effects. The other treatments that are commonly used in the treatment of localized prostate cancer is surgery...both external beam surgery, as well as what's called brachey therapy, or the implantation of radioactive iodine or paladium seeds into the prostate. Again, all of these treatments do have some side effects associated with them very similar to radical prostatectomy.

NEMA: A lot of Americans look to the National Institutes of Health, of which the National Cancer Institute is one, for information on the cutting edge of cancer research and treatment. Anything new in the area of prostate cancer?

BRAWLEY: None of our research findings in the recent past has truly affected the layman. Hopefully, in the future, we will have some of those groundbreaking findings. We do have the ability to diagnose prostate cancer, and that is through screening with both a digital rectal exam and a prostate-specific antigen....we don't really know how many of the men we are diagnosing through digital rectal exam, or DRE as its called...PSA, or prostate specific antigen, have cancers that need to be treated. And then, secondly, we don't know, truly, how effective our current treatments are. As well, the flip side...we can't tell you how many men we're treating who don't need to be treated. And any man who's thinking about being screened really needs to learn as much about this controversy as possible. Know the research that's been done to date and make an informed decision for himself. Hopefully, in the next five years or so, we're going to be able to come up with, this is a man who has cancer, and this cancer is best left alone'....versus, this is another man who has cancer, and this cancer is best treated aggressively right now.' But we don't have that right now.

NEMA: Awareness of prostate cancer and its related problems is on the rise...we'll talk with Dr. Brawley about that, and a condition that scares men out of talking with their doctor, when they could be suffering needlessly. I'm Steve Girard.

 

Transcripts:

Week: 542.1 Guest: Dr. Otis Brawley, Dir. Of Special Populations, Nat'l Cancer Institute Topic: Prostate Cancer- Screening, Part Three of Three Producer/Host: Steve Girard

NEMA: During our series on prostate problems, we've been talking with Dr. Otis Brawley, a researcher at the National Cancer Institute...part of the National Institutes on Health. Doctor, it seems awareness about prostate cancer has been growing, and men are talking about, and dealing with the disease more comfortably than before...do you find that to be true in the men who you treat and educate?

BRAWLEY: We definitely get to see it...while we're researchers, we also see patients and we also end up getting a lot of letters from people who want to know about research and what's going on, and want to know our opinion. And I agree with you wholeheartedly... five years ago, even, very few people were willing to talk about prostate cancer, now many more are. And I think that's an important and a good thing.

NEMA: It's still hard for a man to make a choice on screening when treatment for the disease is still a big question mark....

BRAWLEY: I would just encourage every man who is thinking about being screened for prostate cancer to learn all the issues, all the pros and all the cons for screening and then make an informed choice as to what he thinks is the right decision for him...so frequently we hear, "get screened...it's the right thing to do, it's the only thing to do", and for many men getting screened is the right thing to do, but for some men, their comfort level is such that we in the medical profession and the advocate groups need to accept the fact this individual does not want to get screened, and that's a legitimate decision to make.

NEMA: What is the biggest determing factor to go ahead with screening?

BRAWLEY: Age is almost the only factor that is currently motivating screening in the United States. To a certain extent, race..there are some people who believe that black men should be screened beginning at age 40, and the general population at age 50, every year thereafter. There are others who advocate that men who have a father or a brother who has had prostate cancer should start screening at age 40. That's actually very controversial; the American Cancer Society and the American Urological Association recommend screening, there are a number of other very distinguished organizations that looked at the same data and said there's no evidence that screening saves lives, so we don't recommend it. So, that's a very controversial area as to whether someone should be screened or not. Screening by its very definition involves giving the tests, the digital rectal exam and the blood test to a man who is asymptomatic in that age group with or without family history.

NEMA: Many men are afraid to go to their doctors when they have any kind of symptom related to the prostate....

BRAWLEY: Many of us, as we get older, have swollen prostates that cause us to have difficulty starting our urinary stream, and may cause us to get up several times at night. That's usually, not always, but almost always, something called benign prostatic hyperplasia, a benign swelling of the prostate...and I can't overstress the number of men that I have seen who have problems urinating, and are afraid to go to the doctor because they're certain that it's prostate cancer. In reality, in 99.9 % of the times, the problem is a benign problem, it's easily fixed, and they're suffering for nothing. I think that's an important message to get out.

NEMA: Our thanks to Dr. Otis Brawley of the National Cancer Institute. I'm Steve Girard.