Treatment Options for Sarcomas

Transcript

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00:15 --> 00:48Welcome to Yale cancer answers with doctors in East tag power and Stephen Gore. I'm Bruce Barber. Yale cancer answers features the latest information on cancer care by welcoming oncologists and specialists who are on the forefront of the battle to fight cancers this week. It's a conversation about urologic cancers with doctor Joseph Brito Doctor Brito is an assistant professor of urology at Yale School of Madison and doctor. Gore is a professor of internal Medison in hematology at Yale and director of he middle logic malignancies at Smilow Cancer Hospital.
00:49 --> 01:23Joe thanks for joining me tonight. Thank you so much for having me so eurologic cancers. I'm thinking. There's a prostate gland. I guess that's a bladder. There are several so the most common for certain that most men or prostate cancer for certain is very, very common bladder cancer as well. We also take care of patients with kidney cancer, which is very common and then some of the less common ones things like testicular cancer, which I know you did a show on recently and then cancers of the urethra and even cancers of things like the penis and scrotum so.
01:23 --> 01:54Gotcha it's a wide ranging and you do only male urologic cancers. We do not so we take care of females with kidney cancer bladder cancer as well cancer. The ureters as well. But you know by the numbers because of the prostate gland. It ends up being a lot of men. So when you train in urologic cancer relative urologic. Oncologist, there, we go. Thank you. I knew there had to be a word for it don't turn 60. That's my my advice, although better than the.
01:54 --> 02:29Alternative OK, so if you want to become a urologic. Oncologist do you become a urologist first? Yes. So you do a residency in neurology usually that's one year of general surgery and then for 5 years of eurologic specialty training and then generally speaking, you do a fellowship, so that's anywhere from 1:00 to 3:00 years of fellowship training after specifically and cancer in oncology of urologic cancer types. Although I assume that in your logic residency. You're doing a lot of this right. You are absolutely, yeah, we see alot alot and there are many surgical procedures that we?
02:29 --> 03:01We end up getting involved in even early on in our training. You know things like removing a testicle for testicular cancer is a pretty basic operation. I hate it when you talk. I'm sorry. I won't bring it up. I know this is a sore subject exactly just teasing you have to you have to go without it. So I gotta keep it. Light gotta keep it light right. So did you go into urology because you were interested in urologic cancer or yeah? I was uh. I actually did some research in Boston at Dana Farber Cancer Institute for a couple of years before going to medical school.
03:01 --> 03:32OK, so that was in basic science surrounding prostate cancer and got interested in it at the time your urologist tend to be early adopters of technology, so some of the gadgetry that we use in Urology is interesting robots robots lasers. Scopes sign it kind of sounds like a sci-fi movie, but we use all those things to take care of your logic cancers as well were you one of those robotic geeky kids. Did you like do? They call myself geeky? But probably you belong to the robot club?
03:32 --> 04:05I did not know there was no robot club where I was at least but I probably would have joined if there was well. I would think so, but you like the robots. I do so robotic surgery is actually it's been around for almost 20 years now believe it or not. We still think of it. I think a lot of people think of it as a new technology and in a lot of ways. It is and it's certainly advanced since it started. But we've been using the robot in urologic surgery for almost 20 years now and so urologist were some of the 1st to use the robot for mostly prostatectomy to begin with, and it's become the gold standard for management of prostate cancer that surgically treated now.
04:05 --> 04:37And the prospective means taking out the process removal of the prostate, yeah, gosh. I know that's a complicated surgery. Yeah, it's actually it is complicated. There are multiple steps to it, but it's gotten a lot more standardized and many urologists are capable of doing that, even outside the major academic centers. Now we started to use the robot for some other surgeries more commonly as well. So we use, robotic surgery for kidney tumors now whether we're moving the whole kidney or just the tumor of the kidney, which is called a partial in there for ectomy so.
04:37 --> 05:10It's become more widely adopted even outside the prostate surgery world and if you are using a robot to take out all are part of a kidney our patients, having regular large kidney removal incisions or is it done sort of like a lapras. Copic kind of thing you're correct. We don't. I don't know I said one of the other. It's OK. I don't have an opinion. It actually saves the reason we try to use it for most patients is because it saves them. One of those large insights, so it is more like lap right? Yeah.
05:10 --> 05:45If you've ever seen someone who had an open kidney surgery. They tend to have a big shark bite type incisions, so and that's a big recovery time in the hospital generally more blood loss. So the robot saves a lot of those complications. That's really interesting in my field. Of course I don't deal with surgeons as much because I because I take care of patients with leukemia, but occasionally we have send patients to have their spleens removed and the laparoscopic splenectomy is amazing compared to kind of the open split activities that they used to do when they can do that comes out like in a plastic bag or some.
05:45 --> 06:15Right yeah, we put in a bag and the bag comes out through a much smaller incision than you would otherwise have to make to do the surgery and I imagine that the recovery time is going to be less. It's great, so we, we do, and a radical in the for ectomy or removal of the whole kidney. Generally those patients are in the hospital for one, maybe 2 nights if we were to do that surgery open they would be in the hospital for at least 3. Sometimes, 456 days. So it's a big difference in terms of hospital stay blood loss recovery. Time, and then even once a patients are home. The things that they can do it's just easier to get around.
06:15 --> 06:46Without having a big incision that you have to worry about absolutely so how does this work? Do patients come to you with a diagnosis of cancer already it depends a little bit on the pathway through which they get there, so often urologist who specialize in oncology will be in a big either bigger practice where you have some general urologists who will start the work up or their patients who are sent from their primary care physician who may be kind of a little earlier on the path, which I guess gets into a bigger topic of how we detect these cancers so.
06:47 --> 07:18For instance, prostate cancer, which many people know is detected often by a blood test called PSA and that can be started by primary care physicians through screening protocols, but that's controversial still isn't it in terms of whether people should be getting screened. Yeah, it's a good question and up and down. It's become a little less controversial in the past year, actually So what you're referring to is back in 2012. the United States. Preventative services task force or USPS TF came out the mouthful exactly.
07:18 --> 07:50Came out with a actually a recommendation against using PSA prostate cancer screening and there was a big uproar in the Urologic community because we are the ones who end up taking care of those patients when they're not screened and they present with more advanced disease mean it wasn't because of fewer surgeries in less income. It was not. I can't say that for everyone, but certainly we that's how we felt as a community is that these patients were showing up after that recommendation hit the press with metastatic disease urinary obstruction more advanced symptoms.
07:50 --> 08:20What I thought but I thought the recommendation about screening had been because it wasn't really felt that lives were being saved so it's a good question. There's kind of a lot, that goes into it, what I would say is that some of the data that was used to come up with that recommendation was based on an earlier era and the management of prostate cancer so in the modern era. A lot of low grade prostate cancers that are detected or not managed with surgery or radiation at all. They're actually followed through a protocol. We call active surveillance true you mean I'm going to sit here and you're going to tell me that I have.
08:20 --> 08:51Cancer in my prostate gland going to say live with it might do that. It depends what it is so there's a grading system for prostate cancer and if you're classified and Jackie Gleason search. It's not not Jackie. But Yes Gleason. The Gleason grading system so if you end up with what's considered to be a low risk prostate cancer based on your biopsy. You may not be well served by surgery or radiation because there are side effects of those treatments so if we can avoid those side effects, but still ensure that you're not going to develop a disease that's going to kill you, or have you suffer from.
08:51 --> 08:54Then that's really what we try to do for most of those patients now.
08:54 --> 09:27Yeah, but I I would imagine there must be some patients for whom that's highly anxiety, producing absolutely right. You're right and actually the data show us that most patients that come off of those active surveillance protocols are not because their disease. Progress is but because of the other factors. So what does the active surveillance involved generally speaking we follow the PSA more closely than we would for general screening protocol so that's usually every six months or so we check the PSA values and then they will have repeat prostate biopsies at intervals, depending on.
09:27 --> 09:58What the PSA does and what their previous biopsy showed sofa PSA is going up then you get worried and we look at things like how quickly it's rising and what their physical exam is like to help determine them and how often this sort of be done quarterly so it actually much less frequently in that initially when the protocols came out. They were biopsy in those patients every year we now try to use technologies like MRI of the prostate and MRI guided prostate biopsy to risk stratify them a little better and try to space the biopsies out to.
09:58 --> 10:05Even as much as every 2 years, Oh wow. So it's a little less of a burden for the patient now that's not so bad, yeah, I know in my patients.
10:05 --> 10:20Who have leukemia lymphoma that's been in remission you know they're often able to put things out of their brains for a long time, but then like the week before the appointment. They get very anxious. Of course of course, so I can imagine that.
10:21 --> 10:23That if I had a reassuring physician.
10:24 --> 10:55Who is telling me it was in good shape being monitored and every 2 years I could probably put it out of my head recently well right right and that's part of the job. I mean that's part of the so called art of Medison. I think is trying to help explain those things to patients and Aleve. Some of that anxiety, but you know given you often hear people complaining about you know what food is allowed this week in the New York Times. You know coffee is good coffee is bad fats. Good fats bad right so and similarly. We've had this back and forth a little bit about the PSA.
10:55 --> 11:01You know when it was the darling test and then it was like you shouldn't have one and they even had that myself because when I.
11:03 --> 11:33Moved up to Connecticut for years ago, my Internist said. Well, you're in Oncologist. You do you want me to screen your PSA and I said? Well, you know? I kind of feel that perhaps I should live the values that I teach which in those days, was probably don't do the screening so there was about a year that I didn't get screened. All I have in screen. Previously, which made me feel more comfortable not being screened and then I talked to one of your colleagues and it was doctor. Kenny, perhaps and he told me all the reasons why should be screen, said, OK.
11:33 --> 12:04Then I went back to being screen right right so just to come full circle. The USPS TF change their recommendation last year and actually upgraded it from you know they shouldn't be screened to that. It's more of a shared decision. Making process and put it back in the hands. I think of the clinician and of the patient. So now it's a discussion that we have probably like you've had with your physician about whether or not. It's a beneficial thing. Auto patient by patient basis right at what age should men consider being screened so generally screening population is 55 to 69.
12:04 --> 12:38There are certain populations who should be screened earlier so African Americans are at a higher risk for prostate cancer and should be screened at an earlier age and then there are some patients who we feel are at higher risk for having a genetically inherited type of prostate cancer. So there are certain jeans that have been implicated in prostate cancer and that's a field. That's really exploded over the past few years in terms of the number of candidate jeans, but for instance. The BRCA, one and 2 jeans, which classically have been associated with breast cancer are now being found to be an increasing proportion of prostate cancers are related to those as well.
12:38 --> 13:09I see so I guess if you're a guy and you had your mother had breast cancer, especially at an early age and there's a couple of ants are oz. You might say up here breast cancer. You might question whether you're one of these people who should be starting screening earlier if you could have braka right, so actually last year. There was a big meeting in Philadelphia, where they kind of came up with guidelines for genetically inherited types of prostate cancer. And if you had a family relative who was under the age of 50, who is diagnosed with breast cancer.
13:09 --> 13:41And had a prostate cancer diagnosis, then you would be kind of more at a higher suspicion for being tested. So you would have to get one of those BRCA testing jeans. But those are men who already have prostate cancer right so it's kind of at an early stage right now where we're not really sure should we screen. Everyone should be not gotcha. But we do know that if you do get a diagnosis of ABRCA positive mutation specifically number 2BR C A2 that you are more likely to have an aggressive type of prostate cancer so.
13:41 --> 14:09Those patients should be managed probably a little bit more aggressively fascinating right now, we're going to take a short break for medical minute. Please stay tuned to learn more about advances in urologic cancers with doctor Joseph Brito support for yalecanceranswerscomesfromastrazenecaprovidingimportanttreatmentoptionsforpatientswithdifferenttypesoflungbladderovarianbreastandbloodcancersmoreinformation@astrazeneca-us.com.
14:11 --> 14:14This is a medical minute about survivorship.
14:15 --> 14:45Completing treatment for cancer is a very exciting milestone, but cancer and its treatment can be a life changing experience for cancer survivors. The return to normal activities and relationships can be difficult and some survivors face long term side effects, resulting from their treatment, including heart problems. Osteoporosis fertility issues and an increased risk of 2nd cancers resources are available to help keep cancer survivors well an focused on healthy living.
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14:52 --> 14:54Welcome back to Yale cancer answers.
14:55 --> 15:27This is Doctor Stephen Gore. I'm joining tonight by my guest doctors Joseph Brito. We've been discussing general Eurologic Health in Urologic. Cancers show a prior to the break. We were talking about prostate cancer. I think which is obviously something is a lot of middle aged men worry about and think about and wanted people know, people have had prostate cancer or should be screened for prostate cancer and you mentioned that that surgery surgical approaches are safer than they used to be.
15:27 --> 15:57Yeah, I would say that the recovery times are better the blood losses lower and we know that our surgical outcomes from an oncology perspective are just as good So what men are worried about his directions. Correct always and you're not you haven't mentioned that well. We haven't really talked about it, but that everything is great. We certainly can so erectile function is always a concern for prostate surgery. The reason for that is that the nerves that helped a controller action go right past the prostate so there was a big.
15:57 --> 16:32Advanced by a guy named Pat Walshe, who kind of helped to discover these nuro vascular bundles that go past the prostate So what we try to do now for patients who it makes sense for from a cancer control perspective is to save those nerve bundles when we do prostatectomy and that's just called a nerve sparing procedure. Not everyone is a candidate for that. So it depends on what their biopsy shows us about how advanced the cancer is certainly if it's involving those nerve bundles and we can't save them. It's just not safe for the patient, but the best predictor for how a patient's wreck tile function will be after surgery is how it is before surgery so it's an important thing for.
16:32 --> 17:02The clinician and the patient to discuss before hand to make sure we kind of know what the baseline function is there's an old joke about doctoral. I play the piano again. Yeah, exactly doesn't play the pin up a flower and for the most part we can get patients back to a functional level. It just depends on what needs to be done to get there, so there are many different therapies for erectile dysfunction after prostatectomy, which sort of escalating invasiveness to try to help patients get back there right and erections are one thing, but Orgasm's are not always the same.
17:02 --> 17:34Correct so as part of a prostatectomy or prostate removal. We also remove the seminal vesicle's, which are right behind the prostate and that's where the largest volume of ejaculate comes from so certainly things will not look the same. But we think that the sensation is the same. It's just that the actual act might be quite different so if you are able to spare the nerves and if the men retain their ability to make corrections. They should expect to be able to have orgasm so they should have also heard from one of your colleagues I think that.
17:34 --> 18:04For those who are not able to have erection some of them can have orgasm's anyway is that correct. Yeah, that's true. Yeah, interesting OK, so that's great and some patients can elect to have radiation. I guess absolutely that if right, which has its own set of person minus so it's really become a multidisciplinary approach to prostate cancer so for most patients they should at least be counseled on the options of surgery versus radiation. There's again depends on where their cancer is and what the risk is but.
18:04 --> 18:36But for most patients if their candidate for surgery, there probably also a candidate for radiation. And it just depends on the individual patient and what their preferences are gotcha well before the show. You were telling me they had recently moved out to the new Yale operation at Lawrence Memorial. But I think is a New London. Right so you told me that it's a growing operation, but not so big so how does the patient who sees you get the multidisciplinary interaction sure so we are affiliated with the smilow cancer hospital here and truthfully for really any urologist.
18:36 --> 19:08Taking care of patients with urologic cancers. Now they should be plugged into a multidisciplinary team, so we work with medical oncologists and radiation oncologists to help to come up with an appropriate treatment plan. For every patient and you know being plugged into an academic Medical Center helps with that. But for the most part, all urologist should at least have that capacity available. Even in community hospitals. They should gotcha gotcha. So let's say I'm a man and which I am and prostate cancer, which as far as I know I don't know I hope not. I hope not too.
19:08 --> 19:18And I've been treated successfully by you and I've had positive outcomes in all the dimensions that are important to all of us.
19:19 --> 19:20But.
19:21 --> 19:51That's always possible that the cancer comes back right right. It is possible so it's important to monitor patients, even if they've had a prostatectomy or have had radiation for prostate cancer. Generally speaking, we would follow your PSA level. So, your blood test. It becomes more of a marker of what's happening inside at that point as opposed to a screening test where it's used initially for patients and we really use that as sort of a yardstick of what's going on so if the PSA starts to rise after you've had your prostate removed.
19:51 --> 20:22It really shouldn't come from anywhere except for prostate cancer at that point because your prostate is gone, so that's an indication that things may be coming back, and that does happen. It depends a lot on what your initial biopsy showed what your surgical specimen tells us about whether or not all of the cancer was removed or not, and then we do a prostatectomy. We also take lymph nodes out of the pelvis, so that can help us to know whether or not the disease has spread at that point and all those things just get factored in when we think about recurrence risk for patient and what happens if somebody does recur.
20:22 --> 20:56Sure, it depends a little bit on where their recurring so if you were to have surgery and you had what's called a positive margin, meaning that there may be a small amount of cancer left inside. You could have a recurrence just in that one spot. So those patients may be candidates for advent radiation therapy or radiation after surgery to try to get rid of that one spot if you have a recurrence. That's more widespread throughout the body metastatic disease. Then you may be treated very differently, so prostate cancer is interesting in that it's sensitive to hormone deprivation or blockage of.
20:56 --> 21:26Testosterone, which really sort of starves the cancer of its food supply. If you will write and so that was a major discovery for prostate cancer so there are multiple medications available now to block testosterone, which can control cancer. No matter where it is in the body that's great, but of course, that those drugs have side effects as well? Absolutely. Do gotcha well. That's really interesting and it's good to know that there are backup plans. There are but I think it's important for people to know that just because they've had surgery or radiation.
21:26 --> 22:01They do need to be followed so it's you know you can't just assume that things are gone and they're gone forever. At the very least people should have their PSA checked once a year. Even if they've had surgery or radiation right and if they're working with a good urologist like you they will be informed and they should be followed right gotcha. So the prostate cancer. Those is not the only cancer that you deal with you gave us kind of a list and I think a lot of people don't think a lot about kidney cancer right. I think you're right people. Find out that they have kidney cancer. So it's kidney cancer used to be diagnosed or we would teach the medical students that it was diagnosed where you had.
22:01 --> 22:32A big flank Massan Gross, he materia and pain and Hugh materials blood in the units are a team is Ray being being blood that you can see in the air and gross meaning you can just see it yourself. I remember being taught that kidney cancer was like the great imitator being that it can cause all sorts of patterns plasters and other symptoms that internus would have trouble Triton that certainly can happen as well, more commonly today, we find kidney cancers. Incidentally so there are found when patients have a see T scan for some other reason you come into the emergency Department with.
22:32 --> 23:04A domino pain or some sort of GI bug and you get a cat scan and will see usually a small tumor on the kidney. So we've seen an earlier detection of those tumors based on just the fact that there are found more incidentally now gotcha and that's probably better because I'm guessing a smaller cancer can be cured. More easily right. It's certainly easier to manage from a surgical perspective, so you're robot right exactly right so we use, robotic surgery to do a partial nephrectomy or removal of just a small part of the kidney when we can take that Umarov usually by leaving.
23:04 --> 23:35And leaving the rest of the kidney behind which saves patients certainly kidney function. Overtime and also, if there to you know develop a tumor on the other kidney. It's a way for us to make sure that they're not suddenly without kidneys at all. People can live well with whole kidney that could be missing can live with a single kidney right in that dialysis, yeah, so kiniza repaired. Oregon so as long as the other kidney is functional. And we can usually tell that by a see T scan. But there are other tests that can help us to figure that out, if we can't tell.
23:35 --> 24:05Then certainly wall kidney can be removed. One thing that I think is one of the scarier symptoms for patients in general is blood in the urine which is a pretty common symptom right. It's very common. It you're right. It tends to be a little bit more common in women urinary tract infections can cause blood in the urine and one thing that we, as urologist make sure that patients know and try to get this word out to primary care doctors and emergency departments as well is that blood in the urine that you can see.
24:05 --> 24:36Gross blood in the urine is really never normal and shouldn't be considered that so Unfortunately what we found in the research shows us is that women tend to present with higher stages of bladder cancer because they get diagnosed with a UTI when they have blood in the urine. They may be treated with multiple courses of antibiotics before they get referred to a urologist. So certainly if patients are seeing blood in their urine. They really should approach their primary care doctor about being tested further and if there's no infection. There they really should be sent to a urologist I see.
24:36 --> 25:07Some of those patients, though might have kidney stones. For example, right true. So when patients are sent to us with blood in the year and we generally do several tests to really decide where things are coming from a see T scan is usually the first step and that's done with and without contrast and the non contrast fees shows us kidney stones, so that's part of our work up of patients with blood in the urine so don't necessarily panic. If you have blood in your urine but take it seriously, it could be nothing or at least something not as serious as.
25:07 --> 25:38Kidney or bladder cancer, but it should be worked up. It should be investigated gotcha well. Unlike the kidneys where there's two of them. There's only one bladder so how do you deal with that so if patients have bladder cancer that's advanced San urology that's generally bladder cancer that's invading into the layers of the bladder. Most importantly, if it starts invading into the bladder muscle then those patients may need to have their bladder removed that's a big surgery and as you can imagine as you alluded to, if your bladder is removed. Then you kind of have a plumbing issue so how do you speak?
25:38 --> 26:13How do you get the urine out of the body in there? How do you there are many ways to do it? We have to do what's called a urinary diversion so that's anywhere from taking a small piece of intestine and creating what's called a conduit or away from your end to get out of the body to actually building a new bladder out of intestinal tissue. No kidding and that's a little bit more of an involved process, but depending on patients desires and the stage of their disease. They may be candidates for that, so if you build one of these. I guess neo bladders. If you will, or pseudo bladders than people urinate normally through their penis or through their urethral.
26:13 --> 26:45It's normal ish it does require a lot of learning in terms of how that works you know the sensation is very different because it's not interview did or you know the nerves don't travel the same way or they would have for normal? How do you know when you have to go and how do you make it happen so sometimes patients will actually start to feel a sensation is probably very different or they void at regular intervals during the day, but it's anatomically feels more normal feels right. I mean in the sense that you are coming out of the right hole.
26:45 --> 27:17Exactly right, yeah, interesting in otherwise they need to have a diversion that's like a colostomy bag, except instead of stool. It would collect urine right and I've had patients like that, it doesn't seem very unacceptable. It's actually they've done a lot of quality of life studies to see what patients desire and with those more complicated procedures like the neo bladder. There are also higher complication rates and some of those patients will have trouble urinating normally so they may need to catheterize themselves so a lot of patients will decide they don't want to go through that.
27:17 --> 27:48And will opt for a more simple diversion like an ileal conduit and they do well with those and it can be pretty easy to take care of with proper education and I hate to dwell on sex. But if you have bladder cancer is future sexual function going to be possible and is that going to impact the choice of the surgery. It's a little more complicated. I think for bladder cancer patients. Then, for prostate cancer patients when we do remove the bladder of a man we generally will remove the prostate.
27:48 --> 28:18In Seminole vesicles as well, it's a little bit harder to do a nerve sparing procedure in those patients and most commonly. We don't do a nerve sparing procedure so there still can be sexual function, but it has to be a little bit different, and sometimes they'll have to go actually additional surgeries have to undergo additional surgeries to get to that point and whatever, so for women, most commonly when we remove the bladder. We also remove part of the vagina so there is a part of that surgery, which involves reconstruction of the vagina.
28:18 --> 28:48Depending on what the stage of the cancer is that may be easy to do. Or maybe more difficult if it's more invasive it. Of course, also depends on the patients desires so most of the patients undergoing that surgery are in their 70s or even 80s and may not be interesting. Yeah, they may be easy for you to say young surgeon truly right. But it is something that we need to discuss with the patient before hand. So we know what their desire is does your multidisciplinary team include psychologists or social workers to kind of deal with these.
28:49 --> 29:22Sexual and identity losses absolutely so social workers should be a big part of the team and increasingly because our detection methods in our surgeries are getting better. These patients are surviving longer so there's a big survivorship movement now to try and help patients to help patients help patients really to help some of these survivors. Talk to some patients in the earlier stages of diagnosis and help them understand what their diagnosis is and make the right decision. Doctor Joseph Brito is an assistant professor of urology at Yale School of Madison.
29:23 --> 29:41If you have questions the address is canceranswers@yale.edu and past editions of the program are available in audio and written form at yalecancercenter.org. I'm bruised Barber reminding you to tune in each week to learn more about the fight against cancer here on Connecticut public radio.

Information

Treatment Options for Sarcomas with guest Dr. Gary Friedlaender February 10, 2019 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095