September 1, 2024 • 27 mins
CredentialsPositions
Board Certifications
Education and Training
- Member of the Faculty, Department of Radiation Oncology at NYU Grossman School of Medicine
- Vice Chair Academic & Faculty Affairs Dept Rad Onc
- Director, Brachytherapy Services
Board Certifications
- American Board of Radiology - Radiation Oncology, 1991
Education and Training
- Residency, Memorial Sloan-Kettering Hospital, Radiation Oncology, 1990
- MD from Albert Einstein College of Med, 1986
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
The following is a paid podcast. iHeartRadio's hosting of this
podcast constitutes neither an endorsement of the products offered or
the ideas expressed.
Speaker 2 (00:09):
The following program is brought to you by NYU Land
Gone Health. It's Kats's Corner with doctor Aaron Katz. You're
trusted expert in men's health, providing straight talk on a
wide range of men's health topics and advice on how
to live your healthiest life. Now on seven to ten woor.
It's the Chairman of Urology at NYU Land Gone Hospital,
(00:32):
Long Island. Here is doctor Aaron Katz.
Speaker 3 (00:36):
Well, good morning everyone again and welcome to Katz's Corner
here on wor So glad you could join us this morning.
We have a wonderful show for you today and occasionally
we bring on guests that are new to the NYU
Land Gone system, although not new necessarily to their profession.
And today we're very fortunate to have with us doctor
(00:58):
Michael Zalewski. And I've known my for a very long time.
He is a renowned leader, no doubt, in the field
of radiation oncology and has spent the majority of his
career at the Memorial Slunk Kettering Cancer Center in New
York and recently a few months ago joined the NYU
Langune Promoter Cancer Center as the Director of the Break
(01:20):
E Therapy and Vice Chair for Academic and Faculty Affairs
at NYU Grossman School of Medicine in the Department of
Radiation Oncology, and Doctor Zeleski is also a professor in
the Department of gu Cancer Management, Group leader and he
is no doubt an international thought leader in the area
(01:43):
of a prostate cancer. He's been involved in numerous many
clinical trials, has published throughout the years, has an experienced
break e therapy and radiation oncology, and also someone that's
innovative and a thought leader, someone that people go to,
even physicians go to. They ask him, doctor Zeleski, what
(02:05):
would you do for this case or for that case?
And we are extremely fortunate to have him join the
NYU land Going system. Welcome Michael to the show and
so glad you could join us here this morning.
Speaker 4 (02:17):
Thank you, Thank you so much, Aaron, and it's a
pleasure to be here this morning. I appreciate the invite.
Speaker 3 (02:24):
Yeah, my pleasure. And you know, we've known each other
for a long time and we've done some studies together
and ran some very nice programs in the past, and
hopefully we'll do that in the future. While you were
an attending at Memorial and now we're you know, as
I said, we're very lucky to have you here at
NYU land Going. Let me first start out and ask you, Michael,
(02:44):
you know, when some patient comes to you in the
office and is diagnosed with prostate can so that you
feel is early stage and not advanced, what tests do
you think are the most important so that you can
get a sense of the extent of their cancer and
where the cancer may be at this time.
Speaker 4 (03:04):
Sure, eron, I think as we all recognize, there are
some critical and basic tests that need to be done. Obviously,
what often triggers a biopsy is the PSA and a
PSA level a recent one is going to be important,
(03:24):
I think. While on that subject, I would say that
not infrequently there are these fluctuations of PSAs and PSA
levels can be varied from one lab to another, So
I think it's very important as we prostate cancer experts
(03:44):
know that getting a PSA at a specific lab and
being consistent about it is important. The other thing, of course,
is the biopsy, the prostate biopsy. Having that read or
interpreted by experienced pathologists is very important as well. It's
(04:08):
not that unusual in my practice, and I'm sure you
see this frequently enough, where the pathology is read as
a more aggressive type, such as what's called a Gleason
score of eight, nine or ten, which just as the
characteristic of what the cells look like under the microscope,
(04:31):
and when experts read it, it may be interpreted as
a lower Gleason score, a Gleason score, for instance, of seven,
And there are great deal of ramifications about what and
how we would manage a Gleason score of seven versus
a Gleason score of eight or vice versa. And I
(04:53):
think another important test that needs to be done, and
we have routinely done that for a year years and
consistently on patients I see, is an MRI of the prostate,
and a high quality of MRI of the prostate provides
much more information than the typical CAP scan. It gives
(05:14):
us a sense of where the disease is located. Is
the shell of the gland really encompassing the cancer or
did the cancer try to break through that shell? Are
there any lymph nodes which are present. So all of
that information is of course extremely important when helping a
patient make a decision about what treatment to get.
Speaker 3 (05:37):
Yeah, I think that's very helpful. Michael, thank you. And
you bring up the point about PSA which has been
around i guess almost thirty years now, which is the
standard PSA. There's certain are there forms of PSA. There's
a four K score, there's a free and total PSA
which can be helpful in detecting prostate cancer. But as
(05:58):
you mentioned, the standard ps say is still the value
of it has still holds, still holds a lot of
truth to it, doesn't it for the patient even over
thirty years. You know, it's an interesting biomarker, and we
you know, certainly there are false positives and negatives with screening,
but once you're detected with prostate cancer, it does seem
(06:19):
that the PSA does give us a lot of information,
not only at the time of diagnosis, but I'm sure
you also use it once patients have been treated a
prostate cancer And how do you assess that.
Speaker 4 (06:32):
That's exactly the case. And you know, sometimes, for instance,
people say, well, if the PSA is so low, that
is something we could disregard that's true very often when
people have never been treated for the cancer, and we
can assess based on how high a PSA level is,
(06:54):
to what extent the disease is, how extensive the disease is.
But as you bring up after treatment, it's the serial
measurements of those PSA after treatment, the movement of that PSA,
which some have called the PSA velocity, that also is
(07:17):
very important. So if a PSA is creeping up after
a radical prostatectomy where it should be zero, that may
be an indicator that there is active disease somewhere which
needs to be looked into. And the same with radiation.
If some people have had radiation to treat their prostaate
cancer and the PSA had dropped to low levels, a
(07:41):
slow rise may indicate that there's some activity and that
would often trigger further tests to try to find out
where that disease is located.
Speaker 3 (07:52):
Let's go back again, though, to the patient who's just
diagnosed and thinking about treatment options. You mentioned PSAM. There's
been over the last few years the use of certain
tests on the actual biopsy that are referred to as
genomic testing. What are your thoughts there and do you
(08:13):
think that these are practical and should patients get a
genomic test of their biopsy when they're thinking about making
a decision for treatment.
Speaker 4 (08:23):
I'm glad you brought that up, Aaron, and I do
think that this will become more and more important. And
we've used these genomic assessments. One in particular that I
use routinely in my clinic is known as the Decipher test,
(08:44):
and it's taken off the biopsy, so it's not an
additional biopsy or a sampling that's necessary. And what's done
is that the tissue is evaluated and assessed or measured
for looking at the activity of twenty two genes that
(09:09):
evaluate different kind of cancer pathways, how aggressive a cancer is,
how likely it is to grow, how sensitive it could
be towards radiation, for instance, certain genes that may predict
more likely if there is a higher or lower risk
of metastases or spread of the cancer. And so this
(09:34):
Decipher's score is really adding a tremendous amount of information,
even above and beyond as it's been shown the typical pathology,
the typical Gleason score, and so not that we've thrown
away the biopsy, it's still a very important aspect of
(09:56):
assessing the prostate cancer and its stage and it's risk
for spread. But we also use this decipher test, and
this assessment or genomic assessment, gives us another indicator of
how aggressive or not aggressive it is. In some cases,
for instance, we've used the decipher test to figure out
(10:20):
is a patient a good candidate for active surveillance or
watching the cancer. And if the PSA is low and
there is a small amount of cancer and it turns
out that the decipher test teaches us that it's not
aggressive at all, that could be a very good argument
for just keeping an eye on the cancer. And in
(10:43):
certain types of cancers where it's thought to be more
aggressive than we thought from the pathology, radiation oncologists may
suggest the use of hormone therapy together with the radiation. So,
I mean, I don't recall using this, and obviously it
wasn't around years ago. But the way we practice assessing
(11:07):
the extent of the disease now in recent years, as
you indicated, is really different than what we did from
years ago, and I think this is really progress. We're
personalizing the aspects of the disease and not treating all
of patients like one type of a disease just based
(11:32):
on a PSA level or a Gleason score. We are
looking in fact at the whole patient as well, and
of course at the genomics of the disease, which obviously
gives us a lot of information.
Speaker 3 (11:47):
Yeah, it's fascinating, isn't it. And you know, to your
point earlier about patients getting another biopsy and being concerned
about is there more aggressive disease than the biopsy showed.
These genomics tests have shown that they can be predictive
of not only the area of the biopsy in that
region where the biopsy was taken, but for the rest
(12:09):
of the prostate, because in many of these studies they
looked where they removed the whole prostate and it was
predictive of what's going on even in the rest of
the prostate, which I thought really can give patients a
greater assurance. Like you said, if patient is considering active surveillance,
let's say they had a lower Gleason, a gleas than six,
and they come up with a low genomic score, then
(12:32):
the likelihood of them having something that's more concerning in
the other parts of the prostrate is much less never zero,
but much less. And a patient can certainly start and
embark on a course of active surveillance, which is just
monitoring the PSA and perhaps you know, monitoring the MRI
(12:53):
as well. Let's talk and turn the conversation now, Michael.
I know you've been in the field for many years
in the area of radiation oncology, and perhaps you can
tell us about some of the nuances and some of
the new advances in radiation oncology over the last few
years and what you hope to bring to NYU system.
Speaker 4 (13:12):
Sure, you know, as I reflect on that question, you know,
you begin to realize how the field has evolved so
dramatically over the last twenty and thirty years, and perhaps
maybe more than any other type of cancer, the treatment
(13:35):
of prostate cancer has really dramatically changed as far as
the nuances in radiation and even for surgery and other
type of treatments that are associated with prostate cancer like
hormonal therapy and some of the other treatments have evolved
(13:56):
in a dramatic way over the years. As I think
about it. When I came into the field in you know,
nineteen ninety as an attending in memorials on Cauttering Cancer Center,
we were practicing with radiation techniques that I would say
are obsolete right now and almost you could call prehistoric.
(14:21):
The trumans weren't. The truants were just not accurate. They
were good, but they were not as focused as what
they could be. And what it's come along is really technologies,
super fast computers, the ability to recreate the prostate and
three dimensions and view the normal tissues as well in
(14:44):
three dimensions. And so after that came along three dimensional radiotherapy,
and then further innovations came along which are called IMRT,
which just stands for intensity modulated radiation. And the unique
thing about that is that with the help of computer planning,
(15:06):
we can intensify the dose of radiation to various parts
of the prostate, and the parts that are near the
normal tissues can get less intensity, and the parts that
are away from the normal tissues and hopefully where the
disease is located can get more intensity. And that's why
(15:27):
it's called intense emodulated radiation therapy. And then even more recently,
image guided radiotherapy where the images from mries and of
course cat skins and other type of imaging approaches can
(15:47):
be incorporated into the radiation mapping and planning and give
us more precision and perhaps and what we're fortunate now
to have and I'm teemly using that at NYU, is
the ability to treat patients with what is called mr
(16:08):
linac based planning, and that is basically using MRIs real
time to get snapshots of the prostate and the normal
tissue anatomy while the patient is actually getting treatment, which
(16:29):
is a major innovation. We can do what's called real
time adaptive planning, so on the fly, while the patient
is on the table, we could make these submillimeter adjustments
and enhance our precision to the submillimeter and allow us
(16:50):
to be as accurate as necessary, while at the same
time minimizing the dose to the normal tissues. And this
is a clear breakthrough in radiation delivery. It allows us
to give higher doses more safely and really along this time.
As you know well, SBRT or short course radiation also
(17:14):
given in the form of CyberKnife as one type of
a machine or other type of machines give SBRT. Basically
it's condensed radiation. Instead of the classic forty five or
fifty treatments given daily. We can now deliver these treatments
because of these innovative technologies in five sessions and sometimes
(17:36):
even less, and these five sessions can be delivered more
safely than ever before because we have this image guidance
and because we have this greater degree of focus.
Speaker 3 (17:47):
And are you seeing and that's fascinating, Michael, really, I
mean it must be so gratifying for you, someone that's
been in the field for just only thirty years. You
think about the innovation. Thirty years is nothing, right, and
here you are we use saying it was almost prehistoric
back in nineteen nineties and now you're treating it, as
you said, on the fly, with this mr linax, which
sounds phenomenal, and it would reduce the amount of time
(18:10):
that patients need to be retreated or need to be treated,
reduced their overall toxicity. Have you seen the improvements in
oncological on cancer outcomes as well with this new focused therapy?
Have you been impressed there as well?
Speaker 4 (18:27):
Yes, I mean you see, the mr linac has been
around for about two or three years and studies are ongoing.
It's certainly as precise as what we've been using before,
and I anticipate that it will be associated with less
side effects. There was one randomized trial in fact, called
the Mirage trial, where patients were randomized kind of by
(18:51):
the flip of a coin to either get this real
time adaptive MRII based planning or more standard approach, and
it showed and maybe not surprising, that there were less
side effects associated with the radiation performed with an MRI guidance,
(19:11):
less short term side effects, and these patients are being
continuously followed. So I agree with you completely. It is
super gratifying that we can see these kind of changes
and technology can bring it right to the patient and
patients can benefit from this really innovative approaches, and it
(19:35):
is gratifying because they could get through treatments with less
side effects and their quality of life is not impaired.
That's exactly what's gratifying. That we could bring these patients
through a course of treatment, see them even years later
and you know, doing well. And that's what makes medicine
and radiation nachology right now for me in particular and personally,
(19:59):
so worth file and so gratifying and so meaningful.
Speaker 3 (20:02):
Yeah, absolutely remarkable, Michael, and and thank you for all
of that information. And this the synopsis, so you know
where do you see it? Where do you see the future? Now?
You know, if you were to look, you know you're
you're you're on the cutting edge of radiation oncology. You've
been in the field, you're up today on all the technologies.
Where do you see that the field going for for
(20:23):
prostate cancer management? And and what promise can you give
and tell our listeners this morning?
Speaker 4 (20:31):
Well, I see a lot of promise, you know, as
as we move forward, and probably because I've just been
seeing that continued innovation and continued progress over the years.
So I anticipate that the progress will continue, and I
(20:52):
think that it may come in several shapes or forms
this progress. One of the most promising areas in advanced
metastatic disease, disease that becomes resistant to some of the
effects of hormones, which we call castrate resistant prostate cancer.
(21:16):
There have been, as you know, studies looking at what
we call the field of thereynostics or radioligand therapy where
we can actually deliver these kind of smart bombs, so
to speak, where areas of PSA activity are found in
(21:38):
the body and radiation can be deposited intravenously. It's delivered,
but it can be deposited in various sites, even when
it has spread to multiple areas. There's been an incredible
innovation in imaging, which is the PSNA a PET scan
(22:01):
prostate specific membrane antigen PET scan. It is so much
more accurate than bone scans in terms of being able
to detect if the disease has spread, and in the
last few years it's been one of the most popular
prostate cancer assessments, especially used for more aggressive prostate cancers
(22:26):
and where those areas light up on the PET scan,
the field of theraynostics or radioligan therapy can drop areas
of radiation and deposit high doses of radiation to those sites.
And I've seen patients who have had very advanced prostate
cancers get radioligan therapy and have had extraordinary results with
(22:53):
impressive remissions. It doesn't happen in everybody, but studies and
randomized trials have demonstrated that for the advanced prostate cancer
pation there may be a role and who is to know,
but quite possibly with further studies over the next five
and ten years, that we may be able to use
(23:14):
these radioligan therapies at much earlier states of disease at
where it's not diffusely spread throughout the body, but maybe
in one or two sites where radioligand therapy may able
to eliminate some of the small amounts of metastases that
could be present. And who knows that maybe in the
(23:37):
near future we can use the radioligand therapy to kill
out cells that we don't even know have really manifested
on any scans, and we could sort of wipe those
out patients who are more prone to have the disease
spread and give them preventative treatments that may eliminate cells
(23:59):
that we don't even see now but could be there.
So I think in that situation there is a great
deal of promise for the future. And I think one
other area that could be promising, and urologists have been
really ahead of the game on this is the thought
of more carefully done focal ablative therapies where we don't
(24:23):
we may not, for all types of cancers, need to
treat the whole gland, but we may be able to
treat part of the gland and then ultimately the part
where the cancer is located and hopefully where it's not
spare the other parts of the prostate and that may
ultimately lead to less side effects. And this possibly could
be done with radiation gestets as you've been doing it
(24:47):
for your career with great deal of expertise in cryotherapy
and in other types of treatments as well. So I
think there is a lot of promise for the future
for exciting newture treatments that could impact on the curates
and very importantly on quality of life.
Speaker 3 (25:07):
Yeah, and as you mentioned, and you know, I have
had a great interest in focal therapy, and as you mentioned,
with the new imaging modalities that we have, like the MRI,
the PET scan, the genomics were able to predict not
only who needs treatment, but what treatment might be best
for that individual patient. And you mentioned it earlier, that
personalized care that we're able to give patients nowadays, where
(25:31):
we couldn't do it even twenty or thirty years ago,
or maybe even even ten years ago, but now we can.
And not all prostate cancers are the same. Not all
prostate cancers, as you mentioned, need to be treated, but
if they do need to be treated, we can be
very smart about it using their biology as you mentioned,
using their imaging and their PSA velocity, as you mentioned,
(25:52):
that's the end of the show. Michael. Unfortunately it was terrific.
I had no surprise. You are an outstanding a colleague,
a friend, and we are again very fortunate to have
you here at NYU. If you are interested and you've
been listening to the show, you'd like to see doctor
Zelevski or one of his colleagues at NYU land Going.
You can certainly check him out at the NYU land
(26:13):
Gone system on the web. It's Michael Zlevski, clearly an
international expert in the area of prostate cancer and radiation therapy. Michael,
thank you so much for taking the time out this
morning for speaking with us, and we really really appreciate it.
Thank you so much.
Speaker 4 (26:30):
Thank you a pleasure to be here.
Speaker 3 (26:32):
Yeah, we look forward to more collaboration with you and
your colleagues in the city. Well, that's the end of
the show. Every want hope you have a wonderful day.
Tune in every Sunday here on Katz's Corner. We'll be
back next week with a great show. This is doctor
Aaron Katz.
Speaker 2 (26:45):
You've been listening to Katzer's Corner, Come back every week
to hear more straight talk on a wide range of
men's health topics and advice so on how to live
your healthiest life.
Speaker 1 (26:56):
The proceeding was a paid podcast iHeartRadio's host sting of
this podcast constitutes neither an endorsement of the products offered
or the ideas expressed
The following is a paid podcast. iHeartRadio's hosting of this
podcast constitutes neither an endorsement of the products offered or
the ideas expressed.
Speaker 2 (00:09):
The following program is brought to you by NYU Land
Gone Health. It's Kats's Corner with doctor Aaron Katz. You're
trusted expert in men's health, providing straight talk on a
wide range of men's health topics and advice on how
to live your healthiest life. Now on seven to ten woor.
It's the Chairman of Urology at NYU Land Gone Hospital,
(00:32):
Long Island. Here is doctor Aaron Katz.
Speaker 3 (00:36):
Well, good morning everyone again and welcome to Katz's Corner
here on wor So glad you could join us this morning.
We have a wonderful show for you today and occasionally
we bring on guests that are new to the NYU
Land Gone system, although not new necessarily to their profession.
And today we're very fortunate to have with us doctor
(00:58):
Michael Zalewski. And I've known my for a very long time.
He is a renowned leader, no doubt, in the field
of radiation oncology and has spent the majority of his
career at the Memorial Slunk Kettering Cancer Center in New
York and recently a few months ago joined the NYU
Langune Promoter Cancer Center as the Director of the Break
(01:20):
E Therapy and Vice Chair for Academic and Faculty Affairs
at NYU Grossman School of Medicine in the Department of
Radiation Oncology, and Doctor Zeleski is also a professor in
the Department of gu Cancer Management, Group leader and he
is no doubt an international thought leader in the area
(01:43):
of a prostate cancer. He's been involved in numerous many
clinical trials, has published throughout the years, has an experienced
break e therapy and radiation oncology, and also someone that's
innovative and a thought leader, someone that people go to,
even physicians go to. They ask him, doctor Zeleski, what
(02:05):
would you do for this case or for that case?
And we are extremely fortunate to have him join the
NYU land Going system. Welcome Michael to the show and
so glad you could join us here this morning.
Speaker 4 (02:17):
Thank you, Thank you so much, Aaron, and it's a
pleasure to be here this morning. I appreciate the invite.
Speaker 3 (02:24):
Yeah, my pleasure. And you know, we've known each other
for a long time and we've done some studies together
and ran some very nice programs in the past, and
hopefully we'll do that in the future. While you were
an attending at Memorial and now we're you know, as
I said, we're very lucky to have you here at
NYU land Going. Let me first start out and ask you, Michael,
(02:44):
you know, when some patient comes to you in the
office and is diagnosed with prostate can so that you
feel is early stage and not advanced, what tests do
you think are the most important so that you can
get a sense of the extent of their cancer and
where the cancer may be at this time.
Speaker 4 (03:04):
Sure, eron, I think as we all recognize, there are
some critical and basic tests that need to be done. Obviously,
what often triggers a biopsy is the PSA and a
PSA level a recent one is going to be important,
(03:24):
I think. While on that subject, I would say that
not infrequently there are these fluctuations of PSAs and PSA
levels can be varied from one lab to another, So
I think it's very important as we prostate cancer experts
(03:44):
know that getting a PSA at a specific lab and
being consistent about it is important. The other thing, of course,
is the biopsy, the prostate biopsy. Having that read or
interpreted by experienced pathologists is very important as well. It's
(04:08):
not that unusual in my practice, and I'm sure you
see this frequently enough, where the pathology is read as
a more aggressive type, such as what's called a Gleason
score of eight, nine or ten, which just as the
characteristic of what the cells look like under the microscope,
(04:31):
and when experts read it, it may be interpreted as
a lower Gleason score, a Gleason score, for instance, of seven,
And there are great deal of ramifications about what and
how we would manage a Gleason score of seven versus
a Gleason score of eight or vice versa. And I
(04:53):
think another important test that needs to be done, and
we have routinely done that for a year years and
consistently on patients I see, is an MRI of the prostate,
and a high quality of MRI of the prostate provides
much more information than the typical CAP scan. It gives
(05:14):
us a sense of where the disease is located. Is
the shell of the gland really encompassing the cancer or
did the cancer try to break through that shell? Are
there any lymph nodes which are present. So all of
that information is of course extremely important when helping a
patient make a decision about what treatment to get.
Speaker 3 (05:37):
Yeah, I think that's very helpful. Michael, thank you. And
you bring up the point about PSA which has been
around i guess almost thirty years now, which is the
standard PSA. There's certain are there forms of PSA. There's
a four K score, there's a free and total PSA
which can be helpful in detecting prostate cancer. But as
(05:58):
you mentioned, the standard ps say is still the value
of it has still holds, still holds a lot of
truth to it, doesn't it for the patient even over
thirty years. You know, it's an interesting biomarker, and we
you know, certainly there are false positives and negatives with screening,
but once you're detected with prostate cancer, it does seem
(06:19):
that the PSA does give us a lot of information,
not only at the time of diagnosis, but I'm sure
you also use it once patients have been treated a
prostate cancer And how do you assess that.
Speaker 4 (06:32):
That's exactly the case. And you know, sometimes, for instance,
people say, well, if the PSA is so low, that
is something we could disregard that's true very often when
people have never been treated for the cancer, and we
can assess based on how high a PSA level is,
(06:54):
to what extent the disease is, how extensive the disease is.
But as you bring up after treatment, it's the serial
measurements of those PSA after treatment, the movement of that PSA,
which some have called the PSA velocity, that also is
(07:17):
very important. So if a PSA is creeping up after
a radical prostatectomy where it should be zero, that may
be an indicator that there is active disease somewhere which
needs to be looked into. And the same with radiation.
If some people have had radiation to treat their prostaate
cancer and the PSA had dropped to low levels, a
(07:41):
slow rise may indicate that there's some activity and that
would often trigger further tests to try to find out
where that disease is located.
Speaker 3 (07:52):
Let's go back again, though, to the patient who's just
diagnosed and thinking about treatment options. You mentioned PSAM. There's
been over the last few years the use of certain
tests on the actual biopsy that are referred to as
genomic testing. What are your thoughts there and do you
(08:13):
think that these are practical and should patients get a
genomic test of their biopsy when they're thinking about making
a decision for treatment.
Speaker 4 (08:23):
I'm glad you brought that up, Aaron, and I do
think that this will become more and more important. And
we've used these genomic assessments. One in particular that I
use routinely in my clinic is known as the Decipher test,
(08:44):
and it's taken off the biopsy, so it's not an
additional biopsy or a sampling that's necessary. And what's done
is that the tissue is evaluated and assessed or measured
for looking at the activity of twenty two genes that
(09:09):
evaluate different kind of cancer pathways, how aggressive a cancer is,
how likely it is to grow, how sensitive it could
be towards radiation, for instance, certain genes that may predict
more likely if there is a higher or lower risk
of metastases or spread of the cancer. And so this
(09:34):
Decipher's score is really adding a tremendous amount of information,
even above and beyond as it's been shown the typical pathology,
the typical Gleason score, and so not that we've thrown
away the biopsy, it's still a very important aspect of
(09:56):
assessing the prostate cancer and its stage and it's risk
for spread. But we also use this decipher test, and
this assessment or genomic assessment, gives us another indicator of
how aggressive or not aggressive it is. In some cases,
for instance, we've used the decipher test to figure out
(10:20):
is a patient a good candidate for active surveillance or
watching the cancer. And if the PSA is low and
there is a small amount of cancer and it turns
out that the decipher test teaches us that it's not
aggressive at all, that could be a very good argument
for just keeping an eye on the cancer. And in
(10:43):
certain types of cancers where it's thought to be more
aggressive than we thought from the pathology, radiation oncologists may
suggest the use of hormone therapy together with the radiation. So,
I mean, I don't recall using this, and obviously it
wasn't around years ago. But the way we practice assessing
(11:07):
the extent of the disease now in recent years, as
you indicated, is really different than what we did from
years ago, and I think this is really progress. We're
personalizing the aspects of the disease and not treating all
of patients like one type of a disease just based
(11:32):
on a PSA level or a Gleason score. We are
looking in fact at the whole patient as well, and
of course at the genomics of the disease, which obviously
gives us a lot of information.
Speaker 3 (11:47):
Yeah, it's fascinating, isn't it. And you know, to your
point earlier about patients getting another biopsy and being concerned
about is there more aggressive disease than the biopsy showed.
These genomics tests have shown that they can be predictive
of not only the area of the biopsy in that
region where the biopsy was taken, but for the rest
(12:09):
of the prostate, because in many of these studies they
looked where they removed the whole prostate and it was
predictive of what's going on even in the rest of
the prostate, which I thought really can give patients a
greater assurance. Like you said, if patient is considering active surveillance,
let's say they had a lower Gleason, a gleas than six,
and they come up with a low genomic score, then
(12:32):
the likelihood of them having something that's more concerning in
the other parts of the prostrate is much less never zero,
but much less. And a patient can certainly start and
embark on a course of active surveillance, which is just
monitoring the PSA and perhaps you know, monitoring the MRI
(12:53):
as well. Let's talk and turn the conversation now, Michael.
I know you've been in the field for many years
in the area of radiation oncology, and perhaps you can
tell us about some of the nuances and some of
the new advances in radiation oncology over the last few
years and what you hope to bring to NYU system.
Speaker 4 (13:12):
Sure, you know, as I reflect on that question, you know,
you begin to realize how the field has evolved so
dramatically over the last twenty and thirty years, and perhaps
maybe more than any other type of cancer, the treatment
(13:35):
of prostate cancer has really dramatically changed as far as
the nuances in radiation and even for surgery and other
type of treatments that are associated with prostate cancer like
hormonal therapy and some of the other treatments have evolved
(13:56):
in a dramatic way over the years. As I think
about it. When I came into the field in you know,
nineteen ninety as an attending in memorials on Cauttering Cancer Center,
we were practicing with radiation techniques that I would say
are obsolete right now and almost you could call prehistoric.
(14:21):
The trumans weren't. The truants were just not accurate. They
were good, but they were not as focused as what
they could be. And what it's come along is really technologies,
super fast computers, the ability to recreate the prostate and
three dimensions and view the normal tissues as well in
(14:44):
three dimensions. And so after that came along three dimensional radiotherapy,
and then further innovations came along which are called IMRT,
which just stands for intensity modulated radiation. And the unique
thing about that is that with the help of computer planning,
(15:06):
we can intensify the dose of radiation to various parts
of the prostate, and the parts that are near the
normal tissues can get less intensity, and the parts that
are away from the normal tissues and hopefully where the
disease is located can get more intensity. And that's why
(15:27):
it's called intense emodulated radiation therapy. And then even more recently,
image guided radiotherapy where the images from mries and of
course cat skins and other type of imaging approaches can
(15:47):
be incorporated into the radiation mapping and planning and give
us more precision and perhaps and what we're fortunate now
to have and I'm teemly using that at NYU, is
the ability to treat patients with what is called mr
(16:08):
linac based planning, and that is basically using MRIs real
time to get snapshots of the prostate and the normal
tissue anatomy while the patient is actually getting treatment, which
(16:29):
is a major innovation. We can do what's called real
time adaptive planning, so on the fly, while the patient
is on the table, we could make these submillimeter adjustments
and enhance our precision to the submillimeter and allow us
(16:50):
to be as accurate as necessary, while at the same
time minimizing the dose to the normal tissues. And this
is a clear breakthrough in radiation delivery. It allows us
to give higher doses more safely and really along this time.
As you know well, SBRT or short course radiation also
(17:14):
given in the form of CyberKnife as one type of
a machine or other type of machines give SBRT. Basically
it's condensed radiation. Instead of the classic forty five or
fifty treatments given daily. We can now deliver these treatments
because of these innovative technologies in five sessions and sometimes
(17:36):
even less, and these five sessions can be delivered more
safely than ever before because we have this image guidance
and because we have this greater degree of focus.
Speaker 3 (17:47):
And are you seeing and that's fascinating, Michael, really, I
mean it must be so gratifying for you, someone that's
been in the field for just only thirty years. You
think about the innovation. Thirty years is nothing, right, and
here you are we use saying it was almost prehistoric
back in nineteen nineties and now you're treating it, as
you said, on the fly, with this mr linax, which
sounds phenomenal, and it would reduce the amount of time
(18:10):
that patients need to be retreated or need to be treated,
reduced their overall toxicity. Have you seen the improvements in
oncological on cancer outcomes as well with this new focused therapy?
Have you been impressed there as well?
Speaker 4 (18:27):
Yes, I mean you see, the mr linac has been
around for about two or three years and studies are ongoing.
It's certainly as precise as what we've been using before,
and I anticipate that it will be associated with less
side effects. There was one randomized trial in fact, called
the Mirage trial, where patients were randomized kind of by
(18:51):
the flip of a coin to either get this real
time adaptive MRII based planning or more standard approach, and
it showed and maybe not surprising, that there were less
side effects associated with the radiation performed with an MRI guidance,
(19:11):
less short term side effects, and these patients are being
continuously followed. So I agree with you completely. It is
super gratifying that we can see these kind of changes
and technology can bring it right to the patient and
patients can benefit from this really innovative approaches, and it
(19:35):
is gratifying because they could get through treatments with less
side effects and their quality of life is not impaired.
That's exactly what's gratifying. That we could bring these patients
through a course of treatment, see them even years later
and you know, doing well. And that's what makes medicine
and radiation nachology right now for me in particular and personally,
(19:59):
so worth file and so gratifying and so meaningful.
Speaker 3 (20:02):
Yeah, absolutely remarkable, Michael, and and thank you for all
of that information. And this the synopsis, so you know
where do you see it? Where do you see the future? Now?
You know, if you were to look, you know you're
you're you're on the cutting edge of radiation oncology. You've
been in the field, you're up today on all the technologies.
Where do you see that the field going for for
(20:23):
prostate cancer management? And and what promise can you give
and tell our listeners this morning?
Speaker 4 (20:31):
Well, I see a lot of promise, you know, as
as we move forward, and probably because I've just been
seeing that continued innovation and continued progress over the years.
So I anticipate that the progress will continue, and I
(20:52):
think that it may come in several shapes or forms
this progress. One of the most promising areas in advanced
metastatic disease, disease that becomes resistant to some of the
effects of hormones, which we call castrate resistant prostate cancer.
(21:16):
There have been, as you know, studies looking at what
we call the field of thereynostics or radioligand therapy where
we can actually deliver these kind of smart bombs, so
to speak, where areas of PSA activity are found in
(21:38):
the body and radiation can be deposited intravenously. It's delivered,
but it can be deposited in various sites, even when
it has spread to multiple areas. There's been an incredible
innovation in imaging, which is the PSNA a PET scan
(22:01):
prostate specific membrane antigen PET scan. It is so much
more accurate than bone scans in terms of being able
to detect if the disease has spread, and in the
last few years it's been one of the most popular
prostate cancer assessments, especially used for more aggressive prostate cancers
(22:26):
and where those areas light up on the PET scan,
the field of theraynostics or radioligan therapy can drop areas
of radiation and deposit high doses of radiation to those sites.
And I've seen patients who have had very advanced prostate
cancers get radioligan therapy and have had extraordinary results with
(22:53):
impressive remissions. It doesn't happen in everybody, but studies and
randomized trials have demonstrated that for the advanced prostate cancer
pation there may be a role and who is to know,
but quite possibly with further studies over the next five
and ten years, that we may be able to use
(23:14):
these radioligan therapies at much earlier states of disease at
where it's not diffusely spread throughout the body, but maybe
in one or two sites where radioligand therapy may able
to eliminate some of the small amounts of metastases that
could be present. And who knows that maybe in the
(23:37):
near future we can use the radioligand therapy to kill
out cells that we don't even know have really manifested
on any scans, and we could sort of wipe those
out patients who are more prone to have the disease
spread and give them preventative treatments that may eliminate cells
(23:59):
that we don't even see now but could be there.
So I think in that situation there is a great
deal of promise for the future. And I think one
other area that could be promising, and urologists have been
really ahead of the game on this is the thought
of more carefully done focal ablative therapies where we don't
(24:23):
we may not, for all types of cancers, need to
treat the whole gland, but we may be able to
treat part of the gland and then ultimately the part
where the cancer is located and hopefully where it's not
spare the other parts of the prostate and that may
ultimately lead to less side effects. And this possibly could
be done with radiation gestets as you've been doing it
(24:47):
for your career with great deal of expertise in cryotherapy
and in other types of treatments as well. So I
think there is a lot of promise for the future
for exciting newture treatments that could impact on the curates
and very importantly on quality of life.
Speaker 3 (25:07):
Yeah, and as you mentioned, and you know, I have
had a great interest in focal therapy, and as you mentioned,
with the new imaging modalities that we have, like the MRI,
the PET scan, the genomics were able to predict not
only who needs treatment, but what treatment might be best
for that individual patient. And you mentioned it earlier, that
personalized care that we're able to give patients nowadays, where
(25:31):
we couldn't do it even twenty or thirty years ago,
or maybe even even ten years ago, but now we can.
And not all prostate cancers are the same. Not all
prostate cancers, as you mentioned, need to be treated, but
if they do need to be treated, we can be
very smart about it using their biology as you mentioned,
using their imaging and their PSA velocity, as you mentioned,
(25:52):
that's the end of the show. Michael. Unfortunately it was terrific.
I had no surprise. You are an outstanding a colleague,
a friend, and we are again very fortunate to have
you here at NYU. If you are interested and you've
been listening to the show, you'd like to see doctor
Zelevski or one of his colleagues at NYU land Going.
You can certainly check him out at the NYU land
(26:13):
Gone system on the web. It's Michael Zlevski, clearly an
international expert in the area of prostate cancer and radiation therapy. Michael,
thank you so much for taking the time out this
morning for speaking with us, and we really really appreciate it.
Thank you so much.
Speaker 4 (26:30):
Thank you a pleasure to be here.
Speaker 3 (26:32):
Yeah, we look forward to more collaboration with you and
your colleagues in the city. Well, that's the end of
the show. Every want hope you have a wonderful day.
Tune in every Sunday here on Katz's Corner. We'll be
back next week with a great show. This is doctor
Aaron Katz.
Speaker 2 (26:45):
You've been listening to Katzer's Corner, Come back every week
to hear more straight talk on a wide range of
men's health topics and advice so on how to live
your healthiest life.
Speaker 1 (26:56):
The proceeding was a paid podcast iHeartRadio's host sting of
this podcast constitutes neither an endorsement of the products offered
or the ideas expressed
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