Prostate Cancer Awareness Month (Part 1): Screening Without the Scare Tactics

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0:31positive metastatic castration-resistant prostate cancer, or PSMA-positive MCRPC, who have already been treated with hormone therapy and are considered appropriate to delay chemotherapy. Blue Victo involves contact with radioactivity, which may increase the risk for cancer and cause fetal harm. Drink plenty of fluids, urinate often, use contraception, and talk to your doctor about ways to reduce the risk of exposing others to radiation during and after treatment. Blue Victo can cause low levels of blood cell counts, kidney problems, and infertility. Tell your doctor if you have weakness, pale skin, shortness of breath, bleeding or bruising more easily, and infection or changes in urination.

1:05Side effects include decreased blood cell counts, tiredness, dry mouth, nausea, appetite loss, joint or back pain, and constipation. Ask your doctor about Fluvicto because every day without cancer progression is a victory. Visit Fluvicto.com to learn more.

1:31Let's talk about the mailroom Welcome to the mailroom Welcome back to the mailroom. Dr. Jesse Mills here, as always, joined by Jordan Runta. It's been a beautiful, sunny Santa Monica winter so far. And, Jordan, you're probably suffering through the perils of winter in Brooklyn, but you holding up okay? Got several sweaters on my side right now, but I am surviving. Ah, yeah, well, speaking of sweaters, I'm about ready to change into my carton again and house slippers and do this podcast here with Dr. Brisbane. You know, when I thought about Mr. Rogers and if he did podcasting, do you think he would take off his tie for the podcast or do you think he would keep it on even though it was a radio bit?

2:16My guess is he would probably still keep on his tie even through that, which makes me feel incredibly underdressed here. You know, I have a theory about that. When the Beatles were just starting out, their manager, when they were on radio, would make them wear suits, even though they're on radio because he just wanted them to get into that mode so i'm gonna say yeah yeah no i get that's right that makes sense yes yes dress for the job you want which is exactly one of the greatest bands of all time awesome well we have something really special not only because of the guest i mean you know i get super pumped about all our guests and dr brisbane i'll introduce in a second but also because i want to do something a little different than we've done before which is have a story arc this will be a three-part series so we'll start today talking about the first third of this.

2:59And the overall theme is going to be prostate cancer, because it's a huge theme. Dr. Brisbane has dedicated pretty much his entire career to prostate cancer. He's a urologist, as am I. But it's more than that is a little bit of just talking about the role that prostate health plays in men's health writ large, and how important it is for guys to have good information as they go in. And so that's, that's what we're going to do. The first part of this story is going to be screening for prostate cancer because there's so much controversy out there. For good reason. It's a complicated subject, and we're going to have Dr.

3:33Brisbane unpack that for us. And then the next episode, we're going to talk about diagnosis because the world of diagnosis of prostate cancer is evolving as we speak. and he was recently on the news on TV talking about some of these new diagnostic modalities that we'll have him talk about because he's so involved in the world of things like micro ultrasound and super excited to pick his brain on that. And then lastly, we got to talk about treatment for the men that are diagnosed with prostate cancer. So it'll be bam, bam, bam. And we're going to do this as a story. So we're going to have a guy that's going to basically walk through Wayne's office and go through all three parts of this.

4:09And why is this important is that But prostate cancer, even in 2026, is still a, it's a curable disease that if it's caught early, it's one of the most curable diseases. And yet, even in 2026, more men die from prostate cancer than just about any cancer out there, solid organ tumors at least. So there's still a lot of men that are not getting the access to care or don't have the right information to do that. And a lot of this started with a blood test. one of the early cancer biomarkers we use called PSA or prostate specific antigen. And it's a very controversial test because it actually is not a prostate cancer specific antigen.

4:52And when we talk about biomarkers, they're just that there's some kind of biological test, whether it's from urine, blood, semen, tissue that indicate some sort of actionable item or a risk factor for a disease. And because it's not specific for cancer, the number of men that will have an elevated PSA that don't have prostate cancer is actually far greater. Wayne can correct me on that, but basically it's about a three to one negative cancer risk for a guy with a high PSA. In other words, they're four to one. So if you have a hundred guys walk into your office and their PSA is high, only about 25 of those guys are going to actually have prostate cancer.

5:28So that's where a lot of the throwing out the baby with the bathwater happened in our prostate cancer screening journey. And so that's what we're going to have to figure out is how do we accurately diagnose this condition and how do we go from there in terms of treatment? Because the treatment has also gotten so much more refined, but there's still a lot of risks associated with treatment. And there's still a lot of guys that are getting treatment that may not need it, that actually can do something called active surveillance, which we're also going to talk about. So that's why we have Dr. Wayne Brisbane here.

5:58He is a urologic oncologist and a surgeon scientist, which is actually a big title because the amount of work and training it takes to become a urologic surgeon, it's six to eight years of residency, post-residency fellowship. And all the time, if you're still trying to do science, either basic science, clinical outcomes, you'd only have so many hours in a day. And as we always say, you have protected research time at any major academic center, and it's usually called nights and weekends. So that's protected research time. And that's no dig on UCLA. It's more of a dig on the fact that we're incredibly passionate about what we do to help our guys that we're taking care of.

6:36So as a surgeon scientist, his clinical practice focuses on prostate cancer across the entire disease spectrum. That means early detection and precision diagnosis to advance surgical and focal therapies. That's the other really exciting thing we're going to talk about is focal therapy. He's deeply involved in research aimed at improving how we identify a clinically significant prostate cancer. Again, huge term, clinically significant prostate cancer. Let's remember that. And then how do we tailor treatment to the individual patient? So of those 25 guys, not all of them are going to get the same treatment.

7:08So again, prostate cancer is not like appendicitis. You have a ruptured appendix, you'd go to the OR, you take it out. This is so much more nuanced. And it's so important as patients and clinicians to be super involved, prepared and informed. And Wayne also looks the part of a men's health specialist. I know this his radio, but it looks like he can squat and farmer carry himself around Equinox. And that makes me even more excited to be his partner, his friend and clinic mate. Wayne, welcome, by the way. Thank you so much. We've been looking forward to this for months. I'm so excited. Yeah. So Wayne, you're kind of the guy when it comes to talking about all of these things.

7:45And so it was an easy call to make. And what I want to do is I want to look at a patient journey. So I'm going to be a 55 year old guy. And I'm referred to your office for an elevated PSA. And then basically, you're going to work me up, you're going to tell me what all that means. And as we go through this, we're going to spoiler alert, we're going to find prostate cancer, otherwise, it'd be a pretty short episode. So so that's one of the things, and you're going to go into this and then we're going to really go through screening diagnosis, treatment. So Dr. brisbane let's talk about it welcome to the mail room i'm looking forward to it thanks so much yeah yeah so you know one of the things i guess even before i get into screening is what can a guy do i mean a big part of our our show that jordan and i do is we try to empower men to do something outside of the doctor's office so are there things men should do other than screening for prostate cancer that are preventative how important is family history in the development of prostate cancer.

8:46We'll start with that. Yeah. So, you know, when I was thinking about this, you and I had talked before the podcast a little bit about kind of how this might go. And so I've been kind of racking my brain for a good analogy that we can use for guys who may not be, you know, scientists, but obviously your clientele here is very intelligent. So the analogy I'm going to come back to, which will break down at some point because I'm comparing a mechanical system to a biologic system. and eventually that will outrun its usefulness. But I'm going to keep coming back to an analogy of a car, and not a fancy car, just like a simple, mechanical, the way we use, you know, it can be a stick shift.

9:2683 Yugo, maybe? 85 Yugo? Yeah, yeah, that's it. My first car was a Mazda 323, like a 1980. That's not bad. I told Jordan the other day, I had a 62 MGA. It was probably still the best car I've ever had, And I, you know, a lot of people peak in high school. I automatically peaked in high school. So talk to us about the car. But I do think that just like a car, you know, with the development of prostate cancer, along with many cancers, has to do with uninhibited growth. And so the analogy we'll use is just saying, you know, either the gas pedal gets stuck down or the brake pedal stops functioning.

10:08And those are those are two genetic things that you can be linking to. either the genes that are supposed to turn off growth get broken, or the genes that are supposed to accelerate growth get stuck on. And those things basically is just your normal cells that get kind of growing out of control. That's your basic definition of cancer. And prostate cancer just happens to be one of the organs that's at a particularly high risk for that. That's why we hear about it quite a bit. And so you can, to some extent, prevent that by doing maintenance on your car. And what does that look like? Well, that looks like a whole foods kind of diet.

10:43There's a lot of debate about what that looks like perfectly. But just in generally, I think we can all agree that a good diet is important. Exercise, the amount of exercise is probably important. Intensity is important. And sleep. And so those are the things that you really can do to maintain your cells or your car. And there has been a lot of evidence that has accumulated that that's good for just about everything, prostate cancer included. Eat, Move, Sleep. Sounds like a book I wrote a couple of years ago. And that's true. You know, we had a couple of episodes ago, maybe it was just last episode, we had Josh Offman, who's the CMO of GRAIL.

11:20You know, it was one of these early multigenomic cancer screening tests. And so that was actually really helpful to remind listeners of that cancer metaphor that works pretty well. It's, you know, accelerated growth and decelerated slowing down of that cell division. But one of the tricky things about prostate cancer is it's not a particularly fast-growing cancer. So it smolders for a while. And so that's where I think the screening thing is going to get a little bit dodgy. But also, I guess it gives us a lot of warnings. So at mile 20 ,000, if you miss your checkup, can you get to 40 ,000 okay?

11:57And so you talk to me about that and the cell division of prostate now. It's a little bit tougher sometimes. to diagnose because it's not so, you know, there's no early symptoms of prostate cancer, if that's correct. So talk about that. I mean, if a guy says, hey, look, I feel great. And that's probably going to do. I mean, I'm in best shape of my life. And then this doctor told me I have cancer. What's up with that? I'm not losing weight. I'm getting night sweats. Yeah. Yeah, that's absolutely true. So a lot of the idea behind screening is you catch these tumors while they're small, they're feeble, and it allows you to treat them and cure them before you get to the point of symptoms.

12:35And so it's this idea of preventative medicine. We don't have good screening tests for all cancers, but we do for some. So colon for the, you know, the colonoscopies, prostate is one as well, that thankfully PSA is a good screening test. So let's talk a little bit about PSA. So PSA is, I think of it like a thermometer for the prostate, okay? It's a protein that Mother Nature wants to be there. And Jesse, you can talk about this probably better than I can, but it's a protein that helps with sperm's function, and it helps dissolve some of the proteins around the sperm that help them be released for swimming.

13:18It's a normal protein. they come in. Actually, we think of it as just one protein, but it's actually a family of proteins. And we can measure it in the blood very easily. And in the 1980s, this was really worked out by some very brilliant individuals. And that led to, initially, we were saying, oh my goodness, there's this, when we test this temperature, we can tend to find prostate cancer. What we hadn't done at that point is risk stratify the prostate cancers. Prostate cancer comes in five flavors, I'm going to say. And we can get into that in a second. But we were just saying, you know, whatever flavor it is, it's of cancer.

13:52And that was a mistake. But PSA still is a very, very good risk stratification tool, meaning I can take guys in their 40s, we can get a PSA, and I can tell you pretty much who's at risk for prostate cancer based on that one blood test. And this is some Swedish data that was very useful, showing that basically your early PSA can be a good risk predictor of how you help your cancer development later in life. And as a result, the National Cancer Care Network, this NCCN guidelines, actually suggests men start getting PSAs as early as 45. And that's reasonably early. And guys with a strong family history or at particular risk for prostate cancer, and that can be very simple things, just like men of African ancestry, they can get they recommend the PSA as early as 40 and if your PSA is less than one then that's really really protective you can go for several years before you need to check your PSA again but if it's greater than one you probably need to be checking at least once a year with your primary care doctor because that does put you at risk for prostate cancer development doesn't mean it's a fait accompli but it's it's something that's very important so you really want to think of PSA as a as a thermometer.

15:06Yeah. So brought up a couple of things there. You're right. I like how you said that PSA is a naturally occurring enzyme. It's in a family called serine proteases. And as a fertility specialist, that makes a big difference to us because you have to have PSA because that's what liquefies semen. So in other words, when a guy has an ejaculation, as we most of us probably know comes it up more like pudding. And in order for that sperm to get released, it sticks to the back of whatever you're trying to procreate with. And it in this in the mostly traditional reproductive ways, that would be the cervix and the sperm get released as that PSA liquefies over time.

15:47And so high levels of PSA are not diagnostic of prostate cancer, but they are at least meaning that you have a lot of cells that are starting to make this antigen or this enzyme that could put you at risk for prostate cancer. So it's a normally occurring enzyme and it's a very conserved enzyme as well. In other words, there are other organs that make PSA, which is why one of the things maybe we'll get to when we talk about definitive therapy is that I get this all the time. I say, why is my PSA, it always says less than dot, dot, dot, dot, dot. And it's because even the stomach secretes PSA because it's such a conserved enzyme.

16:25So there's, so you'll, your PSA will never be zero, but most of the time your urologists are like, great, you know, less than 0.01, that's pretty much zero. Your prostate is gone. So, so that's really, that's really an important diagnostic tool. And also I think one other thing I want you to talk about is, especially because right now in the world of longevity, men's health, direct to consumer ads, and the access of drugs that normally were prescribed in the clinic, there's one very common medicine that guys start taking when they're 18, 20, 30 for thinning hair. And tell me what that, now I'm making, I'm pimping you for your oral boards.

17:07Tell me what medicine I'm thinking about. And the reason this just came up is because I had dinner with somebody when we were at the CES in Vegas and she was telling a story about her brother who had a misdiagnosis of prostate cancer because he'd been taking this drug and his PSA was artificially low. So tell me what I'm thinking. It's the best way to play this game, Dr. Brissett. Sure, no, no, no. So you think about finasteride is the drug. There's also a sister drug called dutasteride. I wanna take one step back and then I'm gonna step into and answer that question quickly. So one step back is PSA is a protein that's very, We have these serine kinases all over the body, but the prostate really for this particular form of it is very important at the prostate.

17:56And so we can use that to diagnose prostate cancer. But as you have alluded to, there's other forms or there's other ways that the PSA can be elevated. And there's traditionally three. So prostate cancer, prostatitis, and then kind of prostate size, I'm going to say, just so, you know, as the as the prostate gets bigger, there's more cells, more PSA goes up. and then also as men age, you know, the PSA goes up. There's probably this PSA leak phenomenon where your PSA gets a little more leaky. It's not necessarily a problem, but it's very common as men age that their PSA goes up naturally, okay, so nothing to worry about.

18:31But in general, when we see the PSA goes up, you can, again, that's the idea of a thermometer. If you're exercising, your temperature would go up. Doesn't mean you're sick, okay, or if, you know, when I was a kid, at least we, you know, put it next to a light bulb and get it heated up before so I didn't have to go to school. So there's other things. I said you never, but it's a cute story. But there's reasons. You can get the temperature to go up even when you're not sick. But in combination with other things, like let's say you have a cough or a headache or something like that, then the temperature takes on this.

19:02You say, okay, this fits a picture of you have a sickness. Now, PSA is the same way. It goes up for lots of different reasons. But this particular drug, finasteride and dutasteride actually suppresses PSA production at the level of the prostate. It's a drug that blocks the transition from testosterone to dihydrotestosterone, and that's important at the level of the prostate because it allows the prostate to shrink a bit, but it also is important at the hair follicles, and so that can prevent male pattern balding. So very good drugs, very few side effects, especially at low doses. Initially, this was noticed there was two huge studies, one with finasteride, another with its sister drug, dutasteride.

19:40And the initial thought was that we were going to prevent prostate cancer by giving this drug because it was kind of starving the prostate cancer out. And it did help with preventing low-risk prostate cancer. But we noticed that guys with higher-risk prostate cancers were starting to pop up in the population who was taking the drug. Now, there's a lot of ink spilt on whether it was the drug or whether it was just easier to find. But the take home for guys today in 2026, if you're on finasteride or dutasteride, your PSA won't respond nearly as quickly to a cancer. And so if you just, it's not super hard, but you have to at least tell your urologist or your internal med doc, your PCP, that you're on that medication because you at least have to double the PSA value.

20:29And if you've been on it for a few years, you might have to quadruple the PSA value. And this has actually burned me in my practice. It's something you just have to, this is all I do every day. And I have been tricked by dutasteride and finasteride because they suppress the PSA just so much. So really, the PSA becomes a very, it's a broken thermometer if you're on those meds. And so they're not bad meds. I think they're great meds. But just make sure that you don't rely on PSA for its diagnostic properties if you're on those meds. That's great.

21:27All right, so let's do this. So I'm a 55-year-old guy. I actually am a 55-year-old guy. I'm incredibly healthy. You see this guy at the gym frequently. You're impressed with how robust he is. This is not a personal story, by the way. Very impressed. Yeah, it's because I don't want to get too personal because it's not, you know, it's not me, I promise. But his physician sends him to you because his PSA went up. It was 1.8 last year. All good, right? And it went up to 4.1 on this year's annual lab screening. So appropriate referral to Dr. Brisbane to see about this PSA bump. I'm going to add value to our listeners and also add educational purpose here.

22:01Let's just say also that he started on testosterone therapy last year. He had to keep up with you at the gym. He saw what you were squatting. He was like, I got to look like Brisbane. So I need TRT. My testosterone was low. It was actually 184 nanograms per deciliter, which is about 200 points lower than kind of minimum thresholds for screening, at least by European guidelines, maybe 120 or so by American guidelines. But the bottom line is the guy had low testosterone, PCP, appropriately put him on TRT, and his PSA now is 4.1. First of all, let me be the urologist, because I do a lot of testosterone therapy, as you know, in my clinic.

22:38And say I referred him to you, did I just give this guy prostate cancer by starting him on testosterone and having that PSA go from 1.8 to 4.1? Let's unpack what's happening. Talk to me about androgen receptors, saturation models, and then, you know, walk us through what this case is starting out to for you. What's on your mind? Sure. So to start off kind of saying, did you give this guy prostate cancer? I'm going to come back to that kind of mental model of that car. And the answer is I kind of squarely say no. You know, we don't think that testosterone causes prostate cancer. It would be like I'm going to use the gas tank as the analogy.

23:15So, you know, the gas tank, you can only fill it with so much gas and then it's full. It's ready to go. If you fill it with more, it just spills over the side. Gas is testosterone. Exactly. Gas is testosterone. Thanks for clarifying that. And we think that the prostate's kind of similar. You know, the cancer is from one of those genetic drivers, either something you were born with or something that developed from a spontaneous mutation. That's the gas pedal down, brake pedal's broken, and that's causing the growth. But the gas is the testosterone. And you can't give, the prostate's super sensitive to testosterone.

23:51So even if it's at a testosterone level of like 150 to 200, all the receptors in the prostate are saturated the gas tank is full okay so even at low levels those the gas tank's full for the prostate and so one of the things that's very useful when there's broken cars everywhere okay so we're talking about a different guy now this is guys who have had metastatic prostate cancer and their care there you know there's cancer cells everywhere so you think about all these little broken cars we can pull the gas tank on all those cars by giving a medication that pulls the testosterone out of the body.

24:24And so that can be an extremely effective cancer tool. But in the setting of localized prostate cancer, we think that it's probably the genetic driver and the gas tank is just the testosterone. So that helps you understand one of the common misconceptions. I'd also think that the primary care doctor did the right thing, right? So your PSA, NCCN guidelines would say, this guy, he's got a PSA between one and three, He should do annual screening. And so he is at 1.8. They checked it again a year later. It had had considerable acceleration. And so that would trigger a referral. Yeah, so you're kind of touching on what sometimes we refer to as a PSA velocity.

25:04And so even if I made this a little bit more nuanced and say his PSA was 0.9, and then it went to 2.9, he's still under 3. But is that velocity concerning you year over year? Is that still something that triggers a little more advanced screening just based on PSA alone? Totally. So the speed of ascent is very important. We call that PSA velocity. And the other thing, you know, that we'd probably do is just something super common sense. We'd probably check it again a month later. Just to say, you know, sometimes it's common. PSA, like we said, it's like a thermometer. You can get the thermometer to go up for certain reasons.

25:37So we say, hey, you know, just avoid sex. No, make sure you didn't have the flu at that same time. You know, it probably doesn't matter, but avoid riding your bike for three days and just kind of take it easy and we'll check again. Just make sure there was no false positives. Great. So bullet points here for people out there taking notes are that if your PSA has been on a good trend for a while, has not gone up that 0.75 or 1 a year and it spikes, repeat it. Don't have your doc just send you right to the biopsy suite to say, hey, can we take a look at this in a month or so and make sure it's real?