The Role of Liquid Biomarker for Early Detection of Prostate Cancer - Episode 5
David Albala, MD and Judd W. Moul, MD consider the impact that COVID-19 has had on the clinical experience of patients with prostate cancer and share personal insights regarding telehealth and patient compliance.
David Albala, MD: COVID, I think, hit our whole country, and really turned the way we practice medicine. We saw an explosion happen in telehealth, and these patients did not want to come into the office, but they still wanted to see their physicians. And the beauty of the Exosome test, which really is just a – It's a urine test that I kind of think of like little tweets. The exosomes are tweets of RNA and DNA and proteins that give us some insight on, what is that risk of cancer, of prostate cancer, and of high-grade prostate cancer 7 and above? And the urine test was quite nice. I think that really kind of changed the playing field a little bit. You did not have to do the massage. You could do a tele visit. If the patient had an elevated PSA you would say, "Well, you're in perhaps a gray zone. Let us do a test that may give us a little more insight." You mail them the kit, you get the results back in seven to ten days and then you can say, "I think you should get a biopsy," or "No, I think we're fine. Let us continue to monitor yourself." And bringing them in. Obviously, you did not need to do a rectal exam. I think that that really was a significant boon for us because it allowed us to still diagnose prostate cancer with patients that had elevated PSA's [prostate-specific antigen].
Judd W. Moul, MD: I just want to make a comment about telehealth and just your experience. COVID [coronavirus disease of 2019] has been a terrible situation for the world and our country, so I do not want to downplay, it's been overall very bad time for us. But out of badness comes some good things and we really forced our profession to really embrace telehealth and so the advances that we had just at our hospital in the technical ability to make telehealth work was amazing. What I have found is it's pretty easy for me to develop a good therapeutic relationship with a patient. My clinic is primarily in a cancer center. It is intimidating. And I have these guys coming in with an elevated PSA into the cancer center, they are uncomfortable, many of them are out of their element and they are nervous, their blood pressure's up. I found that telehealth for an elevated PSA, at least a first-time visit, they are at home, they are more relaxed. They can open to me more; they are not as freaked out. And, as you said, they do not like the rectal exam anyway so they can do potentially a lab. We have set up lab and leave so patients can even go to a remote location – four sites in our health system – and do not even need an appointment. They just call from their car when they are in the parking lot and the lab just go ahead and do it. But with exosome, the mail-order test has been really, nice and we can get those results back. And compliance. It blew me away when we started this initiative with Duke Primary Care, really embracing working with primary care on getting these younger guys in, how non-compliant patients are. Sometimes the patients who had the highest PSA's or seem to be at the highest risk are the ones that were most likely to no show. Not only for their PSA appointment but no show for their biopsy. I guess you do not get that that much in private practice. You used to work at Duke Cancer Center, and you know you might have a CEO in one exam room and someone who is low socioeconomic status or low health literacy in the next exam room. The point is that tests like exosome and/or pHi, more data increases the patient's compliance. Some of my embrace of these tests was to try to convince some of these guys that they need to come in for the procedure and that they should not no-show. I do not know if you have seen that in Syracuse.
David Albala, MD: I agree completely with you. Again, we are talking about more sophisticated patients that know a lot about prostate cancer. I am sure many of them have had relatives or family members that have had it so they are really keen on these tests and they know these tests now, which is really a change. The educational level of patients is significantly higher I think than it was 10 years ago. When I was at Duke Cancer Center, I think my active surveillance rate was around 10%. It is now close to 40%. As clinicians, we are seeing, once we diagnose prostate cancer, if they have a Gleason 6, we may do some genomic testing on these individuals. And if they have an Oncotype or a Polaris or a Decipher score that's low risk we are going to follow those patients. Those patients for the most part do quite well, and that is another significant contribution that we've learned over the years to change the way we practice.
Transcript edited for clarity.