Episode 7 – Dr Stacy Loeb

And we’re talking Urology where we discuss the key points of the landmark papers that guide your practice everyday. Our goal is to empower doctors to develop a deeper understanding of the literature to ensure we apply the right evidence to the right patient.

We are all about “bringing the literature to life”.

Joseph Ischia:  Good morning again. I hope you’ve enjoyed your breakfast. It’s now time to sort of change the pace a bit and I want to get you into an empire state of mind.

We’re going to be talking New York. We’re going be talking prostate cancer and from the concrete jungle where dreams are made of apparently with a pocketful of dreams, the city that breathed life into Seinfeld and cobbled the teetering heels of Carrie Bradshaw, all the way from Manhattan we have Stacy Loeb. Welcome Stacy.

So, Stacy, welcome.

Stacy Loeb: Thank you.

Joseph: We did it. It’s a fireside chat so you just got to imagine we’ve got one of those fake fires going in the background here where we can talk. So, we often see you here in Melbourne in September and I know it’s because you’re pursuing your one true love which is Australian Rules Football finals time.

Stacy: That’s right. Go Cats.

Joseph: It must have been wonderfully serendipitous if there’s also a prostate cancer conference going on…

Stacy: And fashion week. You forgot Fashion Week.

Joseph: Yes, I must admit I forgot that. You are absolutely right Stacy. So, thank you very much for joining us. Actually, we’re just having an interesting chat before and you were telling me that you were on the treadmill here once in Australia and on the TV you managed to watch three sports in a row you’d never seen before.

Stacy: That’s right. The first one was the Netball World Championship. Then I thought, “Huh? I’ve never even heard of netball in my whole life.” And I posted it on Facebook, you know, “Look at this funny Australian sport. It’s like volleyball, basketball.”

Joseph: We do. We like to mix them all together and the Australian Rules, have you been [overlap]

Stacy: Yes. Well now, I’ve been with Tony, very very nice. That that that was different to because that’s kind of like soccer but also like American football. I mean, these guys don’t wear any padding and they’re like tackling each other, so seemed a bit brutal.

Joseph: Oh, we breed them tough down here. We should talk prostate cancer and I want to start with PSA screening, so let’s talk about it. The US Preventive Services Task Force has come out and recommended against PSA screening is a few years ago now and that’s largely based on the results of the American PLCO trial which found that men had no advantage from screening. But what we found is that— and recent revelations have shown that in the non‑screening arm, in fact, as many men in the non-screening had screening as in the screening arm. Have you found that American men have stayed true to form and despite being recommended not to have screening are they still having it or do you notice to drop off?

Stacy: Oh, there is definitely a huge drop off. I mean, we are doing so many fewer prostate biopsies. Actually, in the past couple of months, we’ve been trying to recruit to some biomarker studies and it’s for patients who are having a biopsy to get their blood drawn before the biopsy and there has been so few biopsies at the Veterans Hospital that we’re just having very slow recruitment to the studies. I just even noticed it in terms of that, but I mean, this is only one organization the US Preventive Services Task Force, so even though the oncology and urology professional societies do recommend shared decision making, still, that group, the Preventive Services Task Force, is influential among primary care doctors and internal medicine and those are the physicians that order the most PSA tests. Urologists only order about 7% of all the PSAs in the United States. By having a huge drop off in primary care and internal medicine, that’s where most of the screening is done and those patients don’t even reach us in order to have shared decision making.

Joseph: Okay. Are there any changes afoot? Has there been any sort of movements regarding these latest revelations to maybe readdress it or in fact get someone who’s even seen somebody with prostate cancer on the panel?

Stacy: Well, definitely. I mean, it has been a big legislative priority of the AUA to make sure that there are prostate cancer experts represented in the task force. I have heard that the task force is revising the guidelines right now. I don’t know if they’ll take the new PLCO revelations into consideration. I would certainly hope so. I mean, if you think about it, if we were looking at a randomized trial of let’s say a medication for hypertension or diabetes, if over 90% of the controls took the medicine, would that be considered a good trial and would they believe that any impact of the drug? I just think we really have to reconsider this. I mean, that cannot be even on the table as part of the discussion about the efficacy of screening because efficacy is screening versus no screening and that was lots of screening versus lots of screening.

Joseph: Yes, it’s tough to find a difference. I guess one of the other points they make too is that they’re worried about the concerns of the harms of treatment. One of the solutions for that is active surveillance. Now, we’ve been rapid adopters of active surveillance in Australia. I was chatting to Tony earlier and he has been doing it for 30 years. But the Americans seem to be a bit behind the ball on active surveillance, why do you think that is?

Stacy: I mean, there’s no question it’s lower. I’ve been doing a lot of collaborations with the Swedish National Registry which has data for all prostate cancer in Sweden. They’ve got over 90% of very low risk patients and 74% of low risk on active surveillance in Sweden. I just saw the recent data from here in Victoria, 66% of low risk on active surveillance so I think you guys are way ahead because the numbers in the US are more in the 40% to 50% range, at least as of a couple years ago when the most recent data are available. It’s definitely increasing, but I think there is a lot of pressures against it. I mentioned a few of these in my talk yesterday. For one thing, it is kind of a cultural thing and even these randomized trials have trouble recruiting in the United States. I mean, my own dad if you asked him, would he be in a randomized trial of observation versus surgery, he would never agree to something like that. He would just want to have surgery. And actually, even if he had a low-risk disease he would prefer to have surgery and just be done. He doesn’t want to have another 10 biopsies over the course of his life and have to deal with knowing it’s there forever. I think there are some patient preference issues.

Now, could we do a better job with counseling? I think we probably could. I mean, people do not get panicked about basal cell skin cancer even though it is cancer and it has the C word, so could we rephrase the whole discussion? I think maybe we could and these Gleason grading changes may be useful, actually calling it grade group 1 because when you tell someone they have a 6, that doesn’t really sound like the lowest possible number.

Joseph: It sounds like you’re on the bad side.

Stacy: Yes. It sounds like it’s kind of in the middle somewhere. We did talk to patients about this and in focus groups that they said that being told they have a one would make them feel more comfortable about their cancer. Hopefully these little small changes can happen. But there’s still a lot of advertising for treatment in the United States and there’s financial incentives, there’s medico-legal pressures and all of those things are still going to exist.

Joseph: What do you think is the optimal rate we should be aiming for knowing that— I don’t think there’s been a single study that has ever shown a survival advantage for low-risk disease. Should we be aiming for 90-95%?

Stacy: I think we should be aiming for 90-95% recognizing that there is never going to be 100% percent because not all men want it. And so, this was a debate on Twitter a few weeks ago, should you even be willing to do a prostatectomy on those patients? But as I said with my father, active surveillance is not without risks. If you have a guy who had sepsis after a prostate biopsy and he was hospitalized, he may not be excited about the prospect of having another 5 or even 15 biopsies in his remaining lifetime.

Joseph: You bring up some interesting points there and that’s the prostate biopsy. You recently published, if we— you mentioned Twitter, but let’s go back old school. You recently published in European Urology the results of your prostate biopsy and its complications.  Some centers are rapidly moving to transperineal biopsy because we have quite a high rate of sepsis in Australia. It’s probably in the vicinity of 3 to 4%. What percentage of prostate biopsies in Manhattan have been done transperineally versus transrectally?

Stacy: Probably close to zero are being done transperineally. It’s just not offered frequently in the United States.

Joseph: And why is that?

Stacy: Part of it is the logistical considerations, the cost. I mean, it’s very hard to get OR time even just to do big cancer operations. We have six robots at our hospital and they are continuously being used to the point that we’re now adding Saturday operating rooms so that people can get robot time on a Saturday if they can’t get to use one of the six during the week, so this is kind of the backdrop. If we were to ask for an OR to do general anesthesia, to do prostate biopsies all day, that would just be very difficult within the limited OR availability. Plus, then you add the risks of general anesthesia, it’s much more costly, so doing it in the clinic, it’s like a 5-minute procedure. It takes a little bit longer if you’re doing effusion biopsy, but still very short and you can be seeing patients in the clinic. The biopsy is being prepared in the next room over, you just go back and forth. For us, the logistical workflow is easy.  I had one of your Australian colleagues spending a day with me in the clinic and hadn’t seen the transrectal biopsy done in clinic with local anesthesia before and thought, “Gosh, this must be very barbaric.” And I said, “No. Watch. I mean, nobody’s screaming. They’re not crying and there.” They tolerate it well. Most of these guys go to the gym later in the day.

Joseph: Well actually, I learned to do them under local anesthesia. There was a lot of screaming and the patient asked me if I was okay. It was a traumatic experience.

Stacy: Well, he must not play Aussie Rules football because you guys are tougher than that.

Joseph: Yes, the patients are. You’re right. What is your right of sepsis then? Because our health economics guys have looked into it and for every ICU admission and I think that there’s possibly one death a year in Australia, just healthy men having sepsis. That’s why we’ve really moved away and I think it’s got a lot to do with our proximity to Southeast Asia where if you holiday there, you pick up these resistant organisms.

Stacy: Ours is actually very low now but because we’ve taken preventive strategies at all of our hospitals at NYU we have rectal swab cultures which we use for high risk patients and at the Veterans Hospital we do antibiogram-targeted prophylaxis, so about every six months the infectious disease doctors check the antibiograms and check which organisms have resistance and give us a new antibiotic plan. We’ve effectively reduced our sepsis rates at both hospitals using those two different approaches.

Joseph: Okay. I guess another way, I mean, you said there’s a lot of biopsies in active surveillance and one of the ways that we might be able to reduce biopsies are with the new genetic markers or new genetic tests that are around. Now I know that there’s a lot of people or proponents of it in Manhattan but we really haven’t been rapid adopters here in Australia. Why do you think that is? Do you think it’s useful? Does it have a strong role?

Stacy: The genomic tests, I think they can be useful in borderline cases or as I mentioned before, we have a lot of people who are not so sure about doing active surveillance. If you really think that the patient is a good candidate for surveillance and that they shouldn’t need treatment but they’re very hesitant to accept that strategy, giving them this extra piece of data as a confirmation that it really is indolent cancer can be helpful. But we don’t use them in all cases or even in most cases. It’s really just for the borderline patients. What we do use the most is MRI.

Joseph: Okay.

Stacy: Most patients receive an MRI. We do most of our biopsies targeted. If somebody is referred over with prostate cancer who hasn’t had an MRI, usually they would have one before moving forward with the next step whether that’s surgery or active surveillance.

Joseph: So, when do you think is the ideal talks? Everybody should have, “Your PSA is elevated. We’re going to biopsy. You need an MRI.” Is that where you say it being useful?

Stacy: Well, I think the most evidence is there for doing the MRI before repeat biopsy, that famous quote about “Insanity is doing the same thing over and over and expecting a different result,” so if we didn’t find it and we’re just going to stick the needles in randomly again. There was a new consensus statement that does recommend that if you have an experienced MRI program, which we do, that that should be offered before repeat biopsies. Every repeat biopsy that I see, I recommend that they get an MRI first.

Now, initial biopsy that is still more debatable. There are some people in my practice that do attempt to get an MRI before every biopsy because then if that patient is diagnosed, they’ve already had their MRI – and why not do the biopsies the best way possible from the beginning, but the data aren’t totally there, the cost effectiveness of that, so I think that’s probably where the focus needs to be.

Active surveillance, I mean, we are using MRI to reduce the frequency of biopsy right or wrong, not all the data are there yet for serial MRI on active surveillance but certainly it is an intermediate step. Now that we actually have a couple of tests the and the MRI that have been tested in active surveillance patients, it’s nice that there is some other testing options to get away from this every one- to two-year biopsy.

Joseph: Okay. But I guess we don’t need to worry too much though because now we’ve got HIFU. It virtually has no side effects from what I understand, but it’s coming. And I thought one of the best talks that I saw at AUA was the talk from the FDA regulator who stood up and said that they tried to get HIFU approved as a treatment for prostate cancer and that it failed, but it was approved because it was equivalent to a scalpel. Are you seeing this new scalpel being used in Manhattan?

Stacy: It is, it is. Now it is available in the United States, but our patients were getting it before. They were paying cash. I think $10,000 and flying to the Bahamas. You could have the Bahamas weekend and get the HIFU treatment. At least now that it’s available, hopefully people can begin some more registries of it and look at this a bit more closely.

Joseph: Are you adopting it at NYU?

Stacy: We do have HIFU and we were participants in some of the studies of HIFU. HIFU has been available to our patients in some format for quite some time. We have other types of focal therapy too. My Chair, Dr. Lapoor, has done some clinical trials of focal laser ablation and they have cryotherapy, so it’s not the only focal option. I’m not sure who is a good candidate for focal therapy to begin with, but for those who choose that route, there are certainly many places that they can go in New York City.

Joseph: Okay, so it is around here, I guess. It will be coming, I think.

Stacy: And CyberKnife. Don’t forget CyberKnife. Yesterday in my lecture, maybe you saw that my subway stop on Spring Street and on second avenue both have big ads for prostate cancer CyberKnife, so you can’t make it through New York City without seeing some kind of prostate cancer advertising.

Joseph: Very well. It’s coming in the States, so it’s going to be 5 to 10 years ahead of us. And it’s all going to come down to marketing I think, and they claim the “no side effects” is very appealing for what can be quite a morbid treatment for this condition.

Let’s move on to somebody else and that’s really your love of social media. You are really one of the doyennes of social media, with Declan himself is also here [17:57].

Stacy: Well, I should give the credit to Declan because it was he who got me started on Twitter at this meeting. I was here at this meeting and they were tweeting about my talk and I remember this vividly, I was on the stage talking about prostate biopsy complications and they said, “Oh you just got a question from Mike Leverage in Canada who wants to know what prophylaxis are you using.” And I thought, “How the heck does a guy in Canada know what we’re talking about in Australia?” I don’t know if this is creepy or the coolest thing ever. But that was when it definitely made me recognize that I was so young, but I was already a dinosaur, and if I didn’t jump on this it was going to run away without me. I think that ship has sailed. It’s here, it’s here to stay.

Joseph: Well you certainly running at the front of the pack now. What role do you think Twitter will have? I mean, we’ll stick to Twitter, I think it’s probably one of the most common ones we say. What role do you think it has in medicine or conferences? Let’s start with medicine. What do you use it for when you’re following the literature?

Stacy: I mean, it is my main source of news. It is a tailored news stream. If anyone who says that they’re worried that it will waste their time, then I challenge them to make their feed more tailored to their interests because everybody read some kind of news, some journal –something. If your Twitter feed is exactly the things that you would look at otherwise, it’s just coming to you in a very succinct way. I use that to find out about all the new articles that are coming out, to discuss conference proceedings. I mean, how cool is that that you can actually virtually attend a conference in another part of the world and in real time, you can see slides of what people are presenting.

You do have to be careful though, sometimes I’ve seen people give a similar talk at different meetings from year to year. There’s this very famous slide where focal therapy is like getting a haircut because if you get a bad haircut, don’t worry because if it grows back you just get a new haircut. There is this focal therapy haircut slide that kept circulating and then it’s like, “Oh my God, it’s the haircut slide again.” But the discussions are very nuanced and funny like, “Well focal therapy, so – well, it must be a bad haircut. Maybe it’s like an 80s perm focal therapy.” It’s fun to read these comments. Just yesterday there was some interesting Twitter discussion about this study that we talked about where ejaculation frequency reduces the risk of prostate cancer more than 21 times a month associated with a lower risk of prostate cancer and that got a lot of comments on social media. Some of the participants here were saying, “Wow finally a public health message that teenage boys everywhere can endorse.”

Joseph: Absolutely.

Stacy: You get some very nuanced discussion about some of these scientific findings.

Joseph: Very good. I’ve particularly enjoyed a tweet you did, it must have been almost 12 months ago where you sort of gave the do’s and don’ts of conference tweeting. Can you run me through those? Do you remember it or are you so many tweets to the wind now?

Stacy: Well, I think— well, one of my main things is that you should ask yourself two questions every time you tweet. Number one, if this is on the front page of The New York Times tomorrow, is that going to cause me problem? If the answer is yes, then you don’t want to put that out there because these things are permanent. But these meeting, conference proceedings, this is all in the public domain. I think that kind of stuff is fair game, but you don’t want to post pictures of parties or anything unprofessional, definitely never any confidential patient information. It can be a nice way to discuss cases, but it just has to be in very general terms, like, “Has anyone done a prostatectomy after HIFU? Any tips?” without saying, “I’m seeing a 51-year-old man named X-Y-Z…”. so that’s number one – that it has to be able to be on the New York Times. And number two, I ask myself, “Does anyone in Australia care about this?” Because if my train is delayed in New York City or it’s raining or the AUA doesn’t have enough sandwiches at the cafeteria, these are the things that go on there. Somebody over here who’s just following the conference feed, they don’t care. They don’t care that it’s standing room only in the session. They don’t care that you arrived. You don’t need to announce. “Hi, I just arrived to the AUA.”

Joseph: Yes, #AUAsixdays. [overlap]

Stacy: The way to announce that you’ve arrived is to put out there good content from the meeting and then everyone will see you’re sitting there, but they don’t have to hear the long version of every step you took all day. I think it’s all about being parsimonious. Just limit it to high quality content that people care about without a lot of miscellaneous stuff.

Joseph: Yes, I think this is one of my issues with Twitter, I don’t think there’s a single Tweet that would appeal to everybody because I’ve got a group of passionate football supporters. I could imagine there’s not many people in New York that are going to be that disappointed by the umpiring decisions in the last quarter of their match. [overlap]

Stacy: I think with things like that, you can either start the tweet with the name of the football organization and hashtags, so that only people that are following that group also see those tweets in that way your whole following doesn’t have to participate. That would be one way to engage in a conversation like that if you want to without burdening the Americans who don’t care about the referee issue.

Joseph: Umpires.

Stacy: Yes. I think there are ways around it, but every so often having a tweet about your own interests I think is okay because that does show the human side and sometimes you realize you have the same interests as somebody. Just last week actually this guy who I met on Twitter, he’s a urologist in Florida, he had had a few tweets about his fitness regimen and it turns out we do a lot of the same fitness programs. I only do that because occasionally he tweets about his outside interests. He happened to be in New York City last week. We met up and did a fitness class together. I think sometimes even within the professional world, that can be nice for networking to see that these are real people and some of the people you see at conferences may have a lot more in common with you outside urology.

Joseph: Good. Now there’s nothing more New York than your own radio program. Tell us a little bit about that. How long have you been doing it? Tell us a little bit about what’s the background.

Stacy: Oh, almost 4½ years now. This is SiriusXM. It’s US and Canada satellite radio, so it comes kind of preloaded in people’s cars. If you buy a new car in the US or Canada usually that’s in there and so people can continue the subscriptions. There are also internet subscriptions. There’s about 32 million subscribers to SiriusXM and over 100 channels. Howard Stern is Channel 101, I’m Channel 110 – so close, but—

Joseph: Interesting typos.

Stacy: We might have some overlap in the topics actually.

Joseph: He focuses more on the ejaculation studies I suspect.

Stacy: But the ejaculation is a very popular one on my show. I mean, when that study came out I had Jennifer Rider on. Each time she’s published any kind of update on that, I’ve had her on and the questions that you get— because you can dial in and these are people from all over the US and Canada, so it’ll, “Hi, I’m Bob from Vancouver and I’m just wondering, is this like an average or does it have to be every month? So what if I ejaculate only five times one month but then the next month like 40 times, does that still count?” I thought, “Wow. I hadn’t even considered that perspective.” You get some really interesting questions on these shows and maybe a new way of looking at the topic.

Joseph: Well, it might be because teenagers would certainly build up the bank. With the radio show, what was your most popular show that you’ve done that you’ve had the best feedback from?

Stacy: Well, I think that one was certainly a popular one. Another one that was a big hit was the systematic review of penis size. I think all the penis topics tend to be very popular for US radio. As you can probably see from the news that comes over here from the United States, we have some cultural limitations and so that is the kind of thing that gets the audience stimulated. Definitely Burnett has been on with me talking about priapism, that’s an interesting topic for the listeners.

Joseph: Oh yes, they would.

Stacy: We get a lot of calls about it whether there’s any kind of surgeries for penis enlargement that are approved.

Joseph: Very good, so the key issues are being discussed. Alright. We are going to wind up. It has come to the end of our time. I guess one thing I want to do, I just very quickly touch on the dark side of being such a prominent figure and a key opinion leader like you are, have there been any times where you’ve had feedback where you think it was unfair or where—because you really put yourself out there as an opinion leader I think and you get the 95% of people will agree and 5% won’t or whatever it is. Do you have a way of dealing with that?

Stacy: I mean, I think the key is just to try to not take things personally and sometimes there’s debates on Twitter where my heart rate starts to go up, but then I just think I should just be grateful for my life. I’ve got a great family. Everybody’s healthy. I have a good job, great friends. If you just try to step aside from these professional debates and realize that you do have a life outside of this and you’re not going to let it upset you. And fitness, I think you guys have been just so innovative and advanced in bringing all this multidisciplinary care to prostate cancer patients and I mean, definitely, I think if I didn’t work out every day, I would probably go nuts. But fitness is just so critical, just pounding out that stress on the pavement and there’s almost no chance that you can’t feel at least slightly better after a workout.

Joseph: Well, I certainly feel better now. It’s been wonderful having you here today Stacy.

Thank you very much. Thank you everybody for coming along this morning. Do we have any burning questions from the audience before we wrap it up? Look at that. As always, you’ve covered everything and silenced them. Well done Stacy thank you very much.

Stacy: Thank you.

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