Raj Nigam, Consultant Urologist at the Royal Surrey NHS Foundation Trust and The Focal Therapy Clinic is an andrologist with a special interest in the impact of prostate cancer treatment on sexual and mental health, and has spoken several times before on the podcast about age-related implications of prostate cancer treatment. He’s here today to discuss how advances in ageing research could potentially aid in recovery from prostate cancer and its treatment. Or, in other words, if the biggest risk factor in developing prostate cancer is ageing, what can we do to mitigate that risk?
Clare Delmar
Hello and welcome to OnFocus, brought to you by The Focal Therapy Clinic, where we connect you with issues facing men diagnosed with prostate cancer that are little known, less understood, often avoided, or even ignored. Prostate cancer is the most commonly diagnosed cancer amongst men in the UK, and with this somber fact comes a multitude of challenges and opportunities. I’m Clare Delmar. Joining me today is Raj Nigam, consultant urologist at the Royal Surrey NHS Foundation Trust and The Focal Therapy Clinic. Raj is an andrologist with a special interest in the impact of prostate cancer treatment on sexual and mental health and we’ve spoken several times before about age related implications of prostate cancer treatment. He’s here today to discuss how advances in ageing research could potentially aid in the recovery from prostate cancer and its treatment. Raj, thank you so much for coming and joining me today. Welcome once again.
Raj Nigam
Thank you Clare
Clare Delmar
So you’re sort of my go to person to talk both about different types of treatments and how it impacts the sort of wider health elements for men and also how age factors into that. So I’m really excited that you’re interested in talking about where this might be leading us. And I think before we start, it would just be good to sort of set the base case for what recovery needs and how different treatments lead to different recovery outcomes. So maybe you could just describe for our listeners how recovery does differ according to the type of treatment, whether it’s an invasive treatment, an non-invasive treatment, what do you think and how would you describe recovery?
Raj Nigam
Essentially, it’s important to be aware that the treatment options in prostate cancer are very varied. There is a spectrum of treatments ranging from surveillance alone, what’s known as active surveillance or previously known as watchful waiting, ranging right through to the most radical surgery, what’s called a radical prostatectomy and therefore recovery is very much dependent upon the treatment that you choose. And under treatment I do include active surveillance because although there is no intervention as such, it’s important to be aware that the decision to go down the active surveillance route is not without its implications, both mental and physical and not just for the patient, but also the patient’s partner or carers, and so on. It can have an impact upon them as well. But obviously, where you have done a major intervention, which may or may not have led to significant life changing complications in some cases, that will, of course, hamper one’s recovery. And although we are talking about age as a factor in these recovery processes, we do know that age is a fluctuating spectrum now. We used to think of old as a certain number. We no longer think that because there’s a clear distinction between chronological age and biological age. And this is a fascinating area of research that we’re looking into not just in terms of prostate cancer, but in terms of ageing in general, we know that there’s a massive amount of research going on in ageing in the brain and development of dementia and so on, and how people can reverse that. But also, we know that age plays a role in other organs and tissues. So, you know, like I said, ranging from the most extreme treatment intervention to the most basic, all of those will have different impacts upon their recovery. We know from scientific studies that the treatments that cause the greatest urinary or sexual or bowel dysfunction will lead to the most protracted of recoveries and the most difficult of recoveries. And there is a concept of what’s known as decision regret.
Clare Delmar
Okay.
Raj Nigam
And this is a psychological tool. There are many, many surveys that can be done whereby regret is defined and regret is defined as a number, and then that number is allocated to an individual following questionnaire analysis. And we do know that decision regret is highest in the most severe form of intervention, i.e. radical prostatectomy. In fact, there’s a paper from my own institution, which is a large institution that carries out radical prostatectomies, which showed that after 18 months, 30% of men who had undergone a radical prostatectomy had a high degree of regret.
Clare Delmar
Did age impact on that? Did it drill down into various characteristics of those men?
Raj Nigam
Under multivariate analysis, actually, age was not a factor, although one would think that intuitively that it might be that older men perhaps would cope with a greater degree of dysfunction than young men who might be working, for example, have good sexual function prior to the treatment. So age didn’t appear to be a factor. But what was more important, it seems, is the involvement of the individual in the decision making. And this is repeated across the scientific literature that if you involve the man and discuss all the treatment options in detail, then the level of decision regret is less than it would be because they go into it completely with their eyes open, knowing what they may or may not expect. That’s what we try and do at The Focal Therapy Clinic. Yes, we do do focal therapy, but we do like to discuss all the treatment options.
Clare Delmar
It’s fascinating. And I think age is a role in this, too, in terms of even having the questions initially and actually being able to tell those conversations with the doctor. Do you see that it’s having some kind of age related characteristics?
Raj Nigam
And I think that is partly a cultural thing in that perhaps that the older man may not ask as many questions, may have a greater degree of deference to the doctor or the nurse who is informing him about his or her treatment options, and may not necessarily question what other treatment options may or may not be available. The other important factor to note regarding age is that traditionally a lot of older patients, so I put that in inverting commas, have been denied certain interventional treatments, and that hopefully is changing, not just with the older male or the ageing male having knowledge of what is available, but also the fact that older patients now with their comorbidities that they may or may not have being managed better will be able to cope with interventions much more so. Whereas a lot of older men might have just been put on the so called watchful waiting protocol, a lot of these men are now seeking an active treatment for their prostate cancer, and I think that’s a good thing, because they should not be denied purely on the basis of chronological age, their particular treatment.
Clare Delmar
Do you think they’ll come a point where this chronological age versus the biological age will actually be a) measured and then b) applied in these decisions?
Raj Nigam
Yeah. Again, there are scientific measures that are being produced whereby you can distinguish between the two, between chronological and biological age. But we, as doctors, can often do that simply by talking to the patient and knowing a little bit more about our patients and their lifestyle and what is important to them and so on. So I think a lot of it is part of the doctor – patient and the nurse – patient relationship and understanding the involvement of the patient in the decision making process.
Clare Delmar
So in that case, it becomes a little bit more subjective because you have kind of the tools and the experience and the interest to build that relationship. I guess what’s interesting me is that in terms of bringing some objectivity to it, you can see that our understanding of ageing is advancing all the time, and even at the cellular level we’re hearing people talk about longevity, and without getting into that, I’m interested in how you think that this might impact our approaches to both the treatments offered and then therefore the recovery from prostate cancer treatment. Do you think that this will get better informed so that everybody will have access to a more age appropriate pathway?
Raj Nigam
Yes, I think you’re right. I think that certainly age will have an important impact on the recovery process following whichever treatment we do. And we now know that we can manage patients very differently. For example, a patient who might have had an open radical prostatectomy procedure previously will now be having a minimally invasive approach. We know that if we prepare that patient well that the patient will be discharged from hospital earlier and therefore will have hopefully less immediate post operative complications. And whereas previously, age might have been a complete contraindication to carrying out such interventions, that should no longer be a barrier as long as the physiology of the patient is such whereby we know that they’re going to recover and recover relatively quickly.
Clare Delmar
Ok.
Raj Nigam
Your second question relating to recurrence, however, is a much more controversial one, and it’s an interesting area of science on whether age and indeed the recovery process will impact upon future recurrence. And a lot of these are being studied at the cellular level. It’s an interesting area of science, but at present, we’re lacking in evidence on whether recovery actually does impact upon future recurrence of cancer.
Clare Delmar
I mean, if I kind of go back to putting it bluntly at the most basic level, if you look at the biggest risk factor for developing prostate cancer, it’s ageing. It sounds like stating the obvious here, but I could then ask and I will ask, how do you think we can better mitigate this risk? And do you think so called longevity science might play a role in that?
Raj Nigam
Yes. I mean, longevity science is a big area of research at the moment. And there is a concept called cellular senescence, which actually is a double edged sword because we think that cellular senescence, which basically means that our cells which are constantly proliferating and undergoing what’s called a cell cycle, are for some reason arrested, and they stop at that point in time. And we think that is beneficial in terms of tumour development, for example, that certain tumours may only get to a certain size and then not grow any further. But we also know that the other edge of that sword is that we think that leads to ageing because our cells are no longer being renewed as they were when we were younger and therefore we develop wrinkles, our organs age, etc. and don’t function as well. So it’s an interesting area of science on how you can mitigate the advantages of cellular senescence, but actually decrease the disadvantages. There’s a lot that’s been studied in terms of diet, in terms of various factors that can influence ageing at a cellular level to our advantage without losing the benefits of ageing. Because anecdotally we all know that, for example, in very elderly patients, there may be some tumours that are extremely slow growing and prostate cancer is often one of those, not in all cases, but is often one of those. So therefore, there are some advantages to that ageing process. So it’s a case of how can we harness those effects and single out a particular organ, for example, that that particular organ will undergo cellular senescence, but that it won’t have a wider impact on the rest of our bodies.
Clare Delmar
How interesting? I mean, it’s almost like, you know, good cop, bad cop in training it to do the right thing.
Raj Nigam
I’m not a trained cell biologist, but my basic understanding of it is that there is this constant battle going on within us with cell turnover, cell proliferation and also cell senescence.
Clare Delmar
So in the meantime, I think people should keep an eye on what this research is leading to, and it’s always advisable anyway to have a healthy diet and to exercise and do the things that are going to reduce inflammation and basically keep you healthy.
Raj Nigam
Yeah, absolutely right. So I think that the concept of diet in ageing is really important, and we understand a lot more about it now than we used to, and we understand what supplements are important and which are not and also, like I said, which supplements may be helpful in reducing cell turnover so that we do not develop tumours and so on. So there’s a lot of research that is going on in there, and I think that those are the sort of interventional factors that are constantly being studied. And we know exercise also is extremely important in needing a generally healthy life, but also in the non development of psychological, mental and physical problems.
Clare Delmar
I mean, we could talk forever about this, and it’s really interesting because it becomes a multidisciplinary approach, doesn’t it? I mean, we’re kind of integrating cell biology with gerontology and oncology and that gets to be an exciting but often a very controversial and even dangerous area to comment on. I think you’re absolutely right and there are actual journals that are dedicated towards this. Obviously there are gerontology journals, there are psycho-oncology journals, and so on, so I think being wider understood that dealing with cancer is not just a unique specialty process. It is, like you say, quite correctly, a multi-discplinary process and particularly in prostate cancer, because our treatments are so varied, ranging from doing very little to hormonal treatments, for example, the impact of hormonal treatments, particularly in ageing men. All of these things are vitally important in the decision making process.
Clare Delmar
Well, indeed, on that note, I think we’ll finish, but only to add to be continued as the evidence builds. And we get a little bit more understanding of how our older patients are coping with these different treatments. So I want to thank you so much, Raj, because it’s always fascinating to talk to you about this. And I think every time we talk, there’s new information to inform our conversations. So next time, it will even be more detail. So thanks very much again.
Raj Nigam
Thanks for the opportunity. Thanks, Clare.
Clare Delmar
A transcript of this interview and links to Raj’s practise are available on the programme notes, along with further information on diagnostics and treatment for prostate cancer and additional interviews and stories about living with prostate cancer.
Please visit www.thefocalthrapyclinic.co.uk and follow us on Twitter and Facebook at The Focal Therapy Clinic.
Thanks for listening. And from me, Clare Delmar, see you next time.