David Diaz Sr.: Hey, I'm Dave. I'm a father. I'm a son, brother, friend, leader, 25-year Navy and Army veteran, and I'm an eight-year stage four prostate cancer survivor.

Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. Today we're taking a closer look at a condition that affects hundreds of thousands of men each year: prostate cancer.

Diaz: I first found out about my cancer on my birthday at the age of 45. I had no symptoms. I have a family history of breast cancer. I got tested and found out my PSA was elevated, was recommended for a prostatectomy, found out my cancer had spread to my pelvic bone, and from there, life just changed.

Pathak: Prostate cancer occurs when the cells in the prostate gland begin to grow out of control. It's the second most common cancer among men in the United States. About one in eight men will be diagnosed with prostate cancer during their lifetime, and the risk increases with age, though certain populations, including Black men, face higher incidence and mortality rates.

Pathak: In its early stages, prostate cancer may cause no obvious symptoms. When symptoms do appear, they usually are because of the spread of the cancer, and some of these symptoms can include changes in urination, pelvic discomfort, erectile dysfunction, and bone pain. Screening tools like the PSA blood test help doctors detect prostate cancer, and advanced imaging like PSMA PET scans can help with the management of advanced prostate cancer.

Diaz: Anything with cancer, you just think death sentence, and the only thing I could think about was, who's gonna take care of my family. I got pretty much almost all the side effects that you get with hormone therapy, but the one thing that I wasn't really prepared for was the loss of my drive. So I ended up finding a support group.

Diaz: They gave me guidance, they gave me different perspectives, and I just started going in week in and week out. Kept on showing up every week. And from there, I started to heal and started to come around. I had the typical thought process of the masculine male: we gotta be strong, we gotta be stoic, do it alone, and just have to stuff it inside deep.

Diaz: And what a crock. All that stuff comes out in negative ways. That takes a toll on the body. It takes a toll on your mind. But you have to go out there and build your support system. It'll teach you things you never thought about. They'll peel back the layers that are keeping you isolated. You gotta build your team.

Diaz: They're gonna give you great advice, but you also have to go out and do your own research, go in there prepared with questions so you can get good answers either from your doctors or from your support community, and you can make good decisions that benefit you and your family. The biggest advice that I would give to men going on this journey: strength doesn't come from going it alone.

Diaz: In fact, the opposite is true. Find a community, find a group, find support. Share what's really going on—your fears, your frustration, and your victories. Your shared experience is life-changing. Metastatic prostate cancer is part of your journey, but it doesn't define your life. You can still find joy, purpose, hope. Connection is power.

Pathak: We'll be right back with more insight into men's health.

Pathak: And we're back. Let's keep the conversation going. Prostate cancer prognosis varies. Many cases grow slowly and can be monitored, while others are aggressive and can spread quickly if not detected in time. While the exact causes remain unclear, risk factors including age, family history, race, and lifestyle play a role.

Pathak: But diagnosis is only the beginning. For newly diagnosed patients, especially those with advanced or metastatic disease, the road ahead can be filled with questions. What are the most effective screening methods? How do new imaging tools like PSMA PET scans change the game? And what can men do to advocate for timely, high-quality care?

Pathak: In this episode, we'll explore the science behind detection, discuss treatment options, and address the disparities that impact outcomes, along with the practical steps men can take to protect their health. But first, let me introduce my guest, Dr Otis Brawley. Dr Brawley is a professor of oncology at the Johns Hopkins University School of Medicine.

Pathak: The 39th Bloomberg Distinguished Professor at Johns Hopkins, Dr Brawley leads a broad interdisciplinary research effort on cancer health disparities at the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins Kimmel Cancer Center, working to close racial, economic, and social disparities in the prevention, detection, and treatment of cancer in the United States and worldwide.

Pathak: He also directs community outreach programs for underserved populations throughout Maryland as the Kimmel Cancer Center's Associate Director for Community Outreach and Engagement. Welcome to the WebMD Health Discovered Podcast, Dr Brawley.

Otis Brawley, MD: Thank you for having me.

Pathak: Well, I am just so thankful to have your expertise as we dig into today's topic, where we're really focusing on advanced prostate-specific membrane antigen-positive prostate cancer.

Pathak: Before we do that, I'd love to just take a step back and clarify some things for our audience about prostate cancer in general, and then if you can funnel us down to the specifics around PSMA-positive prostate cancer.

Brawley: Well, first off, in all men—Black, white, and other—prostate cancer is the most commonly diagnosed cancer of the non-skin cancers. Of the cancers that traditionally kill, prostate cancer is the most commonly diagnosed for almost all men, including for Black men. It is the second most common cause of cancer death.

Brawley: The prostate is a gland that's down in the pelvis, just below the bladder. The prostate can develop cancer, and if there is cancer inside the prostate, it can be cured through surgery to remove the prostate or radiation that is aimed directly at the prostate.

Brawley: Sometimes the cancer spreads outside of the prostate, into the pelvis, into the lymph nodes in the pelvis. It can even spread further—it can go into bones. This is called metastatic prostate cancer. When we have prostate cancer that has spread, we typically treat it with hormonal therapy. These are therapies that deprive the prostate cancer of androgen.

Brawley: We have shots and pills that shut off a man's ability to make androgen. Androgen is sort of like a stimulant to prostate cancer growth. Men do very well with that, except they have some side effects from those therapies. Some men, eventually their prostate cancer will start growing despite the fact they have these anti-androgen therapies on board, and we call that castrate-resistant prostate cancer.

Brawley: And so you're asking me about cancer which has spread throughout a man's body, and the cancer is now growing despite the androgen therapies, and we now have several therapies that are available to treat that.

Pathak: Okay. So that's really helpful to help us set the stage for what we're talking about. So talk to us a little bit about what we mean by screening, because I think there's a lot of confusion.

Brawley: Screening, by its very definition, is doing a test, and in this case it's a blood test called the prostate-specific antigen test on men who are asymptomatic, and there is controversy about that test. Now many of us, including me, think that prostate cancer screening does save lives.

Brawley: It's respecting the man, and it's realizing that we think it saves lives. We don't know. One of the ironic things about prostate cancer also is there are a number of men who have prostate cancer confined to the prostate that is destined to stay in the prostate for their entire life. It will never bother them.

Brawley: Our conversation about metastatic prostate cancer is about men whose prostate cancer has already left their prostate and they're being treated for disease that has spread.

Pathak: So then let's talk about some of the lifestyle factors, because along with their lungs, smoking can also increase the risk for prostate cancer. So what are some of the other lifestyle factors that play a role?

Brawley: We have good data to show that men who are overweight and obese, it increases their risk of getting that more aggressive kind of prostate cancer — the kind it actually kills and the kind it actually needs to be treated. So we try to get men to try to maintain a normal body weight, try to exercise.

Brawley: We also know that family history is very important. Men who have a family history are at much greater risk of having the more serious type of prostate cancer. And indeed, these are some of the things that one might take into account if one is deciding whether or not one wants to be screened. It's very interesting that our clinical studies tell us that, once diagnosed, equal treatment yields equal outcome among equal men. A stage two Black patient given the same treatment as a stage two White patient has the same likelihood of success of treatment. Indeed, one of the great problems in the United States is we have good studies to show that a substantial number of Black men who have prostate cancer do not get adequate care.

Brawley: How we did these studies is we go to places, and we find that the Black and White patients of the same stage five and 10 years later have the same outcomes from treatment. But when we look at it across the United States as a whole, we find that Black men are twice as likely to die from the disease compared to White men. Black men are twice as likely to die in the United States as a whole. But if they're treated at the right places, they have equal chances of surviving.

Pathak: So then, let me pull on that thread just a little bit more. Is there a higher risk in Black men of having a PSA test being positive and that cancer is going to be more likely to spread?

Brawley: Actually, no. We have data to show that it's about 60 to 65% of men, be they Black or White, who are diagnosed with localized disease, will do very well and never be bothered by their prostate cancer. It's about two out of every three prostate cancers that we diagnose as localized that do not need to be treated. And that's true for Black men and White men.

Pathak: So then along with PSA, I also mentioned PSMA. So tell us what PSMA is.

Brawley: PSMA stands for prostate-specific membrane antigen. This is some of the most exciting work in prostate cancer within the last decade, and it's getting better and better every year. And I should say, cancer is a group of cells that we learned about in biology in high school, and cancer is uncontrolled cell growth. All of those cells are what we call clonal. They're exactly identical, and so these cells on the outside will oftentimes express this prostate-specific membrane antigen.

Brawley: And this has been very important because we have drugs now. They're monoclonal antibody drugs that can actually bind to that prostate-specific membrane antigen. So think of it as a marker on the outside of the cancer cell, and we can inject antibody into a patient and the antibody will stick to that marker on the outside of the cell.

Brawley: An exciting new treatment is where we've linked radioactive lutetium to this antibody. On one end of the antibody is the radioactive lutetium. On the other end of the antibody is the part that's looking for the prostate-specific membrane antigen, and the treatment that we have is we inject this radioactive drug, the antibody-drug conjugate, and the antibody finds the prostate cancer, binds to the PSMA, and it's like bringing a hand grenade next to that cell.

Brawley: When that radioactive lutetium decays, it's going to radiate the cell and kill it, and this drug actually works.

Pathak: That is very exciting. Hold that thought. We'll pick it up right after this. Thanks for staying with us. Let's dive right back in. So in terms of when we're thinking about PSA as a screening tool, where does the testing for the PSMA come in?

Brawley: When we treat prostate cancer that is metastatic, there is a group of men whose tumor will eventually start growing despite this treatment. Now, when the tumor starts growing, despite this treatment, the first signal I have is PSA rising again. And if it's rising fast enough, we need to give the man another treatment.

Brawley: In the last year and a half to two years, some studies have been completed, and the FDA has now approved use of this radioactive antibody in treatment for metastatic prostate cancer that is growing despite anti-androgen therapy. There are clinical studies that show that men do much better with the treatment than they would do with just a hormonal therapy alone.

Pathak: So this is supremely helpful. I'd love to shift us into the health disparities we were talking about earlier. Is there a health disparity in the cancers that are PSMA-positive in the Black community versus in other races?

Brawley: I would use not race as much as socioeconomic status. Men who don't have as good of an insurance — more important than not having insurance is having transportation or not having transportation — very frequently get less than optimal care.

Pathak: This is really helpful, because I think it helps us understand that health disparities really exist in many forms. We're not just talking about race, we're talking about socioeconomic status, and we really want to try to empower all of our listeners to take away from this episode information and tools so that they can access the best care possible. Can you help us understand how PSMA and PET CT fit into this diagnostic and treatment journey?

Brawley: First availability of this lutetium antibody conjugate. Our first use of that was what was called the PSMA PET scan, and what that is, is it's actually the same drug that we use to treat the prostate cancer in a much lower dose.

Brawley: And we inject that drug in the lower dose into a man, and we put them into what's called a PET scanner, which is an imaging machine that allows us to make an image of where things are radioactive. And we use this PSMA PET scanner to actually see where the man's disease has spread to. And if you see one of these images, it's absolutely amazing.

Brawley: So you can see gold patches in a man's ribs, or in his spine, or in his pelvis, or in the area where his prostate is, because that's where the cancer is. And it allows us to figure out how far his tumor has spread or if it has not spread. This PSMA PET only lights up in the prostate, meaning that if all the cancer is confined to the prostate—

Brawley: So if I remove the prostate, I'm gonna cure the man.

Pathak: That is very helpful. So we've dug into a variety of health disparities, and we really talked about socioeconomic status, race, the intersection of both, and healthcare access. Can you help us understand if this is playing a role in the lower survival rates for men with PSMA positive?

Brawley: We have a number of patients who don't understand the importance of getting to the places that can offer high-tech therapy. Sometimes you'll have men who will go to a clinic that may be very good for treating breast cancer because they treat a lot of breast cancer, but they don't see a lot of prostate cancer, but they're only five miles from home.

Brawley: They'll go to that clinic instead of going to a really good place, which might be 15 miles from home. We really need to try to encourage men to be interested in their healthcare, number one, and interested in getting good, high-quality care, number two. And, you know, it's a shame to deprive a man of all the treatment that he should be getting for his disease because it's not available, or sometimes it's available—

Brawley: It's just that the patient is not motivated to find transportation to get the extra few miles to get that therapy.

Pathak: I'm curious. Can you tell us what role you see medical mistrust playing in people accessing the healthcare system?

Brawley: I truly worry about mistrust. I worry about mistrust when we talk about how complicated the screening message is.

Brawley: I worry about mistrust because some of the treatments that we have are incredibly expensive. We are still waiting to see what's going to happen in terms of Medicare and Medicaid legislation and funding for treatment. Failure to communicate on the part of the doctors—that is what I've found to be the biggest reason why patients distrust their doctors. I've also found that doctors who communicate well, and doctors who come from institutions that have a history of taking care of the community that they serve, have a great deal of trust.

Pathak: I'd like to move us into now: how can patients have conversations with their healthcare teams so that they're really prepared to ask the right questions so that they can get optimal treatment?

Brawley: First, I always advise a patient to always have another relative there with them—someone who can be a little bit more objective. Always have a pen and paper there, and go in with questions that you've already written down, and go and take good notes while you're there.

Brawley: Stop the doctor and say, “Spell this.” I think the thing that every patient needs to know is: I have prostate cancer. Know what you have. Know what the stage is. Ask the doctor, what are the treatment options? Ask if there are options or if there's only one treatment available. Ask if there are treatments that might be available at other places.

Brawley: And so those are the major things that I would add. Keep an open mind. By the way, if your doctor is not willing to answer questions, perhaps you shouldn't be willing to be his or her patient.

Pathak: I think great and critical point. Screening happens when you don't have symptoms. So this is in the event that you are diagnosed with prostate cancer, and you need to be told—or you need to be aware of—certain symptoms that might reflect that the cancer is advancing. What are some of those symptoms that you talk to your patients about?

Brawley: Yeah. Symptoms are really important. As we get older, our prostates get bigger and the hole that we urinate through gets smaller. We call that benign prostatic hyperplasia, and we have men who have that problem who are convinced they have prostate cancer. And then they decide to do something I still don't understand—not go to the doctor because they don't want to be diagnosed with prostate cancer. There are treatments for that that can alleviate the man's problem.

Brawley: Go to the doctor, please. Prostate cancer, when it's localized, has virtually no symptoms. As it starts spreading, especially if it spreads to the bone, one can have bone pain. They may have hip pain or even a broken hip, and that's because it had spread to the hip. These are all issues that are indicative of metastatic disease.

Brawley: There really are almost no symptoms for localized disease. It's usually asymptomatic until it has spread. This is one of the reasons why we're so interested in having a screening test that actually saves lives.

Pathak: The fear of finding out is very real for very many patients. Can you give us some very concrete language that we can use so we feel confident in really advocating for ourselves to get that best care?

Brawley: Yeah. Some places will actually have patient navigators and patient advocates that can help you with this. And if that is the case, talking to those patient navigators or patient advocates. I would encourage people to have an interest in their healthcare and to be asking questions, because you're going to get better service if you go in there and you are actually asking questions, having conversation, as opposed to just going in there and saying, “Just do it to me.”

Pathak: I cannot second that point enough. So critical. Do you have recommendations around improving quality of life while undergoing treatment for advanced prostate cancer?

Brawley: Yes. Palliative care physicians are doctors who take care of cancer patients, and their concern is optimizing the patient's quality of life while getting treatment.

Brawley: Palliative care can be very appropriate for someone who has a good prognosis. I would not be afraid to engage a palliative care doctor to help with quality of life. That is a separate specialty from the doctor who treats the cancer. And in the ideal world, the palliative care doc and the doc who treats the cancer are talking to each other.

Pathak: Really helpful. I'd like to sort of, as we close out our conversation, really dig into resources, clinical trials, additional things that patients should be thinking about. And you dispelled one really critical myth, which is that Black men potentially don't participate in clinical trials. So can you share some information around barriers that may be impacting access for Black men to clinical trials and what you've seen as best practices, successful ways of combating that?

Brawley: I think one of the biggest barriers to Black men going on clinical trials is the myth that Black men don't go on clinical trials. We've actually done studies to show that a large number of doctors don't ask Black men to go on clinical trials. But I've already quoted: there's at least 12 well-done prostate cancer studies over the last 25 years that show equal treatment yields equal outcome.

Brawley: Now, people who want additional information: the National Comprehensive Cancer Network, or NCCN, has a website—it's nccn.org. They have patient descriptors of the treatments for all stages of virtually every cancer. You can go there and see how a stage three prostate cancer should be treated, or how a stage four.

Brawley: PSMA positive prostate cancer should be treated, and that's a good source. So everybody, doctors in the community as well as patients in the community can go see how they say that these things should be treated. There's a patient section where they give common lay explanations of the treatment that is beside the doctor explanation.

Pathak: That's really helpful in terms of understanding how these advocacy organizations help patients as they're navigating their treatment journeys. I'd love if you can now talk to a person who's listening. Maybe they are undergoing treatment or they are supporting a loved one who's undergoing treatment and they're feeling alone without support.

Pathak: Can you help us understand where they can go? What advice would you offer to this person that's listening but feeling alone and lost?

Brawley: Many of the larger cancer centers will have cancer support groups for both the patients as well as for spouses. At Johns Hopkins, we even have support groups for siblings.

Brawley: People who talk about their problem actually tend to be able to deal with their problems better. The people who shut themselves off and isolate themselves are those who do a lot more suffering.

Pathak: And can you help us understand—so if you are not located geographically close to an institution like that, can you tell us about online resources or other types of ways to connect with an organization like yours?

Brawley: There are some online resources that are very good. The American Cancer Society has a number of online resources that are very good and can be trusted. The Prostate Cancer Foundation, for example, will have online resources that are trustworthy.

Brawley: But again, when you go online, please be very careful.

Pathak: This is really helpful, and in our final few minutes together, anything you wish I had asked you that I haven't?

Brawley: Especially when we talk about Black men in prostate cancer. The first thing is to realize that screening is a question that every man needs to answer for himself, and he should have a conversation with a healthcare provider who understands the controversy.

Brawley: Second, if one is diagnosed with prostate cancer, please realize that two out of three men who are diagnosed with prostate cancer—the appropriate therapy is observation. We have people, by the way, who are shocked: “I have cancer and you want to watch it? Do you want to watch it because I'm Black? Would you be watching it in a white man?”

Brawley: The answer is, state-of-the-art therapy for the cancers that should be watched is that they be watched, as opposed to getting aggressive treatment, which has a number of side effects associated with it. Among the men who are treated—yes, surgery has impotence, and incontinence is a huge side effect.

Brawley: Radiation has impotence, incontinence, and bowel injury as a huge side effect. Not everyone will get it. Not the majority will get those things, but many people will. Men who are once treated for localized disease need to be observed very carefully because some of them will relapse, and the first time we see them relapse is when their PSA starts to go up and I'm gonna wanna treat them with my hormones.

Brawley: And then my guys who are treated with hormones—some of them will have metastatic disease that we can see on the PSMA PET, and some of them who are treated with metastatic disease will progress on those hormones. And then they are going to be candidates for either chemotherapy with Taxotere or, if they're PSMA PET positive, they're also a candidate for the radioactive ligands. And so there, I've tried to summarize everything in 60 seconds.

Pathak: That was fantastic. That's really helpful. I think that really pulls it together and I just wanna thank you so much for your time today because you have given us so much information.

Brawley: Oh, thank you. It's wonderful to be here. You know, you do a very important thing, which is help to educate people, because the educated consumer in healthcare is the person who does the best.

Pathak: Thank you again, Dr Brawley, for being with us. Thank you so much for being with us today. My key takeaways from this discussion are that screening for prostate cancer is nuanced and somewhat complicated.

Pathak: Unlike mammograms or colonoscopies, PSA screening has mixed evidence on saving lives, depending on who is being screened and when. That's why shared decision-making between you and your provider is essential. That means talking to your healthcare provider about your individual risks and risk factors, especially if you're in a higher risk group.

Pathak: For example, Black men or those with a family history of prostate cancer. Advanced imaging and targeted therapy are game changers. New treatments like radioactive lutetium-linked antibodies target cancer cells directly, offering better outcomes for men with metastatic castration-resistant prostate cancer.

Pathak: Equal treatment yields equal outcomes. This is key. Racial disparities in prostate cancer survival are driven largely by unequal access to high-quality care, not biological differences. To find out more information about Dr Brawley and metastatic castration-resistant prostate cancer, make sure to check out our show notes.

Pathak: Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you are interested in or questions for future guests, please send me a note at [email protected]. This is Dr Neha Pathak for the WebMD Health Discovered Podcast.