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If we know that one in seven men will be diagnosed with prostate cancer in their lifetime, and one in 29 will die from it, why are the rates of prostate cancer screening going down? Listen as host Ian Gillespie learns more about the reliability of screening and what the average man can do to reduce their risk of prostate cancer with world renowned urologist Dr. Stephen Pautler.
Welcome to the DocTalks Podcast, a conversation on what’s new and relevant in the world of Canadian medicine and hospital health care. Join us for each episode, as we interview physicians, patients and caregivers to dive deep into what it’s like to treat and live with some of today’s most common health challenges. Hosted by Ian Gillespie.
Note: The content of St. Joseph's DocTalks Podcasts is for informational purposes only. The material is not intended for and should not be used as a substitute for direct medical advice from a licensed health care practitioner.
To Screen or Not to Screen
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Welcome to the DocTalks Podcast -A conversation on what's new and relevant in the world of Canadian medicine hostpital healthcare. I'm your host Ian Gillespie, and I'm here to ask the question and find the answers you need to know. We want to help our listeners know how to prevent and detect illness, and how to navigate our health care system. Be sure to subscribe to the DocTalks Podcast to stay up to date on new episodes, and follow us on Twitter @stjosephslondon, or visit sjhc.london.on.ca/podcast.
[00:00:00] Ian Gillespie: Hello, I'm Ian Gillespie and welcome to The DocTalks Podcast brought to you by St. Joseph's Health Care London. On today's episode, we're discussing a topic that's difficult for many men to talk about, and that is prostate cancer. Our expert today says there's a lot of misinformation out there about prostate cancer screening that can lead to deadly consequences.
We know that one in seven men will be diagnosed with prostate cancer during their lifetime. And one in 29 will die from it. My guest today is Dr. Steven Pautler, a urologist at St. Joseph's healthcare, London, practicing at St Joseph's hospital. He's also an associate professor of surgery and oncology at Western university.
The Southwest regional surgical oncology head or lead for cancer care Ontario, a Canadian pioneer in surgical robotics and an internationally acclaimed leader in prostate cancer diagnosis and treatment. Dr. Pautler, welcome. Thanks for joining us today.
[00:01:00] Dr. Stephen Pautler : Thank you Ian, for having me.
[00:01:02] Ian Gillespie: let's just start. I'm always good with the dumb question. So let's start with the basic basic question. What is the prostate and what does it do?
[00:01:13] Dr. Stephen Pautler : So it's a great place to start. So our prostate, as males, we're born with a prostate gland which is part of our reproductive system. Its major role comes into play after puberty. And it produces some of the ejaculate fluid that supports sperm, during reproduction. It also happens to be donut, like organ around our urinary tract.
So we actually pass our urine from the bladder through the prostate and, and out the urethra. So it, it plays kind of a dual role in male.
[00:01:50] Ian Gillespie: a again, I'll just dip into a few of the stats here regarding prostate cancer that the uh, Canadian cancer society estimates that this year in the year, 2022, 24,600 men will be diagnosed with prostate cancer. 67 men will be diagnosed in Canada every day. And. Every day in Canada, 13 men will die from prostate cancer.
So those are some fairly sobering statistics. So, but I, and I understand also, you've, you've talked about, there are a lot of misconceptions about prostate cancer and treatment and screening. Maybe let's start with that. What are I, I know actually you, I read an interview where you talked about it um, as a coffee shop talk, I have to admit, I have.
The topic of prostate cancer has never arisen for me in a coffee shop or frankly, anywhere else, which may be part of the problem, but what are some of the misconceptions that are out there?
[00:02:46] Dr. Stephen Pautler : Sure. Sure. So it's um, prostate cancer and the diagnosis of prostate cancer is a relatively controversial field. We have to look back at history a little bit here. So prostate cancer diagnosis really dramatically changed around 1990, and that was with the discovery of a blood test that can help us understand or give us indications that there's something going on in a man's prostate.
So this blood test called PSA, came into mainstream about 92 93 in Canada. And initially when a blood test like this is found there's a lot of interest and a lot of research that goes on. And for most of the decade of the nineties prostate cancers were being discovered through this blood test.
Subsequent biopsy, which confirms the presence of cancer and started shifting this disease to being discovered at earlier phases. Several studies were conducted and initiated in the, in the nineties and in the early two thousands to look at whether there is a group of men that should have PSA testing when they're completely asymptomatic.
So this is the concept of screening for a cancer. Other common screening tests for different cancers include fecal testing for colon cancers. Mamography for breast cancer and women and PSA really dramatically changed the field. One of the problems with PSA blood tests, though, it can be elevated, not only because of prostate cancer. It can be elevated because of enlargement of the prostate, which is largely a genetic condition happens to about 80% of males. As well,
other things like infection or inflammation in the prostate can cause a PSA to be elevated. So PSA by itself, isn't a perfect test. forward to around 2011, there were two large studies of screening male populations for prostate cancer that were published in the New England Journal of Medicine.
Both of these studies showed PSA screening for men and each study had different populations of men, slightly different, but let's pick the target of age 55 to age 70, and the conclusion of these trials, one from Europe, one from the United States was PSA screening didn't help. This was widely popularized in, in the media.
And Taken up by variety of healthcare organizations to, say, really, we should stop doing PSA testing, which was the wrong message. These studies both had critical flaws that led to erroneous conclusions. And it really put our field back, probably 20 years to this day, many family doctors will, will tell their men that they don't believe in PSA testing. One of the key messages really should be PSA is still a good test. While it's not perfect, if a man, you know, over age 40,
Has new onset of urinary symptoms or something going on doing a PSA is quite a rational thing to do as well, you know, we're our, our cutoff for screening PSAs is typically age 70, but if a man's over 70 and has some new onset of symptoms, a PSA can be useful as.
Now where the field gets a bit muddy, and I use that term on purpose, is PSA by itself, isn't great. We always have to do a rectal exam and rectal exam in conjunction with PSA makes the clinical assessment of the patient much better. And that's where men don't like to talk about peak prostates and PSA testing. So that that's some of that controversy in the field.
[00:07:12] Ian Gillespie: wow. Strangely I recently had a PSA, but my doctor did not perform a rectal exam. Now I'm wondering why or is that common?
[00:07:21] Dr. Stephen Pautler : It's it is actually very common. Many primary care don't do the rectal exam routinely in, in our urologic specialty, we consider Both to be complimentary of each other and really should be done. And part of that is because a, a PSA can be normal yet a man can have a irregularity on examination of the prostate, and that should still be investigated.
[00:07:46] Ian Gillespie: right. So even though, before a man gets screened or decides to seek screening, what are some of the symptoms that they may see or should be on the lookout for? Hmm.
[00:07:56] Dr. Stephen Pautler :
So, majority of symptoms are with respect to voiding. So frequent urination, urgent urination, blood in the urine, painful urination. Changes in urinary habit, so going from, you know, I get up once a night to have a pee to I'm up five times at night to pee. The inability to urinate. Now all of those symptoms could be related to prostate cancer, but the majority of time they actually are not.
They're usually related to either infection or inflammation in the prostate or enlargement of the prostate, but they really need to be checked out. Other symptoms can include constitutional type problems. So inadvertent weight loss, poor appetite, bony pain. Some of these symptoms are related to advanced prostate cancer.
Thankfully that's the minority of patients who come in to see us.
[00:08:50] Ian Gillespie: Right. So if uh, a man discovers these or finds these symptoms seek screening it is positive. What's the next step? What, what, usually? I I'm sure this is a complicated answer to a simple question because I'm sure there's many variables, but what generally then happens to someone who has tested positive on the uh, PSA
[00:09:08] Dr. Stephen Pautler : On the PSA. So, I, I. Qu quantitate that in the sense that there's no real testing positive on PSA, unless it's absolutely sky high. If it's sky high that's prostate cancer. For example, if it's in the thousands. Most PSAs are between one and 10, for example. So if there is clinical suspicion uh, there is a uh, clinic that we host here at St. Joseph's which is our, our London Middlesex clinic for prostate cancer diagnosis called our Prostate Diagnostic Assessment Program. So family doctors refer into this program, they're seen by myself for there's four oncology colleagues who evaluate the patient. And then would proceed to recommend a biopsy of the prostate.
if there is high enough clinical suspicion of prostate cancer,
[00:09:59] Ian Gillespie: and again, sorry. That's the prostate diagnostic assessment program at St. Joe's. How long has that been in existence, dr. Polter
[00:10:05] Dr. Stephen Pautler : Oh, we've, we've been going now for at least five years with the prostate cancer program.
[00:10:12] Ian Gillespie: Wow. So after screening treatment I suppose is actually, is there, let me, before we get into treatment, is there any, any steps that a normal man can take to ward off or delay or avoid prostate cancer? Is there anything regarding diet or exercise that has a positive effect?
[00:10:29] Dr. Stephen Pautler : So great, great question. Prostate cancer prevention has been uh, subject of a lot of interest in the last 20, 25 years. There have been numerous studies done to look at preventing prostate cancer either by dietary supplements, for example large study, there were over a thousand men from London that were enrolled in this trial looking at selenium supplementation and seeing if that would reduce the risk of prostate cancer.
In the end, that trial was a negative trial. It did not show that dietary supplements could really make a man avoid the potential for prostate cancer. There have been two large studies looking at class of drugs called five alpha reductase inhibitors. These are drugs that were designed for shrinking the prostate for men who have enlarged prostate and have urinary symptoms.
So we have many thousands of patients on these meds and there were two large studies that looked at them in the context of preventing prostate cancer development. And they actually both reduced the risk of prostate cancer development by about 22-24%. Having said that health Canada and the FDA did not approve these drugs
to solely be prescribed to prevent prostate cancer development. And the reason they, they did not approve them, they did find that men on treatment with the drug compared to placebo, did still develop prostate cancer, and some of those were higher grade prostate cancers. So both health Canada and the FDA said, while these drugs are quite safe to use for enlarged prostates under the supervision of a physician, be it a family doctor or a urologist, we don't really feel that the evidence is strong enough to recommend their use in prevention.
Now, diet, certainly a diet that's heart healthy, so low in saturated fats high of fruit and vegetables will benefit a man not only from the heart standpoint, but likely from the prostate standpoint.
[00:12:34] Ian Gillespie: Right. The old Mediterranean diet, is that right?
[00:12:36] Dr. Stephen Pautler : Regular exercise has, has some, there is some evidence that it reduces prostate cancer progression.
So, one of, one of our colleagues who practices at university of Michigan commonly will say, you know, if, if. I talk to my patients and I say, I can give you a prescription today. And that prescription will reduce your risk of getting prostate cancer, and if you do get it, reduce the risk of it being a bad cancer and taking your life reduce your risk of erectile problems and urinary problems, et cetera, et cetera.
Would you take it? And universally people say, sure, sure. I'll take it. What is it? What is it? And he says a healthy diet and exercise.
[00:13:17] Ian Gillespie: right.
[00:13:18] Dr. Stephen Pautler : So, so that I, I think we, we undervalue that, although we don't have strong scientific evidence for some of some of those claims it's building
[00:13:28] Ian Gillespie: And is is there a, there must be a strong genetic, is there sort of a predisposition, a genetic cause for prostate cancer, I mean, is there something to look for if my father had it or my mother had something else, I'm more likely to get it?
[00:13:40] Dr. Stephen Pautler : Yeah. Great question. So we've understood for many years that prostate cancer can run in families. And over the last 20 years, there's been very significant analysis looking at genetic predisposition, looking at family histories indeed to the point that We now have a genetic screening panel.
So if someone is diagnosed with an advanced prostate cancer or they have first degree relatives with prostate cancer, Breast cancer or ovarian cancer, we can run genetic screening on them to see if they carry an altered gene that has led to their development of prostate cancer. If you have first degree family members with These cancers or with prostate cancer. So a father, a brother, your risk doubles. And if you have two first degree relatives you're almost at about a 50% chance of developing the cancer yourself. So we do offer genetic testing now to the appropriate individuals who are diagnosed with the disease.
And then if they're positive that expands to their, their first degree relatives, their children brothers, sisters, et cetera.
[00:14:52] Ian Gillespie: And again, the general recommendation is men that should start screening between age 45 and 50. Is that correct?
[00:15:00] Dr. Stephen Pautler : So correct. The Canadian guideline is at age 45, if you have a first degree family member with prostate cancer. And most of us will, if let's say your mother had breast cancer and a sister has breast cancer, we'd expand it to that. man as well. So a and with genetic testing now that is really a, a situation of screening.
So if you do carry an altered gene that puts you at higher risk, then yes, yearly PSA testing and, and digital rectal exam is recommended.
[00:15:31] Ian Gillespie: you talked earlier about this rather misguided study and the effect it had. And I'm wondering too, with the recent pandemic I think I read somewhere that prostate screening is actually decreasing. Is that correct? And if, if so, and that's a dangerous trend, what, what do you think are some of the causes of that?
[00:15:47] Dr. Stephen Pautler : Yeah. So, definitely as a result of those New England Journal papers back in 2011, the Canadian body that recommends periodic health exams, screening tests to primary care doctors recommended against PSA testing. And again, that's in a screening context. So someone without symptoms, unfortunately, some, some primary care doctors have kind of taken that as carte Bloche and don't do PSAs ever, which is wrong.
So certainly if a man's symptomatic, it's not really called a screening test. You're case finding. Having said that if you have a first degree family member or history of, of the other malignancies, as I was talking about, then screening PSA is still recommended in those men. As well with the pandemic unfortunately face to face healthcare has, has been a challenge.
So many of my primary care physician colleagues couldn't see patients face to face to, to advise them regarding testing or not testing. People were fearful of going into doctor's offices or to the hospital. So deferring their healthcare has happened as well, which has been a, been a challenge.
We're at a relatively safe space right now with COVID. Our numbers are low in our community and more patients are accepting to come in and be evaluated, but there's still some fear out there. Absolutely. So I think that's contributed. So mix messaging with some poorly controlled studies, as well as misinterpretation on the behalf of, of my colleagues.
And then COVID on top of things. So I think those are, are all contributing.
[00:17:24] Ian Gillespie: Right. what is my option? If my doctor falls into that category, you mentioned, and is one of those doctors who won't arrange or provide for a, a PSA test. What's what's my option?
[00:17:37] Dr. Stephen Pautler : Yeah. So, they they're, unfortunately in our system, not a lot of options you can pay for it. But you still need a physician's order to get the test.
[00:17:47] Ian Gillespie: I see.
[00:17:47] Dr. Stephen Pautler : PSA
[00:17:47] Ian Gillespie: I can't just approach the, the at St. Joe's I can't go to the prostate diagnostic assessment program directly.
[00:17:53] Dr. Stephen Pautler : no, no, unfortunately, no. They're, the demand is huge. And this, these are for men, who've already had PSAs that are abnormal or abnormal rectal exams. So, they have to be referred in by a primary care physician or nurse practitioner. So.
[00:18:09] Ian Gillespie: right. So again, if my doctor doesn't do it, I'm kind of between a. Rock in a hard place, which may not be the best analogy or it might be a good analogy for prostate.
[00:18:18] Dr. Stephen Pautler : Yeah, I think, you know, having a, having an informed discussion with your doctor is, is wise advocating for yourself is wise. You know, and, and they may have legitimate reasons. You know, if, if a man has less than a 10 year life expectancy be it because of heart disease or another malignancy or something else, then doing a PSA is probably the wrong thing.
And I would agree, don't don't get that test because something else will likely get you first.
[00:18:46] Ian Gillespie: Oh, it's a, it's a slow is that is it's a slow developing cancer. Is that fair to say that?
[00:18:52] Dr. Stephen Pautler : So it's fair to say most are slow developing and slow growing. Not all of them. There is evidence from a autopsy series that was done in Detroit for young men who died either from gunshot wounds or motor vehicle collisions. And these men were in their twenties and thirties and they did autopsies and looked for evidence of prostate cancer under the microscope.
Histologic or pathologic prostate cancer. And roughly one third of men in their thirties in Detroit had prostate cancer identified. Now definitely not one third of them had clinical prostate cancer. So cancer that would be visible because a PSA is elevated or an abnormal rectal exam. And we don't know the, the natural history of those tumors that were identified histological.
So the messaging there is it can develop, it develops in a majority of us as we age, but not all of these are significant cancers. And one of the problems has been over diagnosis. So diagnosing too many men with prostate cancers that are not significant cancers and aggressively treating them. Now, this has been a phenomenon across the border in the United States.
It has happened here in Canada and in Europe. Australia, but certainly to a greater degree, I believe in the US. And we've taken a more rational approach in Canada to treatment. So not every man who's diagnosed with a prostate cancer, do we recommend radical treatment being surgery or radiation treatment options.
[00:20:33] Ian Gillespie: I see.
[00:20:34] Dr. Stephen Pautler : Many men are, are candidates for what's called active surveillance. So we're actually with full knowledge that they have prostate cancer, but they have a small amount of a low grade or non-aggressive cancer they're of cancer, their PSAs aren't sky high. So we monitor them and we, Alter their treatment course
if the cancer tells us they need treatment. So if we see signs of progression in the amount of cancer, the aggressiveness, the PSA. Not all men do well with that strategy. Some men that is a, a burden on their mental health. They are anxious and stressed. So part of our job,
[00:21:15] Ian Gillespie: they want to take, take action.
[00:21:17] Dr. Stephen Pautler : yeah, absolutely. Part of our job is to educate them.
Part of our job is, is to help them during this journey. When active surveillance first was proposed, one of the leaders of this was a colleague from Toronto uh, who really our American colleagues were actually quite aggressive towards, you know, saying this is, this is heresy or going to have patients die.
And really over the last 30 years, he's proven that that is not the case. And to the point now Americans are adopting active surveillance. They have been for more than 10 years. and really that is the discussion of overdiagnosis and overtreatment is something you would never have heard 20 years ago in the states.
Now we hear they've kind of adopted our way of looking at the disease.
[00:22:06] Ian Gillespie: So, again, the treatment kind of boils down to, well, you either, as you said, surveil it or monitor it or it's either then surgery or radiation or a biopsy, which I guess would qualify as surgery. Is that is that right? Have I got.
[00:22:23] Dr. Stephen Pautler : So D no, I, I would correct that uh, biopsy is really a diagnostic step. So we're trying to identify the cancer. From there we use
[00:22:33] Ian Gillespie: Radiation and surgery then
[00:22:34] Dr. Stephen Pautler : radiation or surgery or, if it's advanced disease, you may use a combination in conjunction with hormonal treatments. The technical term is androgen deprivation therapy. Even More advanced cases,
that's their primary way of treatment. And chemotherapy has been making strides over the last decade or so as well in earlier use of chemo in certain appropriate scenarios.
[00:23:03] Ian Gillespie: And I know this may be part of men's general reluctance to kind of confront this disease, but sometimes things like incontinence and erectile issues are a result of the, is that the radiation treatment? Is that that correct?
[00:23:18] Dr. Stephen Pautler : So it can be radiation or actually more commonly surgery. So the surgeries I do unfortunately do render some men in incontinent permanently. Now, thankfully that's a minority of the patients as a long term sequel I of surgery.
[00:23:34] Ian Gillespie: Could you put a number on that? Like, are you a minority? Is it
[00:23:37] Dr. Stephen Pautler : So in.
[00:23:38] Ian Gillespie: 20% or
[00:23:39] Dr. Stephen Pautler : Yeah, in, in my personal practice. So I track the outcomes of every patient I've operated on.
So I've done more than 865 robotic prostatechtomies at St. Joseph's since 2005. And when you look at incontinence, so we leave a catheter in a man for two weeks after surgery. Remove that catheter. Every man is universally in continent. Some gain back their you're in control very quick within the first couple weeks.
Some it takes two months, some it's six months, some it's a year. If you look at the outcomes, as far as permanent incontinence, so leaking urine to the point that it is impacting their quality of life at, at a year in my series of men, it's it's 3.5%. So it's quite low. Now there are, you know, at around 17% of men will still wear what we term a safety pad in their underwear, just in case they squirt a little bit of urine here or there, it may be with strenuous lifting.
It may be with a sneeze. A lot of men will report after having a couple beers on the golf course, they are a little more relaxed. They, they dribble a little bit. But for the most part, most men gain back good urinary function following surgery. It's a challenge at first. It, it certainly is, but they're prepared for that.
We have some expert physiotherapists in the region who help with men kind of relearning the whole urinary control piece of their life.
[00:25:10] Ian Gillespie: And are there any, what about the erectile difficulties? Is that,
[00:25:14] Dr. Stephen Pautler : So erectile difficulties, yeah, definitely happen now.
[00:25:19] Ian Gillespie: As prevalent or mm-hmm
[00:25:20] Dr. Stephen Pautler : quantitating erectile function before surgery is something that we have standardized questionnaires. We know that 60% of Canadian males by age 60 report erectile dysfunction of some sort it may be situational, it may be one time it happened,
it may be routine. So understanding a man's baseline function is important. During surgery, there are nerves that are very closely approximated to the prostate that. Run to the penis and provide uh, stimulus for erectile function. Now, sometimes we have to sacrifice those nerves at surgery because they are also a root that cancer tries to escape from the prostate and grow along these nerves.
So what we do at surgery matters. How a man is functional before surgery matters. And then after surgery we know even if we spare these nerves, they're, they're stunned. They don't function immediately. I spoke to a patient earlier today, who I operated on in May and this man has continents. He has normal urinary function and he's already having erections, which, which are sufficient enough for sexual activity, which is really the exception.
Most men it's somewhere around six months to two years following surgery that we see sexual functional recovery, if it comes back. But again, we have to quantitate that. If you are already having troubles before surgery, surgery's not going to help that. And in most men that will be the loss of efficient erections.
Not all is lost if, if you're not having spontaneous erections, we can rehabilitate with oral drugs like siltadalof il, known commercially as Viagra, cialis, LA Vitra. There are penal injection therapies that can be used, which is a more invasive drug delivery to provide stimulus for erections increasing blood flow to the penis.
And then there's even surgeries to put in artificial penal implants, which one of my colleagues is a n expert at doing those. so there are many ways to treat the erectile dysfunction. One of the other problems or controversies I find in this field south of the border, again, being a competitive market for patients.
So. Institutions and surgeons are not always, let's say forthright with their exact outcomes. Some institutions advertise sexual functional recovery of 95%. Well, if, the lay public hear that they think, okay, that's great. Well, you, you, Canadian surgeons must be bad because in my best patient cohort, even if I do the very best nerve sparing, I'm only seeing about 72% regain sexual function.
And that's with aid with, with oral drug therapy and some men onto injection therapy. We're not doing a worse operation. We're simply reporting the true outcomes. Uh, You have to remember the consumerism in the states is such that if one place says, oh, my erections are 70% and the next guy down the road says 90%,
who are you going to pick? You're gonna go to the 90% guy, but I, I think we have to be very cautious with how some of this is reported.
[00:28:43] Ian Gillespie: I, is that an honest to goodness trend or a lot of Canadian men going to the US because of those statistics?
[00:28:49] Dr. Stephen Pautler : So I, I would say no. I, I would say no, but early in robotic experience, so in the two thousands, we did have men cross and uh, go to Detroit for surgeries. And the reported outcomes were quite eye opening. So when I had some patients who elected to go there and come back and they quote, they have a transfusion rate of less than 1%, yet three patients of mine who went, had transfusions.
It, it confused me a bit. So, again, healthy skepticism when you're looking at for-profit healthcare, I think is, is important. And unfortunately that's left up to the patient these days. Sure.
[00:29:32] Ian Gillespie: Dr. Pautler, what, What's the approach that uh, you take for, for men who develop some of these negative side effects from the treatment?
[00:29:39] Dr. Stephen Pautler : We work with them Ian, to, try to understand exactly how it's impacting their quality of life. And there are some basic first steps that as their surgeon that I would take looking towards pelvic floor physiotherapy, for example, for some men for incontinence. Some men have overactive bladder.
So there are medications that can be used. If they don't initially respond and it's quite problematic, then I actually have colleagues here who are experts with voiding dysfunction and treatment of incontinence. Uh, And I would have them referred To my colleagues for evaluation. There are with respect to erectile issues,
if they're refractory to oral medication or injection therapy, then another colleague of mine here is, is a nationally renowned surgeon for erectile dysfunction. And I would have them evaluated for consideration of a penal implant, for example. So we do have. The comprehensive care and, and different platforms for care all here at St.
Joseph's uh, indeed many men from Southwestern Ontario have these complications at other institutions with other colleagues, send their patients here to my colleagues for evaluation. So we're lucky to have all the, all the expertise in house.
[00:30:55] Ian Gillespie: Right. We should probably wrap up pretty soon. I just wanna touch on though, the is probably not a simple topic to quickly dispense with, but the, the robotic surgery that you're pioneering, can you give us a quick sense of what that's all aobut?
[00:31:09] Dr. Stephen Pautler : Sure. So it, it surgical robotics started really in the late nineties, early two thousands. I was at the point in my career where I was a young up and coming surgeon and had the opportunity to learn some surgical robotics in my fellowship and then returned to London in 2002 at the time had a robot called Zeus and then had just got a new one called DaVinci.
So the story goes really commercially available robots since about 2004 have been exclusively da Vinci robots, and London has a long history of innovation in, in medicine. And we had the second daVinci in the country at the third at St. Joe's and subsequently in 2012, another robot came to Vic. So we have the highest concentration of surgical robots based on population.
And I've been lucky enough to, to have my career here, where we have very supportive administration at our hospitals, surgical robotics is not cheap. So it is an expensive piece of equipment for us to use. There's nothing magical about the robot, but basically what it does is it miniaturizes our hands.
So we're using instruments with little wrists. The instrument itself is only about eight millimeters in size, and there's multiple arms to this robot that we can go in and do the exact same surgery we could do with our hands through a bigger open incision.
[00:32:41] Ian Gillespie: Right.
[00:32:42] Dr. Stephen Pautler : But minimize the trauma to the patient. So we do see faster recovery.
We see improved early continents. I, in my practice I've seen better erectile functional outcomes with robotic than I ever saw with my open surgeries. So it has been something that over the last uh, 20 years, we've really proven that we can use surgical robotics in the Canadian system,
to the point now there, I believe there's 32 robots in the country. There is now a competitive company making a surgical robot that just got Health Canada approval. So, we do expect there should be, likely even more surgeons able to offer this type of surgery over time. Hopefully the price points for the equipment will drop a bit to make it more affordable in our system.
[00:33:34] Ian Gillespie: What can you tell me, just, what percentage of the surgeries are performed robotically
[00:33:41] Dr. Stephen Pautler : so that's a, a great question. So for, for prostate cancer in the United States, more than 90% are robotic. so that gives you the, the magnitude south of the border. Now the costs are passed on to the patient. In, in Ontario, we're about 40% are robotic. So still down, although that number each year has been increasing.
[00:34:07] Ian Gillespie: And I guess w would that number be higher in London because of St. Joe's technology and so
[00:34:13] Dr. Stephen Pautler : So it's not, not quite they, the, I do have other colleagues who are still doing open surgeries in town. And so, uh, our numbers wouldn't quite be above 50% robotic, but there's several who, others who are also trained with robotic surgery, who either do it at London health sciences, or who come to St. Joseph's to do them.
[00:34:34] Ian Gillespie: Is there any research on the horizon that you're optimistic about or excited about that is gonna make some big changes in treatment? .
[00:34:40] Dr. Stephen Pautler : So, there are many, many studies undergoing at this time. Movember, which has been a worldwide fundraiser has, has raised huge amounts of money that's been going into research. I'd highlight one study that we're doing locally in London which is looking at specialized pet scan imaging for prostate cancer called PSMA pet scans.
These are done currently at St. Joseph's on our pet scanner and we're able to identify, men when they have recurrent prostate cancer and alter what we used to do for treatment, which was more of a shotgun approach, and hone it in on their individual circumstances. This pet imaging will also help us likely develop protocols
for which men need more aggressive treatment upfront or men who maybe require less intensive treatments upfront and may end up playing a role in monitoring prostate cancers eventually. So I'm quite excited about our molecular imaging platform and you know, the world is changing with artificial intelligence and, and that may also
come into play a role in helping men decide what to do when they're diagnosed or perhaps what not to do and personalize their care. So exciting times.
[00:36:07] Ian Gillespie: I'm optimistic, too.
Right. Okay. Dr. Putler. Is there anything else just that we haven't touched on that you think is important just to mention, or maybe um, wrap up with one final thought?
[00:36:20] Dr. Stephen Pautler : Yeah, I think I encourage men who are diagnosed with prostate cancer to educate themselves and their families we're here to help them work through their journey. And every man's journey is slightly different. To talk at the coffee shop, as I've mentioned in, in other talks what, what somebody's uncle bill had is not necessarily what you have and really asked the questions and will help help men get through their journey.
[00:36:46] Ian Gillespie: Dr. Putler. Thank you so much for taking your time out and sharing your expertise with us today. Thank you.
[00:36:53] Dr. Stephen Pautler : My pleasure, Ian. Thank you.
Ian Gillespie: That's it for this episode of the DocTalks Podcast. Thanks for joining us, and join us next time when we'll continue our conversation on what new and relevant in the world of Canadian medicine and hospital healthcare.
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Until then, stay healthy.