Prostate Cancer: A Conversation on Screenings, Treatment, and Advances

Early detection and self-advocacy are the keys to combating prostate cancer. As a medical oncologist, as well as president of Virginia Oncology Associates, Dr. Fleming not only shares his professional insights but also his personal journey dealing with prostate cancer. He emphasizes the importance of the PSA test, which plays a critical role in early diagnosis. 

Dr. Mark T. Fleming is board-certified in Medical Oncology.  He received his B.A. at Philadelphia’s prestigious University of Pennsylvania and his Doctorate in Medicine at the Medical University of Ohio.  Dr. Fleming completed his residency at Temple University Hospital, Philadelphia, PA, and his Medical Oncology Fellowship at Memorial Sloan-Kettering Cancer Center, New York, NY. He then joined Virginia Oncology Associates (VOA) in August 2006.   

Cancers of the Bladder, Kidney, Prostate, and Testicles, as well as Phase 1 novel drug development, are Dr. Fleming’s special clinical interest and expertise.  He is heavily involved in cancer research serving as a principal investigator for clinical trials, locally and nationally, collaborating with institutions like Duke University Network, Hoosier Oncology Group, Prostate Cancer Clinical Trials Consortium, and Sarah Cannon Research to provide the latest treatment options to patients.   

Dr. Fleming currently serves as the Medical Director of US Oncology’s Genitourinary (Bladder, Kidney, Prostate, and Testicular Cancers) Research Committee. He is also pivotal in coordinating the VOA’s genitourinary research program and backing up the Phase 1 program.  In addition to his clinical and research activities, Dr. Fleming is an active leader within the medical community previously serving as both the Division Chief of Eastern Virginia Medical School Department of Hematology & Oncology and President of the Medical staff at Sentara Careplex Hospital. As a co-founding member and past president of the Hampton Roads Prostate Health Forum, Dr. Fleming is a passionate speaker on the importance of cancer education and the Early Detection of Prostate Cancer.

Resources mentioned in this podcast 
 

Prostate Cancer Foundation: https://www.pcf.org/ 

NCCN (National Comprehensive Cancer Network): The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) are comprised of recommendations for the prevention, diagnosis, and management of malignancies across the continuum of care. https://www.nccn.org/ 

Hampton Roads Prostate Health Forum: https://www.hrprostatehealth.com/ 

Thank you for listening! If you're interested in hearing more from Virginia Oncology Associates, make sure to subscribe to Cancer Care Connections on Apple Podcasts, Spotify, or anywhere podcasts are available, or listen online at cancercareconnections.buzzsprout.com.

Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information, visit us at VirginiaCancer.com. or find us on Facebook or Instagram at Virginia Oncology Associates.

Transcript

Speaker 1: 0:08

Welcome to Cancer Care Connections. On this week's episode, Cheryl Tans spoke with Dr. Mark Fleming. Dr. Fleming is a medical oncologist and currently serves as president for Virginia Oncology Associates. Cheryl and Dr. Fleming dove into prostate cancer. They discussed the importance of screening and advocating for yourself in order to find facilities offering the latest and greatest treatments. Dr. Fleming also filled us in on why the treatment and research for this cancer are so important to him.

Cheryl: 0:44

We're sitting down today with Dr. Mark Fleming, a leading figure in cancer research and a passionate speaker on the importance of cancer education and the early detection of prostate cancer. He joined Virginia Oncology Associates in 2006 and is known for his work in bladder, kidney, prostate, and testicular cancers, as well as phase one drug development. Dr. Fleming has co-authored articles that led to the approval of new cancer treatments. Currently serving as the medical director of US Oncology's Genitourinary Research Committee, he is at the forefront of cancer research. Dr. Fleming, thank you so much for joining us today.

Dr. Mark Fleming: 1:21

Thanks for having me.

Cheryl: 1:23

I know that this passion for research and cancer education is personal for you. Can you talk about that, please?

Dr. Mark Fleming: 1:33

Yes, well, I woke up every morning to hear "Get up and be somebody. Those are the words of my father. So when I was growing up, that's what I heard, just as I tell my kids, do what you have to do before you do what you want to do. Those little sayings that your parents give you go a long way. And that was my father saying get up and be somebody.

Dr. Mark Fleming: 1:54

And I lost my father to prostate cancer. So I didn't know it at the time when I had chosen my path to become a prostate cancer researcher. I didn't know my father had prostate cancer and I think it goes to that generation of parents who did not necessarily share things with their children. Hopefully, that will change. And I think that gets to why men don't necessarily get tested because there's a stigma. They've heard the doctor might do this, and the doctor might do that. But at the end of the day, if you want to take charge of your health, you want to be in control of your health, then you need to proactively get tested. Especially in African-American men, because there's a disproportionate amount of more aggressive as well as early onset of prostate cancer in African-American men.

Cheryl: 2:39

I'm so sorry for your loss, Dr. Fleming. As we were talking earlier, before sitting down to do this podcast episode, we were talking about the prostate-specific antigen test, and how you're noticing fewer men getting that test.

Dr. Mark Fleming: 2:55

Yeah, it's unfortunate. I think that primary care physicians, which my father was, have a very tough job, and I think that they got the wrong message that it doesn't benefit men. I wish we had something better, but it does impact diagnosing men earlier when they're potentially curable. So there are no symptoms of prostate cancer. You can't palpitate a lump like a woman might with breast cancer. You might not see blood in your stool like someone with colon cancer, and that's why you have to be proactive in a disease that might not have any symptoms.

Cheryl: 3:35

And you mentioned it earlier, that once detected, most prostate cancers, if they're found early, men have an excellent chance of survival.

Dr. Mark Fleming: 3:40

Absolutely, so the treatments for early localized prostate cancer vary widely. You can monitor it depending upon if your disease is not that aggressive. There's surgery, there's radiation. There are different types of radiation therapy: brachy therapy, therapy, external beam radiation therapy, and proton therapy is a type of radiation therapy. There are multiple options for men, and I usually give the analogy that the treatments for localized prostate cancer are like my wife's closet of black shoes. And that is that she doesn't necessarily go in her closet and say this is the best shoe, it's the right shoe for the right occasion. So it might be for someone, depending on If you're 83 years old and you have other issues, surgery is probably not going to be the right answer for you. So wearing heels to go to the soccer game might not be the right approach. And so we have varied options for men with both localized disease as well as advanced disease.

Cheryl: 4:39

I like your analogy with the shoes.

Dr. Mark Fleming: 4:40

Yeah.

Cheryl: 4:41

Very appropriate, and I know that your focus on prostate cancer and bladder cancer is personal, but it also means you go out of the area to bring treatments back home, back to Virginia Oncology Associates. Can you talk a little bit more about that?

Dr. Mark Fleming: 5:00

Yeah. So you know, in my effort to get up and be somebody, my role was to build a world-class genito urinary program here locally. You know my kids only know Virginia as home. I go to church here and so this is home to me. So being able to bring the latest and greatest technologies is awesome. You know, and we've done that and we're not done. I think there are more opportunities. We've gone into diagnostic testing, which I had never gone into before, finding the more effective tests to be done. And I think also when you look at genito urinary cancers, collaboration;

Dr. Mark Fleming: 5:41

I just love working with my colleagues, especially from Urology of Virginia and TPMG Urology, because they believe in collaboration. And they're collaborating with me, even though we have a different tax ID to say, at the end of the day, we want the best for our patients. And that's what it's about, you know. Healthcare is very competitive and I would challenge anyone, "Are you offering the same type of programs that we're offering here?" And I'm very proud of that? And I know there are some health systems that don't refer to me and I take that personally and I know that you are not serving your patients.

Dr. Mark Fleming: 6:18

The reason why I'm so passionate about that is this, my father was a primary care physician and I grew up in Cleveland. I won't say the name of the institution that he did not like because he was a community doctor. And he did not want to go to that institution because they didn't have an emergency room. They did not put themselves out to the community. They're a first-rate facility. He was with his local urologist, but his local urologist, as empathetic and compassionate as he was, wasn't offering the latest and greatest treatments. I had to convince my father, who had years of I don't want to go to that institution, dad, you need to go there because they're offering new, novel therapies and, quite frankly, I wanted him to be a round as long as possible.

Cheryl: 7:06

Absolutely. Dr. Fleming, I know you take pride in offering the latest in medical advances to patients at Virginia Oncology Associates. How did you get started on this path?

Dr. Mark Fleming: 7:16

I personally have been involved with three or four new drugs or new technologies that patients get earlier. One of my favorite stories is, and I'll never forget this story. I'm a married man, and my wife Rolanda. We had a young daughter and it was just the two of us. We had no family. We didn't have any aunts or uncles. We didn't have any grandparents to watch her. So when she was born I was trying to build my career.

Dr. Mark Fleming: 7:43

I'm an ambitious guy and I remember my wife was working. She had to travel and I said, "I need to go to Orlando. She looked at me on the way a wife can look at her husband and say, well, why do you need to work again? And I basically said I really need to go to this because there's this new drug, enzalutamide, that it is the hot new drug for prostate cancer, and I just have to go." I got to talk to Mohammad Urmidt and I need to get on this trial so I can bring it home to Virginia Oncology. I go to Orlando. It was a big ASCO meeting, the American Society of Clinical Oncology, and I met with him and I begged and pleaded. "I will put people on this trial. I got lots of patients. I saw the excitement in this drug I can accrue these patients. Just to make a long story short is I was one of the highest accruers on the trial.

Dr. Mark Fleming: 8:46

I was on the New England Journal of Medicine paper, which is almost unheard of for a community physician, being in the New England Journal of Physician and I had patients who were on that trial. The very first patient, I'll never forget, he was a teacher. The therapy at that time was a chemotherapy. He progressed on that like I'd never seen anybody. It's like I gave him water. He did not respond whatsoever. And so at that time, this is 2008, we only had one alternative, an FDA-approved drug, and I had this clinical trial. It was a placebo trial because we didn't have a standard of care. So he could either get nothing or this new drug Enzalutamide. He said, "I don't want to do a placebo trial". I don't normally say things like this, but I said to him that If you take the standard of care, you'll be dead in three to four months. Wow, because he was going to progress. If he didn't work with my best drug, it's not like he's going to respond to the next thing.

Dr. Mark Fleming: 9:45

He had his legs swollen. So if you put your legs together. I want everyone to put their legs together. His left leg was swollen twice the size of his right leg. It was because he had lots of lymph adenopathy left-hand his side. And he gets started on the trial. Within a week's time, his left leg decreased to the size of his right leg. Amazing, it was amazing. I'd never seen anything like it and I didn't know if he was getting the active drug or if he was getting the placebo. And we all believed that he was getting the active drug.

Dr. Mark Fleming: 10:18

I remember I went to talk to the makers of this drug and I was the happiest person in the world. My patient was responding. He went back to work. So he had to quit his job and then he was able to go back to work because of a clinical trial and he did great. He had advanced metastatic prostate cancer. Where I had one time told him he was going to live a few months, he lived a few years after that fact. He was able to enjoy quality of life following that. So that drug was FDA-approved, and so that's why it matters where you go for your care.

Cheryl: 10:50

Just you sharing your story about picking up and going to other states, other areas, to bring treatments back here should be a message to people listening; to caregivers who have relatives who maybe are dealing with this disease themselves. There are more new treatments recently than there were 20 years ago.

Dr. Mark Fleming: 11:12

For prostate cancer. There's a new treatment and it really began with new technology what's called PSMA PET scan, so prostate-specific membrane antigen. And there was a new treatment, Pylarify is the brand name. But the imaging, if I were to show you a picture of a PSMA PET scan, versus a usual CT scan or bone scan, the conventional imaging, the accuracy that we can get with that study, is that much better. So we can find disease earlier, we can find metastatic disease earlier and we can be more intensive with our treatments. So we did a trial with a next-generation PSMA PET scan, an RH PSMA PET that recently got FDA- approved, to which I don't want to be biased, but it appears to be better based upon, even more effective of doing that. So we're finding better ways to find cancer. We're utilizing genetic or genomic testing.

Dr. Mark Fleming: 12:18

So in this past year, there have been two new combinations that have been approved for prostate cancer. Again, that's what my area of focus is. So that drug I told you about, enzalutamide, which was approved back, I think, 2009. Now, combining that with talazoparib, a drug that's called a PARP inhibitor, which targets the 10% of men that have a DNA repair mutation; the most common being a BRCA mutation. So what men should hear, like myself, I should get genetic tested because I can find out, if I am at higher risk. And we can do that with blood and saliva, so something that's relatively noninvasive. But we now have treatments to target that. So that combination was recently approved; enzalutamide and talazoparib, as well as another combination, abiraterone plus olaparib.

Dr. Mark Fleming: 13:15

So again, moving technologies or treatments that we knew worked for advanced disease, moving it earlier. The other combination, and I'm very proud that we were one of the leading accruers, is using lutetium earlier on. So we know lutetium, which is a PSMA radioligand that targets prostate cancer cells. So men with advanced disease tend to have PSMA on their cancer cells, about greater than 90%. And now we have a treatment that has less side effects when compared to chemotherapy.

Dr. Mark Fleming: 13:53

We know that it works after chemotherapy. We did a trial. We're waiting on the results we reported at ESMO, European Society of Medical Oncology, in late October to know that that treatment is available early on. Well, I have colleagues. There'll be colleagues in the community, who will when that drug comes out, they'll have it. But we have years of experience because we've been using that drug. We participated in that trial and we'll continue to continue trials because that's the first wave. And I think of treatments as kind of our cell phone. So there's 1G, 2G. I think we're up to 5G. And if you look at 5G and what your phone can do now versus what it did when the cell phone just came out is different. The same thing happens with technologies that treat cancer care.

Cheryl: 14:41

Yeah, leveling up. We talked a little bit about genetic testing earlier, but I think it's important to really focus on this point. When should someone get genetic testing for prostate cancer? Who's the right person? Who should be listening to this and saying I need to get this?

Dr. Mark Fleming: 14:56

If you have a family history of prostate cancer, you should engage in the early detection of prostate cancer. I would suggest that age 45 would be for African-American men or someone with a family history. They should begin to start looking at using PSA as kind of the first indication. With regard to genetic testing, it's really, in my opinion, when someone is ready. If they're interested, that's why there are genetic counselors. And we have genetic counselors here who can guide someone through yay or nay. Because if there's no clear indication to do it, your insurance company might not cover it. There are clear indications. You have a family history, if you have cancer, that it will quote, be covered. But I'm from the school of if you want to be active in your health, why not ask the qu estion? We've now evolved to the point, where you used to have to get referred, but now our genetic counseling program, people can come and talk to our genetic counselors to find out if they're the right person.

Cheryl: 16:02

For patients or their families who want to do a little bit of homework before coming to see you, before getting a test, or before anything; where would you direct them to go?

Dr. Mark Fleming: 16:12

I think there are national sources and there are local sources. I would say nationally, the Prostate Cancer Foundation, NCCN Guidelines, National Comprehensive Network Guidelines are specific for patients. And locally, the Hampton Roads Prostate Health Forum. Full disclosure that you know I'm one of the founders of that organization and past president, but it is very patient-centric and partner-centric.

Cheryl: 16:40

Are you finding that patients are more educated before they come to you and as they have more information, they want more things and more treatments early?

Dr. Mark Fleming: 16:50

I do so. There are patients who are very well informed and they read about different aspects of prostate cancer. One of the things I have to do is place it in its clinical context. So my mentor, Howard Scher, had the clinical states model: Is your disease localized? Is there a disease, what we call the rising PSA clinical state, that we can't find the disease, but we know that the disease is returned because the PSA is rising? That's when we have better imaging techniques like the PSMA PET scans. That's very helpful in recognizing disease earlier.

Dr. Mark Fleming: 17:29

Commonly, as a medical oncologist, I get involved with metastatic disease and there's really kind of what's called hormone-sensitive metastatic disease and castrate-resistant metastatic disease. Hormone-sensitive metastatic disease is really when someone's initially diagnosed and unfortunately, their disease is advanced. Though they have, quote stage four disease, they'll live with this disease for many, many years. A much, much different disease than someone who has been on hormone therapy, which is the initial treatment to lower testosterone level levels treat your prostate cancer. One of the things we've made advances in getting is back to the concept of when we utilize new drugs in most advanced disease and we now know when we intensify early onset disease in metastatic setting, we know patients do better. We're now incorporating systemic strategies, chemotherapy, what we call antigen receptor targeted therapy, as well as genomically tested therapy, and also radiation therapy. So we're combining. It's really a multidisciplinary field of medical oncology, urology, radiation oncology, and we should never forget the primary care physician. Primary care physicians are very valuable. They can manage side effects and assist me and, when necessary, we can get palliative care involved.

Cheryl: 18:50

Anything else you'd like to share, Anything that is on your heart. As you study this, you work with patients dealing with prostate cancer, bladder cancer. What do you want to say?

Dr. Mark Fleming: 19:02

It's a multidisciplinary field, and so I believe that your partner, spouse, family member, primary care physician, urologist, radiation oncologist, medical oncologist; that the best optimal care in the future will be when all those people are working together towards helping you if you are diagnosed with this disease, and for groups that are doing multidisciplinary care, they're ahead of the curve.

Cheryl: 19:31

Dr. Fleming, thank you.

Dr. Mark Fleming: 19:32

Thank you.

Speaker 1: 19:37

That's all for this episode of Cancer Care Connections. Stay tuned for our next episode, where Cheryl will be talking with Dr. Christopher Paschold, oncologist hematologist for Virginia Oncology Associates. They will discuss how lung cancer screening helps catch the disease early, which increases the chances for a long-term positive outcome. Don't forget to subscribe to our podcast via Apple Podcasts, Spotify, or anywhere podcasts are available, or listen online at cancercareconnections. buzzsprout. com. Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information, visit us at VirginiaCancer. com or find us on Facebook or Instagram at Virginia Oncology Associates.