This edited transcript accompanies a previously recorded educational consultation with Dr. Hyung Kim. Professional actors portray the patients. Punctuation, paragraphing, speaker labels, and clear caption errors have been edited for readability; repetitive filler has been removed. It is not a word-for-word transcript. Timestamps link to the recording. Recommendations and numerical estimates reflect the recorded example and should not be applied to an individual patient.
Watch the original consultation video · All consultation videos
0:12 — History, symptoms, and family history
Dr. Kim: Nice to meet you. I have reviewed your records. How can I help today?
Patient: I was recently diagnosed with prostate cancer, and I would like to know the next steps.
Dr. Kim: Let us review the information. Has anyone in your family had prostate cancer?
Patient: My father was diagnosed in his 60s and my brother in his 50s. My father had surgery and radiation. My brother is on active surveillance. Unfortunately, my father died of prostate cancer despite treatment.
Dr. Kim: Thank you for completing the urinary and sexual function questionnaires. How often do you wake at night to urinate?
Patient: At least three times.
Dr. Kim: Have you been treated for an enlarged prostate, with medicines such as Flomax, Uroxatral, or finasteride?
Patient: No, I have not taken medication for it.
1:42 — Why prostate cancer decisions can be difficult
Dr. Kim: Before discussing your Gleason score, I want to explain why prostate cancer management can be controversial. There are debates about PSA testing, whether a detected cancer needs treatment, and whether surgery or radiation is the better option.
Many older men have prostate cancer that never becomes the cause of death. Some cancers grow slowly enough that a person dies with the disease rather than from it. At the same time, prostate cancer can be deadly. It is the second leading cause of cancer death in men after lung cancer.
The challenge is distinguishing a potentially dangerous cancer that needs treatment from an indolent cancer that can be monitored.
3:23 — Understanding the Gleason score
Dr. Kim: Your Gleason score suggests high-grade cancer. A pathologist examines the tumor under a microscope and assigns grades to its growth patterns. In the grading description used here, the patterns range from 3 to 5, with 5 being the most aggressive. The most common and second-most common patterns are added to give the Gleason score. If there is only one pattern, the two numbers are the same.
The Gleason scores range from 6 to 10 in the system described here. I describe 6 as low-risk and generally monitored; 8 to 10 as high-risk and usually treated in younger, healthier patients; and 7 as intermediate, with the plan depending on other factors.
4:43 — An example prediction without treatment
Dr. Kim: Before this visit, I entered your information into a nomogram, a mathematical model that estimates outcomes. This is a model I developed, peer-reviewed and published in a cancer journal, that predicts what may happen without treatment.
In this example, I enter age 56 and a Gleason score in the 8-to-10 category. Assuming an American man of average health, it estimates a life expectancy of about 15 years, to age 71, and about a 40% chance of eventually dying from prostate cancer rather than another cause.
Patient: That is below 50%?
Dr. Kim: Yes. People are sometimes surprised that even with a high-risk cancer, the chance of dying from another cause may be greater. But 40% is still a substantial risk, and treatment may lower it.
6:24 — Stage and the goal of treatment
Patient: Does that help stage the cancer?
Dr. Kim: Stage describes how far the cancer has grown or spread from where it began. We use information such as imaging to assess that. Your bone scan and MRI show no evidence of spread, so we would treat you with the goal of cure.
PSMA PET scans and prostate MRI are the more modern imaging studies used for staging.
7:12 — Surgery and radiation options
Dr. Kim: The two main treatments discussed here are surgery and radiation. Radiation can be given from inside the prostate with radioactive seeds or from outside the body, called external-beam radiation. I am a surgeon, so I would like you to meet a radiation oncologist to hear more about that option.
Patient: Which is more effective: radiation or surgery?
Dr. Kim: In the studies discussed in this recording, cancer control with either treatment alone appears similar, but the side effects differ. As a surgeon, I may have a bias toward surgery, so it is important that you hear the radiation oncologist’s perspective. I will explain what I consider advantages of surgery, while recognizing that radiation also has advantages.
8:49 — An example surgical nomogram
Dr. Kim: Another model, the Memorial Sloan Kettering nomogram, estimates what might happen with surgery. We would remove the prostate and the seminal vesicles, the two glands shown here.
The model estimates a 63% chance that the cancer is growing outside the prostate. That can still be removable if we take a wide enough margin. It estimates a 10% chance of involvement of the seminal vesicles and an 11% chance of spread to pelvic lymph nodes. Lymph-node involvement can make treatment more difficult.
In this example, I describe a 42% chance of being cured by surgery alone. That means 58% may need additional treatment.
10:29 — Additional treatment and treatment sequence
Dr. Kim: If surgery alone does not control the cancer, radiation may be recommended. In this recording, I describe the radiation dose after surgery as lower than the dose used when radiation is the primary treatment.
I also suggest substituting radiation for surgery in the 42%/58% example because the treatments were described as similarly effective.
One reason I favor surgery first in this discussion is that surgery after radiation can have higher risks. Radiated tissue may be scarred and heal less well. In the recording, I describe those risks as approximately fourfold higher and suggest multiplying the surgical risks by four.
Patient: Are those side effects erectile dysfunction or urinary problems, such as needing pads?
Dr. Kim: Those are important questions, and we will discuss them.
12:16 — Illustrating a possible course of treatment
Dr. Kim: Returning to the example, I describe radiation as controlling the cancer in about half of the 58% not cured with surgery alone. That leaves roughly 29% cured after additional radiation and 29% still needing further treatment.
For that latter group, I discuss hormone treatment. Prostate cancer uses testosterone to grow. Lowering testosterone can slow or control its growth, even when it does not cure the cancer. In this recording, I describe the possibility of controlling it for about ten years in some cases, during which some men may die of another cause.
I then estimate, using this simplified sequence, that the chance of dying of prostate cancer could fall from about 40% without treatment to about 15% with treatment, with more than half needing radiation and almost 30% needing hormone treatment. I relate the residual risk to aggressive disease, including lymph-node involvement.
[Editorial note — the 40%→15% calculation and the 42%/58%/29% sequence are statements from the example recording.]
Reducing risk comes at a cost: treatment side effects. That is an important part of deciding what is right for you.
14:32 — Urinary control after prostate surgery
Dr. Kim: Let me draw the anatomy. The bladder sits above the prostate. The urethra runs through the penis and carries urine out. Urinary sphincter muscles help hold urine in the bladder and relax to let it out.
After the prostate is removed, we reconnect the bladder to the urethra. A Foley catheter drains the bladder while that connection heals. In the plan described here, you go home the next day with the catheter and return in about two weeks to have it removed.
In this recording, I describe immediate urinary incontinence after catheter removal as occurring in everyone, or 100%, because one part of the continence mechanism has been removed and the remaining muscle needs to compensate.
We teach Kegel exercises to strengthen the pelvic floor muscles. Control often improves over three to six months and may continue improving for up to 18 months. I quote persistent minimal leakage in 5% and moderate leakage in another 5% after 18 months.
Patient: Does incontinence mean continuous, uncontrollable leakage?
Dr. Kim: It may mean leaking a little urine when you cough, sneeze, or bear down and increase pressure in the abdomen. With minimal incontinence, one pad may last all day. Someone may still work, exercise, or play golf but not be completely dry. This is sometimes described as being socially continent.
With more significant incontinence, someone may use two or three pads a day. Carrying supplies and worrying about leakage through clothing can affect quality of life. There are additional operations that may improve significant persistent leakage, but they involve further surgery.
18:01 — Erections, nerve preservation, and individual recovery
Dr. Kim: Another important risk is erectile dysfunction. The nerves for erections run alongside the prostate. When it is safe, we separate and preserve them. Sometimes that is not possible because of the cancer’s location.
Even when preserved, the nerves can be affected by surgery. In this recording, I describe immediate erectile dysfunction as occurring in everyone, with recovery taking 12 to 24 months. For someone starting with normal erections and with nerves preserved on both sides, I quote recovery in about 80%, with about 20% not recovering.
Age-related changes and pre-existing erectile problems also affect recovery. I explain that careful nerve preservation cannot guarantee that erections will return.
Similarly, recovery of urinary control depends partly on patient factors and the strength of the remaining continence mechanism, not only on surgical technique. There are things the surgeon can do to reduce side effects, but individual factors matter too.
Patient: Would this cause bowel incontinence too, or only urinary incontinence?
Dr. Kim: The side effects we are discussing with surgery primarily involve the urinary system. Radiation can also affect the bowel.
20:15 — Open and robotic prostatectomy
Dr. Kim: Traditionally, an open prostatectomy was performed through a midline incision below the belly button. Many procedures are now performed robotically through small openings.
There is a lot of advertising around robotic surgery. In this recording, I say that when either operation is done well, cancer control and recovery appear similar. I perform prostate cancer surgery robotically because of the visibility and comfort for the surgical team.
Patient: Does robotic surgery help me heal more quickly?
Dr. Kim: In the comparison described here, postoperative pain, hospital stay, and recovery are about the same. One consistent finding is less blood loss with robotic surgery, though a better overall recovery is not seen consistently in every study.
Patient: Can nerves be spared better robotically?
Dr. Kim: An experienced open surgeon can also preserve the nerves well. The surgeon’s experience matters.
To review the decision, we are weighing a possible reduction in cancer risk against the risks and side effects of treatment.
22:32 — Molecular testing and research discussed in the recording
Dr. Kim: I would also like to explain the clinical trials that were available when this consultation was recorded.
One trial used existing biopsy tissue for molecular analysis, looking at genes expressed in the tumor. We would not need to take additional tissue. Just as a Gleason score helps classify risk, a molecular profile may provide more information. Often the results agree, but sometimes they differ. For someone deciding between treatment and active surveillance, that information may be useful.
In this recording, I describe a trial evaluating a new molecular test with testing provided without charge, as well as commercial tests that a patient or insurer might pay for. I also describe a high-resolution MRI study for patients choosing active surveillance and say that its resolution is nine times that of a standard MRI.
24:17 — HIFU and mapping cancer in the prostate
Dr. Kim: Another trial discussed here uses HIFU, which stands for high-intensity focused ultrasound. A probe is placed in the rectum and focuses ultrasound energy on a small area of prostate tissue, heating and destroying it without an external incision. Moving the probe allows treatment of part or all of the gland.
The study described here asks whether we can treat only part of the prostate. In this recording, I suggest that whole-gland ablation may offer less advantage than removing the prostate, but that partial-gland treatment might control cancer while avoiding some prostatectomy side effects.
The challenge is knowing where all the cancer is so that we do not leave untreated disease. To create a more detailed map, we combine an experimental high-resolution MRI with PET/MRI, which provides molecular information, then target abnormal areas with MRI-ultrasound fusion biopsy. The pathology and imaging help us map the prostate.
In this example, the biopsy shows cancer in the left lobe. If repeat mapping confirms that the relevant cancer is confined to one side, that side could be treated with HIFU in the trial, a process called hemi-gland ablation.
27:03 — Diet, supplements, and exercise
Patient: Can diet or nutrition help with these treatments? I have read about supplements online.
Dr. Kim: There are things you can do to support your health during treatment. As a general rule in this recording, I caution against relying on supplements in pill form. Some early studies suggested benefits, but larger randomized trials, using placebos for comparison, did not always confirm them and sometimes found harm.
For example, I discuss vitamin E increasing rather than decreasing prostate cancer risk and selenium not reducing that risk, with concern about diabetes. The point is to obtain nutrients through food in ordinary food quantities rather than assume that high-dose supplements help. I recommend a heart-healthy diet and exercise.
In this recording, I describe interval training and suggest briefly increasing the heart rate, resting, and repeating two or three times over about ten minutes. I say it has been associated with better prostate cancer outcomes.
29:24 — Causes, family risk, and focusing on next steps
Patient: Was there something I did that caused this? Could I have prevented it, or am I still doing something that causes cancer?
Dr. Kim: Some cancer risk is linked to inherited genes, and some is linked to environmental exposures. Smoking and lung cancer are an example of an environmental association. Prostate cancer probably involves both inherited and other factors.
Your father and brother had prostate cancer, and your father died from it. That family history is important when considering your risk. The environmental causes of prostate cancer are not completely understood. Rather than blame yourself for something in the past, focus on understanding your options now.
Speaking with me is part of that work. You should also speak with a radiation oncologist, and I encourage other surgical opinions if they help you process the information. Hearing a consistent message from specialists can help you decide.
30:55 — Race, family history, and screening
Patient: I have heard that African American men are more likely to get prostate cancer. Is that true?
Dr. Kim: In this recording, I discuss higher rates of diagnosis and high-grade disease among African American men and the roles that biology and access to care may play. I also discuss potential benefits of screening in higher-risk groups.
Patient: Given my father and brother’s history, should men in my family be screened? At what age should they start?
Dr. Kim: In the guidance cited in this older recording, I describe an American Urological Association recommendation for screening men aged 55 to 69 every other year, with consideration of earlier screening for higher-risk men. Screening should be on the radar for men in your family because of the family history.
32:13 — Radiation consultation and second opinions
Dr. Kim: Do you have other questions?
Patient: You have answered most of the ones I wrote down. Can you refer me to a radiation oncologist?
Dr. Kim: Absolutely. We can refer you to someone who specializes in prostate cancer. After hearing about radiation and speaking with a surgeon, you will be better placed to decide how you want to proceed.
Patient: Is it appropriate to have several consultations or get more than one opinion? Will every physician give the same information?
Dr. Kim: Second opinions are appropriate. Three types of specialists care for prostate cancer: urologic surgeons, radiation oncologists, and medical oncologists. In the localized-disease discussion here, surgery and radiation are the main local treatments. A medical oncologist can also contribute another perspective. We have a multidisciplinary clinic where patients can meet all three.
33:52 — Choosing an experienced surgeon
Dr. Kim: When considering surgery, look for someone with relevant training and experience. In my case, after residency I completed fellowships in minimally invasive surgery and oncology, and my practice focuses on urologic oncology.
Patient: I understand you have performed this surgery many times. Can I feel confident that you are experienced?
Dr. Kim: You should ask anyone who may operate on you about their experience, and you should not feel shy about it. In this recording, I describe having performed hundreds of these procedures. Experience matters, but patient factors still affect whether urinary control and sexual function fully recover.
Patient: Thank you.
Dr. Kim: It was a pleasure meeting you. Please contact me with questions. I would like to help you navigate the options and decide how to treat this.
35:22 — Timing the decision
Patient: Should I have surgery sooner rather than later? Given my case and family history, it sounds as though I should act soon.
Dr. Kim: Although we have described this as aggressive cancer, in this recording I explain that prostate cancer often progresses more slowly than patients fear, and that taking time to obtain consultations can help you make an informed decision. I say that a few weeks or months to gather opinions would be unlikely to change the prognosis in the example being discussed.
I know this can keep you awake at night. Getting information and the consultations you need can help you feel more confident in the decision.
Patient: Thank you. It was nice meeting you.