Great American Smokeout: The Link Between Smoking and Prostate Cancer With Stephen Freedland, MD

Oncology Data Advisor: Welcome to Oncology Data Advisor. Today, we're having this interview in honor of the Great American Smokeout^®, which is a day for raising awareness around smoking and sharing resources for people who are trying to take the first step towards quitting. The aspect of this that we're focusing on today is the link between prostate cancer and smoking, and here today to talk about this is one of our Editorial Board members, Dr. Stephen Freedland. Thanks so much for coming on today.

Stephen Freedland, MD: Well, it's great to be here, and I'm looking forward to it. Thanks for having me.

Oncology Data Advisor: To start off, would you like to introduce yourself and share what your research focuses on?

Dr. Freedland: I'm a Urologist at Cedars-Sinai Medical Center in Los Angeles, as well as at the Durham Veteran Affairs (VA) Hospital in Durham, North Carolina. My research is very much focused on prostate cancer and several different aspects of that, but one of the things that we focus on is how lifestyle factors—diets and exercise, but also smoking—may actually link with prostate cancer and what we can do about it and change our lifestyle to improve our health.

Oncology Data Advisor: For a little bit of background, how has smoking historically been viewed in relation to prostate cancer? Is there any more controversy compared to other types of cancer?

Dr. Freedland: Yes, so when we think about smoking-related cancers, prostate really doesn't come to mind. I mean, certainly we think about lung cancer and other types—bladder cancer, urological, even kidney cancer to a degree—but prostate hasn't really made the list traditionally. That's where I think some newer research suggests that it probably should be making the list.

Oncology Data Advisor: What is some of this research that suggests a link between smoking and prostate cancer?

Dr. Freedland: There have been several studies over the years that have kind of pointed to that link, but I think one of the things that's really unique about prostate cancer is, first off, it's extremely common. The second thing is that most often, it's diagnosed via blood test. It's not that you have symptoms and you're coughing up blood or something—it's a blood test, which is a prostate-specific antigen (PSA) screening test. Based upon that, then we'll do further evaluations, ultimately a biopsy, and diagnose the cancer. Smokers are less likely to get the blood test or less likely to follow up once they get it. We may actually be missing some of the cancers.

That was some of the research that we did several years ago involving a trial of men trying for prostate cancer prevention—they were on a drug or a placebo for four years to try and prevent prostate cancer. It's the only way we know if this drug works, is to ultimately do the biopsies. Men who were smokers were less likely to get the biopsy. So, that was one of the first clues that we may be missing these cancers. When we looked at the men in that study that actually did have a biopsy, it showed that smokers were more likely to have aggressive prostate cancer.

There have been studies done by several different groups, including ours now, that have actually linked smoking with aggressive prostate cancer, including prostate cancer death. So, we don't think smoking's necessarily related to the risk of getting prostate cancer, but it does seem to be linked with the risk of dying from prostate cancer.

Oncology Data Advisor: Is there any additional research underway to further investigate this link?

Dr. Freedland: Yes, so we just got some funding from the state of California—which we're very appreciative of—and we're starting to look at this in the VA health system. We're really looking at understanding the links that are going on, because this link with more aggressive cancer, maybe it's because they're being delayed in the diagnosis. For the same reason we may see fewer cancers, we may actually see more deaths. So, we're trying to explore those. What's the likelihood of getting the blood tests in the first place? What's the likelihood of being referred to the urologist and getting a biopsy? How are their outcomes? We're really trying to tease that out.

At the same level, people are starting to look at the genetics in terms of the genes that are active in the tumor of smokers versus non-smokers to really understand, at the biological level, what's going on within the tumor. So, I think there are a number of different groups trying to answer and really tease out what these associations are. But again, there is this increasingly clear link between smoking and death from prostate cancer.

Oncology Data Advisor: In light of this data, how do you suggest that clinicians counsel their patients who are smokers?

Dr. Freedland: It's a great question; it's a tough question, because there are many, many reasons to not smoke in the first place, and if you are smoking, to stop. Do we really need yet one more cancer that's linked with smoking to force people to quit? If they haven't quit from everything else, is this going to be the one? It's hard to know, but I do think it's certainly more data that smoking is not good for us. So, you can just add one more thing to that list when clinicians talk to their patients.

For some patients, prostate cancer is particularly concerning. It's a very sensitive organ of the body. It's located next to even more sensitive organs within the body. Many of our treatments can have significant side effects, including problems with erections, hormonal therapy, and castration therapy, which is common treatment for prostate cancer. Certainly, these are things that most people would want to avoid. So, I think one way we can try to avoid all those side effects of treatment, including the advanced treatments and their side effects, is to not smoke, and if you are smoking, to stop. So, I think it helps tell a richer story, but I think there's a pretty rich story even without prostate being on the list.

Oncology Data Advisor: So, along those lines, for patients who are considering quitting smoking and taking that step, are there any resources you recommend that clinicians can share with them?

Dr. Freedland: Yes, the American Cancer Society and the American Lung Association have some wonderful resources. I'm not a tobacco expert, coming from the urology point of view, but there are some data. It's amazing to see the power of suggestion and the power that clinicians have, to even say, "Hey, are you smoking? You should probably stop. It's not good for you." There's actually data that there are some patients—it's obviously not the majority—but there are situations where, by simply doing that five-, ten-second, "Hey, you really should stop. It's not good for your health," there are patients who actually stop from that. So, I think as clinicians, we need to be mindful of patients out there that are struggling with this. Again, there are a lot of resources—the American Cancer Society, the American Lung Association—there are resources out there. There are medications that people can take to help during that transition period, because there is a physiological addiction. It's not that you're weak, you can't do it. There's biology there. So, we have medications that can help overcome some of that biology and help patients transition to being tobacco-free.

Oncology Data Advisor: Great. As we wrap up, is there anything else that you'd like to mention in honor of Great American Smokeout or your research in this area?

Dr. Freedland: No, I think it's part of the overall being healthy. When we look at ways to prevent cancer, it's, don't become obese, make sure you exercise, eat right—though we all debate what "eat right" means—but don't smoke, and drink in moderation. They all kind of go together. So, I think it's part of a global recommendation to get healthy, exercise, lose some weight. With smoking, there are really not any health benefits to it. So, it's really something that shouldn't be nearly as widely taken up as it is.

Oncology Data Advisor: Great. Well, this is great to hear about your research in this field and some ways we can raise awareness in honor of the Great American Smokeout. Thanks very much for coming on today to share all of this.

Dr. Freedland: Thanks for having me, and thanks to the listeners for listening in.

About Dr. Freedland

Stephen J. Freedland, MD, is Director of the Center for Integrated Research in Cancer and Lifestyle and Associate Director for Education and Training at the Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute. He also is the Warschaw Robertson Law Families Chair in Prostate Cancer and a Professor in the Department of Urology at Cedars-Sinai in Los Angeles. Dr. Freedland also holds a Staff Physician appointment at the Durham VA Medical Center in Durham, North Carolina. Dr. Freedland has published over 700 articles and served on numerous American Urological Association and American Society of Clinical Oncology guideline panels for prostate cancer. His research interests include the role of diet, lifestyle, and obesity in cancer, cancer health disparities, and cancer risk stratification.

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Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.