On this episode of On Call for Men’s Health, Dr. Michael Lutz talks with Dr. Jason Hafron about how prostate cancer screening has changed, and why PSA should be treated as a starting point, not a diagnosis. Dr. Hafron explains that early in his career, an elevated PSA usually led directly to biopsy. Today, the process is more thoughtful. A PSA result needs context, repeat testing, risk assessment, family history, and sometimes newer tools like biomarkers or MRI.
Dr. Hafron says the goal is not just to find prostate cancer. It is to find the prostate cancers that matter. Some men need treatment. Others can be safely monitored. That is why shared decision-making is so important. Patients need a clear plan. They also need to understand what each step means, what it does not mean, and what information would change the next decision.
A major theme is fear. Some men are anxious and want every test available. Others avoid screening because they fear biopsy, treatment side effects, or simply hearing the word cancer. Dr. Hafron says the best approach is to slow the process down and take it one step at a time. Screening starts with a blood test. An elevated PSA does not mean cancer. It means more evaluation may be needed.
The conversation also covers the growing role of blood-based biomarkers like IsoPSA. These tests can help identify men who are more likely to have clinically significant prostate cancer. They may also reduce unnecessary biopsies and help communities where high-quality prostate MRI is harder to access. Dr. Hafron is careful about the term “liquid biopsy,” because these tests do not diagnose cancer or replace tissue biopsy. They help decide who may need one.
Dr. Lutz and Dr. Hafron also talk about community screening, primary care, and the need to meet men where they are. That may mean workplaces, churches, barbershops, sporting events, or mobile health programs. Prostate cancer screening can also open the door to broader men’s health care, including blood pressure, diabetes, and cardiovascular risk.
Looking ahead, Dr. Hafron is encouraged by artificial intelligence, PSMA PET imaging, better biomarkers, advanced therapies, and research that brings clinical trials closer to patients. He believes the future depends on collaboration, better communication, and systems that help physicians provide consistent, high-quality care.
(00:00) Intro
(02:01) Why Dr. Jason Hafron Focused on Prostate Cancer
(03:23) How the PSA Conversation Has Changed
(06:34) Shared Decision-Making in Prostate Cancer Care
(08:31) The Role of Family in Treatment Decisions
(10:17) Managing Anxious and Avoidant Patients
(13:35) New Tools Between Elevated PSA and Biopsy
(15:51) Fear, Blood Tests, and the Limits of “Liquid Biopsy”
(17:45) Rethinking the Digital Rectal Exam
(19:28) Clinical Pathways and Quality of Care
(20:28) Helping Patients Navigate Online Information
(21:46) Blood-Based Tests and MRI Access
(23:43) Community-Based Screening and Men’s Health
(25:29) Primary Care’s Role in Early Detection
(27:32) What Urologists Need Before Referral
(33:47) AI, PSMA PET, and the Future of Detection
(38:32) What Gives Hope for Prostate Cancer Care
(41:42) New Therapies Beyond Hormone Treatment
(45:56) Balancing Work, Family, and Wellness
(47:22) Legacy, Systems, and Better Urology
On Call for Mens Health - Dr Jason Hafron - PSA on PSA Version
Speakers: Dr. Michael Lutz & Dr. Jason Hafron
[Intro Playing]
Dr. Michael Lutz (00:07):
Welcome to On Call for Men's Health, a PSA on PSA, and I'm Dr. Michael Lutz. After decades in urology, I've seen how a single blood test, a difficult conversation, or the right next step can change the course of a man's life.
And if there's one thing I've learned, it's that prostate cancer detection is not as simple as one test or one number. It requires judgment, context, communication, and increasingly better tools to help us make better decisions.
In this series, I'll be joined by colleagues and leaders in men's health for honest conversations about how we can improve prostate cancer detection and care from access and awareness to emerging technologies, and the future of testing. So, consider this, our PSA on PSA, a public service announcement about what physicians, patients, and communities need to know now. And this is On Call for Men's Health.
And today, we have Dr. Jason Hafron joining us. He attended Loyola University Medical School, following which he performed a residency at Montefiore Medical Center, and then a urology fellowship at the Cleveland Clinic.
He presently serves as a chief medical officer and medical director of clinical research at the Michigan Institute of Urology, and he is a professor of urology at the William Beaumont School of Medicine at Oakland University. But most importantly, he has served as a member of the board of directors at the Michigan Men's Health Foundation, which I'm exceptionally proud and excited to have this moment with Jason.
Jason, I've known you for a long time. I mean, I've known you going back to 2008. In fact, I remember our first meeting, I remember the venue well, and I looked at you after our conversation for about an hour, and it was very evident to me that you were going to become a major player and leader in urology.
So, I'm just kind of curious, what's it about prostate cancer that made it become your focus?
Dr. Jason Hafron (02:01):
I think if you go back to 2008, it was just the start of robotic surgery, minimally invasive surgery. Robotic surgery offered us the opportunity to perform complex surgery with small incisions. Patients virtually stayed overnight, were able to go home faster, recover, better quality of life. So, that's what really drew me into it.
But as I matured, as I moved through my career, I was equally fascinated by the complexity of the disease, the challenge, not just how to treat the prostate cancer, but essentially determining who needs treatment, who can be safely monitored.
The other thing that turned me on to urology and prostate cancer was these long-term relationships with our patients. Prostate cancer is a long-term disease that many of these patients we've been with for 15, 20 years, starting with the screening, the treatment, the surveillance, and ultimately survivorship.
So, I think it's that combination of innovation, clinical judgment, who to treat, not to treat, and those lasting patient relationships is what really made prostate cancer my focus and continues to motivate me today.
Dr. Michael Lutz (03:12):
When you think back to those earlier days of prostate cancer screening and early detection, how has the conversation around PSA changed over the course of your career?
Dr. Jason Hafron (03:23):
It's kind of cool. It's changed significantly from residency, fellowship, and now today. I mean, early in my career, PSA was often treated as a yes or no. If it was elevated, the next step was usually biopsy. And then we entered this weird phase with understandable concern about over-diagnosis, over-treatment, which was all appropriate concern.
But unfortunately, based on some governing bodies, the response was to avoid screening altogether, and that probably was the worst thing we could have done. Today, we've evolved. Today, we recognize that PSA is a starting point. PSA is not a diagnosis, an elevated PSA does not mean you have cancer; it tells us to look more carefully at a man's individual risk.
So, the question today is not whether to simply to screen or not, but it's more about how to screen more intelligently, whom to test, whom to start, how often to repeat it, things like that. And we've really come a long way over the last 20 years.
Dr. Michael Lutz (04:27):
You just alluded to the USPSTF in other organizations and the guidelines that were changing and morphing and affecting our practice and care of patients. Have you adapted or how have you had to adapt your practice to those changing guidelines?
Dr. Jason Hafron (04:43):
I mean, guidelines don't always agree, and this is confusing for a lot of physicians and urologists. And it's even more confusing for patients because we have multiple bodies that make these statements or guidelines, and sometimes they're (in) conflict, and it's like a perfect storm for complete confusion.
What I like to follow is the AUA framework. I think they offer the best guide, and essentially, what they recommend is consider a baseline PSA around 45 to 50 and maybe begin earlier. If you're African American, you have a higher risk of strong family history, or if you have certain inherited mutations, you want to start around 40 to 45.
But after that, you want to get periodic PSA testing. And if PSA is newly elevated, what we usually go and this is what the current guidelines recommend AUA and NCCN, which are national US cancer guidelines, is that patients should get a repeat PSA test. And then if the repeat PSA test is still elevated, then they would consider adjuvant biomarker or an adjuvant PSA test, plus or minus an MRI.
Guidelines, we know this Michael, you know that they provide essentially a framework but the man sitting in front of us as an individual, the final plan has to ultimately reflect their risk, their situation and ultimately, their preferences on how they feel that they should be cared for.
Dr. Michael Lutz (06:14):
Well, I think you hit it right on the head, it's all about individualized care, and when we treat that person, everything is about that one person. We also know that things have been discussed lately about the role of shared decision making. How has shared decision making played a role with regards to screening, biopsy, or monitoring treatment?
Dr. Jason Hafron (06:34):
Yes, shared decision making is not just a cliché, it's not just a buzzword, it's reality. And I think shared decision-making is central to prostate cancer evaluation and treatment because prostate cancer is different than a lot of cancers in the sense that there's rarely one treatment. There's a lot of options or there's a lot of decisions that have to be made.
And as a physician, as a urologist, it's not just simply handing them a list of all the options that they can do; my responsibility as a urologist is to walk through each of these options, explain the evidence, explain the literature, and together, we can find a recommendation or option that fits what matters most to the patient.
So, that same conversation occurs multiple times through a patient's journey from the time that they have an elevated PSA. With the elevated PSA, do we do a biopsy? Do we follow the PSA? Do we treat? How do we treat? Do we use surgery, radiation, cryoablation, NanoKnife? We walk through this.
So, this concept of shared decision-making is really central and a key technique that is required for all urologists because ultimately, patients want a partnership. They want a partnership with their urologist, with their physician, but they also at the same time, want us to help guide those choices essentially. So, that's really shared decision-making. It's that journey between you and your physician, you and your urologist to come up what you think is the best solution or treatment for your current situation.
Dr. Michael Lutz (08:10):
So, you've really hit it on the head with the patient-doctor relationship. But there's another piece to this: it's the family. It's the family members, because we all know from our support group experience that each family member deals with the prostate cancer diagnosis in a very different way. So, what role have you seen family members play in the decision-making process?
Dr. Jason Hafron (08:31):
I think family members are critical for decision-making. Very often a spouse, a partner, is the reason a man even comes in. We know that men typically are not great patients, don't take great care of them — it's usually the spouse, the partner, or the daughter or the children that force them to go to the doctor.
But I think that second person, whoever that second person is, improves the visit because they can remember the details, write down, keep notes, ask questions that the patient may not think about and help carry that plan home. So, after the visit, that patient's partner, they can sit down and discuss it and go through it.
And it's interesting too, and I'm sure Michael, you've experienced this too, is that patients and partners focus on different things. Typically, what we'll see in our offices or in my experience, is that the patient will be focused on urinary control, sexual function, totally appropriate, while the partner may be focused more on survival, efficiency of treatment.
Both concerns are legitimate and it should be discussed together, but having that partner in the room, having that support, it really makes the physician visit or the outcome that much better. So, I always encourage patients to bring someone they trust, particularly when discussing a new diagnosis or considering a treatment that really makes the overall outcome that much better.
Dr. Michael Lutz (09:59):
The one thing we've learned in many years of practicing, is that patients are all different. They all have their own unique requirements. How do you manage that incredibly anxious patient who wants to have every possible test done versus that avoidant patient who just says, "I don't even want to know."
Dr. Jason Hafron (10:17):
I mean, that's the fun of being a physician, that's the fun of connecting with all different patients from all walks of life, and that's what I really enjoy. Specifically, the anxious patient, I think what works well is just stating the facts. More testing is not the answer. I've found it effective to have a clear plan.
If you define that plan up front with that anxious patient, you can kind of lower that temperature, lower that anxiety level, and kind of just walk them through, what we'll treat, what we'll test, when we'll repeat it, what will trigger it. So, they kind of have that roadmap and understand what to expect.
The avoidant patient is different, and I take a different approach with that patient. I kind of try to understand why they're avoiding, what are they actually afraid of? And it's not the blood test, it may be the biopsy, it may be the treatment side effects, or it could be something that a relative or their father went through many years ago. So, I really try to understand what's bothering them or what's triggering that avoidance. That really helps.
So, I think overall, whether they're avoidant or anxious, it's breaking the process into smaller steps. Today may involve a blood test, let's just focus on the blood test; tomorrow may involve a biopsy, but let's not talk about that now. Let's not talk about potentially what the biopsy results would indicate, let's just do it one at a time.
And then the other thing that we see a lot is a well-informed patient that decides not to proceed, can be very frustrating for a physician. And I see a lot of my younger partners get really angry or mad that this patient's not doing what they're supposed to do or not doing what I recommend. I think as you evolve and you get more mature in your practice; you have to respect that choice.
Obviously, you're going to document that discussion and say you went through all this, and the patient still doesn't want to do what you think is best for that patient. But I think what you evolve to is that even though the patients say not now, that doesn't have to mean never. And frequently, I'll bring that patient back in a few months or a few weeks, whatever it requires, to revisit that, and we can discuss that further down the line.
Dr. Michael Lutz (12:42):
Giving all this a little perspective, the prosthetic specific antigen or PSA blood test hasn't been here forever. In fact, it was just discovered in 1979 and wasn't really used clinically until the mid-1980s, which dates my career. And I can tell you that before PSA, the majority of men were diagnosed with metastatic prostate cancer.
And it was the PSA blood test and its implementation that changed the annual diagnoses of prostate cancer in the United States from 79,000 cases a year to over 200,000 cases a year. And things really changed rapidly in the 80s and 90s, and where it was becoming implemented as a better screening tool.
Over the past several years, you've seen more tools emerge helping us become better physicians and better understand prostate cancer risk. What innovation in detection has changed your day-to-day practice?
Dr. Jason Hafron (13:35):
I kind of started off this conversation, Michael, there's been significant innovation for the better. The biggest change is now we have useful tools from that elevated PSA until biopsy. Historically, elevated PSA equals biopsy. No longer that's an acceptable standard of care. And we've developed blood-based biomarkers that are really better than a standard PSA. They're more accurate and can better determine who needs a biopsy and who doesn't.
One of the tools that I use on an everyday basis is a blood marker called IsoPSA. IsoPSA is fascinating because it doesn't just look at the concentration of PSA, it looks at the modification of the proteins, and it can measure these modifications.
We know that prostate cancers secrete different types of PSA, not standard PSA, and again, this blood test can separate the ones that are modified by cancer as opposed to the ones that are produced by benign prostate cells.
Ultimately, what does that give us? That gives us the ability to more accurately predict of these patients with an elevated PSA who has clinically significant prostate cancer, who's going to need a biopsy, who's going to need an MRI. And it's these adjuvant type tests that have really evolved the field so that not everybody needs a biopsy, not everybody needs an MRI of their prostate.
Dr. Michael Lutz (15:03):
And the reason that's so important is because in the past, we had to use things like free-fractionated PSAs or we had to calculate the PSA density by knowing the patient's exact prostate volume. But even then, the glandular to stromal ratios were different in every prostate, so you don't really know how much PSA is being made by the benign gland.
And so, these tests are incredibly helpful in narrowing down and helping us be more accurate in predicting prostate cancer risk. That really is an important part of what we're doing and how we can be better as urologists, and better to our patients and help allay some of their fears.
Do you think fear plays a role in keeping men from getting screened in the first place? And do you think advancements in these liquid biopsy technologies can help be used to allay some of these fears?
Dr. Jason Hafron (15:51):
Yeah, definitely. I mean, fear absolutely plays a role, especially in men. But it's, again, important to understand where this fear is coming from. When these patients say they have fear, is it the examination? Is it the biopsy? Is it treatment side effects or simply hearing the word cancer? Many men are also less connected to the health care system, may not have a primary care (doctor). So, is this fear often layered upon limited access?
I think a simple blood test lowers that barrier. It's familiar, it's quick and far less intimidating than most men expect with prostate cancer screening. Secondary biomarker tests like IsoPSA are very effective, and they help men avoid unnecessary biopsies or unnecessary treatment if they've gotten that right up front after their elevated PSA.
One thing that I'm careful about is this term (and we see it a lot in the press) “liquid biopsy.” And I think the liquid biopsy is very misleading, especially to non-physicians. Liquid biopsies are not a biopsy. They do not diagnose prostate cancer; they don't replace our tissue biopsy. They basically essentially help us decide who would benefit from a biopsy.
So, I think we got to be careful when we say the word liquid biopsy, but definitely blood based technologies can make screening easier. But at the end of the day, it's trust, it's a clear conversation with the patient are still what matters most.
Dr. Michael Lutz (17:27):
I really do love these, “Just A Blood Test” campaigns. I know that Novartis did that for the halftime for the Super Bowl. And I think that there's some comment about the role of the digital rectal examination. Do you think it's outliving its usefulness, or do you think it needs to be thought of differently?
Dr. Jason Hafron (17:45):
No, I think we've moved beyond the digital rectal exam. I think this basic message just a blood test is invaluable. I think men and urologists and health care leaders like yourself, Michael, need to promote this, because at the end of the day, prostate cancer screening begins with a simple blood test.
And I think this digital rectal exam is not a strong standalone screening message, or what we've learned over the last few years is it's not really a great screening tool, and is no longer the center of our screening conversation.
So, digital rectal (exam) still has some limited role, but I think what we should message and you do a great job of messaging through the foundation is the simple message: screening starts with a blood work, it starts with a blood test. The examination, probably we don't need to talk about it because we only use it in unique situations, depending on the individual issues.
Dr. Michael Lutz (18:49):
Well, that's been our mantra this year about more life, and we really believe that through proper screenings, proper treatment, proper diagnosis, men can celebrate more life, and that's really what our goal is.
I know that your role as the chief medical officer as well as the implementation of the clinical pathways at the Michigan Institute of Urology are really important in getting urologists to be on the same page, and to perform the same care for all patients.
How do you educate and engage urologists to incorporate some of the newer diagnostic tools that we've just talked about into their practice to improve the diagnostic process?
Dr. Jason Hafron (19:28):
I'm glad you brought this up. You know what I think about pathways, and I think pathways are the foundation of quality of care. The care that I give in Michigan should be the same care that is received in Chicago, New York, and California. And that should be based on literature, it should be based on outcomes, it should be based on quality metrics.
So, I think the challenge is engaging physicians to adopt these pathways, integrate them into their practice. But I think once you've shown the data, once you've shown the outcomes and given essentially the why, why this is important, most physicians fall in line and will ultimately follow the pathways because they're obviously supported by good studies and good outcomes.
Dr. Michael Lutz (20:13):
Don't you think patients are now much better educated? I mean, they come in with “Dr. Google” in their back pocket, they're more engaged in the screening process, and oftentimes, they'll even ask for specific tests that they've read about. How do you help walk them through the process?
Dr. Jason Hafron (20:28):
Yeah, I love it. It’s kind of weird, they always start off the conversation with, "I'm sorry, I looked online," and I said, "Don't be sorry. I love it when patients are educated and read online and come in with new ideas or new thoughts, and it's educational for me."
So, I think the key is that we want these patients to come in informed. We want them to be involved in their care. So, my role has shifted from simply just providing information, but I try to help those patients sort through this information. Is this a reliable source? Is this advertising? Is this social media? To really kind of pick through this and really find out what is good quality data or what's good quality information.
Patients need a map and not a lecture. And where we are now, what the next decision is and what information would change that plan. The more that they can do on their own only makes my job that much easier.
Dr. Michael Lutz (21:27):
MRIs are becoming a more important tool in prostate cancer detection, but not every single patient has the ability to get access to MRI or high-quality imaging. How do you think the role of these blood-based tests can be used in communities where perhaps MRI access is not available?
Dr. Jason Hafron (21:46):
That's why I'm a big proponent of blood-based tests, because blood-based tests are standardized. It doesn't matter if you're in Iowa or Alaska or even a major metropolitan area. These are all read nationally, they're all standardized. So, there's no variability in interpretation of the result.
What we see in MRI, MRI is a great test, but there's a lot of variability in the quality of the reading. There are centers of excellence that do a high-quality job, but in the everyday community or in outside major metropolitan areas, the quality of the MRI varies a lot, and we see that a lot in the data. That's why blood-based tests, national tests like this, where they're in national reference labs, are very helpful if you don't have access to high-quality MRI.
The issues you brought up are real, too. MRI is expensive — access, a lot of the hospitals, MRI schedules are full, they're hard to get into. But if you can just order a blood test in your office, like an IsoPSA, which I do quite often, you can get a result within a few days and really know that patient's risk of clinically significant prostate cancer right away.
Dr. Michael Lutz (22:59):
You’re practicing in what I consider a very challenging time when it's the ever-changing point of entry for patients into the health care system. Now, there's availability of online platforms, urgent care facilities, and even pharmacies, and so many of the providers are not even physicians. They're advanced practice providers like physician assistants and nurse practitioners, and even pharmacists.
So, the dissemination of this up to date and accurate information regarding the role and the opportunity of screening and early detection have become even more challenging. So, my first question is, is what do you think about community-based screening versus patient selected screening and how do we get more men engaged in this screening process?
Dr. Jason Hafron (23:43):
Important issue, I'm glad you brought it up. Community screening is important. I think we can reach men who would never probably schedule a traditional office visit. I think we need to meet men where they are. Whether it's the workplace, their church, the barbershop, community organizations, sporting events.
I know the foundation is doing great work with the mobile health program; we need to go to where the patients are. Because prostate cancer screenings, it starts with that blood test that we need to do, but also, we're talking about prostate cancer and that's what I talk about, but we got to talk about broader issues like men's health.
That same encounter where we're just trying to get a PSA blood test either at their place of work, their church or wherever these men are may also identify untreated high blood pressure, may identify diabetes or cardiovascular disease, which are far more important than prostate cancer.
So, I think community screening is extremely important, especially in men who won't typically go to a doctor's office, and that we need to develop innovative strategies to bring these men in. I think we got to move past the goal of just getting that PSA test, but really taking that PSA test or developing a pathway to connect them to a health organization to make sure that they get the appropriate screening or really the appropriate follow up based on their testing results.
Dr. Michael Lutz (25:21):
So, what role do you think a primary care physician can play regarding screening and early detection with the role of PSA blood tests?
Dr. Jason Hafron (25:29):
They're critical. I mean, they're the front line. Primary care is where most prostate cancer screening decisions are made, and that's where early detection strategies need to start. So, I think we have to work very closely with our primary care colleagues, with our NPs and PAs. They're critical because they're on the front lines.
So, we need to work with them, develop educational strategies for these people, understanding the workflows, their issues, so that ultimately, these patients can get screened. And then once they're screened, they have the knowledge or the pathway to get them to the appropriate specialist.
So, they are huge and we need to develop more collaborative efforts to help create consistent education, shared measurement or shared metrics or outcomes, and do this better across the entire state of Michigan.
Dr. Michael Lutz (26:25):
Interestingly, you brought that up. You've been a longtime participant and partner with the Michigan Urological Surgical Improvement Collaborate. And I really believe that this is a true role for MUSIC to actually help perpetuate knowledge and understanding within the community for the role of screening and opportunities to get more men engaged into the screening opportunities and health care system.
Dr. Jason Hafron (26:51):
Yeah, I couldn't agree with you more. I mean, one of the foundational missions of MUSIC was to make Michigan, the state of Michigan, number one in urological care. And there's only so much we can do in the operating, so much we can do in the office that we have to think beyond the traditional doctor-patient relationship and extend our reach into primary care, mid-level providers and essentially the communities of the men that we serve.
Dr. Michael Lutz (27:18):
When a patient is found to have an elevated PSA, either by the primary care physician or out in a community-based screening, what kind of information do you wish they had before they came to see you or be referred to a urologist?
Dr. Jason Hafron (27:32):
If you read the guidelines, what's most important, we never go off of one elevated PSA. So, it's always nice if whoever's finding that first PSA, do a second. You like to see two elevated PSAs before you would call it an elevated PSA.
Also, you want to make sure there's no other issues going on, make sure that they don't have a UTI, that they haven't had a recent hospitalization or recent instrumentation, or extreme exercise or any reason that their PSA could be elevated.
Also, medication history matters. Are they on dutasteride or finasteride that also can affect or lower a patient's PSA? And then I think prior PSAs, I like to see that graph. I like to see where they've been over the last decade or so, or if we have that to see what's their trajectory, that also is helpful and then finally, family history.
Family history, as you know, we look at advanced prostate cancer and where that's going. Family history is more and more important. Do they have any history of breast, ovarian, pancreatic cancers? There's a lot of genetic syndromes that we are finding associated with prostate cancer and as ancestry or can really change our risk assessment. So, that's extremely important.
But I think the message that we have to carry in (and Michael, you do a great job of educating the men and families of Michigan) is that an elevated PSA doesn't mean you have cancer, it's just a reason for further evaluation. It's not a diagnosis of cancer. It just means that we have to potentially do some more checking and see if this is real.
Dr. Michael Lutz (29:19):
You said your favorite quote is, “The best way to predict the future is to create it,” from Peter Drucker. Is this what drives you?
Dr. Jason Hafron (29:26):
Yeah, because it kind of is like opposite of what we're taught in medicine. In medicine, especially in surgery, we're trained to react to a problem, how to solve a problem. Bleeding, we know how to stop bleeding. Infection, we know how to stop infection. But what I focus on now is meaningful progress requires us to build better systems before the next patient arrives.
And that's why I focus a lot on pathways. That's why a lot of my clinical research and adoption of new technology is developing processes and pathways to improve patient care, to make the urologist a better physician.
Every patient who benefits today is because of years of work or years of planning before they even arrive. And I think that's so important as we develop these large pathways or health systems that we're so lucky to be a part of.
But the reality is this kind of work is not glamorous; it's a lot of work. It's looking at registries, it's looking at protocols, it's educating physicians. And then the difficult work of building consensus around physicians is always challenging. But overall, I try to not complain about it, but really create processes or create a future that is better or that we can essentially better control.
Dr. Michael Lutz (30:55):
I had a recent podcast interview with Dr. Craig Rogers, and he quoted his mentor, Dr. Patrick Walsh, saying the following. He goes, "We make important discoveries by working on important problems, which often comes from listening to our patients." And he said, "To those who have the privilege of sailing uncharted waters comes a responsibility to make those charts."
It seems like physicians and leaders, just like you, have that responsibility to innovate, design and create that path forward. Do you feel that you're navigating uncharted waters?
Dr. Jason Hafron (31:31):
No, I don't think we're navigating uncharted waters. I think we're putting the pieces together. I think there's a lot of great technology, a lot of great thought out there that is connecting the dots or making these observations real.
I think the first responsibility is choosing the right problem. Solving the wrong problem extremely well does not help patients. And I think listening to patients is really not just a courtesy, but really informative and really helps you become a great doctor, but a great researcher.
Patients ask important questions. If you go back and when a patient asks you, "Do I really need a prostate biopsy?" That's a personal question. That's what the patient's asking, but ultimately, that's a great research question. So, it's taking those everyday problems of patient, do I really need to do this, to saying, "How can we answer that question better?"
And what we found over the years with the elevated PSA, we've been able to answer that patient question in a research format, is develop new technologies, adjuvant blood tests, multi-parametric MRI to really go back to that patient, "Do I really need this biopsy?" "Yes, you do. You have an abnormal MRI; you have an abnormal IsoPSA. Your likelihood of clinically significant prostate cancer justifies this biopsy."
And that all starts with going back to the patient, but also connecting these different pieces of information, these different technologies. So, largely leadership is transitional, taking the best evidence, making it practical — making it practical to your patients, practical to the community and the practices that we work in. So, it's really taking that back to our clinics or where our patients receive care.
Dr. Michael Lutz (33:30):
I've always said knowledge is power. And without a doubt, what you've just described is the power, not only for you as a physician, but power for the patient to help navigate the decision-making process in moving forward.
How do you envision prostate cancer evolving over the next 5 to 10 years?
Dr. Jason Hafron (33:47):
I mean, what we've seen over the last decade is amazing. I mean, it's been an incredible run. The innovation of where we've seen advanced prostate cancer, biomarkers, genomic, I mean, it's just endless. I think what we're going to see in the next few years is very exciting, and it's just going to accelerate.
I love the AI technology that we're seeing. I think artificial intelligence will be able to take all of this information that our brains are trying to process between the MRI, between IsoPSA or any adjuvant biomarker, the clinical risk factors, and be able to put that all together, and really give the patients and physicians a really detailed prediction of their risk of clinically significant prostate cancer.
We've already seen for advanced disease imaging PSMA PET is disruptive technology; it's changed how we treat this disease for the better. And I think what we're seeing in pharmacotherapy — I do a ton of research in a lot of advanced disease and the new therapies that are coming are amazing.
I mean, it's just so exciting to hear that and to see what's coming, and how the field is moving forward. It's only getting better and better. We're not at a cure yet, but hopefully, someday, we will be.
Dr. Michael Lutz (35:10):
What changes do you think would be best to improve prostate cancer research, patient advocacy, and ways to advance access to innovative cancer care for patients?
Dr. Jason Hafron (35:21):
Like I said, we do a ton of research at MIU, at Michigan Institute of Urology. We've been basically involved with every major drug approval in the last decade. We're moving fast with a lot of trials in prostate cancer, but I think the research has to be practical. It has to ask, answer, and serve real-world problems.
A lot of times we get focused in the weeds or these rabbit holes that aren't really going to move the needle or really improve quality of care for a lot of our patients. And I think what we've shown at MIU over the last decade is something that's being duplicated across the country.
We're teaching at the AUA, we're presenting at the American Urological Association, is that community practice infrastructure is probably the ideal research infrastructure for clinical research. We need to bring these trials to our patients, to our communities, so that the trial results reflect the patients who are suffering from this disease, specifically African Americans.
Historically, African Americans represent less than 5% of clinical trials when they represent 13% to 15% of the US population. When we bring trials to the community, we can make the trials more reflective of what the patients are that we're treating.
Essentially, for the last whatever years, we've designed trials around institutions, we need to design trials around the patient. And as long as we start designing these trials close to the patient, developing endpoints that are meaningful to the patient, we will see improvement in outcomes and improvement in the quality of our treatments.
Dr. Michael Lutz (37:04):
Getting more men engaged in healthcare has been one of the missions of our foundation. And since 2011, we've performed these annual men's health events at Ford Field and soon to be at the Wayne State University Fieldhouse.
And since 2011, we've screened over 10,000 men, performed over 100,000 screenings, and the data has become overwhelming that when a man gets screened at these events and they're found to have an abnormality, over 90% of the time they go on and get follow-up care for that abnormality. So, we know that men are looking to get engaged. They're looking for these resources and looking for these opportunities.
And one of the goals that you just alluded to is our mobile men's health mission that we're trying to implement, and we'll be starting this year so that we can actually democratize the screening process. You mentioned that one of the advantages of the IsoPSA blood tests, unlike MRIs, is that it is a national standard of applicability because it's a standardized clinical biomarker.
And one of our goals is to offer something that men can actually have as a screening tool and democratize the way they get screened so that whether they're in rural Michigan or near a major city, they get the same screening opportunity that they would heretofore not be able to get by being in a rural community.
Just looking ahead, what gives you the most hope about the future of prostate cancer detection and treatment?
Dr. Jason Hafron (38:32):
I think we've already seen it. We've seen it over the last five years or so. We are better at distinguishing cancers that can cause harm, cancers that need to be treated from those that don't need to be treated, we can watch.
We are seeing the barriers are falling down and we have these very elaborate blood tests, we have MRI, so ultimately, we can decide who needs a biopsy, who can go on active surveillance, who we can spare unnecessary treatment. Things like that are really changing and have been improved over the last five years.
And then I think advanced prostate cancer, we have very effective treatments for advanced disease. We're seeing five-year survivals significantly improve. Trials are reporting out five-year survivals that are double, triple than what we would ever expect.
A cool thing that we're starting at MIU is a couple of new trials where we're trying to go away from hormone therapy. So, over the last decade, we've kind of used hormone therapy, these advanced agents to move chemotherapy kind of towards the end of the line further to the right, we always say.
Now, what we're doing is trials where we can potentially do them hormone-free. The mechanism of action, how these drugs are being applied is do we really need to put on hormones on all our patients?
So, a major change in thought is happening, and it's a credit to the technologies, pharma developing these novel mechanisms of action where we can even mention the thought of a cure before or thought of treating a patient without hormone therapy.
But I think a lot of this which is key, and as we go to the future, is collaboration. It has to be part of our culture. We have to work with our communities, whether it's mobile screening, collaboration with our primary care, collaboration with our mid-level providers, collaboration with music, these state registries. We need to share data, we need to compare outcomes, otherwise, we can only do so much improvement or these improvements will only occur in pockets.
What's exciting is … I'm the middle-aged, or the old guy now, the next generations of physicians, the people we're hiring or working with, our residents and fellows, are starting at such a great base. The concepts of shared decision-making, our foundational teaching core, core requirements, active surveillance, biomarkers, we had to learn over time, now these are acceptable starting points, and it's exciting to see where the next generation will take our field.
Dr. Michael Lutz (41:25):
Well, about 10 years ago, I remember asking you if you ever saw a day where we would no longer use hormonal therapy to manage prostate cancer because I was noticing that the chemotherapeutics were just coming along so rapidly and so successful. Do you think that'll ever happen?
Dr. Jason Hafron (41:42):
Yeah, I mean, we have one phase-three trial that's going to be open shortly. It's a novel mechanism of action that is trying to not use hormones. And we've seen a couple trials that are looking for FDA approval to see if they can use different mechanisms of actions without just going right to hormones. It's a paradigm shift, and we're not there yet, and it's going to take years of research, but we're starting to see people challenge it.
There are new therapies. One of the therapies that we're working on is the coolest mechanism of action is that typically prostate cancer is not immune reactive, it's a cold immune cancer. And what we're doing is we're doing cryoablation, we're freezing the cancer, it's called SYNC-T, and then after we freeze it, we inject an antibody cocktail.
So, we take this cold tumor, make it immunoreactive, and we create antibodies to that patient's cancer. So, we create essentially a personalized vaccine that we can use to systemically treat this cancer.
We have another drug that uses T-cells that's coming online, prostatomic, where we're going to use the immune system to draw to the cancer cells to actually engage the cancer cells with immune therapy.
The most exciting one is a new therapy that's called RIPTAC, where we can use an androgen, this is so cool. They use a protein that binds to the androgen receptor. So, the androgen receptor is not the mechanism, we're not disrupting the androgen receptor, we're just using it as a receptor to identify prostate cancer.
And then what happens inside the cell is that protein binds with a pan protein that's required for cell function, and that kind of just locks up the cell and kills the cell. That's totally independent of any androgen deprivation therapy, totally independent of hormone therapy. It's early, but again, that's where we're headed.
So, all exciting and all great stuff and we just got to continue this innovation to eventually get to a point where we can cure advanced prostate cancer.
Dr. Michael Lutz (44:04):
This is absolutely a great discussion. I am now coming to what I call our second opinion segment. And I want to ask you, what is the one thing in prostate cancer you think we need to rethink? Anything from how we screen, how we communicate risk, or how we even guide men through the next steps after an elevated PSA?
Dr. Jason Hafron (44:22):
I think we need to rethink how we communicate elevated PSA. Too often, the results appear on a patient portal, red flag, double, triple, red flag, PSA is elevated. We have essentially automated the delivery of fear to our patients.
An elevated PSA does not mean a man has cancer. It means we should confirm the result, repeat the PSA, place it in context, order our additional testing, adjuvant biomarker, multi-parametric MRI. We need to do a better job of communication about an elevated PSA. The message should really include three things: what the result means, how much concern we should have, and what happens next.
I think a better message is your PSA is elevated. That's common and can occur for a million reasons. We just need to repeat it and do some more testing to see if there is anything significant here. I mean, every day we just see these men, women, families just kind of freak out about the elevated PSA, and it's really, we need to do a better job of communicating.
Dr. Michael Lutz (45:33):
I've always thought that when you communicate to patients, not only to tell patients what a PSA means, but also what it doesn't mean. And I think you've actually said that more than enough times during this meeting today, and I really appreciate what you've shared.
How do you find a way to balance your personal wellness with all your professional commitments?
Dr. Jason Hafron (45:56):
That's a good question. I don't know if I've figured that out. I think it's a constant challenge to continue a process of setting priorities, adjusting them as life changes, changes within the family or changes within work. I think it's a constant battle. But family time, exercise and sleep have to be treated as real commitments. My family is my focus. It's just maintaining a strong team within my family.
Purpose matters. I think I enjoy what I do. Meaningful work is energizing but the balance and the equilibrium is challenging. It's something that I work out every day and have to maintain that. I mean, I was up at 5 a.m. on my treadmill this morning, but it does require commitment and balance.
Dr. Michael Lutz (46:54):
Well, it's really evident. I've watched you and your family grow up over the years. So, it's evident that you do know how to create a sense of balance and priority in your life. And there comes a time in our lives when we kind of reflect what our lives have been, our legacy, and even how we want to remember.
And you just did refer to yourself as the old man of the group so I don't feel uncomfortable asking you this question, even though I know you're still way too young for this. But have you had any thoughts regarding your legacy?
Dr. Jason Hafron (47:22):
No, I appreciate that, even being considered. I think legacy is not about being remembered as a person, more about leaving something useful behind. The most meaningful impact I can do is not a title, it's not an operation or an instrument. It's helping physicians practice better urology, improving the care of their patients, improving care of patients I've never personally met. That's the legacy I want to lead.
Systems outlast individuals. It's not about me; it's about the patient. And if I could leave that behind, ultimately, that would be a great legacy to the field. But it's really not me. My professional legacy is important, but it's really my legacy to my kids and my wife. I mean, that's the most important.
Dr. Michael Lutz (48:15):
There's no question your family is the most important legacy you can ever have. But from my perspective as a former partner, I can tell you that you've left an impact on a lot of people's lives, physicians, patients and families. And so, you've definitely been impactful and you still have a lot more to go. So, thank you for all that you do.
And I definitely want to thank Dr. Hafron for this great conversation. And I want to thank you for joining us. I'm Dr. Michael Lutz, urologist and founder of the Michigan Men's Health Foundation. And it's through our events, resources and this podcast that we're dedicated to men's health advocacy and awareness.
We're focused on education, research and treatment of prostate cancer and men's health related issues. And for more information about the work we do and how you can get involved, visit us online at www.michiganmenshealthfoundation.org.
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