← Rena Malik, MD Podcast
Rena Malik, MD Podcast
Do Supplements Like Selenium and Vitamin E Help or Harm Prostate Health?
01:51:30
In this episode, Dr. Rena Malik, MD discusses prostate cancer with Dr. Scott Eggener, focusing on prevention, screening, and the latest treatment options. Together, they break down myths, review evidence-based strategies, and emphasize the importance of individualized, patient-centered care. Listeners will gain practical insights into managing prostate health and making informed decisions.
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- [00:00]
A
Today we're going to talk about prostate cancer.
- [00:02]
B
It's really a behemoth of a disease. Almost everyone diagnosed with it. It will not be a long term problem for them. However, the flip side of that is it's still the second leading cause of cancer death in men in the United States. There's a ton of like, large data, long follow up out to 15 years. And the really good news is for almost all men with Gleason 6 or grade group 1 prostate cancer, when you go on surveillance, the likelihood of you ultimately dying from that prostate cancer is 1% or less. The chilling and disturbing thing is that even amongst men diagnosed with Gleason 6 in the United States and Sweden, we have data that the rate of suicide goes up. Measurable, really low, but measurable. All for something that has a 1% chance or less of ever causing them a problem.
- [00:55]
A
You mentioned medications like finasteride or dutasteride, which we often prescribe for enlarged prostate. What is the data on those medications and the risk of prostate cancer?
- [01:06]
B
Yeah, this is a cool story.
- [01:09]
A
Imagine getting the news that you have prostate cancer. It's terrifying. The anxiety, the uncertainty, the fear of what's coming next. It's easy to get overwhelmed. Welcome back to The Rena Malik, M.D. podcast, your trusted guide for leveling up your health, science, sex life and relationships with evidence based tools. I'm your host, Dr. Rena Malik, urologist and pelvic surgeon. And today we're talking about prostate cancer, but more importantly, we're talking about how to navigate that journey from prostate cancer screening through diagnosis and treatment. My special guest is truly someone who shaped my approach to patient care, Dr. Scott Egnor, a distinguished urologic oncologist and chair of Urology at UCLA. He has over 350 peer reviewed articles. He's a leading researcher in prostate cancer and focuses on reducing over diagnosis and over treatment. He's also a prominent voice in clinical trial design and cancer guideline development for major organizations like the American Society of Clinical Oncology and the American Urological Association. He also happens to be my mentor from residency. He instilled in me the importance of humility and truly listening to our patients. And today he's bringing that same empathy to you. We'll discuss how to prevent prostate cancer, why absence observational data about vitamins and minerals might not pan out the way we expect it to when we put it to the test. What screening really matters for you and how to uncover the safest, most effective path forward when it comes to prostate cancer. We also cover a Little bit about testicular cancer and kidney cancer. Before I get into the podcast, I just want to say I have been looking and searching for a way to help each and every one of you in a way that actually works. So finally I figured it out. I developed an app with Studio.com that basically gives you an AI version of me in your pocket, along with self guided modules, weekly challenges, and daily health practices that can really help you level up your sex life to have better sex. Check it out@studio.com Rena well, Scott, thank you so much for being on the podcast.
- [03:12]
B
Absolutely.
- [03:13]
A
Looking forward to it. I, I, I want to share a story. So for my audience. Scott was one of my mentors in residency and there's still so many things that you said during residency that I still remember, one of which was when I was a junior resident and I was in your clinic. You always introduced yourself as, hey, I'm Scott. You never said, I'm Dr. Egnor. And I just thought like this amazing, accomplished urologist who is so humble. And I still remember that. And the other thing I always remember is in the or you would say something's hard, you do the easy stuff first and the hard becomes easy. And I always remember that when I'm in a tough spot, I say, okay, I'm gonna go work on this easy part of the operation and then I'll come back to this. And it always works.
- [03:56]
B
Well, I wish I could take credit for both of those, but I learned that from people that I saw and modeled it and latched onto it. And so hopefully you do the same and pay it forward.
- [04:06]
A
Yeah, yeah, it's really wonderful. And it's funny to see it on the other end. Like I have my residents come back and tell me things that they do that I taught them and obviously they were learned behaviors from other from my mentors as well. So. But today we're going to talk about prostate cancer. So I want to just start with what is the single most important thing that someone listening to this podcast will learn during the podcast and that they should take home about prostate cancer?
- [04:31]
B
Yeah, as you're aware and some of your audience is aware, it's really a behemoth of a disease and it can be really complicated to narrow it down to kind of take home. The great news is almost everyone diagnosed with it, it will not be a long term problem for them. However, the flip side of that is it's still the second leading cause of cancer death in men in the United States. So it's something worth paying attention to. And considering getting screened and doing things that you can to lower the likelihood of you having to deal with those problems.
- [05:05]
A
I think the important take home is cancer death. Right. Not just cancer, because I think a lot of people here, like 80 year olds, many die with prostate cancer, but not from prostate cancer. And I think the important thing there is that it still is a big cause of cancer death.
- [05:21]
B
Yeah. There's a tremendous number of men that are suffering from the disease. Their life will be cut short by it or they're dealing with side effects from some of the treatments for metastatic disease. And I hope and presume we'll get into all that.
- [05:33]
A
Yeah. So let's start with prevention. I think it's really important and a lot of people want to know what are the things they can do to prevent prostate cancer if they are, you know, a young man or even a middle aged man and they're looking to try to not be in that second highest risk of prostate cancer death.
- [05:52]
B
Yeah, I think the starting point for each person with a prostate is what's my risk? And there are people that are lower risk at baseline and there's people that are at higher risk. And the higher risk folks are when you have a family history of it and not just kind of early stage disease, but you've had family members that have had metastatic disease or died from it. Any African ancestry. And then there's all these genetic abnormalities that people can be born with or pass on. You know, the most common ones are BRCA1, BRCA2, but there's a whole laundry list of others. ATM chek2, pal B1 and, and kind of knowing what your risk might be. And as you get older, your risk starts going up. So know what your starting point is. And then there's a whole bunch of things that can be done to lower the likelihood. And then there's a lot of things that are pitched to you that may be helpful, may not, that you have to decide whether you want to do so. The unsexy things that are kind of data based and proven are the things that most people already know. Eat real food, probably not too much. Alcohol is known to be a carcinogen. Even for prostate. There's a little bit of a signal. Exercise. There's great data on exercise, some really cool observational studies and even a randomized study suggesting that high intensity interval training can slow the growth of prostate cancer.
- [07:16]
A
So how much high intensity interval training and how often?
- [07:19]
B
Yeah, so this was a really cool study that was done out of Edmonton and they randomized patients with early stage prostate cancer that were getting monitored and half of them went on a hiit regimen three times a week. I forgot how long. And the others just kind of got a handout of like take good care of yourself, you know, here's some exercise suggestions. But it was monitored exercise three times a week. And the really cool thing for people that do what you and I do is that they saw benefits in psa. They saw benefits on follow up biopsies, both molecularly and a lower likelihood of progressing. So this is all kind of an early signal. It was a small study, but as soon as I saw that I started telling almost all of my patients that were interested in this space. Here's something that there appears to be an interventional thing that we know is good from head to toe for other things, but it's suggests it might be good for prostate as well.
- [08:14]
A
I do think high intensity interval training is really interesting because there's like so much data for a variety of different things. Even in sexual health. There's evidence that high intensity interval training can improve time to ejaculation for men with premature ejaculation. So I think there's, there's so much benefit and I wonder what the, the metabolic adaptation is with specifically high interval, high intensity interval training that's so unique compared to just regular aerobic exercise. But it seems to be like everyone should at least try to do it at least once a week in terms of part of their routine with exercise. But more is potentially better.
- [08:48]
B
Yeah. And you and I have talked about it before. I mean if you could put exercise into a capsule, let alone high intensity exercise, it would literally be the first trillion or quadrillion dollar pill. I mean it is just so good for everything. And even I'm always struck by the data, even on just going for long walks. You don't even necessarily have to be doing triathlons or training for something endurance. But getting out of the house and going for walks has measurable benefits.
- [09:14]
A
Absolutely. There is actually data on bph and two hours of walking a week can reduce the risk of getting bph.
- [09:20]
B
That's wild. In a good way.
- [09:22]
A
What about supplements or vitamins? And there's actually been some really good strong evidence and studies looking at this for prostate cancer.
- [09:29]
B
Yeah. And I'd love to give you the laundry list of things that are data based, proven in a proper way. There's some observational epidemiologic data that things like soy and pomegranate and broccoli can be beneficial in lowering the likelihood of Getting prostate cancer or having less dangerous prostate cancer. But there's always cautionary tales in there because when randomized trials are done, sometimes they're disappointing. And to the credit of the medical community, there are a couple trials that are worth mentioning. The select trial looked at selenium and vitamin E. And for decades there was observational data that those could lower the likelihood of prostate cancer, probably hundreds of millions of dollars in sales. And then a massive two by two randomized trial. And then the shocker, in a disappointing way, is they were both more harmful than helpful. So if you took vitamin E, you had a slightly higher likelihood of getting prostate cancer. And if you took selenium, it didn't change your prostate cancer risk, but you had a higher likelihood of getting diabetes.
- [10:34]
A
That's crazy.
- [10:35]
B
Separate from that, there was something called the meal study that was run out of ucsd. It was people with early stage prostate cancer on surveillance, a couple hundred people. And they were randomized to a healthy diet, bumping up fruits and vegetables, lowering red meat, all these other interventions. And then there was a control arm that got a piece of paper and we enrolled in that. And it was kind of in line with everything you and I subscribe to. And you really hope it's beneficial. But the reason you do these trials, it wasn't beneficial, it wasn't harmful, but it didn't have any measurable benefit. Now maybe they needed to have more real prostate cancer. Maybe it was helping them in other ways that weren't measured, but it was a negative study. And then vitamin mineral supplements, I mean, we can go through them if you choose. I mean, calcium, it turns out, is, you know, potentially harmful if you take calcium supplements.
- [11:31]
A
I didn't know that.
- [11:32]
B
There's another side to it. If you're on hormone therapy, you want to be taking it for your bone. But as far as a prophylactic or preventive, it can be harmful. Vitamin D doesn't seem to have any benefit whatsoever. Mixed data on fish oil. There's some medications that we might get into the five ARIs, finasteride and dutasteride, where there's kind of the banner headline. But then I think some layers beneath it where there may be some benefit and, and there's obviously a lot of others that have been looked at and studied.
- [12:01]
A
Before we get to it, I do want to talk about lycopene because there's some data on lycopene, right? At least in food form or also supplement form. I don't know. I think I know the food data is that eating Cooked tomatoes or things with high lycopene content may be beneficial. Is that accurate?
- [12:16]
B
Yeah, a lot of the things I mentioned are epidemiologic observational data. The soy, pomegranate, lycopene, tomatoes, cruciferous vegetables, anything that's green and natural. But as you're aware, and some of your audience might be aware, that is not kind of watertight, absolute truth. Because, yes, if people eat a lot of lycopene in real food, you know, tomatoes and other things, they seem to have a lower likelihood of getting prostate cancer. Great news. Is it the lycopene? Is it other things they're doing in their life that weren't measured? Is it other things in their diet that just weren't measured? Well, unknown. So it may be helpful. There's probably little downside in eating all those healthy things anyways, but that's not absolute proof or truth.
- [13:08]
A
Right. And I think the important take home from that is that observational data did not translate in randomized controlled trials, which is really why supplements are such a scary sort of area, because most people are not doing randomized controlled trials. In fact, there's very few randomized controlled trials of supplements, at least the ones I know of in urology, you know, it's saw palmetto, vitamin E, selenium. Those are the only three I can think of off the top of my head. And so we can only give you data based on observational studies which may or may not actually translate to real benefit or potentially harm.
- [13:42]
B
Yeah, phenomenal point. I mean, you know this. But there's literally an infinite list of things that, you know, have, you know, thought to be helpful in medicine, and then when studied, turn out to tell a different story. But It's Human Nature 101, our operating system. It would be great if there was something easy, cheap, and accessible that you can go down to the store and buy and helps prevent all sorts of things. So we all latch onto it. But what you do great. And what the medical community should do is just be honest with everyone on, here's what we know, what we don't know, and here's what's unknown.
- [14:15]
A
Right, Right. And I think doing the things that you've mentioned, the unsexy things, is really going to give you benefit across multiple areas of your life. And so that is, most people don't have that all together. Right. They may exercise, they eat. Right. But they probably don't sleep. Right. Or they have a lot of stress in their life. There's usually some area where you can improve and that's what you should really focus in on.
- [14:38]
B
Yeah, totally agree with you. And it's. For many people, it's a privilege that they don't have to be able to have access to, you know, cheap, healthy food or sleep as much as they want, or join a gym or live in a climate where they can't exercise or life gets busy. So it's aspirational. But those are the easy. Often, you know, when they can't advertise for themselves, so they don't get pushed on us as much, but they don't make any money. I love the Michael Pollan. He's an author and a food expert. You know, eat green, not too much. And he has other things that are helpful. And one of them that always latched on to me is shop at the periphery of the grocery store and buy things that can't advertise for themselves.
- [15:24]
A
Yeah, absolutely. You mentioned medications like finasteride or dutasteride, which we often prescribe for enlarged prostate. And so in that vein, what is the data on those medications and the risk of prostate cancer?
- [15:39]
B
Yeah, this is a cool story because, you know, as you know, we have randomized trials and kind of dialing it back, there was some evidence, early evidence, that taking these medications which prevents the conversion of testosterone to dht, may be able to lower the likelihood of being diagnosed with prostate cancer. And to the credit of our government and some companies and investigators, and mostly the patients who enrolled in these trials, we have two huge randomized trials that told the story of finasteride and dutasteride. And they were slightly different trials and different types of patients. And we can go into that if you want to. The banner headline of these was, yes, it lowered the likelihood of being diagnosed with prostate cancer by about 25%. And that's a really big deal, particularly when you think of the prevalence of prostate cancer. If you could lower the likelihood of that happening by taking a pill once a day, that has some potential side effects, but relatively low likelihood. And these were long, well done studies. However, when both of these studies came out, there was a suggestion of a potentially dangerous signal that if you took these medications day over day for years at a time, there was about a 1 in 100 chance that if you get prostate cancer, it could be a more dangerous kind. So early on when these trials came out, it was like, oh, we're going to do this to prevent things, but there may be a dangerous signal. There's a whole colorful story going through ODAC and the fda, and it didn't make it through for that reason. And that story kind of caught on. What? I think, knowing the data, you know, kind of frontwards and backwards and giving long lectures on it and talking to patients, you can absolutely lower your likelihood of being diagnosed with prostate cancer by 25%. But if you're willing to sign up for a 0.5 to 1% chance that it might be more dangerous if you get prostate cancer, you should consider talking about it with your doc. And in some ways, it's no different than, like, aspirin data. I have a great slide where if you take aspirin for prevention of certain cardiovascular things, it'll lower the likelihood of those bad things happening. But, yes, if you take a daily aspirin, you're slightly increasing the likelihood of having a worrisome bleed at some point in your life. And we hand it out like candy in the medical community. We haven't done that with the five aris.
- [18:06]
A
Interesting. Yeah, that's a really good way to put it. And I think the other question that people get a lot is, get confused about is, is having an enlarged prostate.
- [18:14]
B
Put you at higher risk of getting prostate cancer?
- [18:17]
A
Correct.
- [18:17]
B
No. And in fact, it may put you at higher risk of having a biopsy, having an unnecessary biopsy, because, you know, with psa, it's still kind of front and center of people who choose to be screened. They get the simple, cheap blood test called the psa, and there's signal and noise in the psa. The signal that we all want to find is, is there a worrisome prostate cancer or potentially worrisome prostate cancer, but there's all this noise in the PSA also. And one of those things is an enlarger prostate. And so we try to separate those two. And there's many ways of doing that, of trying to figure out, is this the noise from a large prostate or is this a potential cancer signal that we have to pay attention to?
- [18:57]
A
Yeah, definitely. And I've seen it in my practice. Guys with very large Prostates can have PSAs that are extremely high, and they've been biopsied, and they're negative. So I think that's really, really important to understand. A couple things that I think come up often as questions about prostate cancer risk is how often you have sex or how often you ejaculate and how that correlates with prostate cancer.
- [19:23]
B
Yeah. Again, back to epidemiologic data. There's some really intriguing observational data that suggests the more you ejaculate, the lower the likelihood of being diagnosed with Prostate cancer. Now, it's important to put some guardrails and caveats up there. There's some other observational studies that did not show that signal. If it is true, and maybe it is true, you and I could come up with some very good reasons why, you know, you're flushing the pipes, these toxins, inflammation, and you're just kind of clearing the prostate. But again, we don't have absolute truth on that front. And it may be just other thing. Those other things those people are doing in their life.
- [20:04]
A
Right.
- [20:04]
B
Are lowering their likelihood of getting prostate cancer.
- [20:07]
A
The way I use that data is always to say, like, look, if you are masturbating or having sex a lot, it's definitely not going to harm you, so don't feel guilt about it. And if you're not, that's okay, too. The interesting thing about that data was that it compared. The data showed that people who ejected more than 21 times a month compared to those who ejected four to seven times, not less than four times. And so that tells me, like, okay, there's something there, but it's not universal necessarily.
- [20:33]
B
Yeah, that's a great point.
- [20:34]
A
Yeah.
- [20:35]
B
And, you know, from a nerdy science side, the more things you compare, the more likely you're going to get some significant P value. And it's not like some 20, 21 is some magic value like you got to get from 20 to 22 for this week.
- [20:46]
A
Right.
- [20:47]
B
If there is an association, there's probably some continuous, you know, incremental benefit the more times you ejaculate.
- [20:55]
A
The other thing that comes up often that I don't think people realize is how tested testosterone and prostate cancer are linked. Meaning does low testosterone prevent prostate cancer or help or put you at higher risk for prostate cancer?
- [21:08]
B
Yeah. Like many things in the prostate space, it can be messy. And it's not kind of a pithy headline that tells the whole story. And there's layers to it. So, in general, your baseline testosterone level does not predict your likelihood of getting prostate cancer in the future. And there's a lot to unpack there. But the point being is, if you have a low testosterone and you have a medical reason to go on, testosterone supplementing your testosterone to a normal level does not appear to increase your likelihood of getting prostate cancer. That has been transformed over the past couple decades and more recently, this traverse randomized trial, that is the best evidence we have on that front.
- [21:51]
A
Yeah. And I think there has been a lot of observational data that linked having low testosterone to putting you at a higher risk of getting Prostate cancer. Have we seen any really strong evidence that would negate that necessarily?
- [22:06]
B
There is some evidence. Again, it's all observational and absolutely positively. There is some yet to be fully elucidated thing where sometimes some higher grade prostate cancers aren't as responsive to testosterone. There may be a chicken and egg thing with low testosterone and more worrisome cancers, but still not completely flushed out.
- [22:29]
A
Interesting. I guess I would dive a little deeper. So the Traverse trial looked at transdermal testosterone. So in urology we don't. Tend to. Or at least in men's health, we don't tend to compare the difference between transdermal, injectable, any other formulation of testosterone in terms of increasing. If it increases testosterone and it does on lab value, then it's doing what it needs to do. Whereas in the menopause space they often say transdermal is safer in terms of risks for breast cancer and stroke and all those sorts of things. Clots. Do you think that there's a difference between formulations?
- [23:08]
B
I'll defer to you. This is more your space than me. I don't have expertise in it.
- [23:12]
A
I mean, I would assume that if you're increasing your hormone levels of testosterone that the outcome would be similar in terms of as long as they're physiologic, you shouldn't say, see any downtrend. But I wonder. I mean, I don't think it's been looked at, to my knowledge.
- [23:25]
B
Yeah. To this point. And it's an important one. So when I was training, the thought of giving anyone testosterone who had a history of prostate cancer or active prostate cancer was anathema and you would get screamed at or proverbially screamed at. So it's crazy to think now that I have a whole bunch of patients that are on surveillance for the early stage prostate cancer. We're monitoring it, we're not treating it. And they have a real reason for going on testosterone and we give them testosterone to get them to a normal level. To more directly answer your point on a very simplistic level, the way I've always thought of it is if there's a prostate cancer cell and it's exposed to a certain level of testosterone, let's say 400, and it's coming naturally from someone's body, or if it's getting supplemented to that level, how is that cell going to be behaving any differently depending on whether it's endogenous or exogenous?
- [24:20]
A
Yeah. And that's interesting because I think that's where we. There's a divergence between how we treat women and men. So, you know, when a woman gets breast cancer and she's premenopausal, people aren't like, you know, she's exposed to a lot of estrogen, but then when they're postmenopausal, oh, they can't get estrogen. Right. And so it's similar, I think, and they're just behind the urology community in moving the needle in that direction to say, yeah, it is safe because there's so much benefit in terms of overall health with having a normal testosterone. Right. I think the challenge obviously becomes in many of the treatments, which we'll talk about later, is you are reducing your testosterone to very low levels.
- [24:56]
B
There are amazing parallels between the breast cancer world and the prostate cancer world. We've written some papers with some breast cancer experts around the country, and the analogies are fascinating. And in general, side to side, we have so much more to learn from the breast cancer community because they've done more trials and they've been more progressive with things. There are a handful of things that they are in the early stages of learning from us. One of them is surveillance for early stage disease like dcis, and they have trials ongoing. And the second is what you mentioned of hormone levels later in life. Benefit versus harm.
- [25:35]
A
Yeah. Yeah, it's fascinating. So let's talk about screening a little bit. I think you talked about psa and let's tell people, you know, how often should they be screening? There are obviously guidelines. And then if they're at high risk, like the things you mentioned, like brca, African American family history, when should they start, how often should they get it and when should they stop?
- [25:59]
B
Yeah, all great things that could be standalone topics. Again, it would be so great if it was simple, easy, kind of a catchphrase. But there's to individualize things and to do it in a smart, sensible way. There's always layers and complexity. So number one is knowing your baseline risk that we alluded to. Second is deciding whether you want to be screened or not. Unequivocally, screening in this country has led to fewer men dying from prostate cancer. And the great news is, even before we got better medications for advanced disease, there's about a 50% lower likelihood on an age adjusted mortality level going down. Basically 50% fewer men dying from prostate cancer. That's a massive win. We should shout it from the rooftops. The problem, which you're well aware of, is there's a much higher likelihood that you got unnecessarily tortured by screening, unnecessarily diagnosed, treated, and may get exposed to potential side effects for the rest of your life. And history kind of comes alive. You can't tell the story without knowing our history. And the history was PSA came around. This early screening mechanism will save all these lives. Everyone should get one. Everyone should do it the same way, starting at a certain age, get it every year, almost never stop. And we saved a lot of lives. We also tortured millions of men. We are in such a better place now because we have more information. We've transformed things, but there's still a lot of work to do. So as best as possible answering some of your questions there average risk or higher risk, men should absolutely have a conversation with their physician on whether they want to be screened or not. And there's online tools because it can be complicated. It's not just a simple yes or no. But if you choose to be screened somewhere between age 40 and 55, you should get a baseline PSA based on your risk factors and your baseline psa. And I try to teach our trainees to know what median PSAs are for each decade. We should risk stratify screening. So this kind of, you know, everyone get a PSA every year. Doesn't make a lot of sense. We need to do what the colorectal, you know, colonoscopists do to screen for that disease based on your risk and your baseline psa. Come back in a year, come back in two years, come back in four years. And this is embedded in many of the guidelines. And then based on that, there's next steps that we can walk through and ultimately talk about, you know, when to stop as well.
- [28:33]
A
I find that. Well, obviously, PSA screening is something that we are very used to, but I find that in the general primary care, like, they don't have a lot of time, Right. To go through this process. It is, there's a lot of, I think, challenging misinformation about psa because as you know very well, the US Preventive Task Force at some point gave PSA screening a D grade, meaning, like they should not recommend it, which changed. But based on that, a lot of people change their mind about PSA screening and still don't have all the information, or they just screen everybody every year because they don't have the time. So I think for the average person. Person, if they want to be proactive, should they go and look at these? Are there places where they can find these tools and we can link them in the description?
- [29:18]
B
Obviously, yeah, it's a great Point and worth emphasizing. And I think we need to shine the light on ourselves. The medical community kind of screwed up prostate cancer screening. I'd like to think it was well intentioned in many places it was. But this screening everybody indiscriminately led to plenty of harm. And what ends up happening with this DE recommendation is dialing it back. And the kind of reality for most patients is they just go to the doctor. And the doctor, the primary care doc, is either soured on PSA screening or is all in and says yes or no. There are good resources through the American Cancer Society, the Prostate Cancer foundation. There's interactive resources, there's true shared decision making tools that are out there. I mean, I can tell you there's not a topic in medicine I feel more comfortable with. I have a lot of expertise in it and voting with my own feet. I'm a 52 year old man and I check my PSA. So kind of voting with my own feet. I do think there's value to it.
- [30:18]
A
Yeah, I think it's very complicated. And I think that the challenge is people are scared of cancer. Right. And so when you. One of the things that I do want to really touch on is we often talk about stopping PSA screening at some point. And so the guidelines would say 69 would be when you could stop PSA screening. And that comes from median age, life expectancy, which is 75 for the average man in the U.S. and so nobody wants to really face their idea of when they're going to die. And so when you talk about this with patients, they're like, no, I just want to keep getting screened. So how do you talk to your patients about this?
- [30:55]
B
Yeah, I think it's the common theme of our talk. There's always more layers and nuances to it. So the reason 669 is often the high end is the largest trial that showed a benefit to prostate cancer screening was in Europe, where they took data from a bunch of different countries, bundled it together, but the inclusion Criteria was age 55 to 69. It lowered the likelihood of dying from prostate cancer by roughly 25%. So 69, true to the data, was the upper edge. Now here's where all the nuance comes in. So the curves start diverging. There's a couple trials that have shown a benefit. The best are out of Scandinavia. There's European data, but the death rates start converging about eight years after enrolling. But they start diverging. I'm sorry, not converging. Diverging at about eight years. So in General, you don't want to screen someone unless you're fairly confident they're going to live 10, 12, 15 plus years. There are 69 year olds, there are 59 year olds where it would be crazy to screen them because it's really unlikely they're going to live a while. I am very comfortable screening men in their 70s or even, even early 80s if they're really healthy and gonna live a while. Now, screening someone in their low 70s or low 80s is wildly different in your goals and how you manage things than a 55 year old healthy person without any medical issues. But I do think there's potential value there.
- [32:21]
A
Yeah, I think the challenge becomes like it is supposed to be a shared decision making process. And so you're asking someone, hey, do you want to be screened for cancer? And you can talk about it till you're blue in the face, but usually the answer is yes. And so the challenge then becomes, okay, you screen them because you did it, you did your job, you tried your best to explain the data, they still said yes. You do your screening, it comes back with an elevated psa and now you're faced with another checkpoint, like, do I go ahead with another test? Do I go ahead with an mri? Do I go ahead with a biopsy? And what do I do if those things come back positive? And I think people are like, I'll be fine. Everyone thinks I'll be fine. I'll deal with the data as it comes. But it does lead to this significant anxiety, this significant stress and these risks.
- [33:10]
B
Potentially phenomenal points. There's a lot to unpack there. But once you get on the screening train, you sometimes, you know, the trains left the station and sometimes it's, you know, literally saving their life, which is the ultimate goal of it. And sometimes you wish you could kind of put the train in reverse because you end up doing a lot of testing and there's not a lot of there there or you diagnose a cancer that the patient may or may not benefit from knowing about.
- [33:38]
A
So let's talk about when you get an elevated psa. What are the next steps for someone? Should they be getting a digital rectal exam? That's actually another question I have. So there's evidence, at least in the family medicine literature, that we don't need to do digital rectal exams anymore. What are you teaching your trainees and what do you think is appropriate?
- [33:55]
B
Yeah, an aha moment for me is when we took a deep dive into the data for one of these guideline committees to put it out There. And if you look at the dre, the digital rectal exam, which is the finger feeling the prostate, if you really want to be a scientist and beholden to the data, there's really not a measurable benefit until the PSA is greater than 3. Now, kind of outside that data, circling back to something we talked about in everyone I'm screening, I do like to do a prostate exam. It's very low yield. To feel a cancer, it can happen. And those are the anecdotes that get a lot of stories. I put my finger in and I found a cancer that I think was really helpful to diagnose the person, but way more common is I want to get a sense of the size of the prostate. And this gets back to the BPH or no bph, you know, do they have a small, medium, large, extra large, or 2xL prostate? Because that goes into interpreting the PSA or what's called the PSA density. And I will make dramatically different, you know, decisions and give them different advice depending on the size of their prostate and their PSA level.
- [35:01]
A
Yeah, I agree with that completely. And I think for me, I mean, there's a lot of data that can be garnered from a prostate exam. The tone of their pelvic floor, the, you know, the. Is there tenderness? You know, again, how big is the prostate? And those really do play a role into many symptoms they may be experiencing outside of, you know, just screening.
- [35:20]
B
Yeah.
- [35:21]
A
Especially when they're at the urologist. And speaking of, are there symptoms that.
- [35:24]
B
People should be looking out for for prostate cancer? There are, but almost always by the time you have those symptoms, you've got an advanced cancer. I think it's great when guys come to see the urologist because they have new urinary symptoms, because they're getting evaluated. I find it great that they're sitting there and addressing it. And it's really reassuring for me to tell them your urinary symptoms. It's almost a never event that it's from prostate cancer, even though the fear of prostate cancer is what's brought them into the office. But then at least we can work on quality of life, addressing their urinary symptoms, decide whether they want to get screened for prostate cancer and other things. But yes, if you're having terrible urinary symptoms from prostate cancer, it's usually advanced. And obviously, if it's been metastatic and you're having symptoms throughout your body, it's treatable, but not curable.
- [36:17]
A
Yeah, yeah. I think that's the biggest take home for so many people. Is there's a reason we do screening is because there are no symptoms, often most of the time. So once you have a high PSA and say you've examined their prostate, you think there's a concern for prostate cancer. What are the next steps?
- [36:33]
B
Yeah, there's a lot of steps along the way and there's, you know, different ways that different urologists approach it. Step one, for me with my patients, there's a lot of cheap, easy, reassuring things that you just take it stepwise. So as I explained to them, I want to feel their prostate, I want to know their age and risk factors, I want to know their total psa, which is what we've talked about. There's another extraordinarily valuable easy piece of information called the first free psa, which almost every laboratory in our country has available. It's an inverse relationship to prostate cancer risk. So you want your percent free PSA to be high rather than low. If you have an elevated psa, there are many things that can cause that. It can be a large prostate, it can be a wimpy cancer, it can be a real cancer, it can be inflammation, it can be an infection, which is why almost always you just repeat it a couple months later. You don't need antibiotics. That's harmful rather than helpful. There's randomized trials on that. If you think you have an infection, you treat the infection, but you prove it first. You gather all that data. If after all that data and the repeatsa, there's still something worth paying attention to, then the next steps are there's ancillary blood and serum tests, blood, serum or urine tests that you can get and we can go through some of those, or what some people do is get an mri.
- [37:55]
A
So, yeah, let's talk about those ancillary tests, because there are so many at this time, commercially available biomarker tests that you can do at that time of pre biopsy. And so I think for the average person, you know, they go to the urologist and they just expect the urologist will do all the things that are available to them. But there's so many, and I think that the average urologist probably can't keep up with all the different genomic tests. So which ones do you think are the most helpful in this situation?
- [38:23]
B
Yeah, so this space is really busy and it's really good news that there's six to eight tests out there. Probably the most common ones are called Prostate Health Index 4K, SelectMDX, ExoDx. There's some investigational ones in Europe, Stockholm, 3 and then there's others. ISOPSA. They all have potential value. There's various costs, there's various ease of use, and the science behind them is all positive. And what the intent is to try to identify the ones that may warrant further evaluation, to capture the diagnoses that you're looking for, while simultaneously minimizing the number of men that need biopsies, need unnecessary biopsies, or are unnecessarily diagnosed with wimpy prostate cancer that they probably didn't even need to know about. So those are all kind of the secondary biomarker space.
- [39:19]
A
Yeah. And then do you think that now. So MRI wasn't a part of PSA or prostate cancer diagnosis in the pathway till very recently? I would say probably like a decade, less than a decade. Is there value still in doing those tests over getting an mri?
- [39:38]
B
Yeah, no one really knows for sure. So I can tell you, all those biomarkers we just talked about have value. MRI has value. There are people who use both of them. There's people who use one versus the other, and there's people who still use neither of them. There's an ongoing trial in Sweden where they're trying to integrate those into each other. But as standalone, MRI also has value in a very simplistic way. I like to explain it to a patient. Getting an MRI is a form of a biomarker. You get a picture of the prostate, it's a good picture, often a very good picture, but rarely perfect. And it's important to know with any test, particularly MRI of the prostate, you know, you can have false alarms. So just because an MRI shows something or suggests something doesn't necessarily mean it's worrisome. And it also depends on the quality of the MRI pictures, who's reading it. So it can get, you know, complicated pretty quickly.
- [40:39]
A
Yeah. So these are all tools that you can use but don't necessarily have to. So let's talk about the next step, which would say, say you did some of these or did not. Either way, you're now still concerned about a prostate cancer. The next step would be a biopsy. And so biopsy has also changed over the last decade or more. Let's talk about what is the innovation in this phase? What should patients ask for when they're getting their biopsy?
- [41:03]
B
Yeah. Nowadays and in the near future, the standard way of getting diagnosed with localized prostate cancer is a biopsy. There's some provocative data out there that maybe will get to the point one day with next generation imaging, or what's called psma. PET scan that maybe it'll be so darn good that you don't have to stick needles in the prostate. But nowadays, 99% of people in the United States, that's the way they're diagnosed with localized disease. There's many ways of accessing the prostate and getting needles in there. You know, the two most common are going through the rectum or going through the stomach skin. That's between the scrotum and the rectum, which is called the perineum. So it's transperineal or transrectal. Back to randomized trials, which is what we're always thirsty for, to help inform things. It's still considered standard ish to do either transrectal or transperineal. Although the country and other parts of the world with our level of technology, are moving pretty aggressively towards transperineal. The last five plus years, I've never referred someone for a transrectal. It's transperineal. The yield from a cancer detection standpoint appears to be pretty similar. But the benefit is there is either a measurable lower chance of infection with transperineal or pretty similar to transperineal or transrectal, although you need fewer antibiotics with transperineal. So there's probably a measurable benefit there.
- [42:20]
A
And then in terms of people who get an mri, there's also fusion biopsies. So there's different types of fusion biopsies. Biopsies, right.
- [42:27]
B
Yeah.
- [42:27]
A
And so what should they. Are there specific types of fusions that are better than others?
- [42:32]
B
It's a great question. And there's kind of a good news, bad news story to that. So there's a load of studies, including many randomized studies, that if you get an MRI prior to your biopsy, there's measurable benefit. And I always think of it as a triple win. You basically can identify the same number of men with grade group 2 or higher prostate cancer, kind of the cancers we're looking to diagnose. Fewer men need a biopsy. 20 to 50% fewer men need a biopsy if you get good news on your mri. And the third thing, the trifecta is you diagnose fewer men with grade group one or Gleason six, which I think is very beneficial. Now, again, it really depends on the quality of your mri, the fusion technology in the US at least, fusion technology is taking a suspicious lesion on mri, marrying it to an ultrasound image. And when you take your biopsy, you put those needles towards the target and you want to sample that area or around that area to try to be higher yield. Now, that's done with fancy, often expensive technology. And that's largely good news and an advancement. The downside to it is we might also be diagnosing more men with cancer who don't necessarily need to know about it. And the data that doesn't really run the clinics these days is you probably don't always need the fancy technology. It's called cognitive fusion, which is basically, oh, the MRI shows or suggests an abnormality in the left upper part of the prostate. We don't need this fancy technology. But I know enough with my ultrasound. I'll just send some extra biopsies into that left upper part. And the comparative data and even randomized data suggests it probably works just as well as the expensive technology.
- [44:22]
A
That's good news. That's great news because I think, you know, us aside, other countries can't necessarily afford that kind of technology. So if they can get mri that does. I mean, then they have one less expensive thing to worry about. So you've mentioned wimpy cancers, Gleason grade 1 cancers. Let's explain a little bit about what sort of cancers, what result you would get from biopsy and how you would characterize that as wimpy or really concerning cancer.
- [44:53]
B
Yeah, the way I think about it and explain it to any patient I refer to a biopsy is to try to keep it easy for them to understand. But also accurate is I recommend a biopsy. After the biopsy, your results is going to fall into one of three categories. What we're hoping for. No cancer. Hallelujah. The second category is you're going to be diagnosed with a cancer, but it's small, wimpy, and almost assuredly we will just monitor that. But the third possibility, and the only reason we're having this discussion and you're going for a biopsy is in case we find a cancer that might warrant attention and treatment. And we'll have a long conversation about the laundry list of potential treatment options for that type of cancer. Cancer.
- [45:37]
A
And that's a change because this lower grade or Gleason grade six cancer, these used to be treated universally. And so tell us how we've sort of veered from treating everyone to now watching patients.
- [45:52]
B
Yeah, this gets back to kind of the early PSA days. You know, you have a test that can find all these cancers. Finding cancer early, war on cancer must be better. You know, find it early, treat aggressively. So when I was a resident and even fellow, the most common surgery we did was a Radical prostatectomy for Gleason 6 prostate cancer, which is now called in some circles, Grade Group one. Through some iconoclastic pioneers in Canada and the United States and even in Europe, they came to understand that we can monitor a lot of these. And like most things that are disruptive, it was contentious and controversial and heated debates. And we now know with near certainty that monitoring these Gleason 6 or grade Group 1s is absolutely the right thing to do. And that's why it's preferred management in every single guideline on this planet for these early stage, wimpier ones. Now, the next step that myself and many others think, we have a whole movement of trying not to diagnose these things. Okay, you don't want to diagnose people with Grade group one because you don't think it's going to benefit them even knowing about it. These biomarkers we talked about, one of the benefits that are advertised appropriately. So is not diagnosing Grade Group one MRI one of the benefits is that. And so we're saying, even if you get diagnosed with Grade Group one, let's call it something else, and I could give you a long winded, very boring soliloquy on it. But on a very basic level, if you just go to the dictionary of what is cancer and what is Benign, grade Group 1 prostate cancer fits the criteria of something that's benign. It literally cannot cause symptoms, spread, or kill somebody. And until someone proves me otherwise, I will stand up in front of any audience and say, I'm not aware of a human in history who's had a symptom, metastasis or death from modernly graded grade group 1 or Gleason 6 prostate cancer.
- [47:55]
A
That's really powerful. I think that's really important for people to hear because there are still many urologists treating grade group 1 or Gleason 6 cancer with surgery and radiation who likely will not need it.
- [48:10]
B
Hell yeah. And it's really disturbing and it really bothers me to no end. In other words, countries around this planet like Australia, England, Sweden, and dare I say, even more civilized from a prostate standpoint. More than 90, even 95% of people diagnosed with grade group one go on surveillance, which is probably the benchmark of where it should be in our country. Nationwide, the latest data we have is at 60%. So to your point, 40% of men diagnosed with this for one reason or another, and there's many potential reasons, go have treatment that they probably didn't need at that point in time. Now, we do highlight in the United States a remarkably impressive cooperative group or collective. It's something called music In Michigan, where they made an effort to improve the quality of prostate cancer care. And in the state of Michigan, their surveillance rates parallel those of some other countries. We need to try to do that elsewhere and we're making incremental progress. It just hasn't been as fast as we'd like.
- [49:18]
A
Yeah, we had Dr. Davenport, a radiologist from Michigan on, and he was also mentioning about the music program, and that's such an amazing innovation that I really think would benefit us if we use that as a model nationwide.
- [49:33]
B
Absolutely. In almost every disease space.
- [49:35]
A
Absolutely. I mean, it's amazing what they've done. Let's tell people the data. If you're diagnosed with Gleason 6 cancer, what is the likelihood, what is the percentage of men who go on to getting a Gleason 7 or grade group 2 cancer?
- [49:49]
B
Yeah, there's a ton of like, large data, long follow up out to 15 years. And the really good news is for almost all men with Gleason 6 or grade group 1 prostate cancer, when you go on surveillance, the likelihood of you ultimately dying from that Prostate cancer is 1% or less, and it's as low as 0.1% in some of these massive observational cohorts. Now, it's incredibly important to know you need monitoring, you need follow up. And for the most part, year over year, about 5% of men that start on surveillance, there will be a change noted in their prostate. It was either always there, but now it was picked up on a new biopsy or something has changed in their prostate and they may benefit from getting treatment at that time. And if you go out about 15 years, for the most part, about half the guys that started on surveillance may need treatment and benefit from it at some point, but the other half, cruising along 15 years later never needed anything done or they've passed away from something else.
- [50:56]
A
So I'm going to play devil's advocate. So say you have done surveillance, say you done more biopsies. This is something one of your colleagues at Chicago used to say, is that if you biopsy these people over and over again, you now make surgery more difficult. And so if half of people are going to go get Gleason 7 or grade group cancer or need some sort of treatment, isn't it better to treat them at Gleason 6?
- [51:21]
B
Absolutely. And I love, you know me well enough to know I love every aspect of Devil's advocates because it enhances the conversation. So a lot to unpack there. So first of all, there's a lot of people who try convincing people to have treatment straight up front for a lot of reasons that we won't get into. I think surveillance is the way to go for almost all of those folks. It used to be everyone on surveillance got a biopsy every year. And that was just being rigorous and conservative. We now know through data that was published in many cohorts, including one of our friends and colleagues, Dr. Kearns wrote a great paper for some of these people on surveillance that are low risk. They don't need a biopsy every year, but you can probably go every four or five years with them. So you should individualize it and tailor it. And then as far as making treatment more difficult, there's mixed data out there, but there's some data to suggest that that might be a myth. The more biopsies you do, that it would make surgery more difficult. I can tell you, the very first study I did as a fellow, it was told to everybody. You had, you know, if someone had a biopsy showing cancer and they were going to go have surgery, you had to wait six to eight weeks. Why? Because it could make the surgery more difficult. The godfathers of urology always told you that if you had a difficult surgery, there had to be a reason for it. Turns out it's a total myth. So the very first paper I looked at at Sloan Ketterene, thousands of patients time to surgery. You know, time between biopsy and surgery doesn't matter. You can operate early. And that biopsy did not impact the quality of the surgery.
- [52:54]
A
Yeah. I mean, there's so much. We talked about this earlier, but there's so much dogma in medicine that people. There's a lot of superstition and there's a lot of dogma that people hold on to, and they don't challenge it.
- [53:06]
B
Yeah.
- [53:06]
A
And it. And then, you know, it does take some randomized controlled trials or some real investment to disprove these things. And sometimes even when that's there, as you mentioned this morning, people still don't know.
- [53:18]
B
Yeah. I mean, as someone who really loves doing research and doing trials, to me that's the excitement, asking these questions. We've always done it this way. Is it really the right way or the wrong way? And I have a whole hour long talk of things that in urology and outside of urology that we just had wrong. And it took people to come up with data to prove it wrong. There's a great quote that always resonated with me. 50% of what you and I learned in surgical training was wrong. The hard part is distinguishing which 50%.
- [53:49]
A
It is crazy. It really is. So I think the important thing for people to take home is that we don't have all the answers. And some things that we say, usually they're not harmful, but sometimes people do things because that's how they've always done them and it's not always accurate. I think that the key is if you are someone who's had prostate cancer and you're diagnosed with Gleason 6 or grade group 1 cancer and you want a second opinion or a third opinion, there is time to do that and to talk to other doctors. You are not. And if you decide that, you know, because of the data that we've discussed and someone who tells you that, yeah, 50% of you will need treatment and you, you just want treatment now and you decide that as a decision and you find a urologist who wants to do that, that's what you decide, that's okay. But you owe it to yourself to get a second opinion with someone who thinks differently.
- [54:40]
B
Heck yeah. And so for guys that are listening to know when you're diagnosed with a Gleason 6 with near certainty, it had been there for years and sometimes even decades. There is no rush. The chilling and disturbing thing is that even amongst men diagnosed with Gleason 6 in the United States and Sweden, we have data that the rate of suicide goes up, measurable, really low, but measurable all for something that has a 1% chance or less of ever causing them a problem. And so my talk with them is just drowning in your future is bright, bright, bright. Here's why, here's objective data, here's quality of life, things we should talk about. And so it's really important that they have a good understanding of it. And when someone's diagnosed with it, even if they're the healthiest person ever, statistically speaking, there's three to five other things that are way, way, way, way more likely to get them at some point in the long run than this small wimpy.
- [55:47]
A
Yeah, I mean 1% is really low. And I think it's so important to talk about this because it's hard for even a urologic oncologist who trained to take care of prostate cancer to stay up to date with the data. And it is innate in everyone to find a cancer, treat the cancer, right? That is like an innate, like, oh, you hear the C word and you want to do something about it. And so you and well intentioned urologists will still say the right Thing is to treat you because they still believe that and they feel strongly about that. And, and I think you have to understand that there's a lot of personal feelings and maybe difficulty with actually keeping up with this data because a lot of it is very relatively new.
- [56:34]
B
Yeah, there's a lot of fascinating social science and psychology that comes into it from the doctor side, from the patient side. And let me just clarify. And I've done thousands of prostate cancer. I've done thousands of surgeries and something like 2,000 prostate cancer surgeries. I'm not a nihilist. You know, I do a lot of surgeries. It's not that everyone should be monitored. And a couple times a year I will operate on someone with grade group one. But those are more outliers. And I always said, and maybe you heard me say at some point, the worst indication for a surgery, particularly when it comes to cancer, is patient wanted it. If their starting point is that, to me, the ultimate gift to that person and it gives me a lot of joy is let's get comfy. Let's take as much time as we need. Let me explain to you why you don't need anything done at this point. We're going to monitor it. Your future is bright, bright, bright.
- [57:23]
A
I find that honestly, oftentimes when the patient wants something and they push for it, unless it's like an elective procedure, which they could obviously choose to have, it sometimes goes wrong. I don't know if there's like it's a suspicious thing or what, but that's where the complications seem to happen. And they may have everything going for them. They may be the healthiest person ever, but for some reason it's like, like it's, it's a, it's a superstition. I don't know. But I do see that happen.
- [57:53]
B
I think it's science, it's bad juju and karma. It just has to, has to play out that way.
- [57:57]
A
Yeah. Yeah. Well, let's talk about treatment. So I think, you know, everyone knows options surgery, radiation, but I think people really don't understand the difference. And I will say that when you see a urologist, they're a surgeon, they're going to talk about surgery favorably. When you see a radiologist, they're going to talk about radiation favorably. So you are the most data driven person I know. In fact, that's one of the one things I really enjoyed learning from you, is because everything was data driven. So what is the data? Let's just talk about surgery and radiation and we'll talk about other options.
- [58:29]
B
Yeah, but think about that. It's so disturbing that your advice should be based on the training of the person. It's one thing if there was randomized data to say one is definitively better than the other. And everyone who walks in the door should get A versus B.
- [58:44]
A
Right?
- [58:45]
B
So I would put it out there, and I would say this to anyone, including friends and colleagues. If everyone who walks in the door, you're saying here is the best one for you, and that's your norm. I mean, in the dark of night, maybe start asking yourself some questions. So I do get it from kind of an efficiency simplistic, you know, kind of just, let's make this clean and easy for someone and say you have been diagnosed with this. Here's what I recommend. I can tell you how I've approached it, because it's. The only way I'm comfortable with it, is we set aside 30 minutes, I start explaining all the options to them. And it can range from monitoring, which is active surveillance, to various treatment options. And I make a point of mentioning surveillance and all the treatment options to almost every single patient diagnosed. And for some of them, they are literally all on the table. And for others, I say, this is why surveillance or focal therapy or surgery is a bad idea for you. So let's narrow it down. But it's relatively rare that I talk with someone and I say absolutely, positively, here's my firm recommendation. It's, here's the data, here's the potential side effects, here's your situation, here's your quality of life issues and function. You know, you have to make a decision. Help me help you ask whatever questions. You don't have to decide today. You have easy ways of accessing me. I encourage second and third opinions. Go meet with whoever you want. And then they ultimately have to, you know, come to a decision.
- [60:14]
A
I hope that most people are doing this, but I do feel like in modern healthcare there is limited time. So having 30 minutes is very difficult for a lot of doctors just based on reimbursements. I mean, we're one of the only professions where we get paid less every year based on, like, Medicare reimbursement. And. And I think it is. And honestly, I feel like people may say, yeah, this, this, this, there are options. This is why I think this is best for you. And that is so they will tell them the options, but they will still sort of lean on what they know, what they know, what they feel comfortable with. And that's again, social science, human nature, to some degree.
- [60:52]
B
All valid points. And we all have biases and blind spots. And I always thought the challenge is to try to minimize as possible. It's impossible to make them go away.
- [61:02]
A
Right, right. So let's talk about the difference in terms of surgery and radiation.
- [61:08]
B
Yeah. Two, you know, fundamentally different approaches with the same goals. I mean, the ultimate goal of treating a cancer in the prostate is hopefully the cancer never causes you a problem and hopefully you maintain your quality of life, you know, and have minimal side effects. The reality of it is the prostate is at ground zero. You know, I say this kind of sophomorically, but if the prostate was on our elbow, there'd be very little controversy. It's down near all these important structures and even in the best of hands with any treatment, you need to understand there is a risk of shorter, long term side effects. So these are long winded conversations. I'm a numbers guy. I just kind of see the world through numbers. So for most patients, not all, I tend to give them percentages in likelihoods, and for those who don't want to talk in numbers, I give them more broad strokes. But yeah, I mean, there's with surgery that, as you know really well, the two main things we worry about are incontinence or erections. Thankfully, there's a pretty darn low likelihood of things going sideways with the surgery itself or anesthesia or any of that. Radiation is non invasive, but there's a half a dozen different ways of getting radiation. Sometimes you need, you know, testosterone blockers, sometimes you don't. There's short courses of radiation, long course. And the things you worry about, there are urinary symptoms, erection difficulties, and a low risk of bowel related problems.
- [62:31]
A
Yeah, so there's side effects with both. What are the rates of erectile difficulties, incontinence for both?
- [62:39]
B
Yeah, it depends who you ask. And there's data out there in general, whether it's the radiation side or the surgery side, the more experienced someone is, the lower the likelihood of side effects. I've been doing it for quite a while and I try to be as active as I can with people. I can tell you the numbers I share with people is that about 30% of men never have any leakage after surgery. 70% will have it, but it can range from weeks to months to many months. You know, the average time to get it under control is three to six months. By a year after surgery, roughly 95% of guys are happy with their urinary control, meaning totally dry or very rare leakage. But there's still, you know, anywhere from a 2 to 5% chance that even after a year you're going to be troubled with your urinary leakage. And there's things that can be done from conservative to more invasive. What you've done, you know, to help people out. Erections are still the Achilles heel of surgery. I don't care what anyone tells you. Okay. And there are some salespeople out there that, you know, you know, rose colored glasses with it. But if you walk into a surgery with quality erections and your surgeon's intent is to spare the nerves that are important for erections, there are some men who never notice a difference. Never notice a difference, but that's probably 10, 20% straight out of the gate. Most will notice weaker erections and the return of erections typically takes longer. It can take 6, 12, 18, even up to 24 months. And even the most optimistic scenarios, you know, with simple things like pills. I've never told anyone that there's a more than 75, 80% chance, depending on their age and health and everything, that their success rate is going to be 75, 80% chance that they get the baseline start operating on. Some older people don't do complete nerve sparing. Those numbers drop dramatically. So they need to be on board with that as a possibility. And as you're aware, I mean, that's why it's so important to have these conversations with men about how important their erections are to them, for themselves, for their partner, for sexual activity. It's really helpful as a surgeon when they say it doesn't matter to me, it's not a part of my life, as opposed to the other extreme of, you know, I'd rather be dead than not have an erection.
- [64:52]
A
Yeah. It's so important. And I think those numbers are very accurate based on the data. And I really worry that there's a lot of rose colored glasses when they talk about surgery and people are blindsided. They don't realize what their life will be like. And I know there's data on regret after surgery and it's not zero.
- [65:14]
B
Yeah.
- [65:15]
A
And I think it's because we're not educating people well enough.
- [65:18]
B
Totally agree. I always like the concept of under promise and over deliver rather than setting really high expectations and then have disappointed patients.
- [65:25]
A
So let's compare that to erection quality after radiation and urinary conditions. And urine is a little different.
- [65:31]
B
Yeah. Unequivocally, the best done studies comparing surgery and radiation, if erections are a really high priority for you, there is a lower likelihood of Erection problems with radiation. Just QED with that now, you may need some hormone therapy out of the gate for six months and sometimes for a couple years. So the early days might be rough, but long term, particularly if you haven't had hormone therapy. More men who have radiation are going to be happier with their erections. Now the urinary story, as you know, is a little different. The good news with radiation is it's very rare to have stress incontinence, just kind of overt, high volume leakage, but relatively common. They have more irritation with urination and so 20, 30% of them will have bothersome irritation that can last a while. There's urge incontinence, which can be a component. There's a small percentage who newly have to put pads in for their urge incontinence and then the bowel related element to it. It should be close to a never event to have bowel related problems following surgery. But with radiation, particularly with time, there's a small percentage of men that will have meaningful bothersome rectal discomfort, change in their stool consistency, and even on rare occasions need interventions for that.
- [66:47]
A
And the hormone androgen deprivation therapy can be pretty problematic for those two years. And that's putting it lightly. I think people can see a very dramatic change in their quality of life during that time and I think that's important to bring up.
- [67:01]
B
Yeah, absolutely agree.
- [67:03]
A
You can tell me, but if there's other things you want to add, but I would say fatigue, loss of erections during that time because of lack of hormones, brain fog, feeling weak, those sorts of things can be really common.
- [67:16]
B
Yeah, a few added layers to everything that's accurate that you mentioned. I mean, you lose some muscle mass, you lose some bone strength. If you need testosterone suppression, it's usually from 6 months to 18 to 24 months. But it's important to know that if you have it for six months, it takes another six months, on average, three to six months, depending on your age, to get your Testosterone level back. 18 to 24 months of the medication, it still takes a while for your testicles to kick in and produce it. And so those are meaningful, important conversations that are quality of life issues.
- [67:49]
A
Let's also talk about brachytherapy. Brachytherapy is essentially implanting seeds of radiation seeds into the prostate. Who is a good candidate for that? And is that still widely used?
- [67:59]
B
You bring up an essential point if you choose the radiation route. There are many ways of getting radiation. The traditional are these invisible beams where you go for six to eight weeks and you go every day for about 20 minutes, it focuses on your prostate. There's hypofractionation and ultra hypofractionation, which the translation of that is condensing it down. And now it's sometimes called SBRT to make things even more confusing. But there's data to support that. For many men that choose radiation, it can be as short as even five days of treatment. More commonly you can get it down to kind of four weeks of treatment. And then there's other ways of getting radiation to the prostate, like brachytherapy, which is a one day procedure where you have these radioactive pellets strategically implanted into usually the entirety of your prostate. They give off radiation for the rest of your life. It decays over time, but it's kind of like in inner radiation, internal radiation within the prostate. People who are eligible for that are earlier stage prostate cancer. So if you have a really high grade prostate cancer or bulky prostate cancer, not a great idea. The other thing is some anatomical issues that aren't worth getting into and then you cannot have baseline really bother some urinary symptoms as measured by the ipss. So most people have some threshold there on who would be a candidate for brachytherapy.
- [69:22]
A
Yeah, I think the biggest thing to think about as a patient is how big your prostate is and how bothersome your symptoms are. So you may have some symptoms, but they may not be that bothersome. But they could get a bit, little, little bit worse with brachytherapy.
- [69:35]
B
Yep. And you added an important one that I forgot is the size of the prostate. Really large prostates are either ineligible for brachytherapy or you take hormone therapy to shrink the size of your prostate to get your seeds and then you go off the hormone therapy. Great point.
- [69:49]
A
Can you stay on finasteride when you have prostate cancer?
- [69:53]
B
Yes, you can, but you often don't need to. So if you've had surgery and your PSA goes to undetectable and you're cancer free, there's no value with radiation. Absolutely, yes.
- [70:04]
A
So yeah, there's no concern that because of that, I wonder, because of that data that showed there may be a slow chance of aggressive prostate cancer that are we, you know, adding some risk by staying on it.
- [70:16]
B
You typically don't need it. And there are some people, and you've seen them probably as well, that stay on their alpha blockers and 5 ARIs, if they don't have a prostate or they've had radiation, they don't really need it. They just of kind keep taking it. No one's told them not to take it. But if you need to, and there's value. Yes. Particularly after radiation, you can continue those medications.
- [70:34]
A
Yeah. I would tell all this is actually a very big pet peeve of mine. When people come in with chronic catheters or they've had surgery and they're peeing great, and no one's ever tried to take them off their medications. And it irks me because I'm like, you don't need these potentially. Right. And especially if you have a catheter or your catheter yourself, putting a catheter in to drain your bladder. And so, yeah, my public service announcement is, if you're on these medications and you're not sure, talk to your doctor about it.
- [71:03]
B
Particularly the alpha blockers where you can turn on, turn off. I mean, every time I give someone a prescription for an alpha blocker, I say, try this for two or three weeks. If it's not helping, don't continue it. And the same goes if they've been on it forever, stop it for a week or two and see if you miss it.
- [71:18]
A
Yeah. People say within a day. Within a day, they notice the difference if they go off their alpha blocker. People who really need it. So, you know, I do the same. What about focal therapy? So there's a whole new emerging area of treatment for prostate cancer called focal therapy. And there's multiple different things you can do, either experimental or now available for patients who have localized prostate cancer.
- [71:43]
B
Yeah. I'm going to go back to the breast cancer analogy because I think it's a good one. So there was a time and a place in the 70s where lumpectomy for breast cancer was villainized, a crime against humanity. There were some pioneers who, you know, offered it to patients, had case series, eventually a bunch of randomized trials that showed it had value. And my understanding is nowadays, roughly 60, 70% of women in this country with breast cancer get a lumpectomy. We are, and this is one of the examples where we can learn a lot from them. So focal therapy for prostate cancer has been around for a while. Not nearly as. As that, but we're following the same trajectory where, you know, it ruffles a lot of feathers. It. It makes some sense to treat just part of the prostate, try to take care of the cancer that might cause a problem, try to minimize side effects, try to minimize need for radiation and surgery. There's case series. You know, there's people that are big proponents of it. There's people that think it's, you know, the. The worst thing ever. The great news now in the prostate space is there are randomized trials that are ongoing now, and so we will ultimately learn whether it has value for people. And at best, there will be a subset of patients where it's an option for them, and it may be a very attractive one. But even in the best case scenario, I'm guessing these are still going to be complicated, you know, long discussions with many options for people, but we'll see what the data shows.
- [73:11]
A
So right now, what are the most promising options?
- [73:14]
B
Yeah, there's a consistent theme in prostate cancer. There's usually layers, and there's usually six to eight different options.
- [73:22]
A
Yeah. So lots of options, but nothing that's available right now that's completed a randomized controlled trial.
- [73:27]
B
There's one randomized trial for something that's not currently available in the United States. It's called PDT photodynamic therapy. And to the credit of them, they were pioneers in doing a randomized trial. They did it for Gleason 6 prostate cancer, which we now know doesn't really need anything. So the current randomized trials, and really, I can't emphasize enough kudos to the companies and the patients that are and the investigators who are supporting this. But they're almost all for patients with kind of real prostate cancers, and they're randomized against surveillance or other treatments.
- [73:59]
A
Okay. So if someone's interested, they should look for a trial to enroll in.
- [74:03]
B
I would always favor a clinical trial versus not. And if you're interested in learning more about clinical therapy, I will tell you there are some really honorable people offering it as an option. There are also some charlatans out there. There's often a financial component to it. If you have someone that's selling you focal therapy and they don't offer anything else, my 2 cents would be try to find someone that can give you a more tempered overview of things. But there's a lot of different focal therapies that are out there. There's cryotherapy, hifu, Ire, Tulsa, and others.
- [74:35]
A
Right, right. And so you can get them, but you generally want to be offered them in the context of other options. And someone who gives you a really sort of tempered discussion, as you mentioned.
- [74:47]
B
Agree.
- [74:47]
A
Yeah. Okay. The other one I wanted to talk about, which I've just seen recently, people. I don't know if there's actually it's been published yet, but people are trying aqua ablation for localized prostate cancer. Has that been published yet?
- [75:00]
B
It has not, but that's one of the ones that's exciting. And again, credit to the people who are supporting that. You know, it makes a lot of sense in the history of medicine. There's things that make a lot of sense that ultimately become standard of care, and there's things that make a lot of sense that we ultimately laugh at and never become standard of care. So the purpose of these trials is to. Is to learn more about it.
- [75:20]
A
That's pretty exciting, though.
- [75:22]
B
Extremely.
- [75:22]
A
Yeah, yeah, yeah. The other thing I want to talk about, we talked about erections, but we didn't talk about orgasm and ejaculation after prostatectomy. I think one thing, actually, I'll share a story. I had someone call me and they said their patient was very upset because the urologist didn't tell them that after they had their prostatectomy that they would no longer be fertile. And so I think there's things that get missed in the conversation that we know to be true and obviously makes sense to us, but sometimes are missed to tell patients. So what can patients expect in this realm after prostatectomy?
- [75:57]
B
Yeah, extraordinarily important in your bailiwick, but anyone who kind of does what I do needs to be sharing it with patients. Also in this, you know, orgasm, ejaculation, penile length, fertility, you know, that should be part of the conversation. I certainly try and I'm probably not always successful, but these are long winded conversations following surgery. The simple thing is there's basically no ejaculate. There's some little glands in the urethra where there may be a little sweat that comes out, but no real ejaculate. Totally unbeknownst to me, until I became a urologist, and unbeknownst to a lot of patients, you can still have an orgasm without ejaculate. It's a dry ejaculate. You can even have an orgasm without an erection. And there's many ways. It's a central nervous system process and you can can speak more intelligently about it than I can, but those are important for patients to know. The penile length issue is essential. Not everyone notices it, not everyone cares about it. But if you do stretched penile length on people that have surgery, on average there'll be a slight shortening, and for some people it's catastrophic. And so that's important to tell them. It may not always, but may get a little short and then fertility. There's no such thing as natural fertility after your prostate's out. So there are ways to either bank sperm or to go into the testicle or do other things after the surgery. But that's Important to know.
- [77:24]
A
Yeah, absolutely. I think the thing about orgasms is they shouldn't change in terms of the pleasure related to them. Although some men, I find, are very. They don't. May not realize it, but when they don't ejaculate, they lose. They have sort of a cognitive connection to releasing ejaculate. And so when they lose that, they do feel less pleasure. And it's not necessarily because they're not having an orgasm. It's because they've now lost that thing that they've linked in their brain with the sensation of orgasm.
- [77:54]
B
Yeah. And you know it better than I, but I have heard from a number of patients that ejaculate passing through, you know, it's either something physical, neurologic, or psychologic that is really important to them that I don't fully understand.
- [78:08]
A
Yeah, I mean, there's. There's definitely some people who attribute a pleasure through urethral stimulation. So there's urethral play, there's urethral sounding that people, men and women, participate in. So. Absolutely, it makes sense. But I think sometimes it's. And it's interesting. I did a poll on my YouTube community, and I think it was like, 20,000 responses. And I asked, Asked people, like, how would you feel if you lost your ejaculate? And, you know, I was like, yes, I would be fine. Maybe I wouldn't care or not. And some people like, no. And some. It was very interesting. Some people were like, it's. It's a no starter. Some people are like, yeah, I'd kind of miss it, but I'd be okay. And some people were like, whatever, no big deal. And it's. It's across the board. There's no, like, right answer. But I will say, like, there's many people who, if you ask them, which many people don't ask them. I ask all my patients. Right. But if you ask them, they're like, oh, no, I want to preserve my ejaculate. And that's another thing I think we don't do well as urologists. People don't talk about it as even a side effect with alpha blockers or medications that they may notice a change. And people can get very upset about that.
- [79:13]
B
Yeah. And also important to know if you're considering radiation therapy, ejaculate volume typically goes down dramatically. It doesn't go away, but there's less. There's less propulsion. There's not as much coming out.
- [79:25]
A
Yeah. Yeah.
- [79:25]
B
And even some of the focal therapies, depending what part of the prostate you're treating it can be ejaculatory, preserving. But there's other areas you treat where they would notice a difference in ejaculation.
- [79:35]
A
Yeah. So I think good questions to ask your urologist specifically if you're doing like a focal therapy and you're not sure because it may be variable.
- [79:43]
B
Yeah.
- [79:43]
A
The other thing I think people don't realize, and especially people who've had prostate cancer don't talk about very often unless asked directly, is when they do climax, sometimes they actually leak urine. And that's something called climactoria. What is the rate of that?
- [79:59]
B
Yeah, like most things, it's dependent on who you ask, when you ask, and how you measure it. But there's absolutely a percentage of people after prostatectomy who have either arousal incontinence or. Or climacteria when you have the orgasm. And in general, after they've healed up and started working on their incontinence, most of the data suggests 5, 10%, sometimes as many as 20% will notice it. And again, it depends on how much it bothers them or not. For some people it's not a bother, and for some it's awful for them or their partner. And there's no great solutions. I mean, the things that we offer are better pelvic floor therapy. Just work on the incontinence in general. You know, a band at the base of the penis, just good old compression during sexual activity. A condom obviously catches it, but that can be really disturbing to certain individuals.
- [80:57]
A
Yeah, it is really challenging. I've seen patients who are totally distraught by this. So I think important to know that there is a chance of this happening. It may not be as bothersome as you think, but. But it can be, and it's not really reversible. So anyway, we've talked a little bit about financial incentives, but I think in any surgery, let's not even say prostate cancer, but there's always would be remiss to say that there's no financial incentive for people to do surgery. And I think with prostate cancer, that can obviously influence how you talk to a patient about their treatment options. Now, in terms of, like, when you're a patient, how can you sort of, what would you suggest for a patient to say, like, hey, I'm getting the best information possible. And it's, and it's. This is a challenging question. I don't know the right answer, but I would love to get your thought on it is how do you tell a patient, like, look, this is likely someone who is financially, you know, incentivized versus someone who's giving you the real data.
- [81:58]
B
Yeah, that's a challenging one. I mean, oftentimes from a patient perspective, and it's even when I'm a patient or maybe when you're a patient, you just get a gut sense or a sixth sense on is this person honorable and have my best interests in mind rather than theirs. And I'd like to think there's not a ton of doctors out there that are totally self serving, that sometimes it's subconscious or just that's how they've always done it. And it's not like just a pure kind of self serving money grab. But those people are also out there as well. Now I can tell you how I tactfully do it. When someone comes to me for a second or third opinion, if they've seen someone out there who I know and have a reasonable, you know, assessment of them, I will always tell this person that that other doc you saw, I think they're great, they give good advice. I would send a family member to them. I'd send someone for a second opinion. If they mention someone else and I have a different opinion of them. I don't, you know, it's not, I don't do the opposite.
- [82:56]
A
You just don't say anything.
- [82:57]
B
Yeah, I try not to. Now, if there's some really egregious stuff happening, I do feel compelled to have to tell the patient. You know, I don't agree with how this was done. I would have done it a little differently, but that's only for the stuff that's really just, you know, really out of bounds or if they're getting just kind of crazy advice.
- [83:15]
A
Yeah, yeah. I think it's challenging, but yeah, use your gut as a guide. I will say that some people are really great salespeople and they are very charming. And I had a guest on who was an expert in narcissism and she said, I don't trust charming people. And I thought about that a lot because I'm like, you know what? The most charming people, the people you meet, and you're just like, wow, they are so charming. Sometimes there's a reason they're really charming.
- [83:42]
B
Yeah.
- [83:42]
A
And so maybe take that. Not that everyone who's charming is bad, but I would say that there is a little bit of a. When they're too good to be true. Anything that's too good to be true, take caution.
- [83:53]
B
That's a great point. And if you have the good fortune of having some connections to doctors or nurses or people on the inside that's always helpful. I think some of the value you and I provide. When a friend or someone calls up and they need an endocrinologist or a cardiologist, you and I don't know much about that, but you can. A phone call or two, a text or two, and you can find out who the honorable good docs are.
- [84:15]
A
Yeah, absolutely. And again, second opinions, third opinions, if you have the time and the luxury to do it. I realize that's not available to everybody, but it's worth it. And, you know, I tell people we spend a lot of time working and doing other things, but we have to prioritize our health a little bit. And so this is the time where it's important to get those opinions. And anyone who gets upset at you for getting a second opinion, that is a huge red flag.
- [84:41]
B
Yes. I'm glad you bring that up because I find that mind boggling. I know if your doctor takes it personally that you're going to talk to someone else about it. You know, flashing warning sign.
- [84:53]
A
Right? Absolutely. And in fact, I tell my patients, like, please go see someone else. I'm happy for each. I will give you like recommendations anywhere in the country, like, happy to connect you with someone else. I really don't have any motivation to keep you if you don't feel comfortable with me. Right. And so. Or if you want to get another opinion that's within your right.
- [85:13]
B
There's also urologists out there who fire their patients if the patient doesn't agree with their plan. I've seen that a bunch of times.
- [85:18]
A
That's crazy.
- [85:19]
B
I'm like, here are your options at times. Here's what I would recommend. You decide to do whatever the heck you want. I'll take care of you. Whatever you choose to do. We'll document it, whatever.
- [85:29]
A
Yeah, yeah, absolutely. I want to talk a little bit about testicular and kidney cancer. I asked my audience to, and they had some questions. So one is, let's talk about testicular cancer. How do you detect it? And how do you do a really good testicular exam?
- [85:45]
B
Yeah. Thankfully, extremely rare. Thankfully. It has the highest known cure rate of any solid cancer. Even when it's metastatic, almost always curable. There's no great screening mechanism that we're going to do for the whole population. But once kids get pubertal, they should check out their testicles roughly once a month. However they're gonna do that, the best way of doing it, I think, is first three fingers on each hand, each testicle by itself, kind of roll it around, it should be a little bit soft. If there's ever a lump, a bump, a peculiarity, anything else, bring it to someone's attention, either a parent or go see a doc. And the good news is, most of those are false alarms. And as someone who had a decent sized testis cancer practice, when people would come in and have false alarms, I would proverbially high five them and congratulate them. Kudos to you for getting this checked out. It's all gonna be okay. But here's what you're looking for next time, because it's really disturbing seeing the opposite of people whose mind played tricks on them and they walk in with terrible testis cancers that never got checked out or it's metastasized.
- [86:57]
A
I remember you had a patient when you were in residency who had testicular cancer and went to some wellness retreat and got metastatic testicular cancer.
- [87:07]
B
Yeah, I remember that guy's name, and I can see his face and his family. And he passed away from it. And that was a charlatan who sold him a bag of goods that they could do all sorts of unconventional things for his testis cancer. And by the time he got to us, that's the rare exception where it was too late.
- [87:29]
A
Yeah, it's really scary. And I would say there are. I've seen it so many times. There are a lot of people who will promote cancer healing things. They have no medical background. They have no, like, understanding of cancer. And it is really scary because, like, these people are charming and they are very good at selling what they have because it. Yes, sure. Is there spontaneous remission of cancers? Yeah, of course. But that's not the norm. And at least know your. At least know what you're getting into. Yeah, right. If you decide to not treat your cancer, that's fine, but see a regular doctor and make that decision after, you know, the information.
- [88:09]
B
Yeah, great points. At least be well informed about it.
- [88:11]
A
Yeah, yeah, yeah.
- [88:12]
B
Because spontaneous remission isn't a. Isn't a strategy.
- [88:16]
A
Yeah, it's not a strategy. It's a. It's a miracle.
- [88:19]
B
Yeah, It's a hope.
- [88:20]
A
Yeah. And then. Yeah, I think it's generally more common in young men. What about older men?
- [88:26]
B
Yeah, it can happen in older men. The kind of. The. The most common prevalence is, you know, from age 15 to, you know, 30, 35. But there are outliers. I've treated men for traditional testis cancer as high as in their 70s, although it's way, way, way less common.
- [88:42]
A
Yeah, yeah. So I think every man should be examining Their testicles generally monthly. It's not hard to do kidney cancer, let's talk about it. Is it on the rise?
- [88:56]
B
There does appear to be a slight increase in incidence, and there are many potential reasons for that. There could be true environmental, lifestyle, things that are. Are happening in our population. There's also a component of the more pictures you take of people, the more things you're going to find in the kidney. Now, when you find things in the kidney, like many things you find on scans, sometimes it could truly save your life. And sometimes you just found something that you literally would have been better off not knowing about it.
- [89:25]
A
Yeah. So Dr. Davenport and I had this great conversation about this because, you know, full body MRIs are now commercially available. They sound great. It's tempting to go get one because, like, oh, I could just screen my whole body, but there are real downstream harms. So please listen to that conversation because I thought it was so good. But I really think that similarly with kidney cancer, I mean, there are great guidelines for small renal masses and what to do with them, but once you have a renal mass, you have to talk about it and it stresses you out. And it's easy to say, let's just take it out when that's, you know, that's the risky procedure.
- [90:03]
B
Yeah, completely agree. If you could go down the street to the mall and for 100 bucks, get a full body CT scan, would you do it?
- [90:10]
A
Before I talked to Dr. Davenport, I would have not seen MRI. Not maybe not a CT. I would do an MRI. Yeah. But now I wouldn't.
- [90:18]
B
Yeah. That's interesting.
- [90:20]
A
Yeah. Because I was like, oh, well, you know, I'm smart enough. This is what I was thinking in my head. I'm smart enough to know that this is a small nothing. But after talking to him, I realized, like, it's never a nothing. You're gonna investigate that nothing. And that investigation can cause harm. And he gave a great story of a patient who had a lung nodule and went through like, you know, 20 different things afterwards and had complications. And so after, after talking to him and understand that day a little better, I said no.
- [90:50]
B
I was offered it with the loosest of indications and I declined. And I always thought of it as like, the full body scan for the average person is kind of like Vegas and gambling. You only hear about the winners in Vegas. You only hear about the full body scans of like, it saved my life. It found this cancer that I never would have known about. What you don't hear about are all the people that lose their shirts In Vegas and you don't hear about enough. The people that get full body scans that are chasing something and they get three, four more tests and more unnecessary surgeries. And so I'm like, you, I opted out.
- [91:22]
A
Yeah. I think it's interesting because I even asked him about coronary calcium scores because I was like, oh, this seems like such a great test for cardiovascular risk, which is so important. And he's like, look, it's still radiation. You still might find a lung nodule. So it's not indicated for everybody. And I said, oh, this is like, it's interesting. It's always, it's exciting to say, oh, I have this technology now. Right. That can find so much more. But then what are the downstream consequences of even just imaging?
- [91:48]
B
Yeah. Be careful what you wish for.
- [91:49]
A
Right, right. Is there screening for kidney cancer? I know there are certain populations that should be screened, but in general population.
- [91:56]
B
Yeah, people have looked into it and there was a group out of the University of Wisconsin many, many years ago that did screening urinalyses looking for blood in the urine. It's relatively rare enough. It doesn't make sense. Now if you were really high risk or if you had a strong family history for certainly if you have one of these congenital syndromes or genetic abnormalities that puts you at risk. That's standard of care. Now I do tell people if they have a family member with kidney cancer, even though it's not in the guidelines, but you have one person in your family, there's no known genetic mutation. Maybe just go get a renal ultrasound at a certain age and every five years keep a loose eye on it. There's no known downside to all ultrasounds, but population based screening for kidney cancer doesn't make sense. There's these multi cancer detection tests that are looking for circulating tumor DNA. Gallery is the most common. Now, gallery potentially is transformational in the urologic cancers that you and I are interested in. The data, the early data isn't very promising, so I wouldn't want to run out and get a gallery test looking.
- [93:02]
A
For kidney cancer in terms of all these cancers and as a surgeon, I mean, I think it'd be amazing if we didn't have to operate on them. But are there any of these where we're getting close to a point where there may be non invasive options that outperform surgery?
- [93:17]
B
Yeah, it's an awesome question and I know it sounds self destructive, but it would be gloriously good if I didn't have to work anymore. If there's some pill or prevention or Non invasive something. And there are cool things in particularly prostate and kidney, which are two of the three that I deal with that, you know, maybe with more data and time we will be able to make things go away with these non invasive strategies and good old traditional surgery, you know, won't be as common. I tend to think there'll always be a role, but maybe it'll be way less, you know.
- [93:54]
A
Yeah.
- [93:55]
B
Be careful what you predict because it'll be never know.
- [93:59]
A
I think that's exciting, right? I think that would be amazing. But I doubt those things will be without risk as well. You know, everything you do will have some downstream side effect or risk with it.
- [94:10]
B
Yeah.
- [94:10]
A
What about AI? I know AI. There's been a lot of research in AI and urology in terms of looking at MRIs with AI and looking at biopsies with AI. What is the most exciting thing you're seeing?
- [94:22]
B
Really, really early days in urology? I mean, obviously pathology and radiology as it affects urologic patients is kind of the first step. And we have seen some data that's come out that an AI version of analyzing your biopsy may have value. There's something called Arterra and there's a couple other companies that are in that space. We'll see how that plays out. But radiology is low hanging fruit and I've participated with some of my radiology colleagues on ways to automate the interpretation of MRI images of the prostate. It's hard to imagine it won't play a role, whether it's standalone, whether it's augmented with a human. I think we'll have to see where the data leads us.
- [95:06]
A
Yeah, it's exciting. I think it's only going to help. I think it's only going to help. The other area that you've worked in is international volunteerism, which I learned about. I actually did the same program, IVU when I was a resident. And I think it's a very interesting space because you can do harm when you volunteer internationally. But I know your organization, ivu actually does a very good job of sort of setting up areas for success when the mission trip leaves, which I think is so important. But talk about your experience with that.
- [95:40]
B
You know, the one paper we wrote together was the survey you did, of course, former IVU scholars on their reflections on it and do they still do international service work? I love it. I recently got back from a trip in Uganda. We're working with UCSF and IVU and the Ugandan Ministry of Health and the Ugandan Cancer Institute to set up a Urologic oncology fellowship in East Africa. And it's really valuable in the sense that there's great buy in by the Ugandan urologists. And we had about 15 to 20 urologists at this camp. And the goal of every trip that I go on with that is not to go there and knock out like do as many cases as you can. And all the people who are coming from overseas are doing the cases. It's always scrubbing with the local docs, trying to give some talks, trying to teach some folks and we learn a ton from them. I have learned a of ton ton on ways they do things just kind of structurally, logistically, technically, even on how to do things more efficiently or when you don't have all the resources available to you. And it's always a wake up call and puts things in perspective. You may have experienced this when you went, but you know, you're a world class urologist. If you weren't around in this community or if I weren't around in this community, it's not going to make a huge difference. People will find people of similar caliber in some of these places we go to. If you don't show up or if the folks there aren't trained, they're not going to get the care they need. To put things in perspective, I recently left Chicago, let's say in the metropolitan area there's 4 or 5 million people and there's something like 250, 300 urologists in the entire country of Uganda it's like 40, 50 million people and there were like two dozen urologists or something like that or three dozen urologists. So you can imagine, you know, what that means for taking care of a population.
- [97:44]
A
Yeah. Well, I went to Honduras and it was a pediatric urology program and the urologists there and the pediatric surgeons had become very good at doing hypospadia surgery. And we were scrubbing with them. I was absolutely learning from them and it was great. It was just, and they were just really at that point learning more complex cases because they were already so good at basic hypospadia surgery. And that was just amazing to see and I loved my experience. It was really wonderful.
- [98:13]
B
One of the cooler ones I went to and it was the most humbling is I went with a mutual friend and colleague of ours, Greg Bales, and we went to Congo and we worked at a fistula hospital and they wanted to learn how to do some slings and some other things that Dr. Bales was bringing talk about going to a place where all they did was Fistulas. This guy, Dr. Mukwege, ultimately won the Nobel Peace Prize for the work he's done. I mean, to think we could go there and offer them anything on fistula repairs short of like slings. I mean, it was eye popping in the best of ways on how talented and sophisticated they were.
- [98:46]
A
Absolutely, yeah. I mean, that's amazing. I interviewed, I remember when I went, went to swu, Society of Women in Urology, meaning they had some international surgeons there and there was, I forget which African country, but she, she was a surgeon there and she, I mean, they have so many fistulas. They're so. I mean, she gave a talk on fistulas. Right. But. But it was so amazing to, to see like they, they. That's their bread and butter almost, you know, so. Absolutely. You can learn a lot and, and I think we can learn a lot from global globalization of surgery. So it's amazing. What are you working on right now that you're excited about?
- [99:22]
B
Yeah, I mean, part of the fun of being an academic place or, you know, taking an interest in research or all these new ideas. You know, I recently joined ucla and part of the attraction are the people, power and history of innovation and tech transfer and novel ideas. And, you know, to me that's like being a kid in a candy store, you know, coming into a place where whether it's just a newer way of doing something or even a crazy idea that's worth pursuing. So there's all sorts of cool trials in the prostate space of better ways of screening people that are at higher risk. There's some surgical techniques that are going to be going to randomized trials to lower the risk of incontinence. There's all sorts of cool stuff with imaging and how to integrate psma, PET, or even these theranostics, which is a way of kind of putting your therapeutic payload onto a radioisotope to deliver it exactly to where the cancer is. And so there's a lot of just really, really cool stuff. The personal stuff I'm most interested in is this naming of Gleason 6 in grade group 1. I just categorically think that public health would be a lot better if we came up with a new name for it.
- [100:30]
A
I mean, I think, look, cancer is a scary word.
- [100:33]
B
Yeah.
- [100:34]
A
And if it's not a true. I mean, like we talk about carcinoma in situ or, you know, ASAP or these other sort of different. Like they're not cancers. Right. They're. They're pre cancers. And so I think it would Be reasonable to say that if, you know, it is sort of a pre cancer and we would save a lot of people stress and anguish from knowing they have the C word. Cancer.
- [100:57]
B
You're preaching to the choir here. We've done the. The cool thing is we've done it many times. There used to be Gleason 2 through 5, prostate cancer. We've done it with a rare type of kidney cancer, pun lump and bladder cancer. The most transformational one was in the thyroid world. They took away the cancer label because it wasn't really warranted. So, you know, it's part of the evolution as we learn more and trying to change with the times in a positive way.
- [101:20]
A
Yeah, I think a lot of people love to hate on doctors and say we get it wrong, but we get it wrong publicly. And I think that's, that's the difference. People get it wrong all the time, but we get it wrong publicly. And the thing is that we, you know, we're keep getting it wrong, but. But we're going to keep trying to search for the answers and doing it with, you know, the right scientific rigor.
- [101:40]
B
It's like the arc of justice. It bends in the direction of positivity. So there's, you know, missteps and, you know, things in medicine that we get wrong. But in general, things to be moved. Things seem to be moving in the same direction.
- [101:53]
A
So where can people learn more about you?
- [101:55]
B
As of a couple months ago, I took a position at ucla. So I'm super proud of the UCLA urology.
- [102:02]
A
You're so humble. He's the chair of UCLA Urology, which is a huge position. And I'm so proud of you, by the way. I'm just so, so proud of you. But yeah, go on the UCLA website. You wrote an article for the Times many years ago, right? That was a great article. Have you written since then?
- [102:18]
B
I've written a couple for the lay press. One was on the difficulty of dealing with surgical complications from the surgeon standpoint, the toll it takes.
- [102:27]
A
Yeah.
- [102:27]
B
And then the other one was with one of the breast cancer experts and we wrote an op ed on kind of these early stage cancer. Should we be calling it cancer?
- [102:36]
A
Yeah. Well, I always. I'm waiting for your book. I think I told you years ago, I hope that you write a book because you're in a very talented writer and I'd love to read it.
- [102:45]
B
Well, I learned today you're gonna have your big old book coming out. That's gonna be exciting.
- [102:49]
A
Yeah, it is exciting. What is that? I know you're an avid reader. So what's a good book you read recently?
- [102:54]
B
There's a bunch of them. So you want fiction or nonfiction?
- [102:58]
A
Go with one of each.
- [102:59]
B
I just finished, you know, Thanksgiving week. I plowed through on audio and paper. The Emperor of Gladness was a great book. Demon Copperhead was a phenomenal book. And then there was a Man Booker finalist that I finished this week that was thought provoking, which was interesting, called audition.
- [103:16]
A
Okay, I'll have to add those to my list. I've been reading a lot of, like, fluff fiction because give me one.
- [103:23]
B
It's a good escape.
- [103:24]
A
What did I just read? I just finished. I'll give it to you after. I'll put in the comments. I'll put in the description if people want to know which book I was reading. Okay. What is a Memory from Chicago? If you have one from when I was there that you want to share?
- [103:40]
B
You know, not to get all hokey, but like, I was so excited to see you today because it's been a while. And you know this because you train residents also. I mean, to be surrounded by trainees, the ones that are just have fire in their belly and are pleasant and talented and have worked their butt off and are going to go help people. You know, getting to spend time and playing an itsy bitsy part in your development and then ultimately becoming a friend and a colleague is like one of the pure joys of what we get to do.
- [104:09]
A
It really is. Thank you.
- [104:10]
B
I mean, as you saw this morning, you were walking up to the car and I'm like, I gotta get out of the car. I wanna give her a big old hug. And we sat and I get to hear everything exciting going on in your life. So that's awesome.
- [104:20]
A
I know. It's really wonderful to still get to see you. And now we're in the same country, in the same part of the world now.
- [104:27]
B
Yeah.
- [104:28]
A
So, okay. I end the podcast with four questions I ask everybody. They can be about life. They can be about urology, whatever you want. What is something you know now that you wish you knew earlier?
- [104:39]
B
That is a really long list, I would say being certain about things.
- [104:45]
A
Okay, you mean that you wish you knew that you didn't have to be certain or that you are more certain?
- [104:51]
B
I used to be far more certain about things, about opinions or facts or medical truths. And I've been humbled enough times in life and in medicine to know that that's not always the case.
- [105:03]
A
I think that's great advice. I think that I love being the dumbest person in the room and just saying, like, yeah, I don't, I don't know, I don't, I'm not certain. And teach me.
- [105:13]
B
I do that a lot more now than I ever used to.
- [105:15]
A
Yeah.
- [105:16]
B
And I love nothing more than a conversation with someone who vehemently disturbing disagrees with me. Whether it's Gleason 6, whether it's geopolitics, whether it's religion. I mean, the worst thing is sitting around a table where it's just an echo chamber.
- [105:28]
A
Yeah. And unfortunately, I feel like more and more that's all we see. Because you've curated your life on social media on your colleagues and your friend. I mean, not your colleagues necessarily, but your friends. Like you've curated that. And especially with social media, I mean, you can literally block out people you don't agree with and so you're not seeing it. And sometimes it is, it is really valuable to see what other people are thinking. And sometimes, you know, you may take some good from what they're thinking and you may surprise yourself.
- [105:55]
B
And to that point, what I love asking people is name me a bunch of things where you've changed your mind on it. Yeah, you know, something and it can be again, medical, societal, political, like, you know.
- [106:07]
A
Yeah, absolutely. What is a non negotiable something you have to do?
- [106:12]
B
I'm going to expose my nerdy side, but many nights, not all nights, I just have this yearning to do the crossword puzzle to piece out before I go to bed.
- [106:20]
A
That's a cool one. That's the first time I heard that one. That's a good one. What's a life hack or health hack?
- [106:26]
B
You'd share eating real food. And then to me, just like exercise in general is just. It's like a therapist.
- [106:38]
A
Absolutely.
- [106:39]
B
It's cheaper than a therapist. And it's just like my happy place to like, just go there and let my mind wander and process everything. Let alone the like innumerable health benefits that come from it.
- [106:50]
A
Absolutely. My. We go as a family and now our kids are working out with us and it is just the funnest. It is so fun, like seeing them get stronger. And like Anil will, my older son will like come over and hug me in the middle of his workout. And it's like the best thing. So I'm like, forget like any other family tradition. This is our family tradition.
- [107:13]
B
That's awesome. That's a good one.
- [107:15]
A
If you couldn't be a urologist, what would you be?
- [107:17]
B
I mean, short of being, you know, the lead singer in a rock band or playing, you know, center field for the Cubs. I wouldn't do anything else. This is if we got a really good gig.
- [107:27]
A
Yeah.
- [107:29]
B
Yeah. I wouldn't change a thing.
- [107:30]
A
Awesome. Well, thank you so much.
- [107:31]
B
Yep.
- [107:32]
A
Thank you guys so much for joining me on today's episode of the Rena Malik, M.D. podcast. Listen, if you are here right now, you have to do me one favor. You gotta go onto your podcast platform and subscribe or follow the podcast. This is what signal podcast networks need to see to see that you are actually engaged and interested in this podcast so they can then share it with more people. If you think this information is valuable and want to do a good deed, please do that for me. And as always, remember to take care of yourself, because you are worth it.