← The Neuro Experience
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- [00:00]
A
Thousands of men lose their sexual function every year, treating a cancer that was never going to kill them.
- [00:06]
B
They've done cadaver studies, and this is in men ranging from 20s into their 80s. And in a large percentage of men that never had any clinical symptoms and never had any diagnosis, they died of something else. They were found to have prostate cancer cells in the prostate.
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A
What's the actual lifetime risk?
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So the lifetime risk of men in general is one out of seven. One out of eight men.
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A
The prostate cancer industry has an over treatment and genomic testing is exposing which tumors actually need aggressive treatment and which ones don't.
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B
So it really only takes one cell going awry, becoming a malignant cell. That's really all it takes.
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A
Today's guest is Dr. Shawn Zimberg, board certified radiation oncologist, medical director at Advanced Radiation Centers of New York and director of radiation oncology at Bronx Care Hospital. Should men be masturbating at least 21 times a month to get rid of the inflammatory fluids?
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B
That study has a positive towards being correlated to a reduction in prostate cancer development. There are other studies which do not show that to be the case.
- [01:11]
A
We're talking about why PSA is broken, why Gleason scores don't tell the whole story. And the one thing that every man.
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Over 40 needs to know, testosterone doesn't cause prostate cancer. But men who have prostate cancer, the testosterone can almost fuel the prostate cancer.
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A
I'm Louise Nicola and this is is the Neuro Experience. Sean, how you doing?
- [01:34]
B
Good. Good morning, how are you?
- [01:36]
A
I'm doing really, really good. I'm excited to get into today's episode, which is from my perspective, a. I wouldn't call it optimization. More so, what do men over the age of 40 need to know as it relates to prostate care? So before we actually get into cancer screening and treatment, I need you to help the audience understand the basics and what is actually happening to men across the lifespan as it relates to prostate care. And walk me through what's happening with that man who is getting up three times a night. What does that actually mean?
- [02:12]
B
Well, let's maybe we'll step back a little bit. The prostate is a gland. As you know, I think a lot of men, believe it or not, may not really realize the functionality of it. But it's a hormonally induced gland. It's an endocrine part of the endocrine gland system. So it is affected by testosterone and male hormones. And as men age, there are changes in the milieu of the hormonal environment and the prostate can enlarge. Benign prostatic hypertrophy. Bph, as it's referred to, is one of the things that can affect men as they get older. And the bladder is like a balloon. It turns into the urethra, and the urethra actually goes right through the prostate. So if there's any growth of the prostate, benign growth, let's say, that can kind of impinge upon almost like a tunnel, kind of getting narrower and narrower, and that can affect the urine flow. And when that happens, men may need to again, maybe get up at night to urinate, go more frequently during the day. Medications can help with it. There's different procedures that can help with it. But in general, most men, if they are having urinary symptoms, end up seeing a urologist. Urologist ends up being almost like a primary care physician for men over 50, let's say. And it's always a good idea to get those things checked when they do start to change.
- [03:32]
A
So, okay, so walk me through. So the prostate is a gland. It's responsible which hormones are getting secreted from the prostate.
- [03:40]
B
Well, the prostate is more a receiver of hormones. So hormones can activate the prostate. The function of the prostate is to make the seminal fluid. So the prostate is, you know, they say the average size is like the shape of a walnut, but that's about a 25 gram prostate. Most men, as they get older, have an enlarged prostate and it can start to, you know, we like to use fruit for some reason as analogies. So a size of a plum, sometimes even a grapefruit. We have men that have prostates that are 5, 6, 7 times normal size. As you can imagine, the plumbing as it goes through the prostate can be affected and that can affect urination. The seminal vesicles are glands like rabbit eared glands that kind of root into the prostate and, and they also provide some of the seminal fluid. Sperm is made in the testicles, and so during ejaculation, the sperm mixes in with the fluid from the prostate and the seminal vesicles. And that's what is semen and that's what is ejaculated. So that's what the function of the prostate is. It's solely to produce a component of the semen.
- [04:43]
A
It's interesting because as I was researching this podcast, I realized that prostate size doesn't really correlate to cancer risk, which is something that I've heard of. You can have a man with a massive, benign, enlarged prostate and another man with a small prostate harboring aggressive cancer.
- [05:04]
B
Yeah, that's true.
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A
Can you Explain this paradox.
- [05:06]
B
Listen, it only takes one cell for all cancers. And as a radiation oncologist, I treat all types of cancers. So it really only takes one cell to go awry in many of the glandular cells in the body. So whether it be thyroid or breast, in women, men also can get bre. But particularly with regard to today's talk of prostate cancer, one cell going awry, becoming a malignant cell. That's really all it takes. And so during a lifetime of constant hormonal manipulation, triggering activation, deactivation, those cells can undergo changes. Some of these changes are proliferative. They can be like pre malignant cancers. High grade prostatic intraepithelial neoplasia. These are some of the terminologies that the pathologists will use. But in general, it isn't, as you say, related to size. Now, psa, which I'm sure we'll talk about, which is the blood test that's quite important for screening and for cancer detection today, is actually related to size.
- [06:10]
A
The world of oncology is still a mystery to me. And I know we've got good cancer screening tests, especially as it relates to prostate cancer. And I don't know if you can answer this. Do you think that it's odd to see people dying of prostate cancer just due to the amount of screening that's available to us right now?
- [06:29]
B
Listen, for any kind of cancer, early detection makes a big difference. If we catch cancers earlier, they're easier to cure and there's less potential for metastases. And ultimately, there's less potential for patients to succumb, to die of their disease. In particular, PSA is prostate specific antigen. It's a protein that's secreted normally by the prostate. Prostate cancer cells also secrete psa, and as a man ages, the PSA can get a little bit elevated just from normal, as we talked about enlargement of the gland. But if there's a cancer brewing in the prostate, then the PSA can be elevated, typically. And there's a little bit of a debate about PSA and screening and over maybe over screening, but in general, it's an easy test to do. It's a blood test, cost a few dollars, and it saves lives. You know, you think of mammography in women. You know, there's controversy around radiation exposure and things like that. But we pick up, you know, it's completely changed breast cancer detection and breast cancer cure. PSA has completely changed prostate detection and prostate cancer cure.
- [07:42]
A
I want to zoom out and just talk about your specialty for a second. We've got, I think what is the. How many specialties are there? And about 22, maybe many more in the U.S. and they seem to be growing each year, which is fantastic. I don't hear. I haven't met many radiation oncologists before and that really intrigues me. So do you do board certification in oncology first and then subspecialize.
- [08:03]
B
So radiation oncology is. It's its own specialty, it's its own residency program. And I trained here in the city at Memorial St. Kettering quite, quite a few years ago. You do one year after medical school, you do a year of internship of any, of any sort of internship. It could be surgical, internal medicine or you know, anything like that. And then you go on to a four plus year residency program specifically in radiation oncology. So I think when most people think hear oncologists, they think medical oncologists. Medical oncologists are. That's a subspecialty of internal medicine like cardiology or pulmonology or rheumatology, for example. Medical oncologists are systemic doctors. They're oncologists and hematologists. Often as an internist, they treat the whole body. So they're using agents to treat cancer that are systemic, like chemotherapy or immunotherapies. As a radiation oncologist, I use radiation, different forms of radiation, whether it be external beam radiation, we have machines that direct radiation. We have injectable forms of radiation, radioligand therapies that we can talk about. One in particular used for prostate cancer, we can insert radiation into the body using isotopes. So radiation is kind of what we have in our toolbox and we have a lot of technologies around that, how to map it out and shape it and direct it. But in general, radiation is a focal therapy. And so if there is a focal problem, radiation can be used to target it. And again, we can talk a little bit more about that. Chemotherapies, those are in the realm of the medical oncologist and the third kind of triad of the oncology team in general. And we all have a lot more support around us in terms of a team. But the medical oncologist for systemic therapies, the radiation oncologist for local therapies and the surgical oncologist. And that depends on what type of disease and what part of the body that we are dealing with. In the brain, the neurosurgeons are the surgeons in that realm. Breast surgeons for breast cancers, urologic surgeons, urologic oncologists. When it comes to Removal of the prostate and then all different parts of the body. There are different surgeons that are, you know, that help to use surgery to potentially remove a cancer and radiation and chemotherapy, depending on the situation, the type of cancer.
- [10:32]
A
It's somewhat similar in different surgical settings. In neurosurgery, where we're using frequency guided to go through intranasally to hit different areas.
- [10:41]
B
Transphenoidal. Yeah, Correct approach.
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A
The patients who come to see you, they're often referred.
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B
Okay, almost. Almost always they're referred. They are. They're coming to us with the diagnosis of cancer.
- [10:53]
A
So they've already had the diagnosis.
- [10:55]
B
They've already had a diagnosis of prostate cancer, and that's almost always from a urologist. And we can talk a little bit about how that happens.
- [11:03]
A
So they'll come to you. They've already had their diagnosis, and then you're going to figure out the treatment plan using radiation therapy in, whatever that means. So let's actually get into the risk factors. And I want to understand lifetime risk and genetic loading. So I've read that if men live long enough, most will develop some form of prostate cancer. What's the actual lifetime risk?
- [11:28]
B
So the lifetime risk of men in general is one out of seven. One out of eight men during their lifetime may develop prostate cancer. They've done cadaver studies, meaning that men who have died of another reason, and they've looked at the prostate, and this is in men ranging from the 20s into their 80s, so all ages. And in a large percentage of men that never had any clinical symptoms and never had any diagnosis, they died of something else. They were found to have prostate cancer cells in the prostate. So it is felt to be on one end of the spectrum, we have kind of prostate cancer that's a little bit more on the benign side. And we have prostate cancer that's much, much more aggressive. So when we use the term prostate cancer, it's really not the best term to use. It's really a catch. All of a wide, wide spectrum of diseases that behave very differently. Again, on one end of the spectrum, we talk about watching the cancer and not actually treating it. And on the other end of the spectrum, it can be very aggressive and very deadly. And you have in this country upwards of 35, 40,000 men a year that die still of prostate cancer, despite, you know, significant improvements in technology and the medications and pharmaceuticals that we have.
- [12:48]
A
I think I also read that not all men will die from prostate cancer, but a lot of men will die with prostate cancer, which was really intriguing to me. And as I Kept learning about this area. I went into genetic risk factors. So, for example, if a man's father or brother had prostate cancer, what does that do to their risk? You know, I mean, neurosurgery, specifically Alzheimer's disease, and we have certain genetic mutations that if, you know, if you do have these mutations, you will get some form of dementia, whether it's frontotemporal.
- [13:23]
B
Right.
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A
But then we've got genetic risk factors, the APOE4 gene, which may raise your risk. Is that the same for prostate cancer?
- [13:30]
B
Well, I think we're in an era where, you know, a lot of the, the genes and the phenotypes that we're talking about. We're in an era now where we're just scratching the surface, I think, in all forms of cancer, both to, both in using genetics or molecular testing to find what forms of cancer are actually more aggressive or less aggressive. So in prostate cancer, we look, can look under the microscope, our uropathologists look under the microscope and they can kind of look at a cancer. And using some objective criteria, we use something called the Gleason score, which determines how aggressive or not aggressive a prostate cancer might look. But we also are using molecular testing now so that cancer can actually be. We can look at the DNA of the cancer and look at the genetic profile and determine how aggressive or non aggressive that cancer may act. I tell my patients it's almost like looking under the hood of a car. The car might look quite fancy and you might think it's a fast car or it might look like a junker and you might not think so, but under the hood, it could be completely different. And so by using molecular profiling of the cancer as well as more of the clinical factors, including the pathologic assessment under the microscope, we're actually able to get much more clearer on how that patient's cancer might act. And then we can start using different forms of treatment, whether it be radiation, whether it be surgery, even some immune therapies now that are targeting specific, like PARP inhibitors, targeting certain mutations that are found through this molecular profiling. It's not as used for detection of cancer just yet, really. PSAs and some other potential changes are used for that.
- [15:19]
A
Is there anything that over the, you know, you've been practicing for, for quite a number of years, Is there anything that it started with in your specialty, like it was only PSA and now you have other forms of picking it up?
- [15:32]
B
I have to say PSA still remains the gold standard. And the, the, the problem with psa, we sort of touched on it just briefly is men's PSA can fluctuate with age. It can fluctuate based on height. Actually, let me give a better analogy. As I said, height, you think of somebody's height and weight in general. You can't use somebody's weight to just say that they're overweight or they're obese. If somebody's £250, but they're 6 foot 5 and they're well built, they're in good health, PSA is the same. A high PSA just by itself doesn't mean that somebody has prostate cancer. If they have a very large prostate. If you, basically, they may have that PSA may be normal for them. So you really have to look at other factors. The controversy with PSA is that it's used as a screening tool for all the general public, you know, in terms of all men. And you really have to look not just at the PSA, but you have to look at other factors like the volume of the prostate. And you have to. We use a term called PSA density where you're, you're sort of the numerator being the PSA and the denominator being the volume of the prostate. So we can get a better sense of comparing again, like BMI and height and weight. BMI is what we look at to see if somebody's height and weight are healthy as opposed to just looking at weight alone. And that's, that's that analogy.
- [16:58]
A
I'll zoom in a bit more on PSA because a lot of people know what that is. I don't know what the cutoff rate is. I think it's what, 75. You know, you go to your general practitioner and I know this because of my father, actually, no, I think it's 70 because he's 72. And you know, I said, did you get your PSA score tested? And he said, no. The doctor said, I don't need to get that tested anymore because I'm 70. I said, that's interesting because didn't the former president get diagnosed with prostate cancer?
- [17:27]
B
So that's always the problem with these recommendations. You know, they tend to not really help the individual. We see, you know, first of all, patients are living much, much longer. We know the population is living longer and healthier in some way. We see 90 year olds with very aggressive prostate cancer and they die of their prostate cancer. And if a blood test could have helped prevent them, we're all going to die of something. But our job is that patients don't die of Their cancer, quality of life and quality of life. So if a simple blood test can be taken in an 80 year old and find an aggressive prostate cancer and that patient can go through relatively simple treatment and get cured and live another 10, 15, 20 years with a good quality of life and certainly not succumb of a metastatic prostate cancer, I find it a little bit of pretzel logic that you would suggest, not you, but that there are recommendations out there to sort of put your head in the sand. I think you always have to weigh the pros and cons of any test. Again, a blood test is not very difficult to do, not expensive. It's not a huge threat to the economics, the medical economics. And the thing is, you don't have to, you know, patients can learn and educate themselves. Just because you have an elevated PSA doesn't mean you have to go to another step. We'll talk about what those steps are. At the end of the day, I think we know information is very important and it help. And really speaking to the right people to help you make that decision is most important.
- [19:02]
A
You're measuring it in your blood. A man gets his results back. Let's say it's 2.5 or 4 or 6.5. What are the recommendations from there? What is good, what is not good, what is high? Like, what's, what's the next step?
- [19:19]
B
Well, in general, 0 to 4 is considered, you know, normal range, but as.
- [19:24]
A
I said, across the lifespan, whether you're 35 or whether you're 75.
- [19:29]
B
So that brings up an important point. If you start getting your PSAs at age 45 or 50, and if you have a family history, you might want to start younger, even, even at 40 or younger at least five to 10 years before your, you know, if it's a, if it's a parent or uncle, a father or uncle who has had prostate cancer, typically a man should start getting their PSA maybe 5 to 10 years younger than their father or uncle was diagnosed, but in general at age 50. And getting it annually allows you to establish a trend in what's happening to the PSA. So if you've had your first PSA and it's 2.5, there's no context for that. You know, what was it last year? So if it's always been in the 2.5 range, that's certainly less concerning than if The PSA was 1 a year ago and it's doubled or gone up 150%. Certainly men who have PSAs above 4, with no other prior PSAS to put that in perspective, those are men that typically would potentially be referred to the urologist for consideration of a workup and possible biopsy of the prostate.
- [20:38]
A
And then where do MRIs come in? Because you're using MRIs as a screening tool, are you?
- [20:45]
B
Well, MRIs have become one of the standards for evaluating the prostate. So if patients get what's called a multi parametric mri, the radiologist, the reading radiologist can evaluate whether there's any nodules that are of concern. There's a scale called the PI rads scale. There's one for the breast, for breast radiologists called the Birad breast or prostate, the B or the P. And basically, if there are any nodules in the prostate that look concerning, look like they may suggest a malignancy, the patient would be referred for biopsy. Biopsies are typically done by the urologist. And if there was a lesion on the mri, they can do something called an MRI fusion biopsy, where they can actually fuse the MRI data set to the ultrasound data set, put them together, and use the MRI as a roadmap to be able to go after those lesions. In particular, oftentimes, the urologist will also do a random core biopsy. In addition to poking at the MRR lesions, they'll also do six, for example, biopsies on the right lobe of the prostate and six biopsies on the left lobe of the prostate. And that gives you some sense because prostate cancer may be seen on an mri, it may not be seen on an mri. And it's important to do a little bit of random sampling to see how affected or not affected the prostate may be.
- [22:15]
A
It just reminds me of, you know, ovarian cancer. It's just, you know, can't pick up on it on, you know, stage one, but, you know, becomes visible on an MRI in stage four.
- [22:27]
B
Unfortunately, when ovarian cancer is diagnosed, it tends to be in a later stage. Yeah, but prostate cancer and breast cancer, since we're talking about different types of cancer, those cancers have things that we can do to have early detection. And ovarian cancer is a good example where, unfortunately, it's hard to have early detection. And therefore, women who get ovarian cancer may not have the best outcomes. Some of them do. But with prostate cancer, the PSA is an amazing biomarker. Again, there's some controversy because we do, you know, there can be other reasons for that elevation, but you have to be discerning. You have to see a professional that knows, you know, how to help you make the right Decisions in terms of pathway. But we can detect prostate cancer extremely early and it's quite, quite curable.
- [23:22]
A
You've brought a diagram in today, and this relates to my next question, not the actual photos of the prostate. Do you want to just show them? Because I have a question. We touched on the genetic risk factors. I want to talk about modifiable risk factors, but can you just show everyone the diagram that you have?
- [23:40]
B
This is the kind of a blow up of the prostate. So this would be a man lying on their back. Feet would be that way, head would be that way. Here's the rear here. This is the anus. This would be what's called the perineum. This is the skin between the anus and the testicles. And this is the prostate. And you can see here the bladder. These were the seminal vesicles. This would be the right seminal vesicle. The left you wouldn't be seeing. And the prostate, as I told you before, the bladder is like a big balloon. It cones down. And the urethra, which you don't see here, is inside of the prostate and comes out the urethra through the penis. When we do a rectal exam, a DRE men usually will have that at their internal, at their internist office or urology office. We can actually feel the prostate through the rectum and we can feel whether there's any lumps or bumps or anything like that. So that's part of a typical exam for a man going for their annual exam. Listen to your lungs, listen to your heart, and a rectal exam is usually done.
- [24:46]
A
I found a really interesting study that I want to bring up, and this comes down to prostate cancer. It was a really well designed study showing that men who ejaculated 21 times per month or more than 21 times per month, had a lower risk of prostate cancer, even after controlling for age, lifestyle and comorbidities. And the leading theory is something called prostate stagnation. That is the infrequent ejaculation, which allows prosthetic fluid to accumulate inflammatory compounds while frequent ejaculation flushes the system. How strong is this hypothesis? It's always intriguing to me, like, should men be masturbating at least 21 times a month to get rid of the inflammatory fluids?
- [25:39]
B
So that study has a positive trend towards number of ejaculations per month being correlated to a reduction in prostate cancer development. There are other studies which do not show that to be the case. And if you take kind of a meta analysis of all of those studies in Fact, it does not appear that the number of times that a man ejaculates during a month, or, you know, in general, is related to prostate cancer. So when we look at the risks of developing prostate cancer, that doesn't seem to be one. That at least has a statistical significance to it. But there is some consideration in terms of, you know, the prostate. Again, it makes fluid. It makes the seminal fluid. If a man is not active for, you know, many, many years, for example, there can be some stagnation. When we look at CT scans or ultrasound scans, we often see calcifications within the prostate. Those calcifications may form in a more stagnant prostate, rather one that's, let's say, more active. But again, there's really is not a lot of data to suggest that men, if they increase the number of times they ejaculated, that they could do a service for themselves with regard to decreasing their risk of prostate cancer.
- [26:59]
A
Is it plausible to draw a correlation between inflammation of the prostate like prostitis? I believe. Is that what it's called?
- [27:09]
B
Prostatitis.
- [27:10]
A
Prostatitis. Okay. That's a term I don't use every day, of course. Is there a correlation between prostatitis and increased risk of prostate cancer if not treated?
- [27:19]
B
There may be, and that's not clear as well. Prostatitis is one of those, almost like gastritis, where there's a range of how it presents to patients and whether or not they are very symptomatic or asymptomatic. Some patients can have an acute bout of prostatitis, almost like uti, types of symptomatology. All of a sudden burning with urination and a lot more urinary symptoms. They can have more of a lingering or a more chronic prostatitis sort of picture. And actually, PSA can be elevated in men who have prostatitis. So one of the things that a urologist will do, if a man presents with an elevated psa, he has no other symptoms, he has no family history, no blood in the urine, nothing like that. Typically, those men will be put on an antibiotic for a couple of weeks to see if it's a bacterial prostatitis, and then they'll have the PSA repeated to see if that elevated PSA was from, indeed, a more benign cause like a. Like a prostatitis, as opposed to a more concerning cause like prostate cancer. And if that PSA comes down, they may not then move forward with an MRI or a possible biopsy.
- [28:34]
A
Yeah, it just Reminded me of, you know, when you go and get a colonoscopy, a man has an elevated psa, maybe a suspicious area on mri. You're recommending a biopsy. Can you walk me through the different biopsy techniques? I know there's transperineal versus transrectal approaches. Why does the root matter and what are you looking for in the pathology reports when you get them back?
- [28:59]
B
So we can actually use the diagram here. So historically, in order to do a biopsy, you need to visualize what you're looking at for a needle. So historically, ultrasound probe would be placed into the rectum so you could visualize, visualize the prostate. And the needles would actually penetrate the rectum to go into the prostate, to pull little cores of tissue out of the prostate. As you can imagine, the, the rectum isn't the, there's a lot of bacteria in the rectum and penetrating the rectum can actually increase the risk of sepsis. And there was maybe anywhere between a 3 to 5% sepsis rate in transrectal ultrasound biopsies today. The more appropriate way or more state of the art method is a transperineal biopsy. And this is where we penetrate the skin and the needles are going through the skin into the prostate. It's a much cleaner, from the point of bacterial sepsis, it's a much cleaner procedure. The risk of sepsis is virtually eliminated. We do tend to still give patients an antibiotic, but not a long or multiple course of antibiotics for this. And you can actually see quite nicely the areas of the prostate and ensure that the needle goes where you want it to go. An MRI fusion biopsy, as we mentioned, takes this one step further. It uses a mapping software and machinery that maps and fuses the MRI data to the ultrasound data. So as the ultrasound probe is moved in and out, up and down, right and left, it actually almost like a virtual reality screen melded on top of the ultrasound so that the needles can go right to the MRI lesion, even though we're not seeing the lesion as well on the ultrasound. And what that does is it increases the yield. It's almost like going to your backyard and you could make some random pokes, but if you had a metal detector or something that could maybe let you mark a couple X's, your yield of finding something actually might be increased. And that's what the MRI fusion biopsy does.
- [31:05]
A
And you're using ultrasound guided, almost always ultrasound guided. You have to. Right.
- [31:09]
B
It's the easiest way. The prostate's, you know, Quite close to the rectum, quite close to the perineum.
- [31:13]
A
Explain the Gleason score. Like, I'm a patient sitting across from you. What does a score of 6 mean versus 7 and 9 and break down Gleason 7.
- [31:22]
B
Specifically, if we had, like, this color blue, you might say it's one color blue. I might say it's one color blue. But if we had a color wheel or we had a key, so we could both maybe come up with the same color blue. It's a way for different pathologists to use objective criteria to come up with the same scoring system for prostate cancer. Like any cancer cancers that look more awry or look more unlike their normal counterparts of a benign cell, we want to be able to understand how aggressive or non aggressive the cancers may be. And that correlates to how much a cancer cell looks or doesn't look like what they once were before they began to mutate. The Gleason score is composed of two components, two patterns. Gleason patterns, either a three, a four, or a five. And that's added to a three, a four, or a five. The first number is the primary or the most prominent component within the cancer. So when a pathologist looks under the microscope.
- [32:27]
A
So I have to cut you off, just so I understand. And the audience is following me. First you do the PSA score, right? We see it elevated, and then. Are we talking about the actual biopsy? Okay, so you biopsy a lesion.
- [32:39]
B
We biopsy a lesion and also take these random cores. So a core. It's almost like taking a straw through a potato, and you pull out a core of tissue. That tissue goes to the pathologist. It gets embedded in wax and gets chopped up into a very, very thin section that can be looked at under the microscope. Oh, my gosh. And the pathologist can identify the glandular tissue. So the prostate being a gland, they'll see normal glands, and they may see some abnormal glands or cells that are forming abnormal glandular tissue. And to the degree that that glandular tissue looks more or less abnormal, they give it a score.
- [33:18]
A
And that's the Gleason score.
- [33:20]
B
That's the Gleason score.
- [33:21]
A
I'm on track now.
- [33:22]
B
Right. Not all cancers are homogeneous, meaning there might be a patch of more aggressive and a patch of less aggressive. And so the Gleason score aims to combine what might be more predominant in terms of aggressiveness, a patch of aggressiveness in the cancer or less aggressive, a patch of that. So the three is the least aggressive pattern. The five is the most aggressive. Pattern. And so the predominant pattern is the first number. So call it a three. And as an example, the next predominant. If that's a 3, that's a 3 plus 3 or a Gleason 6. A Gleason 10 could be a 5 plus 5. It could be a 3 plus.
- [34:05]
A
That's extremely aggressive.
- [34:07]
B
Extremely aggressive, yeah.
- [34:10]
A
A specific supplement that I am taking that helps me with my focus and helps me keep on, you know, that steady stream of just feeling good with perfect clarity throughout the day. I'm taking the truscriptions methylene blue trochee and it's been really surprising. I take it on days when I have to think deeply or be on for hours. It's usually my podcasting days because. Because it supports mitochondrial energy production. And this is really essential for the fuel in your brain. So a lot of people have been experimenting with methylene blue. It makes your tongue blue. And it's just pretty cool. You know, you see people like using it and I really wanted to know what actually does it do. And it actually works really well. So what I notice isn't a buzz or spike. It's more like my brain stays online longer, cleaner, more resilient. And for anyone who cares about ag world, cognitive longevity starts with energy metabolism. So if you want to try it, go to truscriptions.com use code neuro for 10% off your order.
- [35:19]
B
So what we mostly see is Gleason 6s being the, what we call low risk prostate cancer. We see Gleason 7s as being intermediate risk cancer and Gleason 8, 9 or 10 as being what we call high risk or more aggressive cancer. So low, intermediate and high risk. You mentioned the Gleason seven.
- [35:39]
A
What's so special about this?
- [35:40]
B
Well, seven can be, you know, just from the math, it can be a 3 plus 4 or a 4 plus 3, right? They're both Gleason 7. They're both intermediate risk. But a 3 plus 43 is in the first position. So it's a little less aggressive than a 4 plus 3 7, which, where the 4 is the more predominant, that means at least 50% of that cancer had a pattern 4. And so that, that shifts intermediate cancer from a favorable intermediate cancer to what we call an unfavorable intermediate cancer. So within a low risk, intermediate risk and high risk, there's thousands of permutations of. Think of a man getting 12 random cores. They could have one core positive of Gleason 6. They could have 12 cores positive of Gleason 6. In one case, just one little area Was positive. In another, the whole prostate, we found cancer. Both of Those, because they're Gleason 6 are considered low risk, but certainly the risk to the patient is a very different one. With one core of Gleason 6, we might monitor that patient with a lot of cores. We might not. And so you could have five cores of Gleason 7 and two cores of Gleason 6. You could have three cores of Gleason 8. So you can see there's thousands of different permutations and this. But the nice thing is all this information allows us to tailor, really understand what the situation may be and what that patient's risk is, and then begin to tailor a treatment specifically geared to the patient's findings.
- [37:13]
A
Is this where a conservative doctor versus a non conservative doctor would come in? Because if you've both got a Gleason 7, what's the actual standard protocol? Because that means it will. Is there something that dictates what you do next?
- [37:28]
B
So the basic information that you want to find, first of all, is the Gleason score, as we talked about. And that gives you a sense of what the cells look like under the microscope. As I mentioned before, we will now use molecular profiling. So the cancer itself will be looked at in a special lab where they're going to do molecular testing on the DNA of the patient. And we get a huge report on what the molecular phenotype is of the cancer. And that's been validated across tens of thousands of men with regard to how aggressive or non aggressive the cancer may act simply from the genetic profile of the cancer. So that's another piece of information we use. The PSA is another piece of information we use. If a patient has a PSA above 10, that may put them into a more aggressive category than a PSA below 10, a PSA above 20. There's a new type of PET scan, positron emission tomography scan, using a PSMA tracer. So PSMA stands for prostate specific membrane antigen. It's a glycoprotein that is on the cell membrane of all. About 80% of prostate cancers overexpress this PSMA glycoprotein. And we can use a radioactive tracer that actually binds to the PSMA receptor or glycoprotein on the cell receptor, and that can pick up more intense prostate cancers. So if men have a high risk prostate cancer by virtue of their gleason score or other clinical profile, or even an upper intermediate, unfavorable intermediate, we actually typically next would get them a PSMA pet scan, and that can pick up lymph node involvement. So one of the first places that prostate cancer locally can spread to is the local lymph nodes, and that can be picked up on a PET scan, sometimes an MRI as well.
- [39:28]
A
Yeah. All right, so let's move on now to some treatment options. Okay. The three paths. Once a man is diagnosed, there are essentially three pathways. Active surveillance, surgery, or radiation. Give me the 30,000 foot view. How do you decide which path to take?
- [39:45]
B
Well, in general, men that have high risk cancer need treatment. Men who have intermediate risk cancer tend to need treatment. Men that have low risk cancer, there are options for possibly monitoring their cancers, especially when they have what we would even call very low risk prostate cancer. So just like intermediate risk is broken up into subcategories, we tend to break up low risk prostate cancer into subcategories. We look at a lot more information on the pathology report that we haven't talked about yet, like whether there's perineural invasion, whether there's extracapsular extension. These are like nuances of how the cancer may be behaving. But in general, if we don't see any of those poor prognostic pathologic factors and somebody just is found to have one or two cores, let's say, of Gleason 6. So, you know, and this is a typical man that we see minding their own business, no symptoms whatsoever. They just get a blood test for their annual checkup, and the PSA is up a little bit again. They go to the urologist, they have an mri, maybe there's a small lesion, they have a biopsy, and we find one or two cores of Gleason 6 Low Risk Prostate cancer. The next step in terms of talking to them about active surveillance is how aggressive or non aggressive do they want to be with their treatments? The way that I look at active surveillance is that if the entire picture looks like the train hasn't left the station yet or isn't leaving anytime soon, men can choose to keep an eye on the cancer. What does that mean? We're not saying go home and never come back. They have cancer. It's a diagnosis. What we're saying is your cancer right now, there's nothing that's immediately life threatening to you as the man being diagnosed. And we can continue to monitor you in the months and years to come and collect more data about your prostate, about the cancer. And if we do find something that tilts the scale, maybe the train's beginning to leave, then we can divert you to treatment and the studies seem to indicate that when a man is appropriately diverted back to treatment, that their cure rate should be equivalent then to what their cure rate would be now. And so they don't compromise their medical outcome by waiting or pushing off their treatment. And the benefit of pushing off one's treatment is that you're not exposing yourself to the potential risks of prostate cancer therapy.
- [42:15]
A
I know in some cases, some people would be, some patients would be an ideal candidate, and others won't be when it comes to different treatment options and where to go next. Have you ever had a patient that. That you thought you're not an ideal candidate? And if so, what does that mean?
- [42:31]
B
An ideal candidate for a particular treatment or active surveillance?
- [42:34]
A
Active surveillance, yeah.
- [42:36]
B
So I think when somebody's diagnosed with cancer, you know, whether it be low or intermediate or high risk for prostate cancer, the next steps are to meet with the healthcare professionals that may. That are cancer experts. So typically in our practice, we actually want patients that are diagnosed with prostate cancer to meet with both a radiation oncologist and a urologic surgeon to discuss both of those options and surgery or radiation. And both the surgeon and the radiation oncologist will be speaking to that patient about active surveillance. So the diagnosing urologist will, I think, initially give the patient a sense when they tell the patient about their diagnosis, they'll talk about surveillance, if it's appropriate in that case. And then they'll make that referral to me, for example, as a radiation oncologist and to a urologic surgeon to talk about the options.
- [43:31]
A
Talking about localized, curable prostate cancer. Let's move into what happens with stage four prostate cancer.
- [43:39]
B
So, yeah, I mean, unfortunately, we can't cure all prostate cancers. So even if patients present with localized disease and they have radiation or they have surgery, nothing's 100%. Sometimes there are cells that have already gotten out of the bag, so to speak, and there's been spread, whether it's been picked up on a PET scan, a PSMA PET scan, or they later develop metastatic disease. The majority of patients with metastatic prostate cancer have bone metastases. About 90% of patients will develop bone metastases. In those that develop spread of their cancer. Stage four disease. The bone tends to be a favorable milieu, or almost like the seeds in the soil. They tend to set up shop in the bones and grow there. They can also spread to the lymph nodes locally, and they can spread to other organs as well. One of the more fascinating newer treatments that's been approved recently is called a radio ligand therapy. And what is it? We talked about the PSMA PET scan, remember, where the radio tracer is injected into the body and it goes and it travels and it attaches to the PSMA ligand. So we can see it on a PET scan. Well, if you can see it and you can attach to that same PSMA ligand, you can attach a radiation bomber, let's say, in the form of an isotope that's going to give off radiation. That radioligand can act as like a Trojan horse. It can attach to the prostate cancer cells that have spread to the bone or spread to the liver or spread to wherever, and it can attach itself to the prostate cancer. It can be brought into the cancer cell, and that isotope will give off radioactivity and damage the cancer cell in a very, very targeted, directed fashion. There's only one current radioligand therapy on the market, and that was just FDA approved in the last year and a half. And more recently, it was the indication for using it was widened. So almost every patient that has metastatic prostate cancer with a few specific indications is actually a candidate for this. We call RLT radioligand therapy, in which they get six injections over about six to seven months. And that injection goes to every cell in the body that's a prostate cancer cell, and it delivers radiation right to the DNA of that cancer and destroys the cancer. Men who get that therapy live longer than men that don't get the therapy. So there's a proven survival advantage in metastatic stage 4 prostate cancer for this radio ligand therapy. So it's quite, quite impressive.
- [46:37]
A
Can you live without your prostate cancer?
- [46:39]
B
Of course.
- [46:40]
A
Removing the prostate is that, you know, is that an option?
- [46:44]
B
So removing the prostate is. That's a radical prostatectomy. It's.
- [46:49]
A
These words are so cool.
- [46:51]
B
Well, it gets even cooler because today the radical prostatectomy is done robotically. So it's an RALP or a.
- [46:58]
A
We're doing that at Lennox. We're doing some robotic surgery. It's phenomenal.
- [47:01]
B
The robot, the da Vinci robot. I think there's another company that makes another robot now, But I think the radical prostatectomy, the robot was the first real procedure that was indicated for robot assisted use. So today the typical radical prostatectomy is done robot assisted. So the surgeon is sitting over here operating the robot, and the patient has the trocars in the body that the robot is doing. And what they can do is they can get very, very accurate the detail that's needed to dissect out the prostate. Because remember, the Prostate is sitting between the bladder and the rectum, as we showed before. So in general, the prostate has to be separated from the bladder. So the bladder neck is severed and the urethra. The urethra at the other end of the prostate is severed, and then the prostate has to be dissected out and then the urethra reconnected back to the bladder neck. The nerves that control erections are lateral and need to be carefully dissected as well. So typically, unless a man has a more aggressive cancer, they are going to be having a nerve sparing radical prostatectomy where there's an attempt to spare the nerves and improve erectile function.
- [48:20]
A
You know, I'd be remiss if I didn't bring up the topic of testosterone in this. So I remember a patient case that I've had where he's undergone chemotherapy and testosterone levels plummeted, like, completely. I think he was 52 years old. He had like 150 for his testosterone levels. What's the relationship between prostate cancer and testosterone levels?
- [48:46]
B
Testosterone doesn't cause prostate cancer, but men who have prostate cancer, the testosterone can almost fuel the prostate cancer, because, again, through a man's life, testosterone as an androgen, a male hormone, is constantly activating and deactivating the prostate as one of its targets. Prostate cancer can also be activated or deactivated by testosterone. So, interestingly, in high risk prostate cancer, we will often want to lower the testosterone in a man by giving him androgen suppression therapy. And what that will do is it will almost crimp the fuel line to the cancer and weaken the cancer. That weakening allows the cancer to become more susceptible to radiation. So we tend to offer or recommend androgen suppression therapy, actually lowering a man's testosterone in order to weaken the cancer. When we climb into the boxing ring with radiation, we're fighting a weaker opponent. And so most of the studies that have looked at the use of hormone therapy, we call it hormone therapy, really it's anti hormone therapy as we lower someone's testosterone. The studies have shown that, randomized studies, that men who have high risk cancer, who have hormone therapy before radiation and then during radiation, they live longer, they have a better outcome than men who just received the radiation alone. So testosterone plays an important role, not in creating prostate cancer, but in men with prostate cancer, we can actually utilize that to improve their outcomes. One of the other things that we, in men who have gone through cancer therapy, whether it be surgery or radiation, they often find themselves with low testosterone, whether it be, you know, that they had normal, maybe they had a lower testosterone before. Maybe they had treatments that lowered their testosterone. We don't love to give testosterone replacement therapy to somebody that's had prostate cancer. Certainly not right away in the first five years or so. Theoretically, if there's some, if there's one indolent, meaning like a sleeping cancer cell that might not have been eradicated by the radiation or by the surgery giving testosterone, kind of turning on that fuel line could potentially activate that otherwise sleeping cell. And so we don't like to do that.
- [51:24]
A
Is there an increased risk of prostate cancer just from a 42 year old male who's not at risk, who hasn't got a high PSA score, but he's opting in for TRT just for therapeutic purposes?
- [51:36]
B
There hasn't really been shown a specific correlation with exogenous testosterone use and prostate cancer. From what I know, in general, males are meant to have normal levels of testosterone. The normal range can be quite varies. And men that are on the lower end of the testosterone range might start to feel some of the symptoms, fatigue or weakness. Those kinds of things may decrease libido. Men at the higher end of the range may not. And so that's one of the reasons why men would want to increase their testosterone if they're starting to have some of those symptoms. The prostate, like most of our body, has a tremendous number of mechanisms to keep itself healthy, to be able to rid itself of any cells that may be not as healthy and maybe possible precursors of a malignancy. Testosterone level, though, doesn't seem to be one of those things that pushes them over.
- [52:39]
A
Let's get into something called radiation that we've been talking about. So explain to someone with no science background what is radiation? What's it actually doing to cancer cells? Because normally when we hear the word radiation, we're scared. We don't want any radiation. We're hearing radiation from microwaves, from getting on the airplane, and it's quite scary.
- [53:02]
B
So radiation is part of the electromagnetic spectrum. What does that mean? Maybe in high school science we all saw like a diagram. You have visible light is a very, very small part of that. You have infrared and ultraviolet electromagnetic waves. And at the upper, upper end of that spectrum we have radiation, ionizing radiation. So light is a form of radiation. We don't know if something can radiate, Light can radiate. But in general, when we talk about these upper levels, we're talking about something called ionizing radiation. So radiation that can actually affect the body. And how does it affect the body? It interacts with The DNA of our cells and can cause DNA fragment breaks or DNA breaks. Our cells have many, many housekeeping tactics to keep those breaks. Because the DNA of a cell, as you know, it's like a ladder. It's got all these rungs. And if you unwound the chromosome, it would travel around the earth in one of your cells. It's a very, very, very long molecule. So something that is that long and delicate is always undergoing little breaks. So we have mechanisms in our cells that are always fixing those DNA strand breaks. When we target a cancer with radiation, we're causing many, many, many DNA strand breaks, and that overwhelms a cancer cell's ability to keep itself from going. So cancer cells, now you may ask, well, don't you also cause DNA breaks in normal tissue? Normal tissues want to keep themselves healthy in a homeostatic sort of environment. Cancer cells don't really care about keeping themselves healthy. They care about growing and multiplying. And so if we keep hitting them and hitting them and hitting them with little bits of radiation, typically when we give radiation, it's given over multiple days. A little bit today, a little bit tomorrow, and so on. In between those days, the normal cells can repair that damage as they normally would and are normally able to. Where the malignant cells don't really care about fixing themselves, as I said. And over that number of weeks of treatment, at the end of that, they no longer have the capability to multiply because the DNA has been damaged so much and they die. And that's really how radiation works.
- [55:30]
A
So you have done one procedure, right? More than anybody else in the world. I want to hone in on that because you've brought us a diagram. I want to understand where that comes into play.
- [55:43]
B
So I think you're talking about something called the bioprotect balloon. It's what we call a rectal spacer. The prostate itself, as we showed here, the prostate and the rectum are very close to each other. The kind of holy grail of radiation is to give as much radiation as we can to the cancer and as little radiation as we can to the normal tissues.
- [56:08]
A
That's really precise.
- [56:10]
B
Everything we do is attempting to do that. I think I have one more diagram here. There we go. We're going to get a little fancy. So this is a complicated, but yet somewhat simple chart. We call it the therapeutic ratio. So what we're attempting to do with radiation, and if you look at the y axis, this is dose of radiation. So here we're giving higher doses of radiation, and this is the probability of whether we're going to cure the tumor or we're going to cause damage here. I believe it's in green complications. So let's take a dose of radiation that's right here.
- [56:44]
A
Yeah.
- [56:45]
B
And if you see two organs, maybe the prostate, maybe the rectum, and you give this dose here, you're going to cause very, very few side effects. It's a low dose, but you're also going to have a tumor control rate that's not near 100%. If you go higher, higher doses, you may cause more complications, but you're going to get to a much higher cure rate. And so what we're always trying to do in radiation is separate those curves. If you think of the, you know, in the area that you work in, if you think of the brain, and we're trying to treat a tumor near the brain stem, the brain stem and the tumor might be very close, those two curves. So as we increase our dose to the tumor, we're gonna be increasing our dose to the brain stem. And so that's very difficult to do. So in the case of prostate cancer, it's the bladder and the rectum that are sandwiching the prostate. And one of the things that we want to do is try to reduce the dose to the cancer, reduce the dose to the rectum rather. And so here we see if you see the red as being the high, high dose of radiation, that's great because it's conforming perfectly to the prostate. So the cancer is going to get the full dose. And you see here, though, that the yellow may be a little bit of lower dose, a little bit of the rectum is getting that dose, and then a little more of the green dose is getting to more of the rectum.
- [58:11]
A
But you said that if you hit a healthy tissue which wants to remain homeostatic with radiation, it doesn't really matter.
- [58:21]
B
It can matter. It depends how much of that tissue you hit and depends how much dose you hit it with.
- [58:26]
A
So radiation in a normal, healthy tissue can be problematic.
- [58:33]
B
Right. So we talk about like everything. Well, think of surgery, for example. There's always going to be some risks of surgery. There's scar tissue that forms. There's, you know, there's all these different things. So radiation, again, the goal is to minimize dose to normal tissues. The target, the cancer, is always in the body. It's not like we can take the prostate out, radiate the hell out of it, and then put it back in. Then the body's getting no radiation. Of course, we can't do that. So the goal is to try to minimize the dose to all those normal tissues, minimize the dose to the penile bulb, which is a part of the penile base that too much radiation is associated with erectile dysfunction. We want to minimize the dose to the bladder and the bladder neck. Too much radiation to the bladder neck can increase incontinence risks and increase urinary problems down the line. And too much radiation to the rectum can increase rectal bleeding, increase rectal complications down the line. And so in the prostate specifically, we use a lot of different tools and how we can modify and manipulate the radiation. Imagine different beams of radiation coming into the body. Every beam is shaped differently. So when those different shapes interact with each other or overlap, they create a three dimensional high dose region that conforms perfectly to the target. Now, you still may have normal tissues next to that target. And one of the things that this balloon can do is actually physically move the rectum away from the prostate. So in fact, if we go back to this diagram here, again, here we're getting some rectal dose from the prostate radiation, and here's that balloon. So we've come in and we've put this balloon in and it's physically moved the rectum away from the prostate. And here no radiation really is getting to the rectum. And that balloon, by the way, is biodegradable.
- [60:29]
A
The bioprotect balloon spacer.
- [60:31]
B
That's right.
- [60:32]
A
Okay, so adaptive radiotherapy and brachytherapy. So is this like gold standard? Is this happening everywhere? And would you put this balloon in prior to radiation?
- [60:43]
B
Exactly. So when a patient comes in and we're talking about what their treatment options are in general, there are, as we said, surgery is an option for patients with prostate cancer, radiation is an option for patients with prostate cancer.
- [60:57]
A
I don't know if I asked you this. Sorry to keep cutting you off, but my mind's getting blown right now because I know you brought the product to show us the.
- [61:02]
B
We did. We did.
- [61:04]
A
What about chemotherapy as well?
- [61:05]
B
Yeah. Chemotherapy is not used in localized prostate cancer. So if the cancer is only in the prostate or localized within the pelvis, typically chemotherapy is not used. In that case, in metastatic prostate cancers, chemotherapy is one of the possible options.
- [61:24]
A
Can you do a combination of radiation and chemo chemotherapy?
- [61:29]
B
Again, in the setting of a definitive treatment or a curative treatment, chemotherapy is not an option.
- [61:36]
A
All right, let's. Sorry, I had to put that in there just because my eye was. Did I bring that up? Can you show me the balloon?
- [61:42]
B
Sure. So this Device was about 10, 12 years ago, the first rectal spacer, not this one, but the first rectal spacer was FDA approved. I was actually part of the FDA pivotal trial that was used to get that approval. And it's a gel. So we place a needle through the skin into the space here, and we would push a gel into that space, and that gel would push the rectum away. And the gels work quite quite well. They did provide a decrease in the dose going to the rectum as well as some of the other tissues. Gels have some advantages and some disadvantages. One of the disadvantages being that they're at the mercy of fluid dynamics. They may go two right or two left. And so what you're looking for is the most space in between the rectum and the prostate and a symmetrical space.
- [62:34]
A
And this is to preserve the bladder from the radiation, the rectum from the.
- [62:39]
B
Rectum, the rectum from the radiation from the prostate. And so a number of years ago, there was another FDA pivotal trial that my practice and myself also participated in. And this is for this balloon device. And so what the balloon does instead of the gel, it's a fixed, preformed space. And so it's always going to be symmetric. It's always going to blow up in the shape. It's almost like a pancake shape, as I'll show you in a moment. And that solves a lot of the problems that we see with the gels. Sometimes the gels will want to penetrate through the rectal tissues, maybe through some little micro fractures, and the balloon kind of solves those problems. And so we've been quite successful in being able to use that. That balloon gets placed, as you said, prior to the radiation, so that when the patient goes through their treatment again, they're getting the benefit of the. The separation between the prostate and the rectal tissues.
- [63:34]
A
How long does it stay there?
- [63:35]
B
It dissolves. After three months, it begins to dissolve. So it's biodegradable. You can see here on the end of the rod here, it's furled up. And what we do is we place a needle into the. Again, I can show you right here, the needle goes in. Ultimately, we derive this dilator. This is under ultrasound guidance through the space. We call this Denouvalier's fascia through the space here. And then we remove the dilator. And that creates a conduit outside the patient's body and to the base of the prostate. And then what we are able to do is through the sheath here, we place the balloon. What's the balloon made of it's like a vicral, almost like a dissolvable suture material. And so we end up having here, you can see the balloon in that space. And then the sheath gets pulled back, and the balloon is sitting in that space in a furled fashion. And then what we do is we attach saline to the end here, and we can go ahead and we can squeeze that, and the balloon kind of blows up. And you can see that it's will move the prostate and rectum away from each other. Oh, gosh.
- [64:56]
A
What's the diameter of that?
- [64:57]
B
The space that we can get, it's dependent on how much saline you put in. But if we put in about 17 cc's, we're getting about 18 millimeters of space, almost 2 centimeters. It's about 4 1/2 centimeters long. And that's enough to keep the bulk of the, you know, the bulk of the prostate away from the rectum. And then what we do is we kind of flip this over and it will deploy itself like that.
- [65:23]
A
Oh, my gosh.
- [65:24]
B
That's it. So that's the balloon.
- [65:26]
A
Can I have that?
- [65:27]
B
Yeah, of course.
- [65:27]
A
This is so interesting. Okay, so what have you seen in patient outcomes from using this? And how many of these surgeries have you done?
- [65:37]
B
So I've done a. I've done almost 2,000 of these. Wow. Yeah. Yeah.
- [65:41]
A
Is this normal practice around the U.S. you are one of the first people to do this. You've done this more than anybody else.
- [65:46]
B
I have. Putting in a rectal spacer, I believe is standard of care. It certainly should be standard of care for most prostate. For most men getting prostate cancer, radiation. Because if we can, again, if we can move the tissues away from the high doses of radiation and protect the normal tissues, that's going to only provide the patient with a double benefit. One, you're going to cure the cancer or certainly attempt to, and you're going to leave the patient with less risk of complications. And again, those two goals is always what we're as radiation oncologists. That's always what we're trying to attempt to do, again, optimize the cure and minimize the risk to normal tissues.
- [66:24]
A
This is phenomenal. And this will take three months to dissolve.
- [66:27]
B
Yeah. So it'll be stable for three months during the patient's radiation, and then once that's over, it will dissolve.
- [66:33]
A
I love this. Thank you so much.
- [66:35]
B
Yeah, that's pretty cool.
- [66:35]
A
For pointing that out, what are the lifestyle interventions that people can adopt to potentially prevent prostate cancer from occurring?
- [66:45]
B
Well, unfortunately, like all cancers. There's so much we know and there's so much we don't know. And we know that family history does play a role. Genetics plays a role. So if men and age is the biggest risk factor, for every age is a risk factor. The average age of diagnosis is around mid-60s. That's actually much younger than it was decades ago because of the psa. And so, you know, men, most men today we see because their PSA is elevated and that leads to them getting an MRI and a biopsy, as we've talked about. But as you can imagine, if there was no blood test, the cancer would be allowed to grow for another five, 10 years perhaps. And then men might begin to become symptomatic. So in the 80s, 70s and 80s, most men were presenting with prostate cancer because they were had, they had blood in their urine or they had some change, some, you know, pain, or they had a rectal exam where they were found to have a lump on their prostate or something like that. So then the cancer was more, you know, had grown for another five or ten years. Much more difficult to cure. Today we're finding things much earlier and it's much easier to cure. So I would say that get your PSAs. You know, despite the controversy with it, with screening, it really, if we had something like the PSA for all cancers, we would be much, much closer to curing cancer globally. So the PSA is really a remarkable test. Just because you have an elevated PSA doesn't mean that you have cancer. So that's very important. But it's an important test nonetheless, and it's an easy test to get.
- [68:30]
A
So, Dr. Zinberg, you're located in New York.
- [68:33]
B
We, as I said, I'm the medical director of Advanced Radiation Centers of New York. We have nine facilities in the metropolitan area, Long island, the Bronx, Westchester, Rockland County.
- [68:45]
A
So I'm going to link all of your, all of your information in the show notes below. This is part one and I'm so excited to see you back here for part two.
- [68:54]
B
We're looking forward to it. Thank you. Hey, Ryan Reynolds here wishing you a very happy half off holiday because right now Mint Mobile is offering you the gift of 50% off unlimited. To be clear, that's half the price, not half the service. Mint is still premium unlimited wireless for a great price. So that means half day.
- [69:26]
A
Yeah.
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B
Give it a try@mintmobile.com switch.
- [69:29]
A
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- [69:36]
B
Com.