[Music] thank you for taking time from your busy day to watch this special presentation from the El Paso County Medical Society I'm Dr Joel Hendrick president of the El Paso County Medical Society and it is my hope that you will find our program of great interest educational and informative about the medical care provided by some of our best physicians in our country right here in the Borderland from all of us at the El Paso County Medical Society please enjoy tonight's [Music] program treatments for prostate cancer have been very interesting to watch over the last several decades one of our panel members that's here with us tonight has been with us since the Inception of the show and really the first one of the first shows that we did with the prostate cancer show and you were here with Dr Horowitz with Dr chesbro and yourself this is Dr bleed that we're talking about and that was in 1997 so for over 26 years you've been with us so thank you so much for that there's always new research and major new advancements with treatments and as with almost everything technology has been on the Forefront with special treatments and this program tonight is called emerging Technologies in prostate cancer and treatment this program is underwritten by the Rio Grand Urology and also I want to say thank you to the El Paso County Medical Society for sponsoring this program tonight I'm kathern Berg and this is the El Paso physician thank you again for joining us tonight's title is emerging Technologies and prostate cancer and uh Dr Daniel Vogal is with us this evening who has been with us now for 26 years just doing this show but you've been practicing Urology and you've been practicing really in the space of prostate cancer for about how long would you say well I've been practicing Urology for 41 years that's all that's just all yeah and uh I've been dedicated to prostate cancer for my group for about seven years seven or eight years okay and that's quite a time we have someone special here that we've been trying to keep a secret from you who is going to be entering into this room so if we can have a curtain number one open up and have a gentleman that's behind the door walk in this is our Jeffree Spear and I am going to leave this seat for a moment and let him take over over by all means have a good time thank you I'll be brief this is an important topic I need you to get started but I want to recognize you I could probably could spend probably the whole hour recognizing what you've done for for patience for the community I wasn't expecting this and for the medical society so I just I think it's simple I'm going to read what is written on this uh plaque for you we appreciate all you've done Dan we really do and more than anything I appreciate your friendship so it says thank you congratulations on your well-deserved retirement Dr Daniel Boge your leadership guidance and integrity will be a lasting Legacy for those who were fortunate enough to have worked with you however you are most recognized by the quality and Prof professionalism of your advocacy for your Patients health we wish you the very best on your new journey and retirement we love you and we'll miss you on behalf of your staff and Partners at Rio Grand Urology and Rio Grand Cancer Specialists and your colleagues at the op Paso Medical Center uh County Medical Society Dan thank you for all you've done really really special thank you thank you for recog enjoy the program everybody body good to see you to great so we were trying to uh and Dr spear you're welcome to stay for a little while we were trying to keep this a secret because he kept talking about the gentleman who's going to walk in the back door so this has been a lot of fun and again as we were talking about uh you were very much one of the first people that I met as a host doing this and I remember joking about you and Horowitz and chesbro that the three bearded men that always talked about prostate cancer and Dr yeah and the cough drops yes oh my God I forgot about that I forgot about that but this uh with Dr spear coming in again he's past president of the AL Paso County Medical Society had that show not have been a success I don't know if we'd be doing this still 26 years later because prostate cancer back 26 years ago is not something you said on television we talked about testicular cancer that's something we don't talk about we do now but at the time that wasn't something people talked about and you were very you were as stoic as you are right now crack a smile um but th this is where that comes from so thank you from I think audience members at home who've been watching you and been around you for all this time well you know it's been my pleasure really and to me it's always been what can I do to inform my patient and if I can inform my patient and help them in any way I can't ask for more than that and you're always uh when you talk about terminology always bring things to an understanding where everybody gets what you're saying which I thank you for as a person who hosts and now Travis Dr Travis mendle uh now now you get to be introduced but you're like the young one right and so we were talking about that quite a bit too so Travis mendle his technical title is radiation oncologist and again it's real grand cancer specialist which is Under the Umbrella of real grand cancer Urology so thank you for being here I know that we talk a lot on this program just about things that are new and things that are coming up and tonight's program is very specifically about that um on that note and Dr Vogal weed I know that we do this every time we do the show but I think it's so important as a trained urologist for 41 years goodness let's talk about where the prostate is what the function of the prostate is and it's just a good hop into why it is that we look at screenings why it is that we look at what the issues of prostate are not just cancer but we're going to start start off with issues of the prostate that aren't cancer yet that can become Cancers and then we're going to go into all of the oncology stuff but would you like to take it from there sure but there's one thing I'd like to do first is I'd like to welcome Dr Mandel to The Fellowship of the beard The Fellowship of the beard you know I didn't even think about that he still looks like he's 12 with a beard well he reminds me of when I started out in practice because I didn't have a beard and I grew a beard and they no longer told me I look too young to be ad doctor oh and then I found out from Brian today that's one of the reasons why he grew his beard so welcome to the fellowship what was the name of that Doogie Hower MD remember that when it's like there when you're a youngl looking Doctor people just like ah but I'll tell you what if anybody wants to look back and and I I talk about this a lot toward the end of the show but if you want to look at Urology Pro Urology programs or prostate cancer programs the things that you've come I usually watch a prostate cancer program prior to doing this program because I like to be prepared and you just knock it out of the park the first time I met you I thought this guy is so young but then you just you know stuff and then you're not old but you always call yourself the old one um but to just bring this as a combination I resemble the state and then what Dr uh Jeffrey Dr spear somewhere in between which is always kind of nice he's only 20 years younger than I am that's it that's it that's it he looks only about 10 years younger but he's 20 years younger left oh gosh so let's talk about the prostate which is why we're here what is the function of the prostate the the prostate is part of the male reproductive system or if you want to call it that and it it is a sex organ you would not be able to have any children if you didn't have a prostate and it functions as basically uh you know most people know this but your testicles make sperm and your sperm uh comes out through the urethra well it comes out through the ureth it has to go through the prostate first and the seminal vesicles and the prostate add nutrients and lubricants to this to the semen as it comes out so that it can make it on its way into the cervix and the uterus and ovaries in women uh you can see from this diagram it's kind of small and I apologize for that but this is basically the bladder right here this is the prostate you can see that right through the prostate comes the urethra that comes out to the tip of the penis well and these are the seminal vesicles that are sitting behind the prostate they they're usually not this big compared to the bladder the prostate is probably equivalent to an empty bladder but uh whenever when the testicles make the sperm it comes up through uh through this duct here in the prostate and the seminal vesicles contribute to that the seminal vesicles also contribute to storage of semen and uh and they start Contracting when you ejaculate and that's basically the function of the prostate but unfortunately one of the things that it does is it develops cancer right exactly so when we're talking about and it's interesting too because you're looking at women and there truly are age bearing years for women for men that's not the case um you're always going to have the prostate uh you can have children I want to talk about alucino and who is it daero I'm not sure but yes I I see a stutter start in Dr booe No it's not a stutter I was just thinking of uh uh an older actor had kids when he was 80 some years old and he's dead now but uh I can't think of his name but I'll think of it but it's an active blend you know after the age of 50 something women are are we're put to pasture when it comes to that so when we talk about the you it just shows you well I won't say anything oh come on this is this is your this your retirement show you God he's a famous actor and I can't think of his name it had come to you like when when they gave him an Oscar an Indian woman came out on on stage and and said that she wasn't going to Su the Oscar because he didn't want it and I just can't think of his name right now famous actor died a few years back I think he died in Tahiti or Fiji or someplace like that oh my goodness you know what somebody at home right now is Googling it and shouting it at the screen and we're like oh dang it we remember what it is um but we have to I would Google it right now but I want to keep going on this uh Brando oh Marin Brando yes really yes okay had a child at 86 something he had he had two children after the age of 80 from what I understand okay and then you've got Pino and and you've got the you know it it's it's possible it's not 100% right but it is possible but it's still a functioning organ you know at the end of day we're we're kind of focusing in on that um when you start looking for screenings of prostate cancer and then kind of why I was bringing up the 50-year-old and women Etc 50 seems to be the controversial age the American Cancer Society and other organizations like well when do we start screening for prostate cancer and then there's high-risk age groups high-risk ethnic groups what is now the screening golden standard when it comes to prostate cancer and Travis I'm going to throw that one your way or is there a golden standard is there still a lot of controversy around that um I mean the controversy stem from the the task force like back in 2012 when they decided that the PSA screening wasn't worth it and it was C causing more morbidity for these P for patients leading more biopsies and things like that um but I think that's now been been somewhat debunked that PSA screening is important um in general most men or most providers will start screening at age 50 okay um but there are highrisk groups like you said um especially genetic genetically highrisk groups um and so that's you know why we do a lot of genetic screening nowadays and what are those groups if I remember right the ashkanazi Jewish population is that correct um yeah you can have that but I mean there's um there's patients you know especially patients with the family history right of cancer um especially prostate cancer and a first relative that's very high risk um you know we do a lot of screening for kind of high-risk mutations r mutations is a big one um and that's also very relevant in breast cancer as well you know and I remember us talking about this uh a couple of shows back so the braa gene I feel like several years back we only talked about that with breast cancer and now we're looking at that as not necessarily sexual organ cancer but just other glandular glandular type cancers is that correct so is that still a pract and we're looking at new it's not Technologies per se but it's definitely a new way of looking at screenings is that is that still how that's going um well just for like screening for cancer um you know PSA is really what what's used in the in the digital rectal exam um but in terms of just basic Laboratory um tests PSA is really the main one um at least for my understanding but uh really what what you know when I'm speaking with patients about their their lab values everyone's very focused on PSA you know even after treatment before treatment it's you know this test was designed as a screening test and we use it as a tumor marker as well but um it's it's the PSA is really just a number and it really when you when you're tested for PSA there's a number of things that can actually increase your PSA um ejaculation you know surely before if you had a digital rectal exam surely before you were tested all these things can actually raise it so you know patients are always very anxious about their PSA values and they can really FL away quite a bit um and so I think it's it's just very important to make sure that once you have your PSA tested if it's elevated it's important to make sure that it remains elevated um because these you know different different actions can actually raise it you know that's an interest I've not heard that before so on that note if somebody knows that they're getting in so PSA is prosthetic specific antigen it's a a simple blood test you know no blood test is simple but it is a simple blood test um if there are are there for example if they know that they're going to have their blood drawn on Friday are there any ideas or a a sheet that says you know what maybe stay abstain from sex for the for the three days before or don't do this don't do that prior to the blood test is that even something that's written down somewhere or is that discussed with a patient prior to having their PSA I would hope it would be yeah I've never heard of it so I just thought that might be a question to throw out there so the majority of patients who are undergoing screening are actually being seen by their PCP okay um and so I'm sure it's very variable that they're just kind of adding it on the lab test because they saw the the patient's 50 um I'm sure a lot of them will mention it um but it it could easily be missed right but I this is this is probably what happens is the patient has an elevated PSA screening they're sent directly to the urologist so that's a perfect transition to Dr Bo so now we have someone who is let's say he's 55 years old let me just add to what he said okay uh another thing that can affect PSA is the size of the prostate prostate volume the bigger the prostate the more likelihood the PSA is going to be elevated the biggest mistake that even pcps make nowadays is if you look at a Laboratory test and they're going to tell you the normal value is from zero to four and above four is abnormal that's not true okay if you have a 50-year-old that has a PSA of three he probably he has a high risk of prostate cancer oh really generally speaking if you have at any age group if you have a PSA of less than 1.5 your CH your risk of prosty cancer is very very low and you probably don't need to repeat it for 5 years okay certainly if it's less than one even if you have a family history for that person that risk is not that high it would probably check it more often if you have a you know if you have a bracket abnormality but uh uh that generally speaking Yeah number one do check it at the age of 50 check it at the age of 40 or 45 depending on on who you talk to if there's a family history if you're a black male if you have asany Jewish ancestry MH okay just by even if you don't have a genetic abnormality okay if your father or your uncle or your brother has prostate cancer you're at increased risk absolutely and you should be checked at an earlier age so here's a question and say an an average 25y old male if for some and not that he would need it but if you were going to take a prosthetic specific antigen a PSA test on him would there be even a number would he register even if it's somebody that okay yeah they'll register but it'll be a very low number generally point4 yes okay and you know there have been instances whether people very young people that have prostate cancer I've never seen one I think the lowest I've seen is in their 40s oh okay yeah and uh uh the you know they flukes if they're you know they're younger than that it's very very unusual so now we have a 55-year-old that has a prostate or has a PSA and let's just say it's at a seven or an eight so we now know that sent to the urologist you see him what do you do from there like what are the next steps conversation leads to ABC and D well the first thing I would I would probably do is in addition to history family history so and so for I I would check his prosty and see if it's suggested there's a nodule on it or anything like that so physically going dig digital re digal exam because that can give you an indication if he's got this huge prate the other thing that you may consider if you think that person's low risk is repeat the PSA MH okay it could be a lab error or it could be that he was riding the bicycle before he came into the office see again a risk factor I didn't think about not risk factor an elevation I mean because it's direct paranal pressure the prostate it's just like you know if you're doing a prostate massage or you're pushing on the prostate it can elevate your PSA okay but then in addition to that if it's if it's borderline there are additional tests that you can do and what are those those are there's a u a f score there is a psma3 there is a 4K 4K score I don't know you don't use a decipher for that but uh those are you can do those tests and they can tell you whether it's low risk or high risk ultimately it depends on your you know when you see the patient whether you think or not whether you should do a biopsy or not and then we get into the next thing do you go directly to biopsies or do you do an MRI first I would probably that's the question right now I would probably want to do an MRI first because it may identify a really significant focus and this is also controversial too because if your if your MRI doesn't show high risk should you go ahead and biopsy the prostate or not if your MRI has high risk you biop also biopsy the areas of the prostate that don't show it and these are things that have been discussed back and forth in the literature uh ultimately it comes down to the urologist the decision he makes is to whether biops him or not whether do an MRI or not and that's variable and so if you're looking at what is your truly alarming number when it comes to a PSA elevation like when you're like you know what MRI or not we're going to we're going to do a biopsy is there just like 14 15 what is that crazy number I would you know if I go back I would probably say that I would buy I would wouldn't even think about it oh there's other there is an exception you can have a p you know 10 15 20 30 and uh then have an infection oh good and and a prostate infection can make your PSA go up but if if the urine is clear and you have no infection absolutely I would probably biopsy anybody has anything above a 10 okay maybe even lower than that okay and that's kind of where I was I was getting at as far as as far as that goes because the biopsy is always that thing that people take a big breath for it's like oh my gosh and so now Dr mendle somebody has a biopsy it does come back that there it's positive there's there's definitely cancer in the system and so next steps from there so usually um I guess I can just backtrack a little bit like with the MRI um I'm a huge fan of Imaging um we use Imaging a lot for what I do um so I'm I'm a big advocate for getting MRI before biopsy um and it's been shown that the MRI is able to identify higher grade disease oh good and that's that's why it's really important because you can find find these patients that have higher grade and better risk stratify them for treatment um the when you do a template biopsy it's it's more of a it's a systematic sampling of the prostate and so you're going to find more prostate cancer but a lot of it will be low grade um and it'll still be you know sometimes low grade on the MRI but it kind of gives you a sense to kind of where to to maybe take additional samples or something like that when you're doing the biopsies um um and when you're discussing treatment options for patients that have been diagnosed with prostate cancer it's very important to RIS stratify them because they're really what does that mean risk stratify them so basically figure out how aggressive their cancer is got because you there's a there's a very wide spectrum we think of things there's glein scores which everyone's heard of um six and above is prostate cancer um we now kind of think of of these scores in terms of grade grouping and there's there's five grade groups but basically if you're if you're a low-risk patient which is you know essentially a glin six um or a grade group one those are almost almost benign almost benign entities and those a lot of those patients are now pushed towards something called active surveillance okay which is a which is a treatment modality for prostate cancer they're really trying to deescalate active um kind of therapies for patients that can just be watched um because there's morbidity associated with surgery there's a morbidity associated with radiation um and so if you can kind of you know kiick the can down the road for a couple years or even a decade a lot of patients safely and a lot of patients will choose that option so during active surveillance how often do they go in to get to to get rescreened or to relook at and what is it that they're looking at are they doing PSAs each time are they doing MRIs each time so there's different guidelines okay of course there are so everyone we can never make this easy right everyone has their like different way of doing things um the way that I do it is you know of course make sure that we we know all the facts about the patient's diagnosis with imaging so and biopsies so typically what happens in our practice is the patients will have a template biopsy it'll show some type you know low-g grade cancer a lot of times they'll come to me and I'll discuss this with them that hey you're probably a candidate for active surveillance um but I'm going to get an MRI and make sure that we're not missing anything right and you know a lot of times the MRI looks fine and you know we'll we'll do additional testing genetic testing molecular testing which is the Cipher test that Dr V was talking about um that is more of a uh kind of a computer generated risk category for the patient but um but basically we make sure it's safe before they go into active surveillance okay um but once once once they're there the way the way that I approach the situation is they're they we repeat their biopsy 1 to two years after their initial biopsy to make sure that their cancer hasn't progressed and it can progress in sign like number of cores taken um so say they had one core of a gleon six and then they come back and now they have a like four cores of a a GLE six so explain what you mean to those that don't know what the cores taken mean so so so basically when you get a template biopsy most patients will get 12 samples taken from the prostate in in systematic areas um and and it's just it's basically creating a semi map of the prostate and letting you know okay in this part of the prostate there's cancer this is what the pathologist thinks how aggressive it is and then in this part of the prostate we didn't really find anything but nowadays we're catching Pro prostate cancer quite early and so some of the lesions can be very small and the prostates can be huge um and so when you do these template biopsies sometimes things can get missed and so that's why you know in my opinion the Imaging is very important because if if you're dealing with a small lesion whether it's low grade or high grade you want to know that it's there and you can watch it right on exactly it's kind of important to know that this is getting into a lot a lot of the complexity that we really face M because it's not just simple straightforward you know if you go back to historically historically we used to do first we just used to do trans rectal bite we didn't even have ultrasound we just stuck our finger and if we felt the nodu we'd put in the needle above the finger and stick your finger sometimes wow uh then they we got ultrasound we started with six core biopsies and then we went to 12 core biopsies uh some people use templates and they do do 24 48 whatever number of biopsies we used to use a lot of these uh uh saturation biopsies before we had used MRI a lot uh it used to be also that you know before the United States task force we Pro say cancer came out and said you shouldn't biopsy anybody we would biopsy and if we found cancer we would treat everybody because we really didn't know how they did historically and that's where when you say this give me a year approximately like how many years ago are you talking about H well before I before uh 2012 so okay before that so really not that long ago not that long ago no all right and uh you know nowadays it it's really complex because there are a lot of things that you have to take in consideration the complexity is a little bit too much to go to or to try and understand on the show I would think yeah and uh but I guess the most important thing that you need to know is yes you should any every male should be checked after they turn 50 at the least once they should have a PSA done there's controversy now as to whether you should do a digital rectal exam well if you have a very low PSA you probably don't need to have it done but if you come in with a high PSA I'm certainly going to check the prostate I mean not ever check it again or I may check it again if I'm following them and when he you know when he talked about GLE and six tumors which is which is a great group one I heard a grunt come from you well yeah there you know some people this is not me okay again this is why this is so controver some people think that that's really not cancer right okay and uh I don't I'm not sure I there's no way in the world that I know of any urologist say oh as a GLE six I'm not going to follow him okay but they there are people out out there that say well you know that's probably not cancer and a lot of those people do well for a very long period of time but yes they should be followed so let's take it now to as a surgeon and I always look at uh or at least in the old days I thought to myself okay Dr bed urologist he's the surgeon so when is it that um then I want to go really into the new technologies that are going on but when is it that a gentleman has to really decide whether I'm going to have my prostate removed or not talk us through that process with the patients that you've dealt with 20 years ago up until this past year and what the differences are well 20 years ago anybody had prostate cancer we operated on unless they had metastatic disease okay and even you know there we get into all the changes because we used to have relied on bone scans and CT scans to diagnose metastatic disease now we have a psma scan which is you know about 38% more accurate in diagnosing prostate cancer metastases and uh so uh most people will particularly if it's high risk they'll do a psma to see if there's any metastatic disease if if they have metastatic disease then probably not but it depends on the situation again because you can have aligo metastatic disease which is something that he loves uh because you can you you have two options there if you have one or two positive nodes and in the pelvis well you can still do a radical prostectomy and take out those nodes surgically or you know if the patient's 75 years of age or he's 55 and he's a bad diabetic and his kidneys aren't working well you can treat him with radiation and radiate those nodes MH and it also depends on the patient preference some patients are deathly afraid of radiation some patients are definitly afraid of a surgery right and generally speaking if you do not have metastatic disease and you're relatively young a urologist will say well let's take that prostate out now the younger the person is the less likely it is that they're going to have the complications the two main ones are concerned about our impotence and incontinence okay uh but if you compare you know if you get a 60y old or a 70 year old and you give them radiation or you do surgery generally speaking long-term survival the first 10 years is 10 exactly the same I remember was talking about that years ago even um and that is is that still the case and and now this is a good transition into some of the things that we have written down here so there is something called theragnostics thetics the agnostic SOA Dr mendle can't call you Travis um what is that that's that's something that's relatively new to me I've seen it heard about it here and there but I know very little about it so this this is a a technology that's actually been around for quite a while but it's starting to um kind of pick up in the prostate cancer space and the the concept is to use Imaging to identify cancer in the body and in our in our you know world right now we're using pet psma right um which is completely changed my practice everything it's changed everything I do it's changed how like what I how I treat the patients it's it's just really been it's been I thought it was going to be big and it's able to see using this versus in the past so so it it stems all the way to to the actual you know actually wrist ratification you know because you you you're this is a staging staging Imaging and what Dr vulg was discussing before we had CT and bone scan which were essentially useless unless patients had you know a massive bony disease or you know very Advanced P very high PSA usually they're completely useless when we're finding these cancers so early um and so now we're using real staging Imaging and Pet Imaging has been around for a while oh my gosh we use it in a lot of other mes very common for staging we just didn't have this te this technology until like last early last year at least here in it was it was just approved within the last year yeah wow so so is it an Imaging machine I mean maybe describe to us what it what it looks like what the process is when somebody gets this Imaging done it's um it's it's basically a it's like a CT scanner okay um but it's it's souped up it has a camera and basically you're you're um giving patients a radioactive isotope that creates positrons and then you're able to detect um detect that okay in the patients what you need to understand there is that psma stands for prostate specific membrane antigen membrane yes and it's a it's an antigen that's a what they call a transmembrane antigen but it's on the surface of the cancer cell and so the what this does is that the it sends an antibody to that antigen and lights it up and it can be any place in the body it could be in the bones which is the most common it can be in lymph noose or it can be and this Imaging picks that up that you're talking about yeah so so prostate cancer expresses this antigen and so you're able to to tag it and Target it now paron my ignorance and I just want to make sure that I'm understanding it correctly so we're are we talking about metastasis or we we talking about just the idea that when you said so this is metastasized to other parts of the body already in this Imaging can pick that up and it could also pick it up in the prostate or you can pick it up in the prostate bed after the prostate has been removed if you have recurrent disease okay so it's it's it's really um so I have a I can't remember if I talked about this guy last time but um but I had this patient who was in his I think his early 60s late 50s had a rising PSA for almost a decade and had gone basically undiagnosed hm um and he'd been he'd seen our physicians several times had multiple biopsies saturation biopsies went to Mayo went to MD Anderson had all these Fusion MRI biopsies nothing and his when he came to my clinic his PSA was 50 dear Lord and He but but nobody can find anything like where no his like his original one of his original biopsies they found a very low grade 1% of a core and they put him on Act of surveillance very appropriately so even at 50 he kept his prostate this entire time as it was climbing up well yeah his PSA just kept going up they couldn't find anything so no one really treated him and um he came to our clinic and we got a pet scan and in the very like the very front part of the prostate um it lit up oh wow and so I went in there and biopsied it and it came back as a a you know relatively highgrade prostate cancer he was high risk and we treated him and he did great but this Imaging it's it's really just changing a lot of the a lot of the things we do is that patient was you know basically undiagnosed we were able to diagnose him rist ratify him and treat him appropriately based off of his risk um and so it's just it's really changed everything I bet but this is the the the theragnostics has been around for other malignancies but it's now kind of just transitioning into prostate cancer because we have something to Target okay so we have this this the the psma scan that's able to allow us to see these these cancers in the body whether they're localized in the prostate or in the bones or elsewhere in other organs um but now we have a radial isotope that we can tag with the psma litium um and that actually goes yeah the term Theos is used because it it tags but it also is therapeutic that's what he's talking about he'll explain okay yes but we they've been doing this for a while and and like thyroid cancer is a a type of um we use radioactive iodine mhm um patients who have metastatic thyroid cancer we can you can most types of of metastatic thyroid cancer you can give radioactive iodine and that treats the whole body because those cells take up the iodine um the the Tums actually come off of um what's called a dotatate scan um these are patients with neuro endrin cancers um they're like a like kind of a g are patients with what kind of cancers I'm sorry neuroendrocrine cancers neuro indri okay um but basically we don't need to go into the neuroendocrine cancers but but they use this scan to to find these lesions see how many they are and then develop a therapeutic that's radioactive that you can Infuse to the PA Infuse in the patient and it goes straight to those tumor cells so when we use the word therapeutic what we're basically saying is a treatment unless I'm wrong is that correct that's why it's it's called the agnostics because I don't know why they came up with that term because it's basically the same thing as the psma the psma the common ones are polary in the gallium and the the thalium or uum uh is is if if you give it to the patient it will light up where the cancers at but since it it uh actually gives out radiation it can also treat the cancer cell and that's why they came up with the term theragnostics I see and it's and it's it's uh it's very nice to have we're going to be talking about this whenever we get it so it's coming it's coming in the next couple weeks oh that's great cuz I've got about four or five patient you probably have a whole bunch of waiting carry on this conversation that you're having right now honest to God because I think this is fascinating to me because how often on this program do we get to hear that you're excited this is coming in the next couple of weeks you have some patients right now that are going to be using this this therapeutic okay let let me go through it stepwise okay patient comes in patient is referred to me with Advanced prostate cancer okay the the treatment that's been around since I think 1942 is is blocking the male hormone in 19 42 they removed the testicles and they found out that the people lived longer if you remove the testicles and then uh in the 1980s they came out with the injection of Lupron which is also used for breast cancer if I remember correctly or it's definitely used for endometriosis but anyway and so we used that instead of removing the testicles and that's all we had if you have somebody has significant metastatic disease their average survival is a year and a half to two years if you put them on this injection or you remove the testicles uh then we we came out with bicalutamide which is is basically an antigen uh blockade medication uptake blockade medication and it initially it would it would it would complement the Lupron but later on they found out that it didn't have any effect on long-term survival and then they came out with these second generation anti-androgens uh enide uh darolutamide and apalutamide and these basically go to the cancer cell and they keep the cancer cell from using the testosterone that's available it's like blocking it yes well it doesn't allow the cell to use it it blocks it to three different levels in the cell but what you need to understand is uh and this is simplifying it but when you give a patient a shot of Lupron it basically tells the the pituitary gland to tell the testicles not to make any more male hormone and about 95% of the male hormone is made by the testicles right but a certain amount out of male hormone or its precursors is made by the adrenal glands M and that that male hormone can be utilized by the cancer cells so this blocks it and this extends her survival I've had patients on this medication for six and seven years now H okay and then that was the next step and then initially and then there's chemotherapy and usually it used to be that after the Loon if it stopped working the next thing was chemotherapy exactly right okay but now they found that one of the first medications was actually a this is blockade I'm making it confusing and I apologize for that well no this is I think this is so good for a setup because this has never been the same show we've done this show we were joking 26 years but we've probably done a prostate cancer show 30 40 times and it's different every single time that's what's so exciting about it is isn't it it's so complex um and I can't even imagine if you have 10 patients I know you have far more than 10 it's like each one of them is being treated very differently than the other depending on all the yeah variables but you know that became what we call B Al therapy and then they came out with trimodal therapy which is basically is a combination with chemotherapy plus Lupron plus uh Androgen up uptake blockade then is from the radiation side they found that people that are put on I should let him talk about that but they put them on Lupron in addition to give the radiation they did better and the patients got radiation alone then they found that if they add this uh this uh andren synthesis medication that even gives them better response to the radiation therapy so it's become you know and and so anything that happens that's good is exciting and there's research on it every single day and so but you know we're here sitting oh I need this I need this now because I have these patients and I want to help them and and and that's the frustrating part about it but on the other hand I didn't have any of this stuff 10 years ago right and so Dr mendal your your Li your eyes lit up like like three weeks from now you're looking at Dr V it's it's going to be like 3 weeks so very soon going now into um all these different treatment options that are going so radiation and I think in and of itself prostate cancer for the way I look at it uses so many very as of radiation for treatments and I know this new stuff's coming up so just kind of go on a tangent on that specifically because a prostate again is the size of a walnut right so you're looking at breast cancer under granted the tumors are it's not the organ it's it's how big the cancer is or how big that is but the different types of radiation from when you started to what's happening three weeks from now so so basically I mean there there's it's very complicated would probably take a while to explain everything but um but the way that I run my clinic um there's a couple of things one it's all about personalization um now medicine is all personalization and precision ision um and so all the treatments we do it's it's all about you know making sure that we're giving the patient the correct therapy so that's why the risk ratification up front is very important um because you can you can escalate therapy as much as you want um some patients will benefit from it some patients won't but we know which patients will and so that's why it's important to identify those patients before you do anything okay um with just localized treatments you know we have surgery but there's multiple radiation options um there it's all personalizable and the patients all the patients that come to my clinic they come in they actually have a a pre-recorded video that that I made on PowerPoint that they watch it's both in English and Spanish and it goes over all the treatment options and the goal like when I came here the goal was to bring all the treatment options that I learned in Dallas actually here to El Paso so people don't have to leave right they don't have to go anywhere to get something different um and the only thing that we've been missing you know is research and we actually we're actually starting a research program here very soon we hired a PhD oh good um so we're going to be participating or at least you know attempting to participate in one more thing hopefully these like National National trials and so patients won't have to leave to get their you know their prostate cancer treatment right they can get it all done here and we do a very good job we go going from just external beam to hypofractionation to stereotactic treatments where we do our treatments and just five treatments um all the way to brachi therapy and you know conventional treatments so we do everything and we do it very well because we're you know we I treat all cancers you know I treat breast cancer lung cancer brain cancers but um cervical cancer endometrial cancer we a big Gynecology program but um but basically our goal is to make sure that the patients are getting the right care um and it just it all starts from the the beginning but once you once you transition into this metastatic space it becomes very difficult to cure the patient right and Dr F always likees to F fun at me about this because I think I can cure everyone um and never lose that yeah I mean truly that that's a you want that energy in every doctor and I it's not it's not that I like I think I'm going to cure them but I do think I'm going to help them and so that's the important part you have all these a lot of these things are life prolonging okay yeah they they may not necessar quality life they may not be cative but you know we you know as I said a year and a half to two years now if we're getting six and seven and eight years you know this is is a blessing and I have to second what Dr Mandel says about Clinical Research in in my clinic that's really essential you have to be able to participate and it has a double value number one you have more things to offer your patient they may or may not work right okay but at least it offers them something else and then the same thing goes for radiation then there are these combination programs combination you know like I was talking about one medication that he uses in combination with radiation therapy plus the injection well there are other three the other three medications have also been proven to be beneficial to leas and salutto which is one of the first ones that came out that was an androgen update blocker and and every opportunity that you can offer your patients is an opportunity not only to help them but also to help everybody because this is where we learn and this is where all of our patients benefit so when you're looking at uh again with these treatments that are on the Forefront and and I know that in days past they didn't like using the word cure with cancer and when you're looking at prolonging a life and you're looking at quality of life Dr mle I'd love for you to talk about what you see coming I know this we've got all this stuff happening in the next several weeks but if you could take a magic ball the what do you call it the the the glass ball what do you call that thing dear Lord the globe and say 10 years from now uh we need to cut this part out probably uh 10 years from now we are on the Forefront of treating all cancers because I know this is a prostate cancer program but you are treating all Cancers and some of them are similar um what is it that you see 10 years from now that's really going to knock it out of the par because I feel like that's happening right now if we were having this show 10 years ago talking about this do you think think that even would have been something and Dr Ved you you were here from the beginning the the there's one thing that I hadn't mentioned before he answer also have monoclonal antibodies say that slower monal antibodies okay particularly the patients that and then even some of the patients that aren't uh do not have a genetic abnormality if they do then they're the most commonly known one that works in a whole bunch of cancers is pisab which is it you know they've used it for Prost cancer renal cancer bladder cancer I don't know how many other Cancers and basically it's an antibody against one little antigen and it does work uh in in prostate cancer the one that's approved across the board for braco one braco 2 ATM and about 14 others is a lap rib uh which is called limara and I think they even have ads on on TV but that is big for lots of cancers in the future and so it's just one more thing that we have unfortunately it only works for people that have genetic abnormalities the best genetic inheritable genetic disease right and Dr mle I'd like to talk with you about that too because I feel like you have so much research on what's going on in the world of genetics and so when we're looking at prostate cancer yes family history is a big thing but we're also looking at that's relatively small number of people I mean getting older living a little bit longer is where the risk factor is but if you're looking at genetics if your father had prostate cancer what are your chances or if your uncle had prostate cancer what are your chances and in the world of genetics we always talk about that but it's not as big as people think not it's not the large number of the population as people may think correct yeah how would you describe that I I probably couldn't give you a percentage I don't know if if about 30% 20 to 30% if you have an inheritable trait if you you have 2 you have an ATM or braa one which is rare so this is that testing you have to see if you happen to have a gene that is easier to mutate than others that do not have that Gene cor correct but I can't tell you exactly what the uh what the risk is percentage wise if you do not have an inh herble disease even though it it's increased compared to the rest of the population okay but definitely there's an increase I mean I see and I'm sure Travis has seen it too they patients that the father and uncle and one of the brothers has prostate cancer yet they have no inherit trait the problem is that we know very little we know of right that we know that that's what I was getting at the problem is that you know one thing is having one gene but how about combinations of genes that predispose you okay see that to me is what the 10e process is like what are we going to know 10 years from now specifically with this kind of testing well we may know a lot more than we'll most likely know a lot more than we know now but how many genes are there in our gene pool okay so how many combinations and then you get into Snips which is small nucleotide something or the other which also has something to do with inh herble disease I don't know it's there's a lot of research and the more you learn the more complicated it becomes of course right I see I see 10 years as like it's it's just going to be more precise and personalized because we're going to have more information about the genetics and you know we didn't we talked a little bit about germline testing like your heritable genes but there's also the tumors genes that's sematic testing um and there's GNA there's there's already targets for different mutations and for those patients but they're GNA they're going to find more right right so so in 10 years I just I see this this realm of you know you're we're always going to have our our tried andrue local treatments um but I think in the future it's really going to be the patients that have metastatic disease that are incurable and we're able to give give them these life prolonging therapies and it's going to be it's even now it seems like we're treating almost like a like a like a disease a like a diabetes something hope hopefully it could be something like AIDS remember how AIDS was deadly for everybody and now you can live as long as you're on medication you can live a normal lifespan right uh just real quickly uh on on on genetic testing and and and what we call uh germ line mutations and somatic mutations I've uh I've had uh we always do germine mutation anybody has advanced disease that means that in every cell in your body has that genetic abnormality every cell body every cell in your body that that's why it's inheritable because if come and if a if a parent has prostate cancer his son has a 50/50 chance of carrying that Gene okay okay uh because he gets part of his gene pool from his mother they get 50/50 or whatever number you want to call it uh and that is inh herble disease but you can also have genetic mutation in the cancer itself okay whereas you do a germ uh you do a uh germ line on the patient and it's negative it says nothing that we know of is causing it but then you do a sematic test which is done on the tissue itself or you can also do what we call a liquid biopsy where they look for DNA fragments of the cancer cell and that may tell you that give you a genetic abnormality that's treatable so is this all being done on the cancer itself or are these done as testing to see what your chances are of what treatment options are or is that it's done as it it will about 15% 12 to 15% of all advanced prostate cancers theoretically have about have inheritable disease okay in my practice it's about 8 to 10% oh okay okay and and those patients it gives me an additional form of treatment in future or in some circumstances you can start out with that treatment right away uh but uh some of I have two or three patients that do not have an inh herble disease but they actually have a mutation in the tissue the way you find that out is you can actually when they do the and Travis does this thankfully he he does uh when he sends his patients in uh for for the biopsy if they have a high-grade disease he also sends it test tube with her blood so that they can do a see if there's a germine mutation right and then in the future if he does develops it if he's not cured he develops Advanced disease well then you can do sematic tissue on that testing or if it's more than 10 years then you can do a liquid biopsy or if he has a very large lymph node you can biopsy that and do somatic testing to see if there's been a mutation and the the key is is as as as the I guess the theory is that as the becomes more aggressive it picks up more mutations and that just gives you more opportunities for targeting it with some kind of therapeutic correct so it's almost said as it gets worse it's easier to treat not easier it's you have more options at that point it's it's more like I guess you could say it's it can pick up mutations that can be treatable okay um and it's going to be it's a two-fold approach now because now we're looking at the genes in the cancer like the like the actual genetics of the cancer we're also looking at the cellular markers and that's where this Diagnostics approach is because we're looking at what's on you know what does the cancer cell what's it expressing what's it showing and does it light up when we we we target that with with an antigen right and then that those patients if it lights up on a scan and the likelihood that they're going to benefit from that treatment because it's targeting that exact area um or those cells is very high right man I need four more shows specifically on this like I'm a little bit lost right now so I'm going to go back and and watch us and it's a good thing it's really a good thing because you're talking about things that are brand new that we can Explore More in six months from now eight months from now and and yes you're retiring sir Boi but you're you're going to be back you better be we'll be in we'll be in touch exactly that gentleman that you just talked to yes Dr he's taking over the clinic okay and he's a smart guy yeah oh yeah he's he's he's a smart guy not that no I know I I love but what I what I've thoroughly enjoyed Through The Years um is the teamwork when it comes to all this you know the Urology the oncology both radiation and chemotherapy and radiation but it's it's so fascinating to me all the new stuff that's happening and we're we're kind of running out of time so is there anything that we have not touched base on yet that you want to talk about really quick before we end the program he Giggles how many days do you have you you know I think the most important thing from this is number one if you're over 50 get tested okay and then let us take over okay and I guarantee that if you let us take over you're going to be treated just as good as any place else okay I'll I'll never ever claim I'll never ever claim that I'm better because there are a lot of really good people out there but I think I do a good job I definitely think he does a good job and we've been blessed M we've been blessed with a group that's very supportive and we've been blessed with the planning and we've been blessed with uh all the things that we've done to benefit our patients and you guys really are patients first all day every day I mean I I remember again just talking to you from the beginning Dr mendle is there anything that is there anything is there something that we can cover in the next couple of minutes I know there's a lot of stuff to to continue still but what else would you like to bring up before we close up yeah I mean I guess I can just piggyback on um what Dr V was saying that uh you know we we have an amazing team you know we have people like just it's not just my my Center I mean we're we're all about putting the patients first and that that kind of brings the whole team together because we have a common goal we're trying to help these people and it's really like it's almost sometimes I like I don't even feel like I'm at work like I don't feel like I'm working I'm just like I'm there with my you know it's almost like a family there in the in my clinic um when we're there we're getting we're getting this hard hard work done um but that kind of percolates throughout the whole group um you know from the partners I'm sure it's like that in everyone's Clinic where it's oh yeah you know you're you're there with your it's like your friends and family and you're all trying to like like solve these problems and that's kind of the magic of the group yeah it's really you know everyone everyone's like this well it's palatable I mean just listening to you guys and being around you um and again real grand cancer specialist underneath the umbrella of real grand neurology I want to say thank you very much to our audience for continuing to uh join us again this is the El Paso County Medical society's El Paso position and if you want to watch the show again you can go to several places you can go to PBS Al paso.

org you can Al also go to the El Paso County medical society which is epcms decom and then easy also is youtube.com on all of these just look for the El pasos and if there is a specific program you want to find just put that into the search engine also also if you have a question that you would like for any of the doctors from any of these shows to answer feel free to text that in you can uh bring in the question and that is eped Society at AOL.com so I'll I'll repeat the way that goes epme d s o and that's at AOL.com you can text in a question or email in a question and we'll get the doctors to get back to you on all this kind of stuff I'm Katherine Berg and you've been watching the AL pasivos [Music]