Thank you for watching this program tonight with the best physicians of the region.

My name is Dr. Luis Munoz.

I'm the president of El Paso County Medical Society.

It is our hope that you will find this program informative and interesting.

We, at the El Paso County Medical Society invest in community education with our programs.

I hope you'll find this program very informative, with great medical advice and great medical information.

Thank you again for watching this program tonight.

And have a great night.

Treatments for prostate cancer have been very interesting to watch over the last several decades.

Screening guidelines have also changed quite a bit over the years.

We're going to be discussing that along with new and continuous research that lead to advancements in treatments.

Progressive technology has been on the forefront with individualized and specialized treatments leading to personalized cancer care.

This program is titled Precision Diagnosis and Personalized Treatment, and it's also underwritten by Rio Grande Urology and Rio Grande Cancer Specialists.

And we also want to thank the El Paso County Medical Society for bringing this show to you since 1997.

I'm Kathrin Berg and this is the El Paso physician.

Thanks for joining us.

This is precision diagnosis and personalized cancer treatment.

And this is specifically with urology and prostate cancers this evening.

And we have two veterans and a new guy here today, but we have Dr. Jeffrey Spier, who is a urologist and also the medical director, Advanced Prostate Cancer Center here in El Paso.

Dr. Travis Mendel is a radiation oncologist and the medical director for the Rio Grande Cancer Specialists.

And we have Dr. Jesus Herrera-Murillo, otherwise known as Dr. H. Is he asked us to call him urologist and medical director of Rio Grand Urology for Men's Health.

We have a great set aside.

The doctors have prepared a really nice presentation.

And what I like to do to sort of set the stage is go right into that and you'll see a lot of this on the screen.

But Dr. H, if I can ask you, we are looking at advancements and localized prostate cancer care and men's health.

And as Dr. Spier described you earlier, you're kind of the surgeon and you're one that they can kind of help with.

That's usually a first step when someone is diagnosed with prostate cancer.

And again, we're just kind of setting the stage for what we're going to do for this entire program.

So if you can kind of take it from there.

Yeah.

Well, thank you for having me here.

So essentially, when patients come into our clinics, you know, we we see them for elevated PSMA, They're getting screened for prostate cancer.

And that usually leads after many steps, sometimes in counseling to a prostate biopsy.

And then at that point, once we diagnose prostate cancer, then the discussion is basically the treatment options.

And I'm sort of the first sort of step of that when it comes to talking about the robotic portion of treatment for prostate cancer.

So radical prostatectomy is a kind of it's been developed over the years.

It's use a minimally invasive procedure.

The whole goal is to do nerve sparing or avoid damage to the nerves when you're doing surgery in order to avoid things like erectile dysfunction, which is one of the main things that most men will complain about.

The other on here medications, injection therapy, also inflatable penile prosthesis, etc.. And these are things that a lot of people don't just talk about.

So I'm really glad that we're able to be here and bring that up.

Yeah, So.

Exactly.

So the goal of prostate surgery is, is to get rid of the cancer.

And the second goal is to avoid these side effects as much as possible.

And robotic surgery has really helped with that.

Now, if one ends up with erectile dysfunction during that process, then there's medications, injections, things that we can do as well as surgery or penile prosthetic, which we've created this men's health clinic to help men kind of get their sexual life back into into play.

And so these are, again, procedures that we can do.

They take about 30 to an hour and you can regain your sexual life back.

And can you kind of describe what you're doing in the surgery room when you are countering a lot of these side effects, I would say.

Yeah.

So a lot of it is counseling and early counseling, which is why it's important to have a mental health clinics in order to to get these patients prepped for these side effects after surgery or radiation or whatever cancer treatment we're going to do for their prostate cancer.

Mm hmm.

And I walk through them to the steps of surgery.

It's an outpatient procedure most of the time, and they pretty much can use the device.

It's a penile pump, and they can use it after about four weeks to six weeks.

That soon?

Mm hmm.

Okay.

Now, incontinence is the other thing.

That's a big thing that I'm always fighting with Dr. Mendell.

Because, you know, incontinence rate after radiation is very low.

But after surgery, it's a real, real thing that men have to deal with.

And sometimes there's no choice.

They have to have surgery.

And so there is also a device that can avoid these complex or fix these complications.

And it's a it's an artificial sphincter.

Mm hmm.

And essentially what it is, it's a cuff that goes around the urethra.

and it's attached to a small pump.

When you want to go urinate, you press the pump, it opens up the valve, and then you're able to urinate.

And when you're done, it closes back up.

So you're not having leakage.

And it's shown in the diagram here.

And how long has that been around?

Has that been around for a while?

Prosthetic surgery has been around for quite some time already.

Okay.

Or 15, 20 years now.

Very nice.

And we were just talking about when we started the show was 27 years ago.

So to me, it's like that's yesterday.

I wasn't here.

Yeah, I would.

Yeah, I was.

So, I mean, I'm a lot older than you.

A does a little bit.

No, thank you for describing that, because I think that's always a point of curiosity when people are talking about they hear it, but they don't understand what the procedure is and what it is.

It's actually happening.

Dr. Mendell, let's let's take things over to you for a bit.

All right.

All right.

So I'm not going to say anything.

Go.

All right.

A good time.

Thanks again for having me.

This is my fourth year or something like that.

But I'm a radiation oncologist.

We like to start this with "what do I do in the clinic?"

So basically, we see all types of cancer, and we treat these cancers with radiation therapy.

There's different techniques to deliver the therapy.

It can be external beam.

It can be something called brachytherapy, which is an internal type of radiation treatment where we implant radiation inside of patients.

You know, it's a very dynamic, dynamic clinic.

Most of the patients we're seeing have solid tumors.

Prostate cancer is, you know, in our clinic where I work with a, you know, quite a few urologists, we see a lot of prostate cancer and we're always trying to do things better.

So I'm going to go through these slides and kind of explain how we're how we're doing, how we're doing things better.

So the first first slide here is basically discussing the linear accelerators that we use my clinic.

I'm actually at two clinics.

There's one on the west side off Remcon and the other one's George Dieter on the east side.

And we these machines are just a couple of years old now.

One's called the Halcyon and the other one is called the True Beam.

These are cutting edge equipment that have all the bells and whistles to deliver therapy.

It's focused as possible and as precise as possible.

With the next slide on, this is just the basic anatomy and kind of explaining or showing patients where the prostate is inside the pelvis.

And if you move on to the next slide, this shows the anatomy in a little bit more detail.

You can see the organs that are nearby, the prostate, which is shown on this picture here.

But essentially the bladder and the rectum are nearby the prostate.

And so when we're delivering external beam radiation, that's radiation coming from the outside in.

We're trying our best to avoid the other organs and focus most of the radiation on the prostate.

And I always you know, I try to explain to the patients and more, you know, like easy to understand terms, how we're how we use the radiation, how we focus it.

And the best analogy I've been able to produce is, is, you know, I imagine myself as a kid trying to light something on fire with a magnifying glass and where the focal point is, that is where your prostate is, and that's where the cancer is.

And that's what we're trying to kind of burn to kill the prostate cancer and all the other organs and things in between.

They get a little bit of dose, but it doesn't cause enough.

You know, there's not enough dose from the radiation to actually cause toxicity of those tissues.

Some tissues such as the rectum are very difficult to avoid because they can be right on top of the prostate or right right next to it.

And so what we do nowadays is we put a rectal spacing device inside the process, and that's going to be shown here on the next slide.

And so this is these are two, two pictures of an MRI.

You know, you're just different cuts through the prostate.

But here where we're basically showing where the prostate is, where we put the spacing product, and then also where the rectum is.

And the whole idea is to create some space between the prostate and the rectum to avoid rectal toxicities, such as bleeding people looking at ulcerations, you know, all kinds of complications.

And so we do our best to avoid that.

There's different products to achieve this.

The first one was SpaceOAR, and now we have another one called Bio Protect and Varogel And so we utilize all these these different technologies in the clinic and kind of customize our treatments to the patient's current situation as each of the devices have, you know, pros and cons.

And, you know, I'm always so it's funny because a lot of the young patients, they'll come see me.

And, you know, I'm an advocate for surgery patients who are who are young and and fit especially in their fifties.

I'm always you know, I'm always having to, like, convince them that surgery is the right option for them.

And so you can be happy that I'm in the clinic not trying to.

No more fighting.

Get off, get all the patients.

But but, but basically, you know, the way we work is we want I feel the entire group wants what's best for the patient.

And so the way, you know, with the prostate cancer diagnosis, the patients, of course, diagnosed with their urologist and they're also sent to both the surgeon and the radiation oncologist.

And I feel like in our clinic, we're really not pushing things.

You know, I my my goal is to basically explain what, you know, what their options are, what's, you know, the pros and cons, what you're going to be dealing with afterwards.

And, you know, the reality of the situation is that most of these patients that are going to be cured and so you're the chance of curing them is high and you want to make sure that you're going to they're going to have a good outcome.

So a great example of a patient in their fifties coming to see me.

And I know that he's going to be a good surgical candidate.

This is a patient that, you know, an excellent surgical candidate would be someone who's fit, but also someone who had a lot of, you know, urinary symptoms, things like obstructive symptoms that are going to be a lot of they're going to cause a lot of issues for me and for the patient later on.

And so so, you know, good.

I always tell them like, this is a good you're going to kill two birds with one stone here because you're going to remove the prostate and you're going to improve your your your urinary symptoms.

We call them lots, but they're urinary symptoms after treatment.

So these kind of things in this dynamic in the in the clinic, I think is very helpful.

And I know on the urology side of things, they're kind of thinking along the same the same lines.

And so kind of delving into what do you have to deal with after treatment, We have the same issue.

We can cause erectile dysfunction after the treatment.

The nerves are right next to the prostate.

And so when they're in the high dose field, they of course, get nicked and they can cause erectile dysfunction and it's on every guy's mind.

It doesn't matter what age they are, they're 50 or they're 80.

They care about it and they want they want the best outcome.

And so we're always trying to find novel ways to mitigate this.

And thankfully, we have the men's health clinic now.

And so the patients, you know, we do our best to it to avoid toxicity and things like that.

But at least now we have a group that specialize that we can send the patient to who's having issues after treatment at once, you know, once a better outcome.

One of the techniques we're we're exploring right now is something called nerve sparing radiation.

And so this is just a dose map overlaid over the prostate with the spacing device.

And then the circle on the right is is the nerve bundle.

And it's a very small structure that you can really only see on MRI.

So we fuzed the MRI scan to our planning scan that we get so that we can see this, see the nerves and then actually avoid avoid delivering dose to them.

This is a you know, requires specialized equipment.

You know, obviously should be very accurate because you don't want to miss the prostate cancer.

And so we're starting to develop this in the clinic, in the clinical setting.

And we actually have a clinical trial that's coming out here pretty soon utilizing this technique.

But so far it's been pretty successful.

That's enough for external beam.

So we'll kind of transition into this new realm of therapy or radiation therapy called Theranostics.

And this is a very exciting endeavor for the group.

And I think we've basically had everyone buy in to the to the, you know, the excitement surrounding this.

But essentially Theranostics is using imaging and then also their therapy together.

So you're designing what we call tracers.

But essentially you design an imaging agent that's able to localize the cancer and show it on PET imaging.

And I'll kind of explain what that is.

Metastatic metastatic prostate cancer For now.

We don't know what will happen in the future.

They're actually studying this, but, you know, probably not going to be used for localized cancer, but it could be in in the future.

But essentially, you design these agents to to target the cancer cells and they they glow on imaging.

We use PET imaging.

It's it's it looks like a Christmas light lights up and you can see where all the cancer is throughout the body.

what you can do in terms of that Theranostics the therapeutic is you attach a radio, a radioactive piece of metal to this tracer, and then it goes directly to the to the cancer cell and kills it.

So this is a new field that's that's developing.

And it's been it's been around for a while.

The idea of Theranostics, but now the technology's come to the point where we're able to actually image patients and develop therapies that are more targeted.

And so this next slide is just showing kind of one of the the molecules.

This is the lutetium, the molecule that we use for prostate cancer, and this is metastatic castrate resistant prostate cancer.

And this is the new pet unit that we're putting in, our theranostics center that we're building.

And this is going to be on the West side at Remcon But essentially this is a top of the line unit from GE that's that's able to utilize artificial intelligence to to make beautiful images so we can see all the ins and outs and exactly where the cancer is so we can target it with our agents.

So the PSMA there's I'm sure, patients who have been diagnosed with prostate cancer, they've heard of the PSMA pad imaging.

The next slide kind of just shows it's a little a little more technical and it probably needs to be.

But basically, this is just a a protein on the cell surface.

The PSMA stands for prostate specific specific membrane antigen.

And so essentially the tracer is able to go to this receptor that's preferentially expressed on prostate cancer cells.

And that's what we're at, why we're able to image them and target them with the therapy.

And then predict, though, as the agent I was just discussing, this is the radial ligand therapy that we use for the PSMA positive patients So essentially you image the patients with the PSMA.

If the lesions are glowing, that means that they're going to respond almost certainly to this particular agent that has the same target on it.

And on the right here, this is an example of dosimetry from a patient who who has received this therapy.

This patient has several liver metastases.

And you can see the dose is localizing to the liver metastases and then avoiding, you know, majority of the other to the other tissues.

These these agents aren't perfect.

You can see the spleens glowing a little bit.

There's a little bit of a dose in the stomach.

But in general, the patients tolerate these therapies very well.

And I'm thinking of one of the patients that that Dr. Spier sent me.

Essentially, he you know, his end of the line therapy.

You know, I remember walking in the restroom and he was kind of like slumped over and asleep.

And we gave him his first his first therapy or at least, infusion of the pluvicto therapy.

And I think in a couple of weeks he was at Disneyland with his family.

You know, these these kind of things, they happen.

It's not all the patients, but it does happen.

And it really kind of helps improve their quality of life, especially in this this end of life situation with those that are prostate cancer.

I think when I got out of that was the glowing spleen.

There's the spleen going a little bit.

So these really are fantastic slides and thank you so much for again, setting the stage of everything that is happening here.

And again with the advanced prostate cancer clinic, Dr. Spier talked to us a little bit more about when you all started.

There's rio grand urology.

We've known that for many years, but just through the years, they're just been here and been there.

And every time I have you on the show, you're very good about whatever team you're working with.

It's always Travis's point, too.

Sorry, Dr. Mendell, is that everyone is here for the patient.

Like what really is the best thing for them?

Because there are so many, especially with prostate cancer, it seems to be that cancer, that there's so many options of doing so many different things.

But bottom line is it's so individualized and kind of take it from there.

And I think that's great.

I mean, that was obviously, you know, pretty, you know, granular.

We got into the weeds after a little hesitation, but I think once with all that, that was important.

But there's no other way to do it because, you know, this is what Dr. Mendel is doing.

But just to kind of do a 30,000 foot view level, what the journey we want to take the audience on is sort of from diagnosis, unfortunately, to death.

And at Rio Grande Urology and our Rio Grande cancer specialists, I'm I'm not gloating.

I'm just proud to say that we basically follow the patient throughout the continuum.

And so I'm really proud of what we built.

I mean, we have 28 providers, including APS, and I don't know how many employees, and we have five offices and two cancer centers.

So it's not to gloat is just to say that, you know, we want we do want the public to understand that, that, you know, we are an independent practice here in El Paso that is here for the community.

And I mean it when I say it.

And it's just an incredibly rewarding experience because I've got a great team and some fantastic partners.

So I'm proud of what we built.

And so that kind of takes you from the diagnosis.

And Dr. Herrera, who is doing the robotic surgery along with some other my partners, when a patient's referred with a high PSMA we're the ones who see them.

So you start, it's it's from beginning to end.

That's right.

It's like there's a diagnosis, even if there's a question.

And so I have had the honor and the pleasure to take over the advanced prostate cancer cleaner, the clinic that Dr. Daniel Vogel lead, who you know very well built, really helped to build.

And we owe a debt of gratitude to him.

He retired and I was willing to to step in.

And it's just been the highlight of my career because, you know, what I see are the patients that have started to fail right?

Most of the time it's curable, either with the robotic prostatectomy, radiation therapy.

There are other focal therapies out there now that we are embracing.

And of course, we feel here in El Paso that patients can get all the care here, that there's really no need to be traveling to the major centers because we offer it all so.

So and that needs to be said.

It needs to be said.

And also with that comes a support system.

You know, when you leave town, the support system disappears and or you may be able to have one person along with you.

So that is that's huge.

And thank you for doing that.

Yeah.

And so on the advanced, we'll get back to the slides on the Advanced Prostate Cancer Center.

Again, these are patients that are starting to fail.

These are patients that probably had disease outside of the prostate called metastatic prostate cancer and now aren't are not candidates for surgical therapy because that won't cure them because they're in different locations, most likely the bone or the lymph nodes and or they can't get localized prostate radiation to the prostate to the prostate.

And so Dr. Mendell, of course, is available for metastatic disease that's not diffused, not all over the place, but maybe in localized areas that we can help in kind of what we would call whack a mole and get these different areas and potentially cure them.

But I mostly am dealing with patients with grossly metastatic disease.

That means disease all over the body, in the lymph nodes, in the bone, sometimes what we call visceral in organs like the liver and there has been an incredible amount of research done and the medicines that are out there now are unbelievable.

And so, you know, again, I defined what it is.

And again, I find that the fact that it's outside and this is done mostly by CT and bone scan, but those are actually falling out of favor now, aren't they, because of what Dr. Mendel talked about, which is the pet PSMA scan.

This is a question that I'm thinking that audience members are thinking right now.

So when I think see metastatic we haven't even brought up the word chemotherapy.

Where does that lie in this world right here?

I know it's very different what we're doing.

I get it.

But but people, they think cancer, they think chemotherapy, they think surgery, chemotherapy, radiation.

And almost often in that order.

So let me try to simplify it, please, because we do, you know, need our medical oncology brethren and we do rely on they are a part of this, but for localized care, it's not it's not on the list of treatments.

So you've got radiation or surgery or these other therapies that I mentioned.

Right.

Chemotherapy is typically when patients are progressing and I work with a medical oncologist when it's metastatic, but there's certain there's just certain criteria that needs to be met for the chemotherapy.

And so some of these drugs that we have now have really taken over and sometimes chemotherapy isn't even needed.

Wow.

And so the key point that I want to make to the audience is that androgen deprivation therapy is actually medicine, either shots or oral pills that decrease testosterone to almost zero.

Hmm.

Because testosterone, I want you to think of a campfire.

Mm hmm.

Testosterone is the gasoline for that campfire.

And what we want to do is blow that campfire out or put water on it and have, you know, hopefully as much as as we can create embers that are barely burning, we can't cure it.

There is no cure for metastatic cancer.

But we can keep people on this earth for a very long time with these new novel hormonal therapies.

And so that's sort of what I do in my clinic.

I work hand in hand, obviously with all the urologists, but mostly with this guy over here and develop plans.

You know, we have obviously case studies, case reports that we review.

And so we've built a team.

We have a navigation system worth Nurse navigator that that really helps to identify patients.

And so I'm again, maybe I'm trying not to gloat, but I'm very you know, in fact, we've done I would love to talk a little bit more about the navigation system because that is something, too, that once you hear once your family member hears you have cancer, there is you just don't see anything anymore.

And so when you have someone that helps navigate you through the process, either you take that on.

Travis.

Dr. Head, however you want to do it, I need to stop calling you Travis.

But in general, that is a true comfort, I think, because sometimes you really don't know what to do.

And again, when there are so many options out there, who makes the decision?

You know, and I just want to point out, you know, metastatic directed therapy is what I talked about with Dr. Mendell, which is trying to hit these areas with radiation, for example, that aren't all over the body.

And of course, to your question about chemotherapy, when there's grossly metastatic disease, we do add that as a triple or what we call a triplet therapy.

So you've got two types of hormonal therapies called doublet.

And then we sometimes add the chemotherapy to that.

Okay, which can give longer lifespan.

Its overall survival increases in some studies, some have said that the doublet works just as well.

It just depends on where they are and right now what we're really interested in is this there are Gnostics and.

Right.

And the only indication to give Plavix, though, and to give these these great new therapies, which are really they're remarkable what we're seeing.

Mm hmm.

As far as it treating all of these metastatic lesions is that they only qualify if they've completed chemotherapy.

So when there's metastatic disease, as I've always heard it to be, is again, the name of the program is precision diagnosis.

And this is what I think is so fascinating of how you go in and find exactly where the cancers are, what type they are and how to treat them.

This process and I feel like with Dr. Mendel, you said this is your fourth year here.

What did we do six years ago?

You know, I'd love for you to kind of bring us from seven or eight years ago to now.

And I know usually at the end of the show I talk about, okay, what's in the forefront, But just with this specific way of treating cancers, where do you really see us being in two or three or four years from now?

So so I think, you know, I can I can take you from where it was like five years ago kind of when I started and to where we are now.

And it's it's really it's changed dramatically how we diagnose and risk stratify patients through through all stages, you know, localized cancer, you know, rather than just, you know, doing the PSMA and doing a biopsy and doing the treatment or now now we're we're doing the PSMA, we're doing other other tests to, you know, ensure that the biopsy is the right, you know, diagnostic for the patient.

At that point, we're doing template biopsies, we're doing targeted biopsies, we're doing MRI's and things like that to find the lesions.

Now, the PET scan has also brought, you know, another dynamic to that for just localized cancer.

And then once you transition into like stage three, which is in the lymph nodes, potentially stage four, and then also just for it's like metastatic disease, the PET scans really changed a lot of the dynamics in the clinic.

And honestly, the PET imaging has completely changed my daily life.

Like before we had the bone scan, the CT scan, it was it's obsolete.

Like I haven't I probably ordered two of those in the last year.

You know, it's this has just completely changed everything we do.

And so now we know where the cancer is and we go after it.

So a good example would be a patient who's been treated.

Their PSMA is rising.

In the past, that patient would have just been right on hormone therapy.

That's it.

You're getting hormone therapy.

Now we image them and we say, oh, you have a couple of lymph nodes, and I treat the lymph nodes and they go away and the patients aren't maybe that we give the patient hormone therapy for a little bit.

We take them off and most of them do very well.

And so it's it's really it's really changed completely changed the dynamic.

And I think, you know, we're going to continue they're going to develop other markers and things like that that can help better stratify patients.

And I think, you know, the one of the studies that we're we're enrolling patients on very soon here in the next couple of months, which is has it their Gnostic approach is finding patients that have like newly diagnosed metastatic disease after treatment and actually not giving them hormone therapy or utilizing these targeted therapies.

So we'll use that.

We use a technique called SVR T, which is a stereotactic treatment where we focus just on the tumor itself with high dose ablative treatments.

And we're also delivering this pelvic toe agent which is assists radioactive, systemic agents so the patient doesn't have to lose their testosterone, they don't have to go into menopause or anything like that.

And, you know, we do these therapies and we don't know how to how the outcome is going to be.

But that's why we do these studies to to find out to find that out.

And of course, everyone's hope is that the you know, the outcomes are just as good or better and that the patient's quality of life is improved.

And that's kind of the whole goal of this.

It is, yeah.

And I and again, I don't know if I'm speaking, I'm going to just call it the good old days, the old days when there was staging, like I feel like with prostate cancer specifically, scuse me, there are so many different stages and how you diagnosed and staging.

I haven't heard that word yet this evening either.

Is that differing a lot now because of how you're able to target and treat?

I feel like nowadays, you know, the patients are always asking me, what stage am I?

Right.

Exactly, exactly.

And we've all heard for decades and we I feel like like staging for prostate cancer is just a little different.

Like the way in my mind I'm thinking of staging.

It's more of risk categories.

And so you have patients who are low risk.

You have patients that are intermediate risk, and these are all localized.

So you have low, low, intermediate and high risk.

And that in that's its own its own subset of patients.

And those are all patients that are essentially can be definitively treated with surgery or radiation.

We even watch, like most of the low risk patients now, it just watch like they're you know, their cancer might progress.

We'll catch it early will treat them when they when they need it.

Some of these guys especially when they're in their fifties and sixties, I always saw like the best treatment for your erections is is no treatment.

Right.

Like not like no treatment, no surgery, no radiation as long as it's safe.

And it's there's a whole pro we have a whole active surveillance program to ensure that the patients are, you know, as safe as we can possibly make it while we watch their cancer.

But the second we have, we, we detect a problem or a growth or something like that, then we treat them.

So expand that.

When you say watch, is there a certain time when they come in every six months, they come in every four months.

Are there symptoms that they're looking out for?

Because sometimes there are no symptoms, sometimes there are.

And Doctor, that I'm going to get you in a second, too.

But when you say watch active surveillance and I'm assuming it's different for everybody depending on where they are when they start, but how in general does that occur?

Yeah, perfect.

So so we have a like a pretty regimented, active surveillance program.

So the the first step is diagnosis.

So usually the patients, they'll have an elevated PSMA, they'll get a biopsy.

It's it's typically like a template biopsy, just a, you know, a systematic sampling of the prostate.

Then they come to the active surveillance clinic.

And a lot of those patients, if they're if they're low risk, they're actually a candidate to stay in that clinic.

But they're not always a candidate.

So there's a couple of things.

One, we need to get additional imaging.

So usually it's an MRI to ensure that we actually hit the lesion or if there's a large lesion maybe that wasn't sampled that we sample it to ensure that, you know, it's not a different cancer that wasn't sampled and it's a higher risk cancer and we need to treat that patient.

So MRI imaging and then we also do molecular profiling of the cancer.

So this is basically I told the patients it's like looking at the genetics of the tumor and if they're we know certain cancers have higher risk with different different molecular profiles and what's what's insane to me is we still we still use what's called a Gleason score.

I'm sure you've heard of Gleason score.

And now the more modern way to to say it is called grade grouping.

Grade grouping.

And that's essentially what talk sense.

A pathologist looks at the tumor cells and gives you their take on how aggressive they are.

And the pathology pathologists are great, but they're human, right?

So if you give you give a tissue sample to this human and then you give that this tissue sample to that human, they might give you different answers.

Right?

So they're not it's not like a binary thing.

So that's what's nice about the molecular profiling.

It's a computer.

They it looks at it looks at the tumor cells.

It's a microarray analysis.

It's a special RNA, RNA technique.

But basically it it looks at the genes in the tumor and tells you whether or not that tumor is going to behave poorly, even if it looks benign under the under the microscope.

So we check that.

And then after that's done, if the patient's remains a candidate and we say, hey, it's safe, we're going to watch you, then you then you go on to active surveillance.

And typically that's that's every six months you're going to get your PSMA checked and we trend it.

If it's going up, it's concerning.

Right?

So we'll either repeat the biopsy, if it's going up or just treat you if it's going up rapidly and we're just concerned about it.

Typically, the patients will get an MRI every every year or every two years, kind of depending on how stable they've been.

And then we usually repeat the biopsies a year or two out from the previous one in case the MRI didn't pick something up or the PSMA is not as accurate.

So we're always, you know, hedging our bets a little bit on the active surveillance.

But, you know, it's not just we're going to check your PSMA every year, and if it goes up, we'll treat you where it's very it's very regimented.

And we want to make sure we capture those patients that are progressing so they don't become metastatic.

They don't go see Dr. Spier.

Right.

We're trying to put Dr. Spier out now, but this is a shared decision model.

Also.

There's no standard protocol.

It's out in our guidelines, But let's give it a chance to please.

Yeah, It's so surgery, man.

That's how Dr. Spier described as you're walking through the door.

Well, he's the surgeon.

Yeah.

So in that spheres, we haven't talked a lot about that yet, and we're talking about biopsies.

So that's kind of the beginning of everything.

And when again, everyone's different, I get it.

But maybe go through some of the surgeries that you perform on many of these cancers.

Yeah.

So specifically for prostate cancer, you know, I agree.

You know, obviously it we're treating the patient right.

And so like Mendel was saying, everybody is risk stratified.

So even when I get the patient, I'm like, do I need to treat him like, am I going to cure his cancer or try to or avoid metastatic disease down the road?

That's the whole idea.

Not let it progress or but like we talked about, right, there's these side effects that people are always worried about.

Surgery.

Back in the old days, like you were saying, they had open surgeries, you know, and incontinence was one of the biggest issues.

And so when robotic surgery comes around, incontinence rates have gone down a lot more.

And so that has helped kind of me counsel patients like, you know, you get somebody who does a good radical prostatectomy, they spare your nerves, then those risks, those risk are less.

But even said in my mindset, you know, young patients with high disease, I would treat them with surgery because I want to because I know that person is going to live long enough that they eventually may need something down the road.

Radiation they go see Dr. Speer.

And so you want to delay those treatment as much as possible, so become a little more aggressive up front when they start hitting 65, 70, even 75.

I treat that patient way different.

Even if they have a higher risk cancer sometimes or their low risk prostate cancer, I sometimes just say I'm going to get you to that older age so that you can continue to have quality of life because we know we're not going to affect your overall survival at this point.

And so that's where active surveillance or, you know, comes into play.

But during that active stage, I'm always thinking, you know, are we missing a higher grade cancer, like Dr. Miller was saying, or is it time to treat?

And I've had patients where it's low grade and they're just can't bear the idea of having it not do it every six months.

And so it's a joint decision and I've done it on patients.

At the youngest one I did was like 44.

And then there's patients in their fifties who just can't.

But I hold off almost two, three years for some of these patients and then we decide to do surgery at that time.

Great.

They got three years of quality of life and they feel they feel ten times better than just going in, walk in and, hey, you've got prostate cancer, you need surgery.

I think that model or that old way of maybe we treated patients has definitely changed.

And it's more of a shared decision making with the patient and the surgeon.

Dr. Mendel always loved the radiation, so then the patients well informed.

And then when they make a decision, it's going to be the right decision of how they lead into that conversation.

And like I tell them all the time, like, you know, I joke around when I send them to a doctor and all the time, like, you're not going to get these, but you're still going to get erectile dysfunction.

I tell them all the side effects are treatable.

So, you know, in the end, t if you can repeat that, because I think that's so important in this program.

Yeah.

So we treat all the side effects are treatable.

It's just going to take a little bit of time so the incontinence I can fix is just going to you're going to have to wait nine months to a year.

The erectile dysfunction.

I'm pretty aggressive for penile implants but if you can't, you know have your sexual function back by six months then we're talking about a penile implant the guys that get them early, I see them back and they're the happiest because they haven't delayed that, especially my younger guys.

They haven't delayed that sort of personalized thing.

A lot of them are married, a lot of have stable relationships and it's important for them to feel as normal as possible as they're going through their treatment.

Cancer diagnosis and all this stuff.

And that's a big key.

So they so we try to that's the whole reason why we created the Men's Health clinic was essentially to inform patients upfront.

Even though we're going to have these therapies for you, there's going to be these side effects.

We're going to be here along the whole way.

And when the time is right, we'll fix all these little things.

And so if you look at any major institution, they all have sort of this trifecta.

And so like Dr. Spiers say, like really proud of like I'm lucky to have a group where we've created this sort of thing now that patients can come in and they're getting essentially everything upfront, informed, and then getting well treated all the way till basically you're treating the human being, not the disease.

Exactly.

You know, both.

But still it's it's truly human being.

Thank you for that.

And I would say like a plug for surgery.

What I think is is definitely the right thing to do in our group is we have like champions for prostatectomy.

So there's only a handful like a couple of the surgeons in our group that do prostatectomy.

So they're all high volume and high quality.

And so I always tell the patients when they're coming in, they're kind of nervous.

You know, I tell them that like I would let you operate on me.

You know, I think that your skill level is good enough that I would I would let you, you know, same, same with Eisenberg, same with Taber.

We could go, you know, I think we do.

Bag Yes.

So I was the first ones out of surgery with way back in the day.

Yeah.

So but everyone's high volume.

Yeah.

You know so I think that they, they see they, they do this procedure a lot so they're very good at it.

The And I wanted to add that the other way you think about prostate cancer for young guys of being aggressive is I do think of something that some of them will still get radiation afterwards, especially with the really high risk.

You know, 56 year old comes in with really high risk prostate cancer, almost an oral positive, you know, disease.

I that guy is getting surgery, most likely radiation within a year.

And hormonal therapy in that triplet sort therapy.

In my mind, the way I think about it is we're just being as aggressive as possible out front to avoid them seeing Dr. Speer, like next year.

Right.

Right.

You want to avoid that metastatic disease diagnosis because then at that point you are on some sort of clock.

Now there's all these things that now that we're doing that can help that clock be extended.

But essentially now it's now, you know, God or, you know, there's there's a there's a timeframe.

Now, at that point, you use the word earlier, young guys.

And so it just brings up that loaded word of screening.

And I know that, you know, every other year or so it's like, oh, is brand new and oh, this is brand new.

We joked about in the last program, I know you're about to start and start on something.

Do you want to finish that thought?

No, you go for it.

Okay.

So because it's so important people that are watching or listening at this point and they're 45, you mentioned the third year, 44 just a moment ago, and they're like, I'm 45.

I thought I wasn't supposed to do this until I'm 50.

What are the guidelines now?

There are guidelines that you all are the people on the front force, and then there's risk factors.

And maybe you should go a little bit earlier because your risk factors are this.

I'm throwing that out to anybody who wants to take it.

Dr.

Spirit.

Well, I'll start it.

You guys okay?

Yeah, because it is an absolute moving target.

It is.

I know that it has confused not only our communities but even our primary care physicians.

It's very confusing.

You know, there was a task force that was established in D.C. that graded the PSMA a D, and this was done probably in 2016, 2017.

And that really created havoc because the message was PSMA is not important.

Well, it is.

Yeah.

It's an easy blood test.

And, you know, we were very upset.

Not a single urologist was on that panel in D.C.

This is the same panel that came up with mammograms not needing to be done at 50.

So, you know, this happens, COVID happened.

Patients stop going to their doctors.

Right.

So now we're seeing all of these patients coming in maybe a little bit late with high PSMA and some housekeeping items were we're wearing these pens because it's prostate Cancer Awareness Month, by the way.

And so we take this very seriously.

You guys can opine on this.

But at this particular juncture, there are two major risk factors, of course, two that I think of, and that's family history, which we have to isolate an African-American men.

Mm hmm.

My typical advice to my PCP is as if everything's, you know, no history, no family history there.

Otherwise, just seeing their PCP, we usually start screening at 4550.

Okay.

With a family history or African American men, I usually advise at 40.

Nice.

And so then it gets into sort of all of the nuance with PSMA, the number, because people are stuck on.

The number they are stuck on the number of 4.0, you know, and that's just not the case.

This is an age adjusted PSMA and it's on sort of a sliding scale where the younger the patient is.

And, you know, you have to look at a PSMA, for example, in a patient that's 45 and their PSMA is 2.2.

You got to be aware of that.

You got to watch that closely.

Whereas if a 75 year old comes to me and his PSMA is 3.1, you know So this is a discussion that's the importance of the urologist to to kind of be involved.

And if there are questions, usually the PCP is in this community are terrific and they send if there's a question I mean you guys have I mean I think technically speaking rate less than three.

You know that says it's pretty normal.

Okay.

Like I tell patients between three and ten is the gray area.

So ten is where you start to worry above ten most, you know, you're pretty much getting a biopsy.

I don't think a lot of people argue you have to make sure it's a true ten, you know, not falsely elevated because there's things that can create the PSMA too, because the elevated it.

Let's go through those really quickly, too, because that's something I learned really just last year from you, that there are certain things that elevated PSMA depending on what week you do it or whatever.

So if you've had intercourse, you know, the night before and you went and got the PSMA could be elevated if you went on a bike.

Right.

It could be elevate.

If you had an infection.

It can be elevated if you have a 200 gram prostate, which is huge, is going to be elevated.

So we take so just saw Dr. Spier.

He did.

The jury is going to decide Dr. Spira needed an exam.

So it's around.

So I tell patients all the time, you know, PSMA is not the best test in the world, but it's the only test we have.

And if you have prostate cancer, we'll catch it if you if you check it.

And so as long as you're coming in, getting your yearly PSMA done, then you will eventually end up in a urologists office and you will have that conversation.

Now, the nuances of when to do the biopsy becomes creative, right?

And so you you use as much objective data as you can so that because PSMA is not a perfect test Right?

So you you know, you follow a trend.

Is it going up?

Is it coming right back down?

You you maybe get a percent free PSMA, which is just a different, you know, check in a different type of PSM for for prostate cancer.

There's other markers that we can use.

There's MRI that you can use nowadays.

There's a PSMA density.

So you measure the prostate.

If the prostate is really big and the PSMA is low, that density is very, very low.

But if your prostate is very small and your PSMA is really high, that PSMA density is really high.

So you're more likely to counsel somebody.

And there's now calculators you can plug in.

And I tell patients all the time you're going to be because you're in between 55 and 70, you're going to have a risk of prostate cancer.

Right?

Right.

You're always going to be at risk.

The goal is to make sure we catch the patients that need to be treated.

And that's where the I guess, the art of medicine or talking to the urologists and figuring out how how we approach that is is key.

So ignoring PSMA ignores the patient from coming into having those conversations and essentially, you know, treating that patient needs to be treated.

So you were talking about the size of the prostate.

Is there a I know with mammograms, for example, the first mammogram is the baseline.

And from there, everything else is sort of looked at from there.

So if you're looking at a large prostate with the PSMA is staying the same, but is that just naturally a person would have a larger prostate and that's the PSMA would naturally be a little bit higher?

Did I understand?

Right.

Okay.

There is something there.

Now, that doesn't mean that because you don't have a big prostate, you don't have prostate cancer.

Sometimes we find it, there's BPH procedur Yeah.

Large.

Okay.

You know, and we find prostate cancer from those, you know, from, you know, terps or whole lobes, rock ablation or all these other things that we do.

You know, we screen for all these to try to pick and choose the patients that we're going to treat for benign, enlarged prostate.

And sometimes we have to rule out prostate cancer with a biopsy before we treat them.

But sometimes the biopsy is negative and then we do the procedure, we do a whole lab, we get all that tissue out, we send it in, and then now there's prostate cancer, which I've then sent him.

Dr. Mandel Sometimes about those.

So they're I think prostate cancer, like Dr.

M.S., is very unique than other cancers.

It's it's not a staging.

It's a very stratified.

It's a joint decision that you can get creative with the way you treat it.

And so it's and that's the important, I guess, of our job is to make sure we we treat correctly, keep quality of life, keep people here living longer.

Well, I was saying, as you all walked in, this is one of the for me anyway, I feel like this is an ever changing field and it's not one of my favorite terms.

It's the wrong word to use, but to me it's the one that enlightens me the most of many of the program.

It's my it's my favorite show.

There you go.

On that note, I would we're kind of at the eight minute mark, and I just want to make sure that we've talked about everything.

And I love the fact that we had this great setup to go through.

But is there anything that we haven't touched base on that we'd like to talk about?

So some housekeeping Leadless first, just I have one more slide because I do want to just talk about the gearing up for the future.

You've got some great editors on this program.

I'm sure that they'll figure out how to put this last slide in for the presentation.

But just briefly, we talked about it, but the community needs understand we are here for them and we're investing in them.

We're an independent practice, but we feel that the care Gnostics is a game changer.

The imaging is a game changer with our assembly pet that we're bringing in.

And I'm proud to say that we have a clinical research arm that was started in November of last year with a PhD that's come in.

Joshua Ortiz And we have ongoing studies that that I think are going to be great for this community nationally and industry and our industry partners are very interested in this region with our Hispanic population.

Great, We're all from here, right?

We want to serve that population.

I mean, 95% of this group is got El Paso roots.

And so we're excited about the clinical research and then the genetic testing.

So we have state of the art genetic testing.

We're testing everybody for, you know, for germline what's called germline and somatic meaning that we're looking at ways to make sure that the families are treated as well and protected with these patients with advanced cancer.

And then we also are embarking on in advance the same model with kidney and then bladder, because it's not only just prostate, although this is probably, you know, we've obviously have a mature program, but we do want to build, you know, and we're working on it on bladder and kidney cancer.

And so the last thing is we are partnering with, you know, our medical oncologists around the community.

We need them.

And so it is a multidisciplinary approach.

I mean, from the radiologist that read our scans to the hospice physicians, the geriatric internal medicine doctors, a shout out to Dr. Becerra, who's really been helpful for me because these patients are going into hospice a lot of time.

I want to reassure my patients that I'm still seeing General General Urology, that's not going to change.

So please, if you're out there and you're listening, I'm still a general, you know, still stuck seeing General Urology.

But so that's sort of, you know, my message to your audience is that again, not to not to be braggadocious.

We're just proud of what we've built and we're we're here for the long term for for our community and I'm proud of these, you know, young guns to know that will be taken over.

So using the word when you said doing some research to clinical trials, you used the word clinical trials, and I like to use that word is I feel like that's a word people know and hear and get their not started yet that I understand when you said earlier, that's something that's about to come about, is that correct?

So so the programs, it's it's up and running.

We have several trials that we're going to start enrolling patients maybe in the next couple of months.

So there's like there's almost like an onboarding process.

So once once you're once you're designated as a site that's going to open up whatever clinical trial they have to come in, they have to look and make sure that you're capable of of doing doing this work.

And so that usually takes several months.

So we've been identified for several trials actually, or in the in stage processes of of opening up a couple of them.

There's those old male cancers or are they combination currently right now it's just prostate cancer.

We have trials for it.

So there's there's a couple of procedural trials with the spacing spacing agents.

We have like one of the clinical trials that I've designed for the nerve sparing that one's hopefully going to come up.

And then we have the third Isaac Center in the ready in the cloud therapy is specifically the Politico there.

There's multiple trials actually that they're exploring in different spaces.

And so it's Bill was saying before is, you know, right now it's only indicated for very specific patients.

Victor Yeah, it's metastatic and they've they've been on hormone therapy for a while now.

Their cancer is growing despite being on the hormone therapy.

Those are the patients.

Those are the only patients we can give this to.

Okay.

And they have to be post chemotherapy.

They've had to have chemo.

They have all these things.

But now a trial came out, which was last year.

The FDA is going to hopefully approve this medication.

And like earlier kind of spectrum of a disease, a whole nother show, too, of how FDA goes about and gives the check mark and does it.

And we don't have to talk about that tonight or today.

It can't be unsaid that that we do plan.

It's just not about the men.

So our clinical research.

Well, that's going to be designed.

No, no, no.

I mean, I love bladder cancer, kidney cancer.

There are some UTI studies out there that ad incontinence for women.

So we are just kind of in the infancy of this.

So the audience needs to know that, you know, we're going to grow it.

What I would love to do a separate program on that.

I really would.

So, yes, Doctor, to just the the importance of clinical research.

Sometimes people don't really they just think clinical.

I'm the Anderson that you know so the the idea of clinical research in a community is to give options to patients when there's sometimes no options or to have access or medications or certain things that otherwise maybe they can't afford.

And so it does help to have a big academic center with a bunch of research because it does provide this sort of care in the community.

And so, like, you know, I think this is a big component that just we added in what, last year based November, and it's much needed and it's all just for the patients, essentially.

I mean, you know, we're we're busy enough with our clinical work and surgeries and, you know, seeing patients.

But, you know, what do I do with a patient?

Where do I send them?

A lot of them can travel.

And so having that clinical research is very important.

And I think El Paso needs to know that that's that's that's why we're we're working extra hard to I think it's exciting.

And when you said to everything that has to do with options is good in every way.

I thank you all so much for being here and really Rio Grande Urology and Rio Grande cancer specialist.

The men's Health Center.

I think this is great.

So kudos and adoration to you guys.

I think this is on that note, I'm running out of time.

Thank you guys so much that you do.

Thank you.

I'm Catherine Berg.

And this has been the El Paso physician.

Good evening.

I am Dr. Allison days, a past president of the El Paso County Medical Society.

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