foreign [Music] good evening I'm Dr Jeffrey Speer current president of the El Paso County Medical Society for 2022. we at the El Paso County Medical Society are very proud of this program we are certainly grateful for the collaboration of both star studies Studios and kcos for making this program a reality we're also incredibly grateful to miss Catherine Berg who has been such a terrific partner for the last 25 years being this program's host we hope you continue to join us each and every month for this fantastic program and please enjoy the presentation tonight thank you very much there is much optimism when it comes to prostate cancer these days there's new research both currently going on and on the horizon during the next hour we have experts answering questions about prostate cancer everything from screening to diagnosis to treatments this evening's program is underwritten by Rio Grande Urology and Rio Grande Cancer Specialists and also a big thank you to the El Paso County Medical Society for bringing the show to you for over 25 years now I'm Catherine Berg and you're watching the El Paso position hello I'm Catherine Berg and you're watching the El Paso physician and tonight we're talking about prostate cancer diagnosis treatment and new Advanced care options and with me tonight are I consider them two friends now which is really nice Dr vogelweed Who has been around um and we've been doing shows together for about I think 25 years I think you were one of the very first uh guys on the show prostate cancer testicular cancer we talked about all of that stuff way back in the day and then we have a young one with us we have Travis Mandel but there is some uh history with your family and genetics which we're going to get into in a little while too uh but Dr vogelweed his urologist specializing in cancer and then we also have Dr Mendel who is a radiation oncologist specializing in this area as well so what I'd like to do Dr vogelweed is start with you and if you can explain to our audience what your specialty is and kind of migrating into the care that you do with patients today so Urology G yes but you do a lot in the cancer space well right now I pretty exclusively just do Advanced prostate cancer okay I no longer do general urology and uh basically the patients I treat are patients that have been treated primarily for prostate cancer and the disease comes back they either have radiation therapy or they have reticle surgery and after that their PSA is supposed to be go down to a very low level if it starts Rising again then the cancer come back so that becomes Advanced prostate cancer and of course there are patients that show up in the hospital or in the office and they already have advanced disease but that's basically what I take care of okay and then Dr Mendel when we're looking at radiation oncology so I can ask you about the chemotherapies if that's the case I know with with prostate cancer it seems to be less chemotherapy more radiation at least it's how I remember it from the old days and your radiation oncology so if we could kind of take that same question and explain what your specialty is so basically we use radiation to treat solid tumors we target the tumors or several tumors if there's massive disease or anything like that we target the tumors and so I tell the patients we're either going to cure them if they're if they're going for definitive treatment or if they're palliative meaning there's bone metastasis or this cancer is spread other places I tell them that we're basically going to be spot welding spot welding I like that yes very very targeted and I like that too with prostate cancer I feel like over the years there have been so many advances in how tumors are treated specifically um Dr vogelweed and I know this seems over simplistic but for some who don't know exactly where the prostate is can you describe in the anatomy physiologically where the prostate lies and in that I want to almost directly go into screenings because we have the blood test the PSA test we have digital rectal exam and I think the idea of where the placement of the prostate is and what the digital digital rectal exam is that helps people kind of understand those two can you imagine having a party for one of your kids and one of the things that's essential for a party is a balloon okay if you can imagine the balloon and then the neck of the balloon okay okay which is where you inflate the balloon through well the balloon is a bladder and the long tube is a urethra well the prostate sits on the urethra right at the bladder okay okay and the the reason why you can feel the prostate with a digital Oracle exam is that when you do stick your finger up the rectum I could use another word but I won't I know uh you can it's PBS yeah if anything's allowed I think well I think breakfast is a little bit more appropriate education yeah uh you can actually feel the back side of the prostate and uh if there are any changes in it you can feel size to some extent and you can feel consistency and if you have a change in consistency particularly if it's hard or there's a hard nodule then that's suggestive of prostate cancer and then when we're talking about uh screenings again too in combination with the digital rectal exam is usually a PSA test which stands for prosthetic specific antigenous specific antigen yes uh one of the big misconceptions is that if you have a PSA below four it's normal and you don't have to worry about it that's really not true you can have a PSA of 1.5 and have cancer the there is a you know there's an age difference okay it's not the same thing to have a PSA or three when you're 70 is to have a PSA of three when you're 50. exactly right yeah uh to me the rule of thumb is if you have as your from the age of 40 on if you have a history of prostate cancer in your family or if you're uh Ashkenazi Jewish or if you're black then you have an increased risk and you should probably be screening from the age of 40. normally I suggest screening at the age of 50. you only have to do it once you know if you screen and the PSA is less than 1.5 and certainly if it's less than one you probably don't have to check it again for five years okay okay yeah number two if you have an elevated PSA that doesn't mean that you have cancer right okay and there are some tests that you can do nowadays that will help you with that screening and help you decide one of them is to do an MRI of the prostate the MRIs up to certain point couldn't identify a focus of cancer the other is uh genomic testing or you can actually test the urine or you can test the blood and it can tell you whether or not you're in it at an increased risk of having cancer then you can make a decision onto whether or not biopsy that prostate to see whether they do have cancer or not you hit on something that I'd like to talk about I'm not quite sure where in the show I'd like to do that but I would love to talk a little bit about genetic testing but I would like to talk about you hit on some risk factors but then also family history black individuals Ashkenazi [ -_-_ ] individuals yes but then also if ma if mom Mom can't have prostate cancer um but if Dad uncles Brothers Etc immediate family the immediate family so where is the the danger there well the danger is even if you don't have genetic disease this is going to become more complicated but even if you don't have genetic disease if your father or your brother or your immediate uncle has had prostate cancer you are at increased risk if you have inheritable disease you know it could be that your aunt has breast cancer or your father had pancreatic cancer or your grandfather or Grandmother Had ovarian cancer all of these if they carry a specific genetic abnormality and there are several okay then they be can be at increased risk and they should probably be tested it's a simple blood test I'm in full agreement and and Dr Mendel I feel like I'm throwing you under the bus because I didn't talk about this prior to the program but I'd love to talk a little bit more about that so I said breast cancer but there are certain cancers of the reproductive organs that are not the genes aren't shared by the men and women but the tests that are kind of pointing to them are if this is not something you're versed in tell me it's like let's not talk about genetics tonight but I always feel like that's fascinating um when you can like break a gene you can get tested for bracket genes and there's now like a slew of other things you can be tested for and feel free to hop into because I know we we started this but what is it that and I'll start this too it's a simple blood test insurances will cover if there is family history but maybe not but if there's something you're worried about again it's the blood test and I'm asking either one of you and Dr vogelweed's kind of doing the stutter start yeah yeah so I mean I think most patients can get genetic testing um and in your you know your insurance will pay for it if you have some sort of family history okay most patients that come to my clinic they have a cancer diagnosis and so that already kind of puts them to the front of the line for these type of testing and the guidelines for these testings are always changing and so there's a um the nccn is is kind of a guideline that most most oncologists use to you know manage manage cancer patients um and so each each disease site has a specific guideline for genetic testing so there's two different types of testing there's genetic and genomic so it's what your genes are or what does the cancer actually have because the cancer it mutates its genes and that's how it grows right so so the the genetic testing which is what you're talking about right um is is very prevalent actually other disease sites as well outside of the prostate and we're becoming you know it's becoming more in Vogue I think for prostate cancer yeah so but two things I should mention yeah there's they have it for ovarian they have for pancreatic they have it for breasts they have it for colon but genetic testing is not 23 and me exactly expand on that thank you very much expand on that um because it's it's very specific blood tests and testing for medical issues not just yeah the genetic testing is specific for for specific genes I'm sort of repetitious there but uh and that's what you're testing for because there are certain genes and they're not the same ones for for gastrointestinal cancer as they are for prostate cancer there are some genes in prostate and breast and pancreatic and ovarian that overlap with the brackets breaker one bracket two ATM for some of the more common ones uh GI has something that's called the Lynch syndrome and Lynch syndrome is associated with prostate cancer It's associated with uh I think uterine cancer and colon cancer and I think even brain cancer uh so don't quote me on that I'm not no no that's what the disclaimer at the beginning of the show is for yeah cancer cells they have specific genes there's there's genes called oncogenes and there's genes called tumor suppressor genes and so that's why there's so much overlap between different cancers because your cells just inherently use these genes to protect themselves from becoming cancerous so your body's always like your cells they sometimes become haywire and your immune system is able to either eat them or the cell self-destructs because it knows that something's wrong but when you lose that ability to either detect the cell with your immune system or your cell is able is not able to detect that there's a problem okay that's when you get cancer and that's why there's so much overlap between different cancers in the genes and that's why when patients have an inherited Gene that puts them a higher risk that means they're more predisposed to having the developing cancer number one like the bracket Gene we know this for breast cancer right but also they become higher risk with just cancer in general so if they develop a cancer they're higher risk for having that aesthetic disease or higher grade cancer than the normal a person that doesn't have this mutation and so that's why it's become so important in the prostate cancer land because we have a you know the the way that we've we've studied prostate cancer hasn't changed as that much from like the 70s so patients they have an elevated PSA right they go get a biopsy right the pathologist looks at it with their eyes okay if they're looking at it and it's you know they just kind of give you their opinion right um everywhere else all the other fields they're moving to more like molecular testing that's more objective where you have a real not not a person's opinion you have genes you have you know RNA DNA they analyze everything with you know micro array analysis to see what mutations those cancers have and how they are more aggressive than this cancer completely objectively a computer does it so these genes now so now patients we we know which patients are higher risk than the normal population so it turns into you know this patient has prostate cancer do you feel comfortable watching this patient because they haven't inherited mutation that makes them higher risk than just what you see with your eyes so it kind of completely changes the ball game so it's a fascinating time right now where in prostate cancer because it's it's evolving so rapidly there's new things but it's funny because this is all happening and all the other disease sites so like uh like for for brain tumors it's now all basically all staged genetically you know they look at the mutations in the tumor and that's kind of what determines the actual who grade of the brain of the brain tumor okay um and I think that's where a lot of the fields are now moving towards is this more objective data that instead of people telling you like oh this looks scary you know this looks bad right you know we're going to give it a four yes right or this one looks okay or something specific yeah exactly they won't give it a one they'll look at the genes and now it's going to be oh this is high risk right does that make sense it does make sense and I like too that you split it out between there's genetic and then genomic and so genomic is that looking at what is currently existing in the cancer that you have and then being able to I'm going to just try to put it in layman's terms trying to be able to Stage that for the lack of a better word and then look at what treatment that's going to be and you're right the stages is always like well you go to two different doctors and that's stage four well maybe it's stage three depending on metastasis Etc and again it's different with all cancers which to me is always fascinating um my question is to the general audience member and again because everybody hears genetic when there is testing genetic not 23 me but specific genetic testing the paranoia that may or may not come from the results of that and I'd like to I'd like to talk about that a little bit because we don't want everybody running out and demanding genetic testing on specific genes but if there is a higher chance in your family or you're in certain risk factors that might be a good idea to do and Dr vogelweed if you can just kind of play with that thought um of maybe after the show someone's going to say tomorrow they're going to see you at the grocery store and say hey should I go get you know my genes tested and and now they're asking you because we talked about it um how would you like to explain that to everybody you know number one the first thing is just because if you have breast cancer okay your daughters don't have 100 chance of developing it right okay they have a 50 50 chance because they may or may not get the the gene from you okay and then there's expressivity it doesn't not everybody gets it although if you have bracket you have about an 80 chance of getting it that's how high it is but not all cancers are like that and the other thing that people don't think about is that if for instance if you have bracka okay just because you got breast cancer since you carry that Gene abnormality you also have an increased risk of ovarian cancer you also have an increased risk of pro of uh not prostate I don't think you could get prostate cancer but you do have an increased risk of pancreatic and and on the other hand men have about a six percent chance of developing breast cancer I've never seen one prostate breast but I've seen prostate in pancreas for instance I've seen male breast cancer well yeah but if you've seen it have you seen it with prostate yeah and that's interesting as you're looking at extra male hormone testosterone and then extra female hormone you know and that hormonal therapy that's a whole other thing and I feel like years and years ago that was such a big thing and I think not that we're getting away from it but feel free to work with normal testing or not testing treatment hormonal treatment is the first stage okay okay it's still unfortunately it's in a lot of even on my own specialty they just use hormonal treatment and it's passe it's it's it's almost malpractice to just use hormonal therapy but now we're using a lot you know when you have the genetic abnormality we are using immunotherapies right okay yes uh when you talked earlier about chemotherapy I don't even give chemotherapy huh okay that the medical oncologist does okay but I have I do basically hormonal therapy and I do treatment that works directly on the prostate cancer cell and does not allow that cancer cell to use male hormone which feeds the cancer right okay right now there are other medications that we can use like a bracket one and bracha 2 that actually are the the cancer cell itself has the ability to keep the T Cell from recognizing it the white blood cell if you want to call it that okay and this medication interferes with that so if you don't mind explaining how is the medication applied I mean is it is it is it surgically no no no okay they're different ways it could be intravenous it can be oral okay and and it depends on the medication okay and give us some just some case studies of different types of treatments well at least in prostate cancer I don't know if you've heard of limparza they put it on TV all the time it's elaborate okay that that is one of the medications that I can use okay uh for uh for prostate cancer when it's Advanced I don't use that right away okay although if you have a genetic abnormality you may use that first and what does that physiologically do once it's inside your body what is it attacking in the prostate you know I think I believe it's a pd-1 PDL one inhibitor okay and uh and what it does is it just there's this mechanism that the cancer cells that keeps the the the uh if you can imagine this is the cancer cell and and this is the white blood cell I'm going to call it white blood cell because it's easier that way and this one is designed to eat the cancer right but it has a pattern that it uses to recognize the cancer cell okay or a protein if you want to call it that okay but the cancer cell makes another protein that blocks it okay right and so what these medications do is they keep this cancer cell from using that protein and so the the white blood cell can identify it and destroy it I remember somebody very simplistic man back in the day yeah yeah it's very simple it's very simplistic but yeah a very simplistic way of of uh explaining something that's complicated but it's nice because you can put your head around it so have you have you seen I have a good analogy for this have you seen Star Trek before oh heck yeah so they have cloaking devices yes so the cancer cells are able to basically cloak themselves from the immune system and what these medications do is they get rid of the cloaking device so that your immune system can see the cancer cells and Destroy them okay so that's kind of the so that's kind of a Harry Potter reference too because Harry Potter's got the clothes invisibility invisibility cloak yes that's a good way to explain it you can detect it yeah and it's interesting too because cancer is so stinking smart but we're trying to be smarter and that's kind of where it comes in um Dr Mendel I radiation oncology I think especially with prostate cancer there are and have been so many different ways to treat prostate cancer with radiation I remember radiation seeds I don't know if that's still a big thing or not but I remember when that was first coming on the market wrong word to say on the market but uh we talked a lot about that but it was a lot of excitement around it because then it was localized again that's why I was asking about surgery you can put the seeds into the prostate itself it was uh radiating in there but just again you're 12 years old I get it you're super young but in your time of practicing what have you seen as a standard of care with radiation and then going into what's happening now and this could be a whole show but so we'll kind of go in and out if he's super young he's a child genius okay he yeah he's like that doctor is it Doogie Howser yeah yeah it's just like it doesn't it I wonder how many years it's going to be for me to get my white hair yeah you've been here too long but you have the beard you know our prostate cancer and you remember so we had Dr my beard used to look like that 25 years ago yeah good job for wearing a beard um so on on that note of from Days of old to now um do you mind if I when did you start practicing and that way I can at least put a year in my head when we started talking about things so so basically I started with like Rio Grande Urology so I started with them like about two and a half years ago okay and so residency 13 not 12. yes okay um so I'm thinking C so let's let's kind of start with seeds before the before it seeds then like seeds were a new thing talk about that and then going into what you're doing now what you're able to do now so we still do that so so the it's called brachy therapy so when we we implant radioactive pieces of metal that's that's brachytherapy and that's low dose rate so we leave the seeds in there they emit radiation over time and decay um we don't I don't do that as much because we have a essentially a more efficient way of doing it something called HDR which is a different type of brachytherapy high dose rate um where we use an apple afterloader this is a a machine that has an iridium source that comes out on a wire and we implant catheters inside the prostate and it delivers the radiation to the prostate from the inside out um and and instead of leaving the radiation side we take all the catheters out and the patient goes home so that's that's what we do now and I I prefer that method mostly because you can make up for if you know say the catheter is too close to the urethra or something like that you just don't use it you know you can can sculpt the radiation and really what's what's become more popular now for radiation therapy is is being more precise number one so our margins that we use we do everything we can possibly to make sure that our margins are within a couple of millimeters of what we're treating the HDR we're actually boosting lesions and so you put the catheters in we have an MRI that we can see the lesion and we boost that area to higher doses because we know where the cancer is and we've actually started doing that with external beam treatments as well where we we know where the cancer is so five years ago people would just treat the whole prostate at the same dose right right you have your prostate cancer is in there somewhere you treat the whole thing that's it now we're we're a little bit more smart and we're more targeted we know we know where the cancer is so why not give it more dose in that area and you can even limit those to some of the other areas that you don't you know necessarily need to treat and so that's been the name of the game now okay and I think if you looked back kind of like even when I've been practicing so I my residency's five years I've been here two and a half years when I first started in residency I still remember patients were having a lot of rectal toxicity and bladder symptoms and things like that we've now Shrunk the fields and we we put devices like the space War device we talked about it last time but it's basically a gel between the prostate and the rectum I remember that and I hardly ever protective gel right exactly and I hardly have patients complaining of rectal symptoms now so is that a standard of treatment now that gel just I put it into everything I can yeah every single person I can I'll put that in because I you know I think it helps right and it doesn't stay there permanently you just put it in then it goes away after four to four to six months something like that so the body dissipates it's on its own yeah it's mostly made out of water actually so um but anyways I think that the just like you know prostate cancer in general everything's evolving rapidly radiation oncology as a field is it just every five years it's totally different so like things we were doing five years ago we some of them we don't do now right right but at our Center we we you know we basically treat every I treat everything anything any patient that comes male female brain cancer gynecologic cancer prostate cancer we treat all of them and we have all this all the treatments that you can get at most places you know that was the whole the whole goal for me coming back was to bring everything that you can get a university and do it here and so it's good for that I mean really I say that um again I talked about my mother my mother died 29 years ago and she had small cell lung cancer that went to the brain uh gamma knife was relatively new at that time I think gamma knife was introduced 31-ish years ago we didn't have one in El Paso at the time we had just gotten one um and I remember Dr Gupta years ago was talking about that but I'm thinking at that time it was such a brand new thing but when I look at it now the targeting of the 30 year old gamma knife compared to now I know that's not prostate related but just in general is that something that's still used and maybe I'm just talk just a smidge about that I know it's not prostate but it's so fascinating because it's radiation oncology absolutely yeah I I trained on the Gemini from Dallas and we we unbelievable amounts of treatments and it's probably the most precise to be quite honest okay yeah I mean the thing is is with Cam and I've they actually bolt a frame to your head so you can't move and it's I mean you are treating brain tumors or brain metastasis usually that's what we're using the gamma knife for um or you know like an acoustic neuroma or something like that but it's it's very precise on the order of of like less than a millimeter and so these the the problem is you can only do that in the brain right exactly so it's it and and there's there's some kind of technical issues it also takes quite a while sometimes to treat to treat on the gamma knife because it's it's not a linear accelerator it has it actually has Cobalt sources in there that are all focused on one area um and that's how the doses are so high okay and when you do the treatments they're called shots so you kind of move the patient into the area where the radiation is converging okay um and it's kind of the simplistic way of thinking about gamma knife but I I think it's it's used a lot we used it a massive amount in Dallas I know they still are they have dual bunkers now where they have two icon machines and they're just treating patients with the neurosurgeons there and they have one here at Sarah provenance that's I'm pretty sure is pretty busy I just remember the the blood-brain barrier and chemo wouldn't pass that and it was crazy um so Dr vogelweed I'd like to go back to um different types of treatments I know we're talking a lot about radiation you were talking about hormonal treatments like the first line of defense but as a surgeon let's talk about surgery prostate cancer surgery um when do you do surgery when do you opt not to do surgery um again where I think I shouldn't keep calling it the old days but I do but I always think of prostate cancer prostate surgery removal if not is it always at the entire prostate's removed yes um and then from there usually radiation and again that's old days how how is that evolved or is that still kind of the same well you know this the both are used okay okay they're both used and they're used frequently and probably they're both just as effective okay the the differences are age okay the and but generally speaking you're looking for a cure when you're operating on the prostate you're the same way you're looking for a cure when you radiate the prostate right I can tell you that radiation oncologists have slightly different criteria than the the urologists do as far as that is concerned uh because we both think that we're best at curing the disease of course okay and uh and we both are very good at curing the disease but nobody's perfect surgery is usually used more in a younger person okay if you have a 50 year old or 55 year old or even yeah the limit is usually around 70. okay uh of course if you have a 65 year old that's a diabetic and has had an amputation he's not going to benefit from surgery because he's not going to live that law but generally speaking if it's younger healthier male we'll we'll opt to get to operate of course it's always the patient's preference and we do like them to get the medical oncologist's opinion too and but if it's an older patient well then the urologist will probably say well he's going to take care of it he's going to cure it better than we can right he probably is but uh prostate cancer is that cancer that you have so many differing opinions on treatments is it is it the most uh differing opinion of all the cancers for treatment options I feel like that's always been the the Mantra it's like you know look at everything go talk to your doctors and really come up with an answer all together do you know any particular field in medicine where every single doctor agrees with every other doctor excellent point absolutely okay there is and and it may be and I was just you know he was talking about Pathologists Pathologists do a good job okay it's the complicated cases where you need you know we need you to need more studies you need more stainings you'd need more whatever it is that they do uh but you know they're the ones that look at it first right uh and in this particular case there are you know I may say that I'm better if I have a 70 year old that's in good health we probably if he goes for radiation he'll probably do just as well as he did if I operate on them okay uh and then the other thing is if I operate on it doesn't work you know if he has positive margins uh if the he has local disease that came back he's the one that's going to take care of it right you're now he not Dr Mendel well I'm the only one there so yeah well he's two yeah I forget exactly but but on the other hand he the patient may opt primarily and he may be a 60 year old that opts primarily to have uh radiation and then the disease comes back if it's localized you can still come back and take out that prostate of course that's a lot harder to do right and it's fought with more complications but it's doable and if you have a physician that does that a lot then they can probably do okay right uh it just makes it a little bit more complicated but the the the two that we complement each other is the best way oh without question yeah I feel like it's always always a team approach I think it's I think it's kind of changed a little bit um nowadays you know when patients come to my clinic you the way we operate the patients get all the options and I think prostate cancer is probably the disease side that has the most options I mean there are it's you could talk to the patient for two hours about their treatments and so when they when they come see me they so the way it works at our clinics there would be a primary urologist who diagnoses the cancer the majority of the time and they're going to send that patient usually if they're 50 60 or 70 they're going to send them both to a surgeon and to me okay and so we can both go over the options and explain to the patient kind of you know what's going on why is this happening what are we going to do and it allows the pay patient to have an informed decision and it's it's very complicated you know and it's not just this is the best treatment for you and I always tell the patients I'm very biased yeah because of course I think radiation is great right right well Dr vogelwood always tells me of course Travis cures everything yeah so so yeah radiation cures everything yeah so I tell them that hey I'm very biased and I honestly just want what's best for you yeah and sometimes the patients they don't want to get cut on and so they want to get surgery and this is these are even young guys and I even tell them you know if I was 50 I'd probably do surgery personally yeah you know but a lot of this is very personal and so the patients they have to understand what's going on in order to make that decision because it's more of it's more of a personal decision for the patients because they're going to have to deal with the complications become overwhelming then for the patient because they're the ones that have to make the decision on the treatment whereas other treatments it's like the doctor says you need to do a there's not a b c and d here you need to do a is that something that you all run into as a I remember we had one show we had a prostate cancer uh Survivor on and he said that that was you know the overwhelmingness that he had all these options in front of him and didn't know which one to choose and he kept saying what's the best option but again there's all these options so that's where the physician comes in so you give them the options and then you meet the patient you you understand their personality and you help guide them you know and and they'll they'll sometimes be very passionate about one way or the other which is fine but if it's a patient that's like you know doc what would you do right and you can give them their your honest like pretend you're my I'm your father what would you what would you do then you can give them your honest I give them my honest opinion on what I would do right but really like after you talk to the patient for you know 15-20 minutes you know their personality and you know kind of what's going to be a good fit for them and so that's how I feel when I'm speaking with patients I'm just trying to guide them in the right direction um more so for a treatment that would kind of fit their personality or fit kind of what I understand about them exactly okay ultimately the patient's the one that's going to decide what he wants right and we don't want we really don't want to tell them what to do we want them to get a good idea a good understanding and yes it happens just as it happens to them it happens to me you know doc what would you do under these circumstances and there are times when I say 50 50 yeah 50 50 I think it's I think either choice is good for you yeah and and ultimately but but I will not pick for them because if you pick for them then it's your fault I get it and you very much and uh yeah and that uh happens I think that's the beauty of our group though so our our group I this is kind of a shout out to Jeff spear I still he's like my big brother right way to go Jeff Speer I mean I still remember the first president of the El Paso County Medical Society yeah he's he's an amazing guy yeah but he I still remember sitting down his office and talking about these different ideas that that I had when I started because there's there's a way you know there's a business side of medicine as well right and so you're it's very rare to be in a situation where you can sit down and make the best decision for the patient and I still remember vividly in his office because I was just starting I was really nervous and I was kind of like shaking things up and I remember Spirit like looked me right in the eyes and he said you just do the right thing for the patient and good things will happen oh and that's it and that's how that's how we work you know that's that's how the group works and so and I know that every every clinician is is thinking that way they're trying to be that at like the patient advocate you know even in times when the insurance is giving you a hard time and you know it's just we're constantly trying to help and this that's that's like what I love the most about our group is the whole group is like that you know they just everyone's from here you know these are our this is our home these are our people these are our people yeah we're trying our best to take care of them right and so I think that's kind of like the magic of of our group right now I love that I know boy deals with the same the same but I'm not I'm not from here but you've been here long enough so that works yeah that works no but you know if you're a true physician do not do harm right you try to help your patients and uh uh and we do it to the best of our abilities I mean the patients uh if a patient asks me can you guarantee that this will work oh what it does I I have heard a very simple answer for him no I said I said I can't guarantee that it'll work but I guarantee that I will do my best to see that it works right which is different exactly and and I live by that rule yeah you you do the best you can for your patient but you're you're just as human as they are right I always say there's no guarantees in life there's never a guarantee in life it's called taxes yeah taxes um but I I kind of on that note too so if there is say somebody has gone through genetic testing and they are now not genomic tests but genetic testing so they are somewhat predisposed because they do have some genes in there that would make them more apt to get cancer and I'm saying cancer and all in specific matters though for prostate cancer if you have this Gene is there anything that you can do in your lifestyle that can help prevent it now that you kind of have this little this little spot in your head going oh it's all I have maybe a predisposition is there anything that you can do to kind of Ward that away obviously get checked all the time but any person that has cancer of any kind can benefit for improving their lifestyle which includes exercise and diet they do better because prostate cancer with patients that that lose weight do exercise treat the control their diabetes control their high blood pressure they they live longer and they respond longer right okay there's there's no question about that but if I were to tell my patient if you change your lifestyle this will keep you from getting the cancer no right that isn't going to happen What You Do you know it depends on the type of cancer but what you do is you tell them uh you know this is the genetic abnormality that you have and and I'm not a genetic counselor but most of these people that do the genetic testing have counselors that work for them and the the patient can get in touch with them and get counseling on how to take care of how to take you know how to approach the uh the engineering that's actually a really good point so the counselors would then uh if you contact the counselor would kind of give them an idea of okay you are positive for a b c and d let them kind of know what yeah I would get the test and have no idea how to read it um so well I mean it's even hard for us to read it okay because it's I mean there's a hundreds of chains hundreds and hundreds of genes and you know we're still uh you know when you're talking about early we're still in our diapers or maybe we're still in utero as far as understanding genetics it's very very complicated these few tests that we found that are an Associated you know in prostate cancer if you uh theoretically if you have advanced prostate cancer you have about a 12 chance of having some kind of a genetic abnormality and I haven't even gone into one part of that but you have about a 12 percent right okay but the you know in my own personal practice I haven't seen that okay because my percentage is much lower okay okay the other part that I didn't go uh into is uh just because you have it and just because you do not have an inheritable disease the cancer itself from the prostate can undergo a genetic transformation if you want to call it that or a genetic alteration and that genetic alteration may be something that uh is a bracha abnormality for instance or an ATM abnormality and that's helpful to the patient because it may help you as far as how you're going to treat him so you cannot have a terrible disease in other words if you hit if you do not have uh you know you have breast cancer right and you do not have inheritable disease but they test the tumor itself and they do a lot more of this than breast cancer and and they test the tumor cells and they notice it the alteration in the primary is different than what your genetic testing shows interesting that does happen I have a couple of patients where I've tested this doesn't have often but it but it does have it can happen yes and so your treatment then might be a little bit different it may help it may help you with your treatment yes interesting interesting okay just to make it more confusing no that's good though because we have some breast cancer shows coming up so that would be a really nice question you know I'm talking about prostate okay but I'm just thinking you know uh there's just a lot of genetic testing in breast cancer is what my thought process is on that um but what we haven't really hit on yet is and we have like 15 minutes before the show runs out I would love to talk about staging not like spend too much time on it but as the person who usually finds the prostate being in trouble um and then maybe you know PSAs Dre we have to do a biopsy now so maybe talk about biopsying how that's done and then staging if there is a positive cancer diagnosis well the biopsy the traditional way is is trans rectal you put an ultrasound probe in the rectum and you see there's a needle goes alongside it and there's a gun that fires and you do don't see a gun that fires in a medical show okay goodness a goodness a gun that snaps there's a needle that very gently Once Upon uh you make in that area numb sorry I'm messing with you but yes the gun to fire is because it gets a specific yeah I don't know how else to describe it it snaps but that doesn't really right right and the other one actually it's a needle that that goes out and comes back in and it cuts a piece of tissue uh uh true cut is is the term that they use but uh you get that the traditional ways to do 12 biopsies it used to be six it used to be three but now it's and then it's 12 and then we started getting into MRIs and if you MRI identifies the focus you may just decide to biopsy that focus and biopsy nowhere else or you may do two or three biopsies of that focus and biopsy everywhere else that's a personal preference uh and there's a little bit of controversy as far as that's concerned because they say that only the only ones that show up on an MRI the high grade tumors and if you have a low-grade tumor it probably doesn't need any treatment of course when you treat it I'm sure that he's going to treat the whole prostate but with different amounts of radiation but once you've got the diagnosis you have to take in consideration how bad the cancer is that's called the Gleason score or they use grade grouping now you have to decide you have to check and see whether that cancer is spread so you you're going to do uh well we used to do a CT scan and a bone scan which is still considered the certain point of standard of care but there's better testing nowadays now we have a polarify scan a psma scan these are two both of them are these are these are pet scans okay and psma stands prostate specific membrane antigen and so these can actually go directly and sit on the prostate cancer cell oh my goodness and identify it okay okay and so uh if you do a psma scan it's much more accurate than a bone scan and a CT scan for metastatic disease it also can tell you whether the the you could do just a pet scan I can tell you whether you have extra prosthetic extension uh or even if it doesn't the Pet Scan May I'm not a pet scan now uh yeah pet scan a PET CT what is I forgot what pet stands for I know pet scan uh positive positron emission tomography yeah say it slowly positron emission tomography positron okay okay but this this so the staging is fascinating for prostate cancer so so I've really gotten into biopsies more recently um because I do targeted biopsies okay based off the MRI and actually now based off the psma scans so I have a couple couple of stories for you okay I haven't told you this one so you're gonna love it um but anyways for prostate cancer staging it's basically just you use your finger and that's how they're staging patients if you feel for a nodule and that's you know decide well like the whole prostate's hard half the prostate's hard I mean there's a nodule and that's your staging and have we said guys of a prostate it's like the size of net right it varies and as you get older it gets larger okay right okay um so we've we've talked about the BPH and things like that on other episodes yeah okay but um but I think that um nowadays we're Imaging is becoming much more in Vogue and it's more I think it's a little bit more accurate and what we're doing you know back in the day they would do a digital rectal exam then they do a biopsy and it would just be a random biopsy at the back of the prostate the cancer isn't always in the back of the prostate and that's where the MRIs come in so you can you can see the lesions it could be in the back it's probably like 80 of the time it could be in What's called the peripheral Zone but anterior in front of the prostate about 20 of time you can find cancers there and that's where it's kind of this this area is exploded where we're using now MRIs and template biopsies and so they'll get your template biopsy you'll probably get an MRI before or after so the template biopsy would be what then a random bio the other process okay like a systematic okay the process the prostate but now you hit more information up front or even after that all your PSA is high maybe we missed it so you get an MRI there's a lesion in front and then those patients usually come to me and I go in and I Target those areas okay and take pieces of the of that to see what kind of if they have prostate cancer what kind of prostate cancer and so that's really exploded and the story that I have for you so we have a patient who who was had a rising PSA that started back in two like 10 years ago okay he had a biopsy was a random template biopsy and he had a small percentage of One Core Gleason six yeah so it was like one percent like a little speck of cancer and so everyone just says we'll watch it all right so it's PSA goes keeps going up keeps going up he gets biopsies he goes to MD Anderson he goes to Mayo they get MRIs the targeted biopsies all these things nothing no no cancer diagnosis oh my goodness so he comes to me his PSA is 40 which is extremely high and we get we get a psma and there's a lesion in the front that's have it on the psma scan so I go in there and I biopsy and we diagnose something now oh he's gonna get treated unfortunately he wasn't metastatic after all this it was not no after uh after over a decade it was unbelievable so he's gone back and forth so prostate cancer is is weird that way you can have somebody has a high grade cancer and they last a long time and who knows why and you have the these low-grade cancers that you figure they're going to live forever most of your Gleason you know sixes which is you know they don't even need treatment if it's true Lee a Gleason six and that's the problem is that you know ten years ago I mean when I first did started doing biopsies I would wear a glove right stick my finger in the rectum right and then I slide a needle on top of my finger and there have been urologists that took pieces of the needles when they uh I mean pieces of their finger when they do biopsies and then you you felt for that nodule that's the only way you could diagnose it and then you you sort of aim for it and you and you hope you get it and you hope you get it wow so that's like unfathomable of me I can't even imagine doing that with one of those needles because I'd be like go right through my finger well it did yeah thankfully it never happens never happens on the finger and then going in but yeah I went through my glove one time but didn't do my finger geez but it just goes to show how much things have changed we have more information now and we're still learning how to use that information that's the exciting part yeah so we now you know patients get a PS amazing if they have higher risk cancer we can see where the cancer is and that changes our treatment a lot of times and so you know at diagnosis now and after diagnosis this information is very important and so now we have it right we're still learning what to do with it and you guys are so excited it's really cute yeah yeah it's a very exciting time yeah you should ask him about oligo metastatic disease just to make it more confusing okay you know what we can but we have we have seven minutes before the show ends but let's talk about it a little bit because this is the fun stuff this is the new stuff that I like talking a little bit about so so oligo means few all right so you have you have metastatic cancer some patients you know we always thought of metastatic cancers your metastatic your stage four but there's still there's a spectrum of metastatic cancer and where a lot of a lot of practitioners are thinking that if you're able to identify patients who have smaller amounts of cancer one or two lesions up to five there's varying different definitions that those patients are are still curable because they're still I mean the easiest way to think about it is if you had a cancer say five cells snuck out okay they snuck out they started growing somewhere and but only those cells left right right so you treat the where the cancer started and then you treat those other sites and the goal is to cure the patient in reality what always reminds me the the chance of curing those patients is extremely low right you know probably less than 30 percent I've heard you're not allowed to say the word cure when it comes to cancer but yeah but even even if you don't cure them you have to give them more time oh goodness that's that's the important and you can yeah and you do and so you're looking at targeting these like five cells that you said five cancer cells that are gone now and maybe have grown a little bit so this is a therapy that can find those cells yeah so so there's there's varying things one if you have the if you get a pet scan they light up like a light bulb on a Christmas tree and you can see exactly where they are and you target them and that's what I do with the radiation so I'll treat the cancer or the primary started and then I'll find these lesions and I'll treat those in very few fractions with the blade of doses of radiation very focused there is is a new product on the market which is you know the plevicto which is which is a lutician psma scan the psma is probably as I said before is prostate specific membrane antigen it's an antigen that goes and fixes on the prostate membrane of prostate cancer cells okay and it's a it's an isotope that helps identify it but the lutetium is an isotope that actually emits radiation and so if you first you check with the psma to see if their psma positive then you give them pluvicto and so that will that's that's the lootisha okay gotcha gotcha that's a radioactive it's a radioactive isotope and it actually goes and treats that Target with radiation gotcha wow and uh and it and it is it's one of the things one of the new just approved treatments that we have the the four Advanced prostate cancer it's very exciting so so imagine you know just imagine this you can get a scan that shows exactly what targets your type of cancer and then you just Target it with a radioactive element and then it goes to the cancer gets rid of it no you know that almost seems fairytale to me in in a beautiful way because isn't that the hope that everyone has so that's if they have whatever their cancer is you usually don't cure these patients right you're you're decreasing the bulk of disease and the way that the The fluvicta Works is you know it doesn't it doesn't you it's we're never going to cure it you know but I think that it's gonna it's another therapy that's more targeted and it's the this this new field is called their agnostics and basically you're able to to figure out what the cells have on them and so you can Target them with whatever therapy is really related to that Target right um and so it's it's gonna explode probably it is but one of the things that you have to consider is that not everybody is psma positive okay yes yeah not that that's yeah I always I always tell my patients when they come to see me you know prostate cancer smell smells it does uh prostate cancer cells are extremely smart yeah they they can fight anything you throw at them anything and the goal with treatment is not cure the goal with treatment is to extend right and if you can extend life and you can extend quality of life you know if somebody presents with metastatic disease 15 20 years ago I mean cancer is out of the bag he's got in the boat exactly survival is about a year and a half with treatment and we're talking about these five cells that you're talking about now that now no no we're talking about somebody shows up in your office for the first time and they got cancer of the prostate it's already spread I see okay yes with with hormonal therapy which was the standard of care since 1942. uh the survival is about a year and a half to two years okay um nowadays it is rare that you get don't get three to four to five to six years wow it depends you know just as I say not all cancers act the same right not all cancers respond the same and it's you know to me it's disillusioning when I have to tell the patient I don't have anything else to offer you um okay and this happens a lot particularly if you have somebody's 80 or 85 years of age or 90 years of age I have several patients that are in their 90s they're not going to handle chemotherapy yeah they're not going to want chemotherapy even though the chemo the initial chemotherapy for prostate cancer relatively speaking is very tolerable okay but uh it is that that's where it becomes hard but personally I tell them up front I say listen I can't cure you my job is to give you more time and give you quality time and you may or may not be able to do it right but you have you know my feeling is that you have to tell them absolutely I can't I can't agreement with that yeah and you even and I'm sure you may get this too I get patients family comes in please don't tell them oh no I mean please don't agree with that at all okay yeah and and and you have to tell them right your obligation is not to the families to the patient right always and I like the the Jeffrey Speer way to go do what's in the best of the patient yeah that's absolutely yeah the patient and good things will come you guys thanks so much for being here I know this is a an underwritten by uh Rio Grande Urology and Rio Grande Cancer Specialists we've had with us this evening uh Daniel vogelweed and Travis Mendel um and if you have not been able to catch this entire program you can catch it again on pbselpasso.org and you just go to watch find the El Paso physician program on there you can also do it with the El Paso County Medical Society website epcms.com and also on YouTube this has been a great program thanks both you guys for being here I feel like we can talk for another 50 minutes on this I'm Catherine Berg and you've been watching the El Paso physician [Music] foreign [Music] [Music] foreign