neither the el paso medical society its members nor pbs el paso shall be responsible for the views opinions or facts expressed by the panelists on this television program please consult your doctor there is much cause for optimism in the world of prostate cancer it's definitely one of the cancers like breast cancers 20 years ago there's something new every year that's happening with prostate cancer and has been for the last 10 years or so we're going to be talking to two doctors who are experts and this is a live program so if you want to call this evening give us a call we've got the medical students answering the questions but the telephone number 8810013 we are also streaming live on youtube and that number is going to come up on your screen several times so again a live program call with your questions 8810013 this evening's program is underwritten by rio grande neurology and we also want to thank the texas tech paula foster school of medicine for providing the medical students for manning our phones we have with us today isa and also ritika and they are both second years in medical school and usually we get the first year so i don't know what you guys did to get the slots the way to go i very much appreciate you being here and what isa and latika are going to do they're going to be texting me your questions so when you see me on the phone it's not that i'm talking to my teenage kids or anything i'm actually getting the questions from you the audience so we can bring them here to our doctors i also want to say a huge thank you to the el paso county medical society they've been doing this program for over 23 years now and again it's the el paso position the first show we ever did was a prostate cancer show and we'll talk about that in a moment too i'm katherine berg and you're watching the el paso physician thanks again for joining us it's prostate cancer month september it's a month of everything but this is a month i remember 23 years ago when i was talking about that when i was working at the american cancer society travis's mom excuse me dr mindal's mom knows me from those days but my very first show of doing anything in the medical community was the prostate cancer show and i believe dr vogel weed was one of the doctors on that show and for those of you that remember a lot of these docs we also used to have dr horowitz and dr chesbro so it's uh it's been a long time coming and i look forward to coming back to a prostate cancer show every year because there's always something brand new that i learned so right here to my left we have dr daniel vogelweed who is a urologist and then to my left we have dr travis mendel who is a radiation oncologist i'm sorry oh you're my right left i'm a pilot so i'm allowed to say that right people say i get those mixed up all the time so to my right um dr vogelweed at least that one it could be stage left um as a urologist i mean you you do a lot of things it's male and female but obviously tonight we're going to be talking about prostate cancer so in your discipline what is it that you do all day every day so that when questions do start coming in from the audience we know who to direct them to if we're referring to prostate cancer yeah that's you know i mean i'm a general urologist but i do have i'm going to call it a sub-specialization in advanced prostate cancer that i and for the group our group i manage the medical side of the advanced prostate cancer okay and i run that clinic as far as prostate cancer is concerned you know everybody in the group initially makes the diagnosis and decides what the treatment is going to be once that cancer has been treated and if it comes back or if it presents in an advanced stage then they usually get referred to me okay and so in your group how many people do you have in the group about 12 about 12 or 13 something like that i always lose count yeah there are three in las cruces there are four there are four in my office including a pediatric urologist okay travis goes back and forth there's two that go back before between downtown and the east side and they're four on the east side okay which three of those four go back and forth nice so it's a good number and you're all over the place and i i love that and i think that's great for our community as well dr mendal mendel mendol mendol is just fun um radiation oncology so what i would like to do and i know this is almost too simple there's a radiation a radiologist and a radiation oncologist i want you to first differentiate between the two because sometimes people really get those mixed up and we also want to give you your do in really studying and doing what you do so first separate those two and then talk about what your role is all day every day perfect so radiology is a completely separate specialty from radiation oncology and so the radiologists they review mris ct scans chest x-rays and in a dark room with these very expensive monitors and then they give reads and so they are one those are the people that basically look at the pictures in the medical field and then make diagnosis of that or recommendations or what have you um with radiation oncology what we do is we use radiation external beam radiation another type called brachytherapy where we insert either radioactive seeds or catheters that we can deliver radiation from the inside out so we use radiation as a therapeutic to treat cancer and so basically my day consists of seeing essentially solely cancer patients and so i have a regular clinic just like you usually would with a doctor where you come in and see me in the office i evaluate you for different treatment options in the background there's you know between 30 and 50 patients being treated on the radiation machines that we have procedures happening and then planning going on and it's a very very team-centric uh specialty where i have a physicist dr ume we have a dosimetrist we have a therapist it's a very it's a very big team and i'm now the captain of it now you're the captain of the team and i said i was talking you know you look like you're 12 years old but you're a whopping 32 i'm allowed to say that i'm 53 and i'm not going to ask your age um what i'd like to do 27 backwards really good for you yes way to go um you look great and healthy thank you um what i'd like to do is kind of lo have the audience look at you as surgery man and your gadget man um often when i do oncology shows you know i talk with radiation oncologists and and it's like they get excited because there's new toys every couple of years and new ways of doing beans and special beans but i feel like of all cancers that are out there prostate cancer is probably the most specific individualized treatment that can be done out there so on that note dr vogelweed what i'd like to do is um actually i'm going to back up i know that we have a graphic of the prostate area and so i'd really like to explain that to the audience first so that as we are talking through um we can kind of get an idea of what that is so if we can get the the folks in back gracie if we can pop that up onto the screen and uh dr vogel we will talk through what that graphic is and maybe it's up and i'm just not seeing on our monitor and if so somebody yell at me and jump up and down if not we can just let's just walk through i know we don't have the graphic up is it up to the people at home or we can no okay so let's let's talk about where the prostate is located so when there are screenings there's a the digital rectal exam so when a doctor goes in through the rectal area where are you trying to feel for the prostate and what are you feeling for and if we were able to get the graphic up we'll get that out okay the the prostate gland if you can imagine a balloon that your small child plays with that balloon represents the bladder and then the neck of the balloon is the urethra well the prostate sits right around the neck of the balloon and you can usually feel the back portion of the prostate uh yeah you can see it on that picture and you can actually see the back portion of the process you can feel when you do the rectal exam okay and when you're doing that rectal exam what you're checking for is the consistency of the prostate generally speaking if you have a heart area on the prostate or the prostate itself is hard all over that is indication that there may be cancer in that prostate and then sometimes there is an enlarged prostate but it doesn't necessarily mean cancer and i do want you to speak quite a bit about that this evening too because even though this is a prostate cancer program there are people that have benign maybe chronic but relatively benign conditions of the prostate if we can talk through a couple of those okay to start out with every man that has a prostate that prostate as we get older grows it may grow a little bit it may grow a lot generally speaking the more it grows the more symptoms you can have but you can have a very large prostate and have no symptoms or you can have a very small prostate and have a lot of symptoms you don't treat size you treat symptoms okay the other thing that's important is that and this is something that people don't realize because if you go to a laboratory the laboratory will say your normal psa is between zero and four okay that's not true nowadays when we screen patients with prostate cancer personally i look for anybody who has a psa above one 1.5 if their psa is above 1.5 i'm going to want to investigate them further and if it's less than 1.5 you probably don't need to check their blood level for another four or five years okay and that's something that's relatively new it's been out since about 2015 dr crawford put out a chart on that and i have found the most i mean i was just talking to dr mandel today i sent him a patient that i checked his prostate and he had a small nodule and i biopsied his prostate his psa was one his psa was one one and he had cancer okay which is the reason why it's so important to do both the blood test and do the rectal exam right people always ask gosh if i have the blood test why do you have to stick your finger up my derriere yeah and that's why well yeah absolutely and so when you're talking about psas and we're going to have all kinds of radiation questions in a moment but when we're talking about psas um is the goal to have zero is that even a number that exists out there only after they've been treated okay and it's not it doesn't go all the way down to zero but it'll go down to three decimal points all right all right but uh normally if you have a prostate uh uh psa if it a lot of people most people actually have psas less than one okay okay psa start rising as you get older but as long as it doesn't get above 1.5 no matter what the age i don't tend to get too concerned about it okay unless there's a family history of prostate cancer now there used to be and it's not called watchful waiting anymore it's is it surveillance active surveillance active surveillance so talk about active surveillance so we have a prostate let's say we have a psa which is prosthetic specific antigen and let's say it's a 4.5 digital rector exam does not indicate that there's anything wrong so when does a person go into the mode of active surveillance and how active is that is that once every six months that they get checked again once every year how do you usually do that anti-surveillance is decided based on the biopsy okay if you have a biopsy and the biopsy shows one two or even three positive biopsies and those biopsies are low-grade cancer and we decide what low-grade cancer is based on what we call a gleason score yes okay or they also call it a group grade which is a little bit more confusing but a gleason score of six generally speaking is the prostate cancer that you can put on active surveillance okay fortunately we even have additional testing that we can do but i'm not going to get into that because it's a little bit more complicated but more often than not people that have low gleason scores and don't have a lot of cancer or people that you can put on active surveillance and you can follow them every four to six months okay for many years and sometimes there's a there's a person that i know that is i think in the seventh year of active surveillance and for the most part things have just stayed a little bit steady and you may go the rest of your life and never need anything done yeah excellent dr mendel let's talk about you um there are so many again different options and by the time you come into the picture let's say that the options of surgery which we are going to talk about specifically in a little bit um sometimes there's radiation first and then there's surgery radiation to bring tumors down surgery and then sometimes vice versa so when you start coming into the picture the biopsy is positive we need to do some kind of radiation i feel like there are so many different types of radiation from beam to radiation seeds to just different types and because you're 12 years old um you have studied all the new ones out there on that's going to stick to this look at it but what what is not most popular what is most used now in the world of radiation specifically for prostate cancer so basically radiation in the in you know since the for the past 30 years has been kind of a one-trick pony for prostate cancer where you come in you get 44 treatments monday through friday for 20 minutes you get a radiation treatment you do it 44 times and the reason you do that is the thought is the cancer cells get damaged more than your normal tissue cells do and the normal tissue is able to repair itself while the cancer dies so you get a little bit so you can kind of recover from it and it's a little bit more gentle more recently different regimens have been coming up and out and it's been more to intensify treatment because the 44 treatments while it's it's the tried and true approach and what majority of people do there's more convenient and sometimes more intense treatments that we can use for patients with higher risk disease okay and so what dr vogelweed was was talking about these gleason scores they play a very big role in kind of decision making in my field because if you have your garden variety cancer you know they're going to respond well to basically anything you throw at it but if you have a high risk patient who has either lymph nodes or like the possibility of having lymph nodes right or high grade disease inside the prostate it's more difficult to kill and so we escalate treatment with either higher doses or with the the brachytherapy so i'm going to go backwards a little bit to a somewhat basic question so let's say that we've been talking about a cancer that is just in the prostate and now let's talk about disease that has left the prostate because you were talking about lymph nodes so how does one screen for that and let's say not screening this is a person has symptoms they've come to see you psa is elevated judge your director exam is not good uh you've taken a biopsy and now it's spread beyond the prostate what is one of the most common ways that happens and again i know everybody's different but what are some of the common treatments when the cancer is moved a little bit outside of the prostate well it can be generally speaking if the cancer is moved outside of the prostate unless it's only the pelvic lymph nodes and you can answer more to that okay you know you can either you can treat it with either surgery or radiation surgery when you actually take out the prostate you can check those lymph nodes remove them and we do that pretty much on you know a gleason 7 cancer or higher the second option you can answer that better than i can as far as radiation is concerned you can you can i radiate the prostate and radiate the lymph nodes also okay so radiate the lymph nodes but leaving the lymph nodes in and yes you're not taking them out taking it back a step okay once you make the diagnosis we do two things we do a ct scan and that will tell us whether there's lymph node involvement and you can do a bone scan because prostate cancer goes to the lymph nodes and it goes to the bones yes okay the problem is that you have to have a million cells before anything can be picked up so none of these tests are absolute and so no matter what you do no matter what you throw at them there are no guarantees we wish there were but there are no guarantees the good thing is that we're doing more and more and more research we're trying to catch up with breast cancer there's been so much done with prostate breast cancer and they will know so much more about that and we're trying to catch up and find out different treatments to prolong their survival and a lot of genealogy in that as well right there's more and more uh testing in prostate cancer in the world of male cancers which somewhere between 15 and 20 percent of hereditary cancer okay that's a high number so several years ago i don't think we could have said that because we just didn't know and it's associated with bracket breast cancer yes brca1 and brca2 okay plus there are so many other i remember dr rivera talking about that and i'm sure i'll be talking her next month she'll be on for breast cancer and we do talk an awful lot about um just genetics i look at the students when i think about gene therapy and just because that that is such a it's not even new anymore it's just something that everybody's getting taught in in medical school uh dr mandal if we can uh talk talk a little bit now about the lymph nodes because now the prostate cancer has spread to the lymph nodes you're treating both the prostate and the lymph nodes okay this my apologies how many lymph nodes do we have in the groin area anyway a lot a lot a lot i know armpits groins lymph nodes um so and for example breast cancer there's the sentinel node is there anything like that prostate cancer are there specific nodes that you're looking at or that the cancer would spread to first absolutely so so basically um there's there's pathways for noble drainage from every every organ or every you know tissue site in the body and essentially we've we've figured those out and so we know which lymph node basins are going to be at highest risk for metastatic disease and typically if a patient comes in with high risk cancer i'll cover the lymph nodes it doesn't add much toxicity it kind of gives you a little safety net and it makes it to where you know you give them the the best bang for their buck when they're getting their treatments and so the way it works is you start off with a larger field of of radiation and cover the lymph nodes and also the prostate and seminal vesicles and then you at the end of the treatments you hone in on the prostate either with brachytherapy or more external being but it's more focused in on where we know the cancer is okay and in the past they used to just essentially draw fields on an x-ray and just you know i guess plug the machine in and turn it on and blast away but now we're a little bit more sophisticated the fields kind of evolved with technology and every year there's there's something new a new technique and specifically what i do is i you know i try to eliminate as much spray dose or unnecessary dose to different organs in the body and focus the dose on where i know the cancer is and so i look on the ct scan we use a ct scan for planning and i go through and if i see a node that looks suspicious i hit it with a much higher dose than you know just the general dose spread in the lymphatics now when you say you hit it i'm interrupting you only because if you go further then i'll forget to ask this question because of the 44 therapies you were talking about that so you're now in you are applying therapy radiation therapy on the patient who's there is that the same place then every time you do radiation from then on out is the machine lock in on this particular patient no okay this is a place that we do that how does that fascinates me and i don't know how it works so so basically you have prostate cancer you come in and get a ct scan we call it a ct simulation but it's basically a a ct scan that we have a bean bag to basically index your body on the scan okay um the scan we we basically make like a coordinate system in your body and that's how the machine knows where what to target and what to do and me and the dosimeters go in and we draw out the areas that are at risk and i map where i want the dose to go you know high doses low doses it ends up becoming actually quite complicated and then the dosimetrists and the physicists they work to make sure that the radiation dose is being delivered to where i want it to be and there's all kinds of tissue constraints and you know things you need to be careful about and stuff like that that you learn in residency right but in general it's a very efficacious treatment and patients tolerate it very well okay and it's it's funny because patients come in they they they hear radiation and i swear it's like they just watched chernobyl on hbo that's why i wanted to get to that point yeah you can see it and and i'm going to talk about and dr vogue weed you hate this but i have to talk about it we need to talk about incontinence with surgery and we need to talk about sex we need to talk about empty does it too okay you do it too i know but these are the questions that you know and just through the years if you're sitting in front of a patient they're looking at you and you're a human being and they they may not ask the question we're on tv again this is it's live and you're anonymous so call in with these questions so let's talk about surgery real quick and the advances of surgery so let's say 20 years ago prostate cancer removal or any kind of surgery so immediately the thought was incontinence or the thought was well i'm going to be impotent very very different today than it was years ago so i would love for you to kind of walk through maybe a case study we don't need to know their names or anything of someone who has was asking all these questions and you're trying to give them the reality of surgery well the reality is it's still a risk yeah well it is still a risk with radiation it's still a risk with with surgery you know one of the advances that you know about everybody most people know about is that you know now we have robotic surgery yes and robotic surgery has decreased the risk of incontinence to some extent has decreased the risk of impotence at some extent because you have a better view of the prostate and the nerves that go around the prostate but it's not a guarantee you still have that risk and it's still going to happen i think 50 of radiation patients with just the standard imrt have a risk of becoming incontinent doesn't i mean impotence it doesn't necessarily happen right away i stand corrected if if dr mandel wants to correct me because i don't know everything you do no i don't and but uh you know every time we make the diagnosis no matter who the patient is we have to inform them absolutely we have to tell you no this is a risk you have to this is you have a risk of incontinence you have a risk of impotence i'm sure that travis does the same thing dr mandel and uh and then there are additional risks obviously there's a risk of surgery you know you can damage other organs okay there's a risk of radiation you can zap other organs all these things we try to bring down to a minimum risk and are pretty successful at doing that but it's always there it's always there and i'll ask the same question on the radiation side because in my head maybe i'm thinking about the old days that's always one of the questions for the surgeons so now we're talking radiology and again when you're looking at risk factors you said specifically that you're looking at very targeted areas and very targeted beams where 20 years ago it was just kind of like well let's just get everything in there um on that note when when you're getting questions from patients how do you talk with them on what the risk factors are yeah so it's a it's a very common question almost every patient that comes in that's the first thing on their mind that's why we had to talk about it you know it's like do we talk about sex on pbs yes we do do we talk about not being able to pee on pbs yes we do um but it is these are questions that people want to know um so what what what are the biggest fears and what are your reactions to those so i think just erectile dysfunction in general it's you know most guys feel that is losing their manhood and so they're very they're more concerned about that honestly than living sometimes and so i the way i explain it to them is is for radiation i kind of been patients in three groups and so you know one third of patients are going to have you know essentially no side effects from the from the radiation treatments and they're going to continue on their merry way and maybe the in the normal aging process and ed um happens a little faster but they're still able to function and you know things are fine right and i've had those patients i have another group of patients another third of patients that will take a hit they'll take a hit but they can they can take viagra they can take cialis they can take some kind of medication that helps them um and then they're able to you know still have intercourse they're still you know relatively normal okay so they take a hit but there's still options there are treatments for taking the head medications gotcha and then there's another group of patients and these are usually the patients that are diabetic which we have a lot of here in el paso um or have other kind of comorbidities vascular issues things like that that already have ed those will those patients will take a big hit and there won't be any medication that can help and then in those situations a lot of times we have the patient speak with the urologist about some kind of prosthetic device or something like that okay but in general i think radiation has evolved to the point where we're able to kind of shrink our volumes because we're more confident about what we're targeting um in the past patient you know people would use you know maybe a centimeter or more to target the prostate because we have to take into account that it's an organ in the body that's moving not where it's you know it's not always in the same spot at the same time but now you know when i treat prostate cancer i use an mri i make my margins very very small make sure that i'm trying to carve around the areas that are at risk for erectile dysfunction and so in the past dr vogelis correct where it's you know old radiation treatments your your erectile dysfunction is probably 50 if if not more honestly but now i mean i think we'll see in 10 years with my numbers because i've tracked them but basically i like carving around and protect protecting these areas that are at risk i think it's going to help and i think it's more like 30 percent something like that and it's basically dependent a lot of it's dependent on kind of your your uh your baseline issues already and i love that you say you're tracking them so you're tracking the surgeries that you're doing or not surgery excuse me the radiation that you're doing and in general what the areas are and again that's why and dr vogelweed is probably tiring me saying this but every single year there's something new that i've learned because of the tracking and everything that's going on a question here from the audience dr vogelwege i'm send this to you 64 year old male with an enlarged prostate what are the chances that the bladder can be affected with the large prostate and should this be checked so in the old days these were the cards that the medical students used to run to me now they're texting them to me so that's all the information that we have on this question so when i say that that's kind of the disclaimer of we answer it to the best of our ability with what information that we have so again the question yes enlarged prostate wants to know if this will affect the bladder and is that a question that occurs often no okay but i'll answer it anyway okay anytime your prostate's enlarged it can impinge on the bladder mm-hmm makes sense and and you know one of the most common symptoms of an enlarged prostate is urinary frequency you you you urinate more often you have a weaker stream you've got to go you got to go you get urgency prostate cancer can also grow into the into the bladder and that in itself is another problem because if it grows it can actually grow into the ureters that are coming into the bladder and block the ureters and that of course is more advanced more aggressive disease but right it it and it can still have the same symptoms but it also can make your kidneys fail if it get if it advances farther it advances far enough see it would be nice i feel like every time i have you on it's associated with cancer i would love to have a urology show that isn't associated with cancer and talk about all those kinds of issues because there are so many issues right kidney stones oh gosh enlarged prostate and then you can cancer us girls have all kinds of urology problems too that would be a show i want to do um i am going to actually i'm going to throw this out so whoever wants this one again this is another question from the audience we talked about active surveillance how often do you need to get your psa and biopsy done if you have had a psa of three to four that stays that way for years and the cancer hasn't grown and the biopsy was minor i know that it's a kind of a complicated question that goes back and forth but bottom line is we were talking a little bit about that psa is between three and four biopsy stays the same they're asking how often should they get checked okay it's it's a good question okay but let's just assume that the psa was six when you made the diagnosis okay the psa is variable okay obviously if you're going to have a psa 15 you're really a lot more concerned than that you may have missed the cancer but if you're on active surveillance the first thing you do is you know you make the diagnosis you make sure that or make sure that you're comfortable with the act of surveillance and then the standard of care is to repeat the biopsies in a year no matter what even if the psa doesn't change after that it just depends on what the psa does if the psa continues to rise you can either repeat a biopsy or you can order an mri and see if there's a suspicious focus and even if that turns out negative you can do something that's called saturation biopsies you take them to the hospital you do about 30 to 36 biopsies of the prostate and a lot of times you pick up cancers that otherwise you miss interesting right and that makes sense too um i'm going to leave the audience for a minute because we've got a couple more there i want to i want to talk about brachytherapy if i'm saying that right yes because i feel like that is what's been talked about over the last decade but really last five years i feel like i've heard a lot more about that so explain to the audience what that is so basically brachytherapy is when we either put a device inside or catheters and treat treat with radiation from the inside out and so brachytherapy is using like metallic uh radioactive pieces of metal to treat the the pros the prostate or other actually other malignancies as well um and so stay inside the prostate so some of them do so there's three the prostate seeds that i'm sure everyone's heard of yes those are permanent seeds that go inside the prostate and and stay there permanently they decay they release radiation and it's a very effective way of treating prostate cancer it's usually used as just a monotherapy just just seeds alone for low risk and kind of you know favorable intermediate risk patients so kind of lower risk patients okay they can just do that alone and they have a great outcome um we actually at our center we do hdr where we actually put catheters in and then a essentially a radioactive piece of metal on a string goes inside the catheter stays in there for you know a couple of seconds and delivers radiation and then comes out and it goes into each catheter and then you take everything out and the patient goes home they're not radioactive you know that's it so what are you using to get inside the body are you using a sonogram to know exactly where you need to go yeah so it's an active go ahead sorry exactly exactly so we use an ultrasound okay so the ultrasound allows us to guide the needles to where they need to be and not puncture the bowel or the bladder everything like that it's very labor intensive and requires a lot of skill and so kind of the the way it's been evolving in the us is you know people have been moving away from this because it takes a lot of time effort it's a little bit more risky but the outcomes are you know they're they're very good and it's been around for a long time and so it's it's very important to make sure people are aware of these of these techniques because a lot of practitioners they won't do them because it's interesting so if this is one patient how often would one patient have that done i'd say it's very rare okay yeah very rare so if they have it once in other words would they have it again or is it once and done it's usually once and done um i will say this uh with the hdr another another way of utilizing it is for patients who fail their treatments so if you had radiation 10 years ago and now you have a like a local recurrence either in the seminal vesicles which are these little structures behind the prostate or inside the prostate you can deliver radiation focally with catheters brachytherapy to salvage that that situation and it works like 60 of the time so it's a pretty it's a pretty effective way of fixing the the situation it is um while i have you on the chair i am rt so this is intensity modulated radiation therapy what is that compared to what you're talking about so imrt is just a technique um where so inside inside the machine there's a large there's a large gantry and it's inside that the radiation basically comes out it's all it's just x-rays that's all it is like a chest x-ray or a ct scan it's x-rays that come out of the machine head inside the head there's these things called mlc's they're basically these metal leaves that move in and out people can see they move in and out like this and they modulate the beam and so if there's a structure in the way or that needs to be avoided the radio you're able to kind of modulate the beam around that structure so that for example on prostate the rectum is one of the structures that we're trying to avoid right and so we use imrt to avoid the rectum or avoid too much dose of the rectum so we don't damage it and then make sure the majority of the dose is going kind of focusing in on the prostate okay so imrt is a technique to do that the other the other you know type is called 3d where you basically just point and shoot and the beam comes out you can kind of modify it a little bit but it comes out just how it is and there's a lot of possible strength exactly okay and how often is that being used now um it's used um uh very frequently actually in breast cancer it's a great it's it it has its place um and not many people are using imrt for breast cancer but um but just the 3d technique just to kind of graze off the chest wall it prevents unnecessary dose to the rest of the body and it's been a very effective technique and not many people have really moved away from that um but i am but for imrt for prostate no one uses 3d no one anymore well i'm sure there are people but but for the most part it's not a practice that's being used anymore interesting okay because i have here like five questions on imrt but i think you handle every single one of them um i'd like to go back now and talk about surgery and when when is it necessary to actually remove the entire prostate and when that is the case what what is the gentleman looking at going forward in life and let's let's say it's someone let's go with a young person let's say it's someone who's 65 and um it's it's just time that the entire prostate's to be removed they're asking you okay so what what does that mean after my surgery what's the recovery time um etc take that i know it's a huge broad question it is um but it's it's a big one that's one that's out there well when you're treating cancer you take out the entire gland okay you so all the time you take out the entire clinic if you're going to do surgery yes there is such a thing as focal therapy and there's a lot of research being done on focal therapy either with high frequency ultrasound or cryo surgery the problem with high frequency ultrasound and cryo surgery is they prostate cancer tends to be multifocal and in different areas of the prostate you can have a less aggressive or more aggressive cancer and you can't always identify the exact area where those cancers are at although you know you use a template like you could you can use a template and you can get very very close biases to the entire prostate which is very labor-intensive and it's done more in in you know research centers but when you are treating the cancer you take the prostate out okay it's usually uh nowadays it's done under it's a robotic surgery you're usually in the hospital for 24 hours you're usually wearing a catheter after surgery for one to two weeks depending on surgical preference recovery is is is quicker the patient does better with robotic surgery but it takes a while to heal just like anything else and usually you're not ready to go back to normal physical activity until four to six weeks after okay although i've heard of people swinging a golf club three weeks yeah that's a little scary don't do that um when i say that it's like follow doctor's orders uh question here from the audience and i have not heard of this before so part of my ignorance on this a man called in with an enlarged prostate and is wondering if prostate artery embolism embolization is effective i don't know what that is again this is all that we have if we can't answer the question we can't answer the question but again prostate artery embolus embolization what is it number one they've been using it for treatment for bph for an enlarged prostate it's not an effective treatment one way or the other constraint i mean you cut off the blood supply you shrink the prostate oh it's it's as simple as that okay is that a good primary treatment for i mean we have some for bph for an enlarged prostate we have so many different treatments nowadays the standard of care is a trans-urethral resection of the prostate or turp but you know we have eurolift which is basically squeezing the prostate with stitches we have resume which is basically injecting steam into the prostate and cooking it we have laser prostatectomies where you just vaporize the prostate from the inside there's a lot of different treatments and it really depends on the individual situation and individual preference i am uh again typing uh into some of the questions when we're talking about the different preferences and i want to actually go to dr mendel first on this question because again radiation there's so many different options if you were talking about the one third one third one third earlier of what happens after different types of treatment so let's say that there is one guy he's the same 65 year old guy that we had he doesn't want to have his prostate removed so now he is opting for some kind of radiation treatment what options and i know i'm not giving gleason scores or anything like that just some options and i know we've talked a little bit more but just the most common things that you're doing right now is 65 super young should probably have the prostate out but doesn't want to so he's going to the young kid over here that does radiation what do you tell him so so basically i when patients come i have a like essentially a powerpoint presentation that i can show them and prostate cancer it's it's been studied that compared to surgery and radiation and active surveillance if you compare radiation and surgery the outcomes are the same the lines are right on top of each other and this is specifically for low risk and intermediate risk like favorable prostate cancers the outcomes are the same and so we have a lot of techniques nowadays to to treat prostate cancer and it's very specific to the situation um and so like i said before the the most common treatment is the 44 treatments but nowadays people are moving you know sometimes to 20 treatments right which is more convenient for the patient it's it's it may be a better treatment actually um and where as the technology has evolved now we're able to do it in five treatments and so very like it's called sbrt it's stereotactic 44 to 22 to 5. yeah so now now it's now we can do it in five treatments but it's very specific if that doses are higher it's a little bit more risky but it's certainly more convenient and here it's going to be it's it's been a blossom because there's a lot of patients that have to travel a very far like long distance exactly these treatments right and so if they can get it done you know more you know more effectively financially for them um or if this distance is an issue it's a great treatment option for them but again it's very situational it's very situational and and like you said i remember the days too when uh we used to tout that the decision of what you're gonna do for treatment you take the whole family in there because everyone has to figure out who's doing what uh another question here from the audience does um the saw palmetto help with prostate don't know what that is i certainly do yes okay all right south palmetto has been around around for many many many many years okay and if you put a sugar pill right here in salt palmetto right here they're both equally effective gotcha okay okay i like how just direct you are um same thought process here question from the audience is taking cranberry extract supplements help with urinary health so not talk about con cancer but with urinary help in general and i've heard that too cranberry juice cranberry juice is that a thing yes okay tell us why i don't know supposedly because it acidifies the urine it makes it less likely for for you you know for people to get recurrent bladder infections and the pill is equally effective as the juice because it's a concentrate so could it be other do i use it no i don't not usually but a lot of people do and they say oh i'm taking cranberry good for you good for you if it's something you think will help that's always the way it works here so i've actually heard that the cranberries they they apparently inhibit the ability for the bacteria to adhere to the mucosa um and they're in the so if you're looking for urinary tract type infections that's what so say that again it inhibits the bacteria so the bacteria aren't able to actually adhere to the mucosa okay that's supposedly how it works um and then the cranberry juice the what it's actually the cranberry like taking cranberry extract because apparently the carrot cranberry juice especially if you go get like minute maid or something like that it's essentially all sugar and no juice and hardly any cranberry it's just like flavored so that's probably not the most effective way of dealing with it but the cranberry extract where you can get like a high concentration of it that's probably you know technically more effective i don't have any data to support this though i've just read about it because i was interested one time so i am uh dr vogue i'm gonna show this to you there's a name here dr chesbro um i tried to keep questions from past shows on the same topic um and dr chesbro was kind of our our chemotherapy guy so to speak and um at the time this was several years ago when there was an anti-androgen therapy um i remember us talking a little bit about it i know that you're not a chemotherapy guy radiation is that something that is being used anymore i feel like i haven't heard a lot about it lately the uh that's a excellent question i brought you i'm glad you brought it up because okay you know it used to be that you know prostate cancer you can't always cure it okay and if you can't cure it either with radiation therapy or surgery or if when you get the patient start out with the cat's out of the bag well then what do you do next well the standard of care for many many years used to be androgen deprivation you basically block their male hormone and that stops the growth of the cancer that's what i was going to ask cure hormone therapy so that basically is the whole one there and and that can either be done by now we have uh medications that uh block the pituitary they have medications that stimulate the pituitary with the same effect it completely blocks male hormone but even that cancer cells are very smart cells and they can fight anything and they can come up with new ways of fighting the cancer and so you know the last five or ten years have really revolutionized the way we treat these patients with prostate cancer and that's why in my group we actually have a segment that treats these patients that have advanced prostate cancer and you have androgen blockade you have an uh androgen receptor blockages you have medications that actually stop the production of androgens from they're all made from cholesterol you can block the production of the of the energies we have immunotherapy to treat problems yes we didn't even talk about that yeah and i'm missing something uh well obviously you have chemotherapy right and chemotherapy uh doesn't seem to be a therapy that is often associated with prostate cancer i feel like it's surgery it's radiation and every now and again if there is a metastasis there's chemotherapy involved am i wrong chemotherapy was chemotherapy is actually the first thing that was tried okay after you know once you you put them on androgen blockade and they they no longer respond the next thing they did was chemotherapy chemotherapy is harsh in most circumstances and so we've always been looking for other ways of treating the prostate cancer that aren't as harsh and there are a lot of medications and there are actually different stages and different kinds of medications for those stages like if you have a patient that presents and he has advanced disease but he's never been treated you can give them the the androgen you can block the the male hormone plus you can give them another type of medication it either blocks a synthesis or blocks the the receptors of the androgen and the cancer cell okay well there's some medications approved for that there are other medications that are approved for if the pa if the patient has already his psa starts rising after uh he's been treated with these with androgen blockade and uh but they'd have no evidence of metastatic disease they have another group of medications for that if they do have metastatic disease they have another group of medications for that and and it becomes more and more complicated but a lot of these things and now and then we're starting to get into other forms of therapy like immunotherapy we're using parp inhibitors which are used a lot for breast cancer see this is where we've got like seven minutes left but that's what we need to talk about too next time in fact i'm going to make that one on my for the next time we do that um on that note since we have seven minutes i'm going to stop any questions from myself in the audience right now and i want you to talk about something or we can continue on that that we haven't covered yet tonight or something you just want to get across tonight that you know before the show wraps up you know how quickly that happens the i sort of want to do a little bit of a variation of that because as i told you earlier i run an advanced prostate cancer clinic and usually when these people start their prostate cancer advances my partners send those patients to me some of these patients use travis's help because if they have you know like they have a lot of bone pain and they have a metastasis to one of their bones he can treat that and he can get rid of that pain it's paleo palliative but it actually helps the patient right but the whole the message that needs to go out as far as that's concerned is that we can give these patients more time and we can give these patients more quality time exactly and it tends to be a sequential treatment like if they come in we can give them the first we can you know usually these patients have either been on lupron or they've been on some other kind of medication that blocks their male hormone and it's no longer working and so then we can we can give them an androgen receptor blocker or an androgen synthesis blocker i know these are confusing terms but then we can also give them immuno actually the next step is supposed to be immunotherapy where we actually take the patient's cancer or a patient's white blood cells out of his body and then we send those to atlanta they treat those cells and teach them how to fight the cancer and they bring those cells and give them back to the same patient three days later okay it doesn't affect the psa but in in these patients that are in good you know they're still in in good performance status they can give them up to 12 to 14 months of additional time it does not affect the psa no but it does affect long-term survival interesting and it's a three and i i feel like there's that is not the wave of the future it's happening right now but there's more and more every single research every single day and so three days that's gone comes back three days and it starts building up your system more and more well it's actually three treatments two weeks apart three treatments okay and then usually let's say that person has gone for a year could they redo that treatment again no they're not approved for that but if they have if they have cancer in the bones we have radium-223 which dr mendel can tell you a little bit about okay go radium-223 do it so this is a form of injectable like liquid radiation that hones to the bones and is used to treat patients who have you know mini bone metastasis and to kind of build on what dr vogelweed was was talking about in his clinic radiation you know there used to just be patients who have a localized prostate cancer and metastatic prostate cancer but now we're kind of figuring out that patients that have what's called oligometastatic cancer just several lesions in the bones or you know somewhere else this is a different state that's differentiated from patients who have numerous lesions that that you can't target and so now the field is kind of moving towards treating these these lesions these you know two three four five lesions and the bones and the lung and the liver and all different cancer sites and we're finding that treating these lesions is improving patient survival and so this is this is something that i think is going to be very um you know we're going to be talking to each other a bunch because we're you know this this is a state that people are now realizing and it's coming out just in very recent recent papers in the last two or three years that this is the next year's show is gonna let's focus on that too so explain to me when you say when you say liquid radiation my head is thinking okay you're injecting radiation and it's going everywhere that's not the case right what does that mean how are you distributing the liquid radiation so it basically comes in a syringe we order it um and it has a certain half-life and so how long that the the fluid is active okay basically it's it's um radium-223 that's been dissolved in a fluid um you inject it just like you you know start an iv i walk in the room there's a syringe there and i inject it into the into the patient's arm and it's it's all weight-based but basically it knows where to go well it travels to the bones the for whatever reason this this likes to go to the bones um and that's where the prostate cancer likes to go and so it goes there and it and it treats those areas and it's it's very effective for patients who have multiple lesions we can use external beam too if they're having focal areas of pain but this is actually the radium 223 was shown to actually have a survival benefit in patients and this is specifically for patients who are castrate resistant and bone cancer once the cancer gets the bones it's it's painful so that that really helps too with palliative care exactly it can be painful it can't okay it can be because some people have mets all over the place and then not having a lot of pain radium 223 radium is in the same column as calcium okay okay and the periodic table elements and so the actually the the the cells that build up the bone can grab that radium instead of calcium and that's how they they that's how and then once they pick it up it's right next to the cancer cells that are destroying bone and it's a very you know what two or three millimeter penetration yeah it's very and and so it that's why even though you get it it doesn't have this effect that it's going to affect the rest of the family when you get home right right you're not very very tolerable too uh two quick questions from the audience got three minutes which is forever uh question is is there a risk of prostate cancer with testosterone replacement therapy again that's all we know that's as basic as the question is i'm throwing that your way it doesn't you know testosterone thera replacement therapy if it's done properly doesn't have anything to do with prostate cancer okay right and i think what happened there they were listening to hormone therapy but if you have prostate cancer don't do do not do testosterone because that you know prostate cancer feeds on that testosterone right which makes sense another quick question k4 exam what is the credibility of a k4 exam checks for genetic inclination question from the audience it's a 4k exam 4k yeah there are about four different exams if a patient comes in and let's just say he has a psa of 2.5 to me that sort of says well i have to look at this guy a little bit a little bit more in depth so i'm not going to take them directly to a biopsy but there are several exam i mean there's a phi score there's a 4k score there's a pca 3 and the one that i use which is a now i've got a metal block but basically what it is is a urine test and what they do is they tell you whether or not there is a risk for prostate cancer um yeah select mdx is the one i use so they that can tell if you have a risk yeah if it comes back it says there's a risk of prostate cancer then you take them and you do a biopsy if they say there's a very low risk then you just watch the psa i did not realize that was out there just just the idea of having the risk i i stayed away from screening tonight but we have two minutes to go just throw out there really quickly what the screening guidelines are at least today today i encourage every single family practitioner primary care physician to screen any patient over the age of 50 for prostate cancer okay by doing a psa in a rectal exam and if they're black or if they have a family history starting at 40 or 45 all you have to do is do a psa if that psa comes back at 0.7 they don't have to repeat it for five years exactly now i wanted to get that in because i i feel like those have changed every year and that's always like the first 20 minutes of discussions i want to kind of get that in so again 50 and over definitely go get your psa and digital rectal exam family physician they can do that for you there um i want to say thank you very much to real grand urology um nice to have you guys here and if you want to see the show again you can find it at www.pbselpaso.org or you can also go to the el paso county medical society website which is epmcs.com and also this has been on youtube so you will be able to find this on youtube again just type in el paso position and look in prostate cancer and you'll find this show and all the other shows that we've done as well i want to say again very much thank you to dr vogelweed thank you for dr mendel um aiza thank you very much andriy taka thank you very much those are our two second year medical students who have been helping us out a lot tonight and there's a lot of dings going on on my phone so i appreciate that i'm katharine berg and you've been watching the el paso position [Music] [Music] is known can 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