<b>Hello, my name is Dr.

Sarah Walker,</b> <b>and I'm honored to serve</b> <b>as the 2025 president</b> <b>of the El Paso County Medical Society.</b> <b>On behalf of our organization,</b> <b>I want to welcome</b> <b>you and thank you for tuning in</b> <b>to the El Paso Physician.</b> <b>For the past 28 years,</b> <b>the El Paso physician has been dedicated</b> <b>to serving our community,</b> <b>and we are grateful</b> <b>for the continued opportunity</b> <b>to bring this program</b> <b>to you on PBS El Paso.</b> <b>This would not be possible</b> <b>without the generous support</b> <b>of our community sponsors, who help us</b> <b>produce valuable content every month.</b> <b>If you or someone you know is interested</b> <b>in supporting this program,</b> <b>more information is available</b> <b>at (915) 533-0940 or at EP MED SOC</b> <b>at aol.com.</b> <b>Thank you again</b> <b>and we hope you enjoy this program.</b> <b>Presented by the El Paso County Medical</b> <b>Society and hosted by Kathrin Berg.</b> <b>Today, the doctors</b> <b>and the staff of the El Paso County</b> <b>Medical Society would like to honor</b> <b>the remarkable life and legacy of Doctor</b> <b>Richard McCallum, a past president</b> <b>of the El Paso County Medical Society</b> <b>and a delegate to the Texas</b> <b>Medical Association.</b> <b>Doctor McCallum took over the reins,</b> <b>overseeing the production of this</b> <b>very program</b> <b>after the passing of Dr.

Raj Marwah.</b> <b>Dr.

McCallum personally underwrote</b> <b>several episodes of the El Paso Physician.</b> <b>Dr.

McCallum was a pioneering</b> <b>physician in gastro electrophysiology,</b> <b>and he was the inventor</b> <b>of the gastric pacemaker.</b> <b>Born and raised in Australia, Dr.</b> <b>McCallum had a charming Australian accent</b> <b>and endearingly called himself</b> <b>the Tummy Doc.</b> <b>After many leadership positions</b> <b>around the world,</b> <b>he became the founding chair</b> <b>and professor of medicine at the Texas</b> <b>Tech University Health Sciences</b> <b>Center of El Paso, in conjunction</b> <b>with the Rotary Club of El Paso.</b> <b>He founded The Rotacare</b> <b>a care free medical clinic</b> <b>which was recently renamed The Dr.</b> <b>Richard McCallum Rotacare clinic.</b> <b>His last appearance on this program</b> <b>was just a few months ago.</b> <b>He underwrote and was a panelist</b> <b>for The Rotacare Clinic episode.</b> <b>You can find that episode on PBS</b> <b>ElPaso.org</b> <b>EPCMS.com, or on YouTube.com.</b> <b>Search the El Paso Physician</b> <b>and Rotacare medical clinic.</b> <b>Thank you, Doctor Richard McCallum,</b> <b>for all the lives that you have touched.</b> <b>Farewell, dear friend.</b> <b>Treatments for prostate</b> <b>cancer have been very interesting</b> <b>to watch over the last several decades.</b> <b>Screening guidelines have also changed</b> <b>quite a bit.</b> <b>We're going to be discussing the nuts</b> <b>and bolts of prostate cancer,</b> <b>and we're going to be talking about</b> <b>the new research</b> <b>that leads to advancements in treatments.</b> <b>This program is underwritten by Rio</b> <b>Grande Urology</b> <b>and Rio Grande Cancer Specialists.</b> <b>And a big thank you to the El Paso</b> <b>County Medical Society</b> <b>for sponsoring this program.</b> <b>I'm Kathrin Berg,</b> <b>and this is the El Paso physician.</b> <b>Neither the El</b> <b>Paso County Medical Society,</b> <b>its members or PBS</b> <b>El Paso shall be responsible</b> <b>for the views, opinions or facts</b> <b>expressed by the panelists</b> <b>on this television program.</b> <b>Please consult your doctor.</b> <b>Thanks again for joining us this evening.</b> <b>We're talking about the nuts</b> <b>and bolts of prostate cancer.</b> <b>And with us, we have two of our veterans.</b> <b>And I love having</b> <b>both of you guys on the show.</b> <b>We have Doctor Travis Mendel,</b> <b>who is a radiation oncologist</b> <b>over at the Rio Grande Urology</b> <b>and Rio Grande Cancer specialists.</b> <b>And then we also have Doctor Jeff Spier,</b> <b>who is a urologist.</b> <b>And again,</b> <b>thank you so much for being here.</b> <b>I know we've done many shows together,</b> <b>and every time we leave with something new</b> <b>that I haven't heard about before</b> <b>and many people in the audience</b> <b>haven't heard about before.</b> <b>So I want to start with asking Travis.</b> <b>So again, you are a radiation oncologist.</b> <b>Explain to our audience what that is.</b> <b>So, so basically</b> <b>we see patients in their clinic</b> <b>mostly with cancer, but we also see</b> <b>non-cancerous conditions as well.</b> <b>And we use external beam radiation or even</b> <b>or internal radiation to treat tumors.</b> <b>And so the</b> <b>majority of my practice is the,</b> <b>you know, Doctor Spier here.</b> <b>Jeff will send me a patient</b> <b>that has prostate cancer,</b> <b>and we'll evaluate them and explain</b> <b>to them their different treatment options,</b> <b>whether it's active</b> <b>surveillance, surgery, radiation,</b> <b>and if they choose to do radiation.</b> <b>We kind of explain that process to them.</b> <b>And and one of these slides, you can see,</b> <b>on slide</b> <b>three that there's where the prostate is.</b> <b>And then also the, the beams</b> <b>that are being directed at the prostate,</b> <b>to focus the radiation dose on that.</b> <b>I love that you brought those slides,</b> <b>because we're going to talk a little bit</b> <b>about that in a minute, too,</b> <b>because I think sometimes people hear</b> <b>prostate cancer but don't really realize</b> <b>where the prostate is, what the functions</b> <b>are and all that good stuff.</b> <b>So as a urologist,</b> <b>this is a perfect transition.</b> <b>So, your urologist, but you have,</b> <b>as far as I've known, you specialize</b> <b>in prostate cancer the entire time</b> <b>that we've actually had programs together.</b> <b>So what does that mean?</b> <b>I mean,</b> <b>I think we should kind of even dedicate</b> <b>this program to Doctor Vogel, right?</b> <b>He's he had been doing this</b> <b>for so many years.</b> <b>So credit to him.</b> <b>And and just for the for the public</b> <b>to learn more about prostate cancer.</b> <b>So, shout out to Doctor Vogel.</b> <b>So no, I mean, I've</b> <b>been wearing a couple of hats</b> <b>for about 2 or 3 years,</b> <b>but primarily, you know,</b> <b>I'm trained as a general urologist.</b> <b>And so we see, you know, everything.</b> <b>What I like to describe as the kidneys</b> <b>all the way down, you know,</b> <b>I think of my daughter getting embarrassed</b> <b>when I, you know,</b> <b>she tells her friends what what you know</b> <b>what when they ask what her urologist is.</b> <b>But really, we we</b> <b>we are basically specialists.</b> <b>It stands for the genital urinary system.</b> <b>So anything from kidney stones</b> <b>to bladder cancer to enlarged prostate</b> <b>to testicular cancer</b> <b>and a bunch of female, patients as well.</b> <b>So we treat about 30 to 40% of female.</b> <b>In my practice it's about 15 to 20%.</b> <b>So chronic urinary tract infections,</b> <b>you know, overactive bladder.</b> <b>So it's it's a wide swath, right?</b> <b>But I've been wearing this</b> <b>hat of advanced prostate cancer</b> <b>now for for three years.</b> <b>And it's been, you know,</b> <b>just one of the highlights of my career.</b> <b>So that's what we're going to talk about</b> <b>tonight is specifically prostate cancer.</b> <b>I like that.</b> <b>And when we're talked about,</b> <b>advanced prostate cancer,</b> <b>we have been hearing a lot</b> <b>about President Biden too.</b> <b>And so we're going to talk about what</b> <b>people are hearing on the air.</b> <b>And this is social media</b> <b>as well as main media, mainstream media.</b> <b>What exactly is going on with him?</b> <b>How is that relate</b> <b>to other people in the world, etc.

?</b> <b>So I in a weird way,</b> <b>it's it's kind of neat,</b> <b>to have somebody that is in the forefront</b> <b>right now in the mainstream media.</b> <b>I'd like to start with</b> <b>and Travis, you started this off earlier.</b> <b>We do have a great graphic</b> <b>that shows where the prostate or what</b> <b>the prostate is, but I'd love for you</b> <b>to describe the function of the prostate.</b> <b>Why is it such a big deal?</b> <b>Why do we hear about prostate</b> <b>all the time?</b> <b>Oh, I mean, the sphere</b> <b>that's actually yours.</b> <b>So I mean, the prostate is what I call</b> <b>a nuisance, organ.</b> <b>I mean, it really is.</b> <b>I mean, for men,</b> <b>it doesn't serve much of a purpose</b> <b>besides producing seminal, seminal semen,</b> <b>basically.</b> <b>So seminal fluid, to keep the sperm alive</b> <b>and to make it to their destination.</b> <b>Okay,</b> <b>so beyond that, it gets large as we age.</b> <b>It creates symptoms.</b> <b>And it is obviously an organ that has</b> <b>a high risk of developing prostate cancer.</b> <b>So it's about walnut sized.</b> <b>It sits between the bladder</b> <b>and the urethra.</b> <b>And essentially it is just</b> <b>it produces</b> <b>along with the seminal vesicles, semen.</b> <b>And so,</b> <b>you know, it creates a ton of problems.</b> <b>And of course,</b> <b>we we obviously require it, but</b> <b>that's what we're here for is to treat,</b> <b>you know, benign and malignant disease.</b> <b>And that's such a great way of going into</b> <b>screenings, because you've got screenings</b> <b>that can see if there are benign issues</b> <b>or malignant issues.</b> <b>So I feel like, again,</b> <b>we've been doing this show for 28 years.</b> <b>There's always screening issues</b> <b>and questions around prostate cancer.</b> <b>Where are we now</b> <b>in what is recommended for screenings?</b> <b>Yeah, it's a really good point</b> <b>because it seems like we've confused</b> <b>the general public a little bit.</b> <b>Maybe I can just tell sort of a story.</b> <b>I love case kind of have</b> <b>a not not necessarily specifically,</b> <b>but you know what men are hearing</b> <b>from their primary care</b> <b>and sort of the sequence of events</b> <b>when they end up with us.</b> <b>Typically men should be</b> <b>screened for prostate cancer</b> <b>at 50 years old.</b> <b>And that is done by a PSA.</b> <b>And the digital rectal exam.</b> <b>We still advise</b> <b>our primary care associates to do so,</b> <b>but that's not as common anymore</b> <b>because they're relying a lot</b> <b>on the PSA on the blood test.</b> <b>So bingo.</b> <b>That's exactly what I was gonna say.</b> <b>So explain to the audience</b> <b>what a PSA is and what I'm sorry.</b> <b>Good.</b> <b>So the PSA stands for prosthetic specific</b> <b>antigen.</b> <b>And it's an enzyme</b> <b>that's secreted from the prostate</b> <b>that goes into your bloodstream.</b> <b>And basically it's a screening test</b> <b>that we can look at a number and say okay,</b> <b>there's something we need to look at.</b> <b>But everyone needs to understand that</b> <b>PSA is not specific for prostate cancer.</b> <b>Men get very anxious</b> <b>when their primary care doctor says,</b> <b>your PSA is elevated, and it's our job</b> <b>to tell them, look, it can be elevated</b> <b>for many different reasons, elevated</b> <b>because of benign prostatic enlargement</b> <b>or what we call BPH</b> <b>when the prostate gets large inflammation,</b> <b>sitting on a park bench for five hours,</b> <b>I mean, being a bicyclist.</b> <b>So we don't just panic patients</b> <b>about the PSA.</b> <b>It comes in different flavors.</b> <b>And so that's really what we try to,</b> <b>you know, as we sort of partner</b> <b>with our internal medicine colleagues, we</b> <b>we typically want that referral</b> <b>and we want to see those patients.</b> <b>And in 2012, 2013, the US</b> <b>Preventive Task Force came out</b> <b>and really downgraded PSA.</b> <b>And there became it became a problem</b> <b>for urologists because they graded it a D.</b> <b>And so a lot of the screening</b> <b>kind of fell through the cracks.</b> <b>So, you know, it's really still</b> <b>an important screening test.</b> <b>There are other ways to screen</b> <b>for prostate cancer we'll get into</b> <b>including imaging, including an MRI.</b> <b>But it is important to get it.</b> <b>And I failed to mention the risk factors</b> <b>for African American men.</b> <b>We typically say start at 40.</b> <b>And with family</b> <b>history of prostate cancer,</b> <b>we want them screening</b> <b>at 40, sometimes younger.</b> <b>So it's</b> <b>it's a moving target, Kathrin.

It's</b> <b>not something that's just set in stone</b> <b>and the numbers are not set in stone.</b> <b>Let me briefly talk to you about that</b> <b>because that's confusing.</b> <b>Men think 4.0.</b> <b>That number is sort of okay I'm fine.</b> <b>If it's below 4.0, that's not the case.</b> <b>This is an age adjusted PSA.</b> <b>So you have to take a 45 year old</b> <b>very differently than the 75 year old.</b> <b>Right.</b> <b>And so you know, typically 2.5</b> <b>if it's above that in a 50-55 year</b> <b>old male,</b> <b>that's going to raise some eyebrows.</b> <b>So it's important for</b> <b>this is such a great program</b> <b>because the audience needs to know that,</b> <b>you know, you need to ask questions</b> <b>and you need to do your due diligence</b> <b>because that 4.0 cutoff is not</b> <b>necessarily, you know, the end all be all.</b> <b>So a great question</b> <b>after that to follow is</b> <b>that you have now a 2.5 or 75 years old</b> <b>and this person hasn't.</b> <b>So it's a blood test.</b> <b>Let's talk about where</b> <b>where do you go from there.</b> <b>So you've got your</b> <b>your prostate cancer number now</b> <b>or the PSA number not your cancer number.</b> <b>Your PSA number.</b> <b>When does a digital rectal exam come in?</b> <b>Does it come in with.</b> <b>So I think in a primary</b> <b>doctor something in primary doctor</b> <b>you go in, you get your blood test done.</b> <b>You've got to raise PSA.</b> <b>Now we're going to go see a doctor.</b> <b>You would hope that the primary care</b> <b>doctor</b> <b>is getting the PSA</b> <b>and doing a rectal exam yearly.</b> <b>We really recommend yearly.</b> <b>Sometimes we recommend to spread that out</b> <b>if their PSA has been normal</b> <b>over a course of time.</b> <b>We can sometimes say every two years,</b> <b>sometimes every five if it's extremely</b> <b>low, if there's any question at all,</b> <b>there needs to be a referral.</b> <b>But the digital rectal exam</b> <b>remains important.</b> <b>I mean, a lot of my colleagues, myself,</b> <b>we've caught cancer</b> <b>when PSA was less than one, for example,</b> <b>we found a nodule exactly.</b> <b>And that's exactly my point.</b> <b>So what are you looking for</b> <b>while you're feeling the prostate?</b> <b>You are.</b> <b>And you're looking for enlargement.</b> <b>Sure, sure.</b> <b>I mean, basically you're looking for</b> <b>any abnormalities a nodule,</b> <b>a mass irregularity</b> <b>if one side is larger than the other.</b> <b>You know, obviously not</b> <b>the most comfortable exam men are very,</b> <b>you know, they don't get excited</b> <b>to come see the urologist.</b> <b>But this is for the audience.</b> <b>Women don't want me, examiner.</b> <b>Yeah, and there we go through it, too.</b> <b>You know, we just do it in different</b> <b>ways.

But, yeah, I'm with you on that.</b> <b>And that's why I wanted to talk about it.</b> <b>I wanted to not.</b> <b>There's PSA this digital rectal exam</b> <b>is exactly what it is.</b> <b>But it's uncomfortable.

But it it matters.</b> <b>So now we feel a nodule.</b> <b>We feel something that's off.</b> <b>And so now do we go to imaging from there</b> <b>to further</b> <b>diagnose or see what's going on usually.</b> <b>So if it's on like a primary care</b> <b>care's office,</b> <b>they're going to send them to Jeff,</b> <b>you know, and then Jeff is going to look</b> <b>at, you know, look at the whole scenario.</b> <b>Most likely</b> <b>you know, the age of the patient,</b> <b>you know, their family history,</b> <b>all of these things,</b> <b>there's new there's new tests</b> <b>where we're actually testing the urine</b> <b>and looking for</b> <b>kind of like cancer signals.</b> <b>And it can actually</b> <b>risk stratify the patients,</b> <b>you know, whether or not they're going</b> <b>to, you know,</b> <b>be at high risk for being diagnosed</b> <b>with prostate cancer on biopsy.</b> <b>And, the reason people are so,</b> <b>you know, obsessed with this</b> <b>and the reason that the US task force</b> <b>downgraded in 2012</b> <b>is because everyone was getting biopsies</b> <b>and then everyone was getting infections,</b> <b>and it was it was causing</b> <b>a lot of morbidity for patients.</b> <b>Not everyone,</b> <b>not everyone, but, very rarely.</b> <b>But they just thought that the risk but</b> <b>they looked at the risk benefit scenario.</b> <b>Yeah.</b> <b>So but now now it's</b> <b>kind of like they've kind of backpedaled</b> <b>and now, you know now it's more in vogue.</b> <b>And so we're doing biopsies</b> <b>and things like that.</b> <b>And what we do now is we're</b> <b>just smarter about it.</b> <b>Right.</b> <b>We're going to, you know,</b> <b>you know, stratify the patients up front.</b> <b>We'll get imaging usually an MRI.</b> <b>And then a lot of times</b> <b>it would just be doing kind of like,</b> <b>like focused biopsies in areas</b> <b>that are suspicious for prostate cancer.</b> <b>But, you know, in medicine</b> <b>and I'm I'm constantly</b> <b>telling the patients</b> <b>this there's no absolutes in medicine.</b> <b>You know, there's no guarantees</b> <b>like the imaging isn't perfect,</b> <b>the PSA isn't perfect, this isn't perfect.</b> <b>But we use all these</b> <b>all these methodologies</b> <b>to to try to make the best decision</b> <b>for the patient.</b> <b>And it's, it's that's</b> <b>how it's always just let me piggyback off</b> <b>Travis for a minute on the imaging</b> <b>because that is new.</b> <b>So MRI technology has come on the scene.</b> <b>It's been a game changer because now</b> <b>we're able to use oh, I don't know.</b> <b>It's been around for</b> <b>at least 8 to 10 years.</b> <b>But over the last</b> <b>I would say five years to eight years.</b> <b>And even more recently they've become</b> <b>better and better at reading these MRIs.</b> <b>It's not everything,</b> <b>but it's another tool.</b> <b>I call it the three legged stool.</b> <b>As far as the PSA, the rectal exam</b> <b>and now MRI is to just kind of help</b> <b>guide us because they can see lesions</b> <b>that may be suspicious now okay.</b> <b>So that's been that's</b> <b>that's been a game changer okay</b> <b>I don't want to focus</b> <b>too much time on this.</b> <b>But you did say something too,</b> <b>that you can,</b> <b>have a urine screening and sometimes</b> <b>you can see something in the urine.</b> <b>What is it?</b> <b>Go back to that, if you don't mind.</b> <b>I don't</b> <b>I don't remember hearing much about that.</b> <b>So what's the name?

It's a biomarker.</b> <b>So these are biomarkers.</b> <b>And now they're in the urine.</b> <b>So you know you have to pick</b> <b>and choose when to use it.</b> <b>There is a 4K score test that that that.</b> <b>And there's also this exosome DX</b> <b>which basically looks</b> <b>at a biomarker</b> <b>and is looking at genetics to help.</b> <b>It's not definitive,</b> <b>but again, it's sort of a way to steer us</b> <b>in the right direction</b> <b>and look at risk profile on patients.</b> <b>So I almost see that as context.</b> <b>These are biomarkers basically.</b> <b>And just more information</b> <b>for us to make a decision okay.</b> <b>And another another thing to look at it</b> <b>is, you know when we do</b> <b>our biopsy is like say, you know,</b> <b>Jeff does a template biopsy or even I do.</b> <b>It's targeted biopsy.</b> <b>We can miss things, you know.</b> <b>And so like</b> <b>if you have a patient has an elevated PSA,</b> <b>they have some biomarkers</b> <b>that are positive.</b> <b>We do the biopsies.</b> <b>It's negative</b> <b>that someone you're kind of going to be,</b> <b>you know, wanting to keep an eye on not,</b> <b>you know, not just saying, oh, you're not</b> <b>you don't have cancer.

You're fine.</b> <b>It's like, hey,</b> <b>we're going to keep a close eye on you</b> <b>because you're at high risk</b> <b>for having cancer for all these reasons.</b> <b>And again, it's</b> <b>just like we have humans, you</b> <b>know, doing these diagnosis, and we can</b> <b>we can miss things.</b> <b>Yeah.</b> <b>And so it's always,</b> <b>you know, it's always smart</b> <b>to get all your information and, you know,</b> <b>utilize it upfront.</b> <b>Makes sense.</b> <b>So when we're at a point</b> <b>where, we are diagnosing</b> <b>and somebody is diagnosed</b> <b>now with prostate cancer,</b> <b>how does the diagnosing of staging happen</b> <b>from there?</b> <b>There's Gleason scores.</b> <b>There's staging of the prostate.</b> <b>How how does that how does that work.</b> <b>And I'm throwing that to,</b> <b>you know, this is good because right now</b> <b>the audiences with PSA, MRI, DRE</b> <b>Let's just say that we are suspicious.</b> <b>We biopsy either a template, biopsy</b> <b>the 12 biopsies, but now we're moving</b> <b>towards more of a targeted biopsy.</b> <b>So they get the biopsy.</b> <b>It comes back cancerous many times.</b> <b>It doesn't.

Many times</b> <b>it comes back benign.</b> <b>But when it does there's different grades</b> <b>and a grade</b> <b>grouping of this cancer</b> <b>that kind of steers our direction.</b> <b>And that's the Gleason score</b> <b>that you talk of.</b> <b>And that's a pathologic score.</b> <b>That's some thought.</b> <b>That's the pathologist</b> <b>that looks under the microscope.</b> <b>And they're able to ascertain whether it's</b> <b>a Gleason six, seven, eight, 9 or 10.</b> <b>And ten is very aggressive sixes</b> <b>typically sometimes most of the time.</b> <b>Now with Gleason six for example,</b> <b>we're not doing anything.

Wow.</b> <b>Even with sometimes on sevens.</b> <b>And there are two scores.</b> <b>There are two scores.</b> <b>It's either a three, 4 or 5</b> <b>and you double that up.</b> <b>So I'm not you know, you can do the math.</b> <b>Three plus three is six and five</b> <b>plus five can get you.</b> <b>That's just a quick math lesson okay.</b> <b>Thank you.</b> <b>And so basically from six</b> <b>being really low grade to a ten</b> <b>being very dangerous, that's</b> <b>sort of the decision path that we take,</b> <b>whether or not we're going to.</b> <b>And we're going to go briefly</b> <b>over the local treatments.</b> <b>If we if it's localized versus once,</b> <b>you know, it's high risk,</b> <b>sometimes it's already outside of the box</b> <b>and it's metastasize.</b> <b>And we don't have the option</b> <b>for localized treatments.

Okay.</b> <b>So that's a great time</b> <b>to talk about localized treatments</b> <b>because we do want to talk and focus a lot</b> <b>this evening on advanced</b> <b>prostate cancer.</b> <b>So let's talk about localized</b> <b>now that it has not metastasized yet.</b> <b>What are some of the treatment</b> <b>options there.</b> <b>What is okay I'll quickly go through</b> <b>this as Travis will talk about.</b> <b>There's you know, really right now</b> <b>the goal center or to two choices.</b> <b>There's two tracks.</b> <b>And when men come</b> <b>and they want to talk about therapy</b> <b>that we know that can help them</b> <b>locally, it's either the robotic</b> <b>prostatectomy or what you've heard of</b> <b>the da Vinci robot, the fancy tool</b> <b>that we've had for many years since,</b> <b>you know, 2004, it's been around.</b> <b>So it's not new anymore.</b> <b>Or radiation therapy.</b> <b>Now that patients will come in</b> <b>and talk about high intensity</b> <b>focused ultrasound or focal therapies</b> <b>or different ways to treat the cancer</b> <b>with different energies,</b> <b>that's not really standard of care if yet,</b> <b>because the studies are</b> <b>yet to prove that out.</b> <b>So the gold standard really</b> <b>just for simplicity's sake, is surgery</b> <b>or radiation.</b> <b>And that's where robotic surgery we have,</b> <b>you know, we have a few roboticists</b> <b>in our, in our group.</b> <b>They're very obviously very capable.</b> <b>And basically it's, it's about a two</b> <b>and a half</b> <b>to four hour surgical procedure, 1</b> <b>to 2 night stay,</b> <b>small, minimally invasive procedure</b> <b>to remove the prostate,</b> <b>take it out, cross-section it,</b> <b>look at the margins.</b> <b>And that's the advantages.</b> <b>The prostate comes out.</b> <b>And we can see if the margins are negative</b> <b>and it's curative a point.</b> <b>If you catch prostate cancer prostate</b> <b>cancer early it's almost always curative.</b> <b>I mean that's the beauty of screening.</b> <b>It's when it becomes advanced</b> <b>which we'll get into that's the problem.</b> <b>So that's robotic surgery.</b> <b>And I love that you say that.</b> <b>It's just get your screening</b> <b>so you can find out what's going on.</b> <b>If you can get rid of it, get rid of it.</b> <b>So that's one of the reasons</b> <b>that we're here on the show.

Right.</b> <b>And then there's radiation,</b> <b>which is there's radiation.</b> <b>So I first before we go to radiation,</b> <b>the questions always beg,</b> <b>what are some of the complications</b> <b>that can happen with surgery.</b> <b>What are some of the complications</b> <b>with radiation.</b> <b>So that's going to come as a</b> <b>side is a sidebar.</b> <b>Yeah I mean surgery surgery right.

You</b> <b>they have to be usually healthy.</b> <b>I mean, you have to understand anesthesia.</b> <b>There's a risk just by itself.</b> <b>But the two that we talk about</b> <b>is erectile dysfunction and incontinence.</b> <b>Those are the ones that the patients</b> <b>really need to know about.</b> <b>Because in the right hands,</b> <b>those those percentages fall.</b> <b>But you have to do your due diligence.</b> <b>Our surgeons have done hundreds of these.</b> <b>All of the ones that are in</b> <b>our group are capable</b> <b>and they're there, you know,</b> <b>of course things happen.</b> <b>But those are the two obviously most</b> <b>perplexing side effects or complications.</b> <b>And talk about the low levels</b> <b>of those complications,</b> <b>because I think that's important to</b> <b>to throw out there</b> <b>because you say that out there,</b> <b>it's like, well, how you know,</b> <b>you don't have to give me</b> <b>a good percent now.</b> <b>But Kathrin, it really depends on</b> <b>how the patient presented.</b> <b>If a 75 year old is coming to us</b> <b>with ED already, it's he's done,</b> <b>you know, or just a little bit of ED,</b> <b>we say the chances are not very good.</b> <b>There's nerve sparing techniques during</b> <b>this procedure to spare those nerves.</b> <b>And if it's more aggressive,</b> <b>sometimes those nerves can't be spared.</b> <b>So in the in the perfect scenario,</b> <b>I don't have specific numbers.</b> <b>But you know, Ed can sometimes be up</b> <b>in the 40% to 50% range, right?</b> <b>If they're young and healthy</b> <b>and they have a healthy sex life,</b> <b>maybe it's 15 to 20%.</b> <b>Okay.</b> <b>But incontinence is another risk factor.</b> <b>You know, patients early on can can</b> <b>when they laugh, sneeze, cough,</b> <b>they can leak,</b> <b>they can have persistent leakage.</b> <b>So, it just it's very variable.</b> <b>Exactly.</b> <b>And that's a good way of saying it too.</b> <b>All right.

Radiation.

Here we go.</b> <b>Well, so I guess</b> <b>I'll kind of take a step back here.</b> <b>So when I see the patients,</b> <b>I'm always looking to not treat them</b> <b>like a.</b> <b>So I want to do, like,</b> <b>active surveillance.</b> <b>That's kind of my, my number one goal.</b> <b>And so I'm trying to figure out okay</b> <b>what does the patient have.</b> <b>Is it safe to do active surveillance.</b> <b>And that's why the biopsies</b> <b>are so important nowadays.</b> <b>Back, you know, ten, 20 years ago</b> <b>they were just doing,</b> <b>you know, random biopsies and doing this,</b> <b>you know, based care off that.</b> <b>But now we're able to, to, to actually</b> <b>like risk stratify the patients</b> <b>with imaging and things like that</b> <b>and actually target those lesions.</b> <b>And so it makes a huge it's,</b> <b>it's a it's a massive thing</b> <b>for active surveillance</b> <b>because you can put</b> <b>someone active surveillance</b> <b>but not have the full picture.</b> <b>And they have</b> <b>they have worse disease than you think.</b> <b>And they progress.

They become metastatic.</b> <b>And it's a big problem.</b> <b>And so so we we utilize the these targeted</b> <b>biopsies that I do quite a few of,</b> <b>in order to kind of help</b> <b>stratify those patients.</b> <b>Another thing that's very important</b> <b>nowadays is something called molecular</b> <b>testing.</b> <b>There's different groups,</b> <b>that have different molecular tests.</b> <b>We primarily use</b> <b>a company called decipher,</b> <b>and it gives you they use,</b> <b>what's called a microarray analysis,</b> <b>but they analyze the RNA products</b> <b>of the cancer, like the cancer cells,</b> <b>and they're able to give you an actual,</b> <b>like,</b> <b>risk, you know,</b> <b>like either a high risk intermediate risk</b> <b>or low risk based off the molecular</b> <b>profile of the tumor.</b> <b>And why that's important is the Gleason</b> <b>score was developed back in like the 60s,</b> <b>something like like a long,</b> <b>a long time ago.</b> <b>And we're still we're</b> <b>still using that system.</b> <b>And most of the other,</b> <b>you know, tumors that we treat</b> <b>don't use the like the path</b> <b>to create the scoring anymore.</b> <b>We use other you know, other markers.</b> <b>And so this I think, you know, fast</b> <b>forward in 5 or 10 years,</b> <b>I think we're going to be using a lot more</b> <b>of these molecular scores</b> <b>than actually relying</b> <b>on the Gleason score.</b> <b>But anyways, with the Gleason score,</b> <b>you're you have a human telling you</b> <b>what they think these cells look like in</b> <b>humans are not reliable.</b> <b>You know, like they're just not like</b> <b>you give it to five different</b> <b>pathologists are going</b> <b>to give you five different answers.</b> <b>And so like when you have a computer</b> <b>analyze it and look at like</b> <b>the actual products of the tumor,</b> <b>your diagnosis is going to be much</b> <b>more accurate, right?</b> <b>So so that's another,</b> <b>you know, concept that we use for</b> <b>for patients that are undergoing</b> <b>active surveillance is we'll do a biopsy.</b> <b>We'll make sure we have the full picture</b> <b>and we'll run the molecular analysis</b> <b>on that patient to make sure that they're</b> <b>not at high risk of progression.</b> <b>And that's done with the biopsy.

Right.</b> <b>So it's just taken the tissue</b> <b>from the biopsy and doing them.</b> <b>And and you have to get</b> <b>the correct tumor.

Right.</b> <b>So you can't just like</b> <b>if you just do a biopsy and sample</b> <b>like a little small tumor in the prostate.</b> <b>But you missed the big beefy one</b> <b>that was above it, you're not going to get</b> <b>the molecular picture</b> <b>of the cancer in there.</b> <b>You're just getting like a random spot</b> <b>that had a little bit of cancer in it.</b> <b>Not so.</b> <b>So help me visualize the biopsy.</b> <b>So are you able to see what you,</b> <b>for example, when you're talking about 2</b> <b>or 3 different tumors in the prostate,</b> <b>are you able to see where the tumors are</b> <b>so that you can take bits and pieces from</b> <b>all the tumors in there, or is that so?</b> <b>So usually they'll capture sound or.</b> <b>Exactly.</b> <b>So we'll get an MRI or even a Pet scan.</b> <b>And you'll see the lesion.</b> <b>And on the Pet scan.</b> <b>And I do a technique called</b> <b>cognitive fusion</b> <b>where I have a big screen TV up there.</b> <b>I put the image up there,</b> <b>and then I go find it</b> <b>on the ultrasound and say,</b> <b>okay, take 2 or 3.</b> <b>You can I just comment the real quick?</b> <b>I don't want to confuse the audience</b> <b>because some of my patients are out there,</b> <b>okay?</b> <b>The standard of care remains.</b> <b>You know, we're shifting,</b> <b>but the trans rectal guided ultrasound,</b> <b>which is the template which, you know,</b> <b>you get broad swath 12 different biopsies,</b> <b>it's not a lot of fun.</b> <b>Usually is the first step usually.</b> <b>And if things get confusing after that,</b> <b>or the PSA rises</b> <b>or the MRI shows something,</b> <b>that's when I that's my practice.</b> <b>I refer to Travis or one of my partners.</b> <b>Typically it's Travis</b> <b>to do the targeted biopsy, but for</b> <b>the audience, the standard of care remains</b> <b>the template biopsy.</b> <b>And sometimes we're not knowing exactly</b> <b>where that tumor is.</b> <b>And it's still a work in progress,</b> <b>I think.</b> <b>But sorry to interrupt,</b> <b>but I just want to make sure that everyone</b> <b>understands that, that the targeted biopsy</b> <b>is still starting to take shape.</b> <b>And we're referring</b> <b>once there's some uncertainty</b> <b>on the template, regular biopsy okay.</b> <b>Is that fair?</b> <b>Oh yeah.

Totally.</b> <b>And when you're doing the</b> <b>the standard template biopsy</b> <b>and you make a diagnosis</b> <b>and that patient goes to the surgeon</b> <b>and they get it prostatectomy, this kind</b> <b>of stuff that I'm doing doesn't matter.</b> <b>Right.

Right.

Because they're going right.</b> <b>Because the prostate, it's</b> <b>you know it doesn't matter as much</b> <b>when I'm doing my treatments.</b> <b>It makes a huge difference.</b> <b>So say they're not going to do</b> <b>active surveillance</b> <b>and they're going to do</b> <b>they're going to do radiation therapy.</b> <b>I need to know what type of radiation</b> <b>therapy to give them.</b> <b>I need to know how many, how</b> <b>how long of a hormonal suppression</b> <b>I need to do on them.</b> <b>We haven't talked about that yet.

Yeah.</b> <b>And and so like all these things,</b> <b>like the actual, like physical diagnosis</b> <b>matters like massively to me</b> <b>because it's going to tell me</b> <b>which pathway to put the patient on.</b> <b>And, and the reason I actually started</b> <b>doing this is I had a patient in his like,</b> <b>early 60s who had like, you know,</b> <b>he had had a biopsy like a year ago.</b> <b>It looked, you know,</b> <b>you just had intermediate risk.</b> <b>And so I gave him</b> <b>six months of hormone therapy.</b> <b>And just like our quick, what we call hypo</b> <b>fractionation radiation, which is like</b> <b>kind of standard just, you know, easy</b> <b>to easy to do, easy to deal with.</b> <b>And he did fine.</b> <b>He progressed like the second he going off</b> <b>hormone therapy progressed.</b> <b>And I was like, what the heck?</b> <b>Yeah, let's nose and things like this.</b> <b>And so I went in and biopsy them.</b> <b>And he had like a high grade tumor</b> <b>that I just didn't know about</b> <b>because we didn't see him</b> <b>looking in a six month period.</b> <b>So he started this hormone treatment</b> <b>for six months.</b> <b>He was fine.

Then all of a sudden again</b> <b>with the active surveillance.</b> <b>And so, so like,</b> <b>you know, if I could go back in time,</b> <b>what I would have done</b> <b>is, is targeted that lesion or sound like,</b> <b>you know, fat like there was a lesion</b> <b>there that I could target.</b> <b>I would have targeted it,</b> <b>found out that he had high risk disease,</b> <b>and then he would have been on two years</b> <b>of hormonal suppression</b> <b>and other agents as well.</b> <b>And so these kind of things, you know,</b> <b>they they matter</b> <b>and you don't like think about it</b> <b>until until you have that patient.</b> <b>Right.

And like you said, it's</b> <b>it's everybody's human.

Right.</b> <b>And just you learn from everything</b> <b>you've done as a master class.</b> <b>What you're going to do later.</b> <b>I do want to talk about,</b> <b>President Biden here for a moment</b> <b>because, again,</b> <b>I think that's going to bring what people</b> <b>are hearing out in the universe right now</b> <b>and what is happening with him.</b> <b>So either one of you take what type</b> <b>of cancer does have its advanced?

Yes.</b> <b>What does that mean?

You're both</b> <b>smiling at each other like you take it.</b> <b>No, I don't want to take it.

Take.</b> <b>Let's share it.</b> <b>All right.

There you go, doctor.</b> <b>So I think, look,</b> <b>we don't know what took place.</b> <b>We still don't know.</b> <b>We never probably will.</b> <b>But he was 82, I believe.</b> <b>I guess they must have checked a PSA.</b> <b>Or maybe he had lower</b> <b>urinary tract symptoms.</b> <b>Most likely</b> <b>he wasn't urinating well or some symptoms,</b> <b>and they checked the PSA</b> <b>and it must have been very high.</b> <b>I'm speculating.</b> <b>And when it got high like that, they said,</b> <b>look, we need to probably do a biopsy.</b> <b>They did a biopsy.</b> <b>And that's the Gleason nine score</b> <b>that came back on the biopsy.</b> <b>But it's a Gleason score of nine okay.</b> <b>And so it's very important for everyone</b> <b>to understand that that that number</b> <b>is an aggressive number.</b> <b>We talked about nine and ten.</b> <b>So you can't confuse the PSA</b> <b>with the Gleason.</b> <b>And at that point they did imaging</b> <b>and found that he had a metastatic lesion.</b> <b>And so it's important for us to understand</b> <b>that say with the word sorry.</b> <b>So it had moved</b> <b>it had moved outside the prostate okay.</b> <b>And so you know at that point</b> <b>it's a game changer.</b> <b>It's it's a new day.</b> <b>You can't have his prostate out.</b> <b>He can't have radiation therapy.</b> <b>Well, locally.</b> <b>And now it becomes</b> <b>more of which we'll get into</b> <b>is more of a systemic, treatment</b> <b>with hormonal therapy, most likely.</b> <b>I know it's getting a little bit</b> <b>confusing, but that's where he's headed.</b> <b>So we don't know what happened.</b> <b>But it speaks also to the screening</b> <b>because you would have that the PSA</b> <b>for the most important person on earth</b> <b>that that they had been checking PSA</b> <b>even after 70 years old, which was</b> <b>a recommendation in 2012 to stop.</b> <b>Okay.</b> <b>And so a really want to make a point there</b> <b>that I personally have</b> <b>a have heartburn about that.</b> <b>PSA, I check on all healthy men</b> <b>that have 10 to 15 years lifespan.</b> <b>I mean, we're seeing 86, 88 year old men</b> <b>that are going to be around for a while.</b> <b>I'm not saying I check PSA on all 88 year</b> <b>olds, but it's individualistic, right?</b> <b>You got to you have to pick and choose.</b> <b>So we're speculating.</b> <b>But it was good for the general public</b> <b>because it presented a bunch of questions</b> <b>to us.

Everybody's learning about it.</b> <b>And so, you know,</b> <b>I don't know if you have anything.</b> <b>Yeah I agree and I think, you know,</b> <b>this is what I think happened.</b> <b>Is he he's older.</b> <b>His PSA have probably been fine.</b> <b>They start checking them because you know,</b> <b>if you don't have a cancer diagnosis</b> <b>and your PSA has been fine in your 80s</b> <b>and you have no symptoms, you just yeah,</b> <b>you know, if you have</b> <b>like most of the guys in their 80s and 90s</b> <b>probably have low grade prostate cancer,</b> <b>you know,</b> <b>but it's not going to kill them, right?</b> <b>They're going to die of a heart attack</b> <b>or something else.</b> <b>And and so that's why they stop, you know,</b> <b>but then, you know, in his case,</b> <b>you know, you have these outliers</b> <b>like I have, you know, I have a ladies</b> <b>they start, they stop having their</b> <b>your pap smears and things like that.</b> <b>But I have ladies that are 80 years old</b> <b>with cervical cancer in my clinic.</b> <b>So so like these things happen.</b> <b>They're just,</b> <b>you know, they're rare in the</b> <b>what they're trying to do with screening</b> <b>is to get the majority of the patients,</b> <b>not the outliers, right.</b> <b>You know,</b> <b>and so I think that's what happened.</b> <b>But unfortunately, you know, he,</b> <b>he has that diagnosis.</b> <b>So let's talk about the outliers now.</b> <b>So I want to talk quickly about,</b> <b>we were talking about pet CT</b> <b>and then Spect imaging.</b> <b>What is the difference between those two</b> <b>and what do you use them for.

Great.</b> <b>So so we use we use the pet as pet PSA</b> <b>imaging specifically for prostate cancer.</b> <b>We use that primarily for staging.</b> <b>And so the patient comes in</b> <b>if they have what we call unfavorable</b> <b>intermediate or high risk disease,</b> <b>we want to make sure</b> <b>that cancer doesn't spread</b> <b>outside the prostate before we treat them.</b> <b>Because, you know, picture</b> <b>this.

You have high risk disease.</b> <b>I treat your prostate with radiation.</b> <b>Or Jeff goes in and removes it.</b> <b>But they have metastatic disease</b> <b>everywhere.</b> <b>We do not help that patient.

Right.</b> <b>They need to be</b> <b>on some other type of therapy.</b> <b>And so that's why staging so crucial</b> <b>crucial in the pet</b> <b>has it's maybe been like two years,</b> <b>three years that it's been available here.</b> <b>And it has completely changed</b> <b>my practice personally.</b> <b>Like just absolutely,</b> <b>completely changed it, to</b> <b>where we were using like old CT</b> <b>and bone scans, which were, you know,</b> <b>they'd never detected metastatic disease,</b> <b>like hardly ever.</b> <b>And now we have something</b> <b>that's just like, much more precise.</b> <b>We're able to target lesions</b> <b>and things like that.</b> <b>And prostate cancer spreads</b> <b>where first usually.</b> <b>So a lesion either</b> <b>go to the lymph nodes or the bones okay.</b> <b>So just loves to go there.

Okay.</b> <b>And so and we're able to to image that now</b> <b>whereas before with the bone</b> <b>scan, you know you have to get</b> <b>a pretty big lesion to see it.</b> <b>But anyways, so the pet what the pet does</b> <b>is it's a, it's a positron.</b> <b>So Pet stands for positron</b> <b>emission tomography.</b> <b>Here it goes.</b> <b>I'll be really love this part though</b> <b>I like really fast.</b> <b>Yeah.</b> <b>But but basically the the the pet tracers</b> <b>that we use the emit a positron</b> <b>which is an anti electron.</b> <b>It's it's not supposed to exist.

Right.</b> <b>And so it gets annihilated.</b> <b>And I don't think I've ever seen</b> <b>like angels and demons.</b> <b>They had like the anti-matter.</b> <b>And it made this huge explosion.</b> <b>It's that stuff's kind of real.</b> <b>You know if you had a big thing</b> <b>a positrons, it's going to make</b> <b>a, you know, it's going to explode.</b> <b>But but anyways, you have a positron</b> <b>and it, it creates photons</b> <b>that shoots shoot off at 180 degrees</b> <b>and we can detect it.</b> <b>And we know where that event happened</b> <b>inside the body.</b> <b>And so that's how we're able to image</b> <b>these things with Pet scans like where</b> <b>where the cancer is because the tracer</b> <b>sticks to it, it creates positrons.</b> <b>And then we're able to see where</b> <b>where that event happened inside the body.</b> <b>And so that's Pet scanning okay.</b> <b>So the agent we have is called a PSM</b> <b>which stands for prostate</b> <b>specific membrane antigen.</b> <b>And that's the tracer we use nowadays.</b> <b>And it's it's been it's amazing.</b> <b>So completely</b> <b>changed prostate cancer care.</b> <b>And we're still learning about it as well.</b> <b>The Spect is is different.</b> <b>So so this is</b> <b>this is looking for one photon.</b> <b>And so you'll have like radioactive,</b> <b>tracers or even therapies that we give.</b> <b>And I can talk about this later,</b> <b>where we're imaging just one photon</b> <b>that's coming off of the,</b> <b>the radioactive metal that's in there.</b> <b>And it's not as, it's it's more difficult</b> <b>to localize that because it's</b> <b>not it's not coming from like a 100,</b> <b>like 180 degree event with two photons.</b> <b>You're only getting like</b> <b>half the data randomly.</b> <b>And so the images you see with that,</b> <b>which are more like bone scans,</b> <b>where it's like it's kind of fuzzy and,</b> <b>you know, you kind of know where it is,</b> <b>but it's not great.</b> <b>But it is.</b> <b>It is very useful, especially</b> <b>when you're monitoring therapies.</b> <b>Now with the radial eigen therapies,</b> <b>which we'll probably get in.</b> <b>So it's two completely different ways.</b> <b>They're completely different cameras okay.</b> <b>Ones.

Yeah.</b> <b>Just real quick.

Yes.</b> <b>No one.</b> <b>Not everyone gets a Pet scan.</b> <b>Not everyone can write.</b> <b>Basically insurance won't cover</b> <b>for every single patient.</b> <b>It's for the higher grade.</b> <b>The Gleason scores of,</b> <b>you know, typically high grade</b> <b>seven, eight and nine and tens,</b> <b>the Gleason sixes and stuff.</b> <b>We really don't need that</b> <b>for advanced uses for it.</b> <b>And really, it's</b> <b>been an unbelievable breakthrough</b> <b>because you're able to isolate small,</b> <b>you know, tracers in small lymph node</b> <b>that now you know that it's metastatic.</b> <b>And to Travis's point</b> <b>CTS and bone scans are going to be gone.</b> <b>They're just not specific enough.</b> <b>And so</b> <b>now you can really target everything.</b> <b>And I know last time we talked</b> <b>it was very targeted medicine.</b> <b>So I want to get to, to Plavicto.</b> <b>So we also have that on here.</b> <b>Explain what that is.</b> <b>So so now so now we're getting into</b> <b>the kind of there are gnostics okay.</b> <b>And so Theranostics</b> <b>is essentially preparing a diagnostic test</b> <b>like a pet smart scan</b> <b>okay with a therapeutic agent.</b> <b>And so it's therapy and diagnostics.</b> <b>That's where that word theranostics came </b> <b>And we have a video on theranostics</b> <b>including kind of you know.</b> <b>Yeah.

So we're talking through this.</b> <b>So we basically, you know,</b> <b>this is a new field essentially,</b> <b>and in medicine, in cancer treatments</b> <b>and we we built out a facility</b> <b>at a Remcon location</b> <b>that is essentially only for this.</b> <b>We got a pet unit, which is on the video.</b> <b>It's, digital, just top of the line.</b> <b>Outstanding imaging unit.</b> <b>We, these images are read by people</b> <b>who are trained in cancer imaging.</b> <b>It's not just, you know, a random,</b> <b>you know, person that we work with.</b> <b>This is a national group</b> <b>that is this is like</b> <b>experts</b> <b>at reading cancer imaging and Pet imaging.</b> <b>We have the</b> <b>way the facility was designed</b> <b>is to be highly efficient.</b> <b>And so it's in a small footprint.</b> <b>We have three bathrooms, two therapy</b> <b>rooms, which you'll see in the video,</b> <b>and then also cool down in uptake rooms</b> <b>that have their own dedicated bathroom.</b> <b>And so the way this works</b> <b>when you're when you're injecting</b> <b>the tracer into the patient's,</b> <b>they have to kind of incubate.</b> <b>So you inject it.</b> <b>And then the patients</b> <b>wait for about an hour.</b> <b>And when one of our uptake rooms,</b> <b>and they can watch,</b> <b>you know, an iPad or something like that.</b> <b>and,</b> <b>and the, the, the tracer has to stick</b> <b>to the cancer in order to see</b> <b>it has to concentrate on it.</b> <b>And so you wait for that to happen</b> <b>and then you, you put them in the camera.</b> <b>The, the Pet scanner and it'll collect</b> <b>all the, the imaging data.</b> <b>Oh my gosh.

Right.</b> <b>Okay.</b> <b>So now now you have your patient their,</b> <b>their their diagnosis metastatic cancer</b> <b>their castrate resistant.</b> <b>They've been seeing Jeff.</b> <b>And there's a great picture of this</b> <b>in the slide deck of what</b> <b>it would look like, under the scanner</b> <b>where you have metastatic disease.</b> <b>And now you know that</b> <b>that metastatic disease will the, the,</b> <b>the PSA agent is sticking to it.</b> <b>And so what they did with the therapy</b> <b>is they put a, more</b> <b>radioactive agent, lutetium 177.</b> <b>They stuck that to the PSMA.</b> <b>And then you inject that into the patient</b> <b>and then that just goes directly</b> <b>to the cancer cells and kills them.</b> <b>So you can see exactly</b> <b>and treat exactly those cells see treated.</b> <b>That's kind of the mantra.</b> <b>So so in the slide deck</b> <b>they have, you know, a patient</b> <b>that has widely metastatic disease</b> <b>mostly in the bones.</b> <b>And then we have a picture of kind of what</b> <b>the the pelvic agent looks like.</b> <b>And then the disease is gone.</b> <b>So all the black spots on the first slide</b> <b>showed metastatic everywhere.</b> <b>And then just these honing devices</b> <b>is the way I look at it,</b> <b>that just microscopically stick to the</b> <b>cancer cell and treat with with radiation.</b> <b>So we're talking about in pardon me.</b> <b>So I'm just trying to follow this.</b> <b>Your are treating it right then and there.</b> <b>And within that treatment they disappear.</b> <b>No.

So okay so this is the time.</b> <b>Yeah okay.</b> <b>So it's thinking</b> <b>that is just a little too good to be.</b> <b>Yeah.

So they come back several times.</b> <b>But again it's very very focused</b> <b>and very targeted to those specific cells.</b> <b>Exactly.

Yeah.</b> <b>And some of your normal cells</b> <b>take up this this agent.</b> <b>So, so the the auto agent,</b> <b>most of the patients</b> <b>get something called zero storming.</b> <b>It's dry mouth okay.</b> <b>Because your salivary glands</b> <b>have this receptors, this receptor on them</b> <b>and it takes it up.</b> <b>And so you get dry mouth because</b> <b>your salivate glands get radiated.</b> <b>Your kidneys, you're it's</b> <b>this process through your kidneys.</b> <b>So sometimes it can make your kidneys</b> <b>levels go up.</b> <b>They can get nausea, you know, there's</b> <b>there's, you know, toxicity from it.</b> <b>But I honestly, I think it's a lot</b> <b>less than some of the other therapies</b> <b>we've been using in the past.</b> <b>And I look at this as more of like a,</b> <b>like a heat seeking missile</b> <b>versus a shotgun,</b> <b>like we were using shotguns before.</b> <b>Now we have these seeking missiles</b> <b>way of saying yeah.</b> <b>So but they're developing these</b> <b>these type of therapies for all cancers</b> <b>right now okay.</b> <b>So a lot of we you know, with our center,</b> <b>we have a research team that we're with.</b> <b>We've been slowly building up,</b> <b>with clinical trials</b> <b>and things like that in this space.</b> <b>And just across the country,</b> <b>there's hundreds</b> <b>if not thousands of the clinical trials</b> <b>going on right now.</b> <b>Thank goodness.</b> <b>That's one of the questions, cuz</b> <b>we have a whopping 17 minutes left,</b> <b>which sounds like a long time,</b> <b>but it's not.</b> <b>Because I'd like to talk to I want to get</b> <b>to the xofigo in a minute, but let's</b> <b>talk about some of these clinical trials,</b> <b>because I think that is such a</b> <b>a game changer to people like,</b> <b>oh my gosh, what what do I do now?</b> <b>So the clinical trials are involving what</b> <b>exactly around the, around the country.</b> <b>So, so there's, there's different phase</b> <b>clinical trials.</b> <b>And so there's phase one, which are like</b> <b>new agents that they're testing,</b> <b>and usually kind of patients</b> <b>that don't have any other options</b> <b>in terms of treatment,</b> <b>like they've kind of gone</b> <b>through the whole line of therapies</b> <b>and now they're testing something new.</b> <b>And then you have like phase</b> <b>two and phase three trials where they're,</b> <b>you know, it's something that works.</b> <b>But now we're comparing it</b> <b>to two different agents that we use</b> <b>or standard of care agents.</b> <b>What we're</b> <b>currently doing in our center,</b> <b>we have a couple of trials open, but</b> <b>I think the most interesting one is this</b> <b>one called the Delayed Castration Trial.</b> <b>Say it slowly delayed castration.</b> <b>Delayed castration.

That sounds scary.</b> <b>Yeah.</b> <b>So what that is so basically in</b> <b>in in advanced prostate cancer</b> <b>when patients have metastatic disease</b> <b>it's always called the</b> <b>the backbone of therapy is it's</b> <b>called this androgen deprivation</b> <b>or chemical castration okay.</b> <b>And testosterone suppression.

Yeah.</b> <b>Just knock it out okay.

Yeah.</b> <b>And so in the cancer cells they need that</b> <b>that signal the testosterone to grow.</b> <b>And so we we just thought the patient was</b> <b>either blocked the receptor</b> <b>on the cell</b> <b>or we stopped the body's production of it.</b> <b>And that of course inhibits the cancer.</b> <b>Eventually it finds a way.</b> <b>It's like Jurassic Park, lifelines away.</b> <b>Okay.</b> <b>Yeah, but but this with the development</b> <b>of these agents</b> <b>that are more targeted,</b> <b>they're potentially more effective.</b> <b>They're starting to think, well,</b> <b>do we have to castrate the patients</b> <b>because the patients, you know,</b> <b>they have fatigue, they have hot flashes.</b> <b>You know, they have weight</b> <b>gain, endocrine issues like mental issues</b> <b>like it's it's a problem,</b> <b>you know, and it's kind of,</b> <b>you know, like, oh, it's</b> <b>not that big of a deal.</b> <b>It is a big deal for a lot of these guys.</b> <b>Menopause for men.

Yeah.</b> <b>Yeah.

For all that.

Yeah.</b> <b>And it's permanent when you're metastatic</b> <b>you don't get off of it right.</b> <b>And so, so with this agent,</b> <b>these guys that are being diagnosed</b> <b>with metastatic disease,</b> <b>they're starting to be to think, well,</b> <b>maybe we can give these guys this agent</b> <b>and not castrate them, and they'll do</b> <b>just as well as the guys that we did</b> <b>castrate or just delay castrating them.</b> <b>You know, several years down the road.</b> <b>And so I think that's</b> <b>just a really provocative trial</b> <b>and just really trying to like,</b> <b>kind of go back and be like,</b> <b>you know, we've just been doing this</b> <b>because the other people did it,</b> <b>you know, and now it's like, well,</b> <b>why don't we do something different?</b> <b>And this is happening in your clinic</b> <b>right now.</b> <b>And about how many men do</b> <b>you have enrolled in this?</b> <b>So this one, this one,</b> <b>we have just a couple,</b> <b>because it's when you're, when you're</b> <b>finding patients for clinical trial.</b> <b>Got to be that specific.</b> <b>Yeah.</b> <b>It's a these I call them unicorns.

Yeah.</b> <b>Because they have to have</b> <b>all these perfect metrics.</b> <b>And it's, it's tough, you know.</b> <b>And then it's also tough</b> <b>because the patients, they,</b> <b>they know what the standard of care</b> <b>is, is castration.</b> <b>And so they're kind of like, I don't know,</b> <b>this is kind of experimental.</b> <b>And it is, but it's also,</b> <b>you know, you got it,</b> <b>you know, got to try something different</b> <b>in order to drive.</b> <b>Exact change in the medicals.</b> <b>Absolutely.</b> <b>Yeah.</b> <b>So, so yeah, it's</b> <b>it's fascinating when there's, you know,</b> <b>we're, we're doing quite a few trials</b> <b>starting to turn roll them in different</b> <b>you know in and outside of of.</b> <b>Yeah.</b> <b>And I think just just to add</b> <b>there is a great slide here that depicts</b> <b>kind of what's next on the targeted radio</b> <b>like in therapy.</b> <b>And it's busy.

It's a busy slide slide.</b> <b>And in the very middle it shows in market</b> <b>med medication or therapeutics two</b> <b>right now one for neuroendocrine cancer</b> <b>and one for prostate.</b> <b>The rest of those that figure shows</b> <b>everything that's coming, that's on its</b> <b>way in all kinds of different spaces,</b> <b>from GI to breast to lung.</b> <b>We think that radio ligand therapy</b> <b>may be the future, as far as it certainly</b> <b>is going to be an incredible tool to have,</b> <b>and I think the sky's the limit for it.</b> <b>So we're excited to see what happens.</b> <b>But that is an impressive, slide to show</b> <b>what's on the horizon.</b> <b>So on that note,</b> <b>usually I</b> <b>wait a little bit later to ask that,</b> <b>but I really like it</b> <b>when we can seize the moment.</b> <b>So on the horizon,</b> <b>because you both are bringing this up.</b> <b>So having this program</b> <b>five years from now, what do you see?</b> <b>Because right now you're talking</b> <b>about these two in the middle.</b> <b>But we've got all this other</b> <b>these other clinical trials gone.</b> <b>We've got everything happening</b> <b>just in your</b> <b>your best guess</b> <b>and your hopeful optimism going forward.</b> <b>What do you see in treatment</b> <b>over the next?</b> <b>We can go ten years.</b> <b>But I'm thinking right now</b> <b>things are just happening right now.</b> <b>And again, I you were talking about humans</b> <b>making mistakes.</b> <b>You know, computers are much more targeted</b> <b>and I don't care who starts first.</b> <b>But this is the most exciting</b> <b>part of the program</b> <b>is what's what's on the forefront.</b> <b>Yeah, sure.</b> <b>I mean, I think, there</b> <b>there's just going to be more targets,</b> <b>you know, for prostate cancer</b> <b>specifically,</b> <b>there's going to be more targets.</b> <b>And what we're going to end up doing</b> <b>this is probably 5 to 10 years down</b> <b>the road is we're going</b> <b>to image the patient and see what what</b> <b>targets are available,</b> <b>you know, to target.</b> <b>Right.</b> <b>And so you image them and they'll glow.</b> <b>Let me like all right.</b> <b>This is the agent</b> <b>we need to give you.

We'll give it.</b> <b>It'll it'll wipe out all those cells.</b> <b>But there's going to the cells are going</b> <b>to figure out how to grow, you know.</b> <b>And then they'll start</b> <b>expressing other targets.</b> <b>And then you use your other imaging agents</b> <b>to figure out exactly what, you know,</b> <b>what's going to stick those cells,</b> <b>and then you give them the therapy</b> <b>that, that, that cells are expressing.</b> <b>And that's what they're doing.</b> <b>An all in all cancer.</b> <b>So cancer is smart.</b> <b>We're just trying to outsmart the cancer.</b> <b>And it's a continuum.</b> <b>Oh you're fighting like a human.</b> <b>You human will survive.

Right.</b> <b>So like it's it's it's not.</b> <b>We're never going to</b> <b>I don't think we're ever going to cure it,</b> <b>but I think it's going to end up</b> <b>being kind of how like metastatic</b> <b>prostate cancer is now.</b> <b>It's almost like having diabetes, right?</b> <b>It's something that's probably going to</b> <b>you know, some complication from</b> <b>that is probably going to kill you.</b> <b>But a lot of guys, they live in five,</b> <b>ten years.</b> <b>I think there's three things</b> <b>that come to mind.</b> <b>I think I, I totally agree with Travis.</b> <b>I think first</b> <b>is the ability with these studies</b> <b>to start earlier and sequence these drugs.</b> <b>So we talked about the delayed castration.</b> <b>Well, if we can give this radio</b> <b>ligand therapy right from the beginning,</b> <b>I had a patient and his wife come</b> <b>and she's a scientist.</b> <b>She came in and said, Doctor Speer,</b> <b>I want to start Plavicto.</b> <b>So now I don't want him on hormonal</b> <b>therapy, because what we didn't talk about</b> <b>is the awful side</b> <b>effects of hormonal therapy.</b> <b>When testosterone suppressed,</b> <b>that's our hormone.</b> <b>So fatigue, hot flashes,</b> <b>there's a ton that comes with it.</b> <b>So one point is earlier in the sequencing.</b> <b>So being able to give</b> <b>some of these medicines earlier and delay</b> <b>all the others.</b> <b>The second is genetics germline therapy,</b> <b>what's called somatic testing.</b> <b>It's exploding.</b> <b>So to be able not only to target</b> <b>but to target the right individuals</b> <b>with the right drugs,</b> <b>I think that's coming.</b> <b>And we can't, you know, we have to.</b> <b>It's not right to not mention</b> <b>artificial intelligence.</b> <b>I mean, it is here, right?</b> <b>I think it's obviously</b> <b>everyone knows it's exploding</b> <b>and we're going to see an incredible,</b> <b>you know, incredible technology</b> <b>coming our way.</b> <b>I agree, I agree, and I think a lot of</b> <b>people are a little bit leery of it,</b> <b>but I would like to know a little bit more</b> <b>about you talked about germline therapy.</b> <b>And then also just genetic</b> <b>testing in general.</b> <b>Let's talk a little bit more about that,</b> <b>because I think that is</b> <b>it's been around for a while.

Yes.</b> <b>But I feel like it was first</b> <b>kind of born in the breast cancer</b> <b>world, prostate cancer world in general.</b> <b>So how</b> <b>just genetic testing.</b> <b>Let's talk about that</b> <b>and then also go into therapy.</b> <b>So you brought it up</b> <b>and I'll try to simplify it.</b> <b>I think there's two ways to look at it.</b> <b>Number one is to really find</b> <b>that family history okay.</b> <b>So we can</b> <b>we can find mutations that may affect</b> <b>siblings children and generations to come</b> <b>that we can discuss with patients.</b> <b>And this is in the patient themselves.</b> <b>This is in the patient.</b> <b>This is in the patient</b> <b>themselves.

In the germline.</b> <b>There's somatic testing</b> <b>which looks more at the tissue</b> <b>and then figuring out</b> <b>if there are drugs that we have already</b> <b>that these patients will qualify,</b> <b>that most don't like.</b> <b>The Brackett gene is a very common gene</b> <b>that we test in prostate cancer.</b> <b>It's not just breast.

Exactly.</b> <b>So if there's a Brac, Brac, a mutation,</b> <b>then they qualify some for</b> <b>what are called Parp inhibitors.</b> <b>I don't want to get too technical,</b> <b>but there are medications</b> <b>that we can implement</b> <b>when they become resistant</b> <b>to these other drugs.</b> <b>So again, all of these different weapons</b> <b>that we have,</b> <b>and that's part of the germline testing,</b> <b>which was pulling teeth in our community</b> <b>for for a while in the urologic community.</b> <b>Now it's become standard of care.</b> <b>Oh good.

Okay.

Yeah.</b> <b>One of the things I'd probably mention is</b> <b>is between like germline testing.</b> <b>That's your DNA.</b> <b>So all your cells in your body</b> <b>have that that DNA.</b> <b>And so you test it.</b> <b>And if you have a mutation in your DNA,</b> <b>what your tumor</b> <b>is going to have the same mutation.</b> <b>And so if we have an agent that targets</b> <b>that mutation you're a candidate for it.</b> <b>The other thing is tumor cells can can,</b> <b>pick up mutations</b> <b>as they become more aggressive typically.</b> <b>And so you want to talk</b> <b>in all cancers here</b> <b>we talk and process for the most part.</b> <b>Oh okay.

Yeah okay.</b> <b>And so so see your</b> <b>you don't have a bracket mutation</b> <b>but you have this this aggressive tumor</b> <b>that's been a static now.</b> <b>And it's it's it's been hit</b> <b>with a couple different therapies.</b> <b>If you biopsy that tumor</b> <b>it might have that mutation now</b> <b>because these are mutations that it picks</b> <b>up to become more aggressive.</b> <b>And you know</b> <b>kind of like how like haywire becomes</b> <b>more haywire.</b> <b>So it just becomes more differentiated.</b> <b>It likes to spread.

Right.</b> <b>And so that's why</b> <b>most of the most of his patients</b> <b>that he sees were that are metastatic,</b> <b>and they're looking for something</b> <b>to give the patient,</b> <b>they want to biopsy the tumor,</b> <b>or we're even doing, liquid biopsy.</b> <b>He's looking for, like,</b> <b>circulating tumor DNA.</b> <b>They can do that again.

Oh, okay.</b> <b>Okay.

So blood test.

It's okay.</b> <b>Liquid biopsies is a blood test</b> <b>as part of the somatic testing.</b> <b>It's basically a way in the clinic</b> <b>that we can we can send this out to a,</b> <b>you know, a expertise, a lab</b> <b>that can come back and give us</b> <b>some of these genetic risk factors</b> <b>and whether or not they qualify.</b> <b>So, I mean, it's just exploding so that,</b> <b>that that's really important</b> <b>for the audience to hear.</b> <b>They can even ask their primary care</b> <b>doctors about genetic testing.</b> <b>It's not just about urology or us.</b> <b>It's out there and it</b> <b>you know, it's I'm going to throw this out</b> <b>just because I know we're wrapping up.</b> <b>But if people do have questions</b> <b>in the old days,</b> <b>this is a live program</b> <b>people were calling in.

Right.</b> <b>But there are a lot of questions</b> <b>that I can see people having right now.</b> <b>So if you have any questions</b> <b>on the program</b> <b>or any programs</b> <b>that we've seen in the past,</b> <b>specifically this one, please email</b> <b>the question</b> <b>to EPP med sec.</b> <b>So think about El Paso County</b> <b>Medical Society.</b> <b>Just think epp med SLC at aol.com because</b> <b>those questions will go to these docs.</b> <b>These dogs will answer them and</b> <b>then you will get a direct email answer.</b> <b>So that's one of the great services</b> <b>of the county medical society,</b> <b>talks about because you said</b> <b>things are exploding right now.</b> <b>And I can just imagine, like,</b> <b>I've got all these questions,</b> <b>but we don't have time</b> <b>to go through them all.</b> <b>And in fact, one thing</b> <b>I wanted to make sure that we did</b> <b>was go to something else that was on here</b> <b>that I know you wanted to talk about.</b> <b>So, Xofigo, that was a</b> <b>am I saying that?

Right?</b> <b>So there you go.</b> <b>Xofigo</b> <b>and that's what it sounds like a song.</b> <b>So let's talk about Xofigo.</b> <b>Yeah.</b> <b>So, so this concept like this there</b> <b>analysis concept we have, it's been around</b> <b>since like the 60s and 70s</b> <b>when we were treating thyroid cancer.</b> <b>Xofigo is another agent that we've been</b> <b>using for quite some time actually,</b> <b>since like 2015 or 2016,</b> <b>there's a trial called</b> <b>the Alsympca Trial</b> <b>that was published, Journal of Medicine.</b> <b>But basically</b> <b>it's a calcium mimetic</b> <b>that we inject in the patients,</b> <b>and it goes</b> <b>to where there's bone turnover.</b> <b>And when you have metastatic prostate</b> <b>cancer in your bones,</b> <b>there's a lot of turnover.</b> <b>And so this agent goes in into that area</b> <b>where the tumor cells are.</b> <b>The difference between the Xofigo</b> <b>and the plavicto</b> <b>The xofigo is not as targeted but plavicto</b> <b>kind of a different type of radiation.</b> <b>So if he gets kind of a harder</b> <b>hitting radiation</b> <b>and, you know, to kind of go back to</b> <b>what's going to happen in the future,</b> <b>they're developing agents like Plavicto</b> <b>that are hard</b> <b>hitting, like xofigo without with</b> <b>something called actinium,</b> <b>and so you're able to,</b> <b>to deliver a kind of heavier punch.</b> <b>And the way to think about it</b> <b>is xofigo is like a bunch of ping</b> <b>pong balls kind of flying around,</b> <b>and it kills the cells.</b> <b>Or you can use a bowling ball.</b> <b>And that's what xofigo is.</b> <b>Similar to I think plavicto</b> <b>works a little bit better.

But</b> <b>but these agents that they're developing</b> <b>are going to be heavier hitters.</b> <b>And so I think their patients</b> <b>are going to probably respond</b> <b>better to those therapies.</b> <b>The question is</b> <b>are they going to be more toxic?

Right.</b> <b>So I think that's</b> <b>where it's going to be interesting</b> <b>to see how those those studies develop.</b> <b>And here's a quick question too,</b> <b>because you're learning I mean,</b> <b>you both are just amazing</b> <b>because you're your students</b> <b>and you're also masters</b> <b>at what you're doing.

Right?</b> <b>So when you are learning</b> <b>about all this stuff, are there seminars</b> <b>you go to classes?</b> <b>I mean, like, what is it?</b> <b>How do you find all this stuff out?</b> <b>Like by trial and error, right.</b> <b>We like lead them.

Yeah.</b> <b>He's he's like he's like a top dog</b> <b>and nationally and urology.</b> <b>So it's more of a thank, you know.</b> <b>No, I mean obviously</b> <b>we have to keep up with the literature.</b> <b>So we, we,</b> <b>you know, I know he's a voracious reader.</b> <b>The journals that come out,</b> <b>you know, it's also just the networking</b> <b>with our colleagues around the country.</b> <b>Just quickly</b> <b>I'll try to be quick, but we're lucky,</b> <b>you know, we've got a guy like this</b> <b>that has sort of fallen out of the sky</b> <b>as far as the radiation</b> <b>oncology component.</b> <b>So he's part of our group in our practice</b> <b>that I can bump ideas off of.</b> <b>So we've got a radiation oncologist</b> <b>and someone that really has kind</b> <b>of embraced advanced prostate cancer.</b> <b>Yeah.</b> <b>We also have medical oncology colleagues</b> <b>around the community</b> <b>that we obviously rely on as well.</b> <b>So it's a multidisciplinary approach.</b> <b>But we have everything here in El Paso</b> <b>as far as certainly</b> <b>certainly in the GU space as far as cancer</b> <b>goes that everybody needs.</b> <b>And I'm proud of that.</b> <b>You know, I'm proud of the fact</b> <b>that patients aren't having to travel.</b> <b>We're hoping that</b> <b>that continues in the community</b> <b>where they don't have to get on a flight</b> <b>to M.D.</b> <b>Anderson or the Mayo Clinic.</b> <b>We feel like we're giving everything</b> <b>that anyone else in the country is giving.</b> <b>And, you know, I'm proud of the city.</b> <b>I'm proud to be born and raised.</b> <b>He was too.</b> <b>And so, you know,</b> <b>we take a lot of pride in our community.</b> <b>And, you know,</b> <b>so would you guys doing a is</b> <b>amazing again, it's Rio Grande urology,</b> <b>Rio Grande cancer specialists.</b> <b>And every time I sit and listen to you</b> <b>all, it is amazing to me.</b> <b>And if you want to watch this program</b> <b>again, which I'm sure you will,</b> <b>because everything went really,</b> <b>really fast.</b> <b>There are three different places</b> <b>that you can watch this again.</b> <b>We've had Doctor Travis Mendel here,</b> <b>who's radiation oncologist, and Doctor</b> <b>Jeffrey Speir, urologist.</b> <b>And this can be seen again on PBS</b> <b>El paso.org, also on the El Paso County</b> <b>Medical Society website.</b> <b>And that is EPCMS.com.</b> <b>And you can always go to youtube.com.</b> <b>You can watch the show and then</b> <b>all the shows that we've done in the past,</b> <b>at least archived.</b> <b>For the last several years,</b> <b>we've been doing this for 28 years.</b> <b>It's a long time.</b> <b>And if you have a question, email</b> <b>your question to e p m</b> <b>Ed SOC@aol.com.</b> <b>Again, this is a nuts and bolts</b> <b>of bolts of prostate cancer.</b> <b>And we've been talking</b> <b>about very targeted information.</b> <b>And I would say</b> <b>if people have questions again</b> <b>do email here,</b> <b>but feel free to call your clinic.</b> <b>You know, we were here</b> <b>talking about low dose benign.</b> <b>What was it called?</b> <b>Low dose benign radio radiotherapy.</b> <b>And from that program people were just</b> <b>watching like, what the heck is this?</b> <b>And you got all these phone calls.</b> <b>So what I'm trying to tell</b> <b>the audience, be encouraged</b> <b>to definitely make those phone calls.</b> <b>Any last minute words</b> <b>you want to say before we go off the air?</b> <b>Now, I'll just thank you for having us.</b> <b>It's always it's always so much fun</b> <b>being on here.</b> <b>And it's great</b> <b>to have this guy here with me now.</b> <b>Well, and what we, we got to do an audible</b> <b>and also kind of a nod to Chaz,</b> <b>and, you're back in the day.</b> <b>You're pretty amazing</b> <b>to, get screened.

Yes.</b> <b>Ask your primary care doctor</b> <b>about prostate cancer screening.</b> <b>It's just,</b> <b>you know, it can be life and death.</b> <b>So just talk about it.</b> <b>It's never enough.

It's</b> <b>never an easy subject to discuss.</b> <b>But again, the PSA is a blood test series</b> <b>and digital rectal exam.</b> <b>Go every year.</b> <b>If you can just just do it.</b> <b>It makes all the sense in the world.</b> <b>It's Prostate Cancer Awareness month.</b> <b>It is.

Exactly.</b> <b>That's why we're here.</b> <b>And all mental health awareness.</b> <b>So this has been the El Paso Physician</b> <b>and I'm Kathrin Berg.</b> <b>And thank you so much for tuning in.</b> <b>El Paso County Medical Society is a </b> <b>nonprofit organization established in 1898</b> <b>that unites physicians to elevate</b> <b>the health of the El Paso community.</b> <b>We have been bringing the El Paso</b> <b>Physician Television program to your home</b> <b>for the last 27 years on PBS El Paso.</b> <b>If you should have any medical questions</b> <b>relating to this program,</b> <b>you may email us at EP Med Soc at aol.com.</b> <b>And we will try to have our experts</b> <b>answer your questions.

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