Full Transcript Doctor Personalities in Medicine 0:00 Well, doctor Geo Espinosa. 0:01 It's always so fun to hang out with you. 0:04 You are a man. 0:06 I mean, yeah. 0:06 You make everything so much clearer. 0:09 You know, challenging things. And. 0:10 But you bring that awesome humor. 0:12 I still still remember at a conference. Yeah. 0:15 We're up there on the stage, you and I. 0:17 And you're talking about the difference between a urologist and oncologist 0:21 and the surgeon and got the one is the jock and the other. 0:25 Yeah. 0:26 Do you mind just kind of going through the different personalities? 0:29 Well, yeah. 0:30 So the point I wanted to make is how we all get attracted or a certain profession. 0:34 So the orthopedic surgeon was an ex jock, right? 0:37 He he just didn't make it to become a professional athlete. 0:40 Well, become a become an orthopedic surgeon. 0:43 You know, for the most part, oncologists are on the spectrum. 0:47 And this is why I think that a lot of patients struggle with oncologists 0:50 because they want warm and feel they want connection. 0:52 They want to be heard and know the you know, it's 0:56 somebody on the spectrum, particularly at a high level end of the spectrum. 0:59 That's not going to happen. 1:00 And it's unfortunate, but that's the way it is. 1:03 Urologists sort of always have fun, right? 1:05 These are fun doctors. 1:06 What are we talking about all day? 1:08 You know, prostate and penises all day, every day. 1:11 So it's a little bit more a little bit more. 1:13 Lacks a little bit more fun 1:15 with particularly those that are true to the science, of course, 1:18 and doing good work, but it's just more relaxed, laid back and so forth. 1:22 So it's always fascinating to me how different 1:25 branches of medicine attract different type of doctor or personalities. 1:30 And you're 1:31 in nature path doctor specialize in prostate cancer. 1:35 And this is something you'd been done been doing for a lot, a lot of years. 1:39 So it's a little bit challenging. 1:41 I know when patients come into me kind of navigating that whole journey. 1:45 You know, they're different therapies that that are thrown at them, 1:49 you know, from their oncologists, from their surgeon, from the radiologist. 1:53 And then also kind of knowing a little bit 1:56 somebody does should I do biopsy on the biopsy. 1:59 They kind of do grading. 2:01 They do all these different things. 2:03 Do you mind just kind of walking through first in regards to what the different 2:08 diagnosis means in regards to prostate cancer and the level of concern? 2:13 Well, thanks for that, Michael. 2:14 So yes, I'm a natural path doctor that focuses from 2:17 an oncologist perspective only on prostate cancer. 2:21 Thank God I did that because I'm not Michael Carville. 2:24 Right.
Prostate Cancer Types and Risk Levels 2:25 And many like you, you guys are way too smart for me. 2:27 There's no way I could do every cancer and be really good at every cancer 2:31 and all the treatments that go along with it. 2:33 I mean, this that was just too, 2:34 too much for me and overwhelming when I figured that out over 20 years ago. 2:38 So I went into urology and from an ecological perspective 2:41 and let me just stick to prostate cancer so I could know it well. 2:45 And by the way, I still get amazed with new things that I learned. 2:48 People would say, aren't you bored with that? 2:50 Isn't it just like the same thing over again? 2:52 No. And here's why. 2:53 And this is going to answer your question. 2:55 If I have ten prostate cancer patients in my office, they're not all the same. 3:00 Prostate cancer is not prostate cancer, right? 3:03 Prostate cancer. 3:04 You have different levels within advanced prostate cancer 3:08 Michael advanced this five types. 3:13 And we are going to an advanced very high PSA progression. 3:16 There's about five types. 3:18 And that's only advanced. 3:19 There's the intermediate risk. 3:21 There's a few levels below that. And there's the low risk. 3:23 And there's a few levels below that. 3:25 So it's a full full spectrum. 3:27 So what you try to do is figure out 3:30 okay, what is the cancer that they have specifically. 3:33 And how do you create an unfavorable tumor ecosystem in their body 3:39 so that they can not only survive, thrive 3:43 when people say how successful are you with prostate cancer? 3:45 Define success. 3:47 Well, being alive in a by itself is not it? 3:52 Being alive and thriving despite their situation. 3:55 That's what we try to focus on. 3:57 So there's all these multiple levels. 4:00 So it depends which one we're talking about. All in all 4:03 I think that there's a lot of treatment. 4:05 There's there's a lot of conventional treatment. 4:08 And the goal is not only to do natural. 4:10 Maybe sometimes that is the way we do know that there's low risk prostate 4:14 cancer called Gleason Grade one. 4:16 People go on active surveillance. 4:18 They they are not going to die from prostate cancer. 4:21 Sometimes you have a low intermediate risk prostate cancer. 4:24 They are unlikely to die. 4:26 Just yesterday alone I saw a patient 79 years old with. 4:30 So this is interesting actually 79 years old. 4:33 His PSA within an eight month period went up from 4 to 21. 4:37 And I'm scratching my head. 4:38 How can that be? 4:39 Mari shows what intermediate period three. 4:42 Maybe leave it alone. Particularly in a 79 year old. 4:45 He still has a Pet scan, which is a very good scan. 4:49 And this is. 4:49 I also want to say that if you have to have a cancer, probably prostate cancer 4:53 don't want to have. 4:54 And if you want to, if you have to have it in 2026 is in 2027. 5:00 This is the best time to have it. 5:01 Just because there's so many good things out there 5:04 the technology, the diagnostics, they're all much better. 5:07 So his PSA, 79 years old, I don't want to touch a 79 year 5:11 old with medical therapies for prostate cancer. 5:14 I'm going to do great quality of life. By the way. 5:16 This guy is in great shape. 5:18 Parents live to 90, 95 and 100, so he's going to live 5:22 for probably another 20 years. I don't want to touch him. 5:25 He his 5:26 PSA goes up from 4 to 21 power at three. 5:29 Am I missing something? 5:30 He gets a biopsy. Low intermediate risk. 5:32 Gleason grade two. 5:35 Well, I'm not treating that. His decipher. 5:38 Decipher is a genetic score that gives you an idea. 5:41 They take the tumor biopsy and they analyze it, and they give it 5:44 what's called somatic genetics. Right. 5:46 So genetics on the tumor itself, low risk. 5:50 And we're talking treatment for this guy. 5:52 I'm not. 5:53 But then this PSA rising like that is always troubling. 5:56 When PSA rises like that is a reason. 5:59 Towards the end of the consultation 6:00 he says, oh, I forgot to mention that in the beginning 6:03 of this I started to testosterone replacement therapy. 6:06 Okay, now we got it right, not that testosterone. 6:11 And we're going in different directions here, but I just want to make the point. 6:13 Not that testosterone causes prostate cancer, but it can reveal it. 6:18 It can reveal it because the PSA will go up. 6:21 And for the most part, the PSA goes up for benign reasons. 6:24 Not there's more activity in the prostate. 6:27 So to make PSA you actually need to stop. 6:30 So now the testosterone that he was getting is increasing the production 6:35 of PSA going in his bloodstream bringing everything up. 6:39 So the point is this is just one case, right. 6:42 Maybe the types of patients that you see are more advanced prostate cancer. 6:45 Well that's a whole different thing. 6:47 Even dietary it's different. 6:49 So let me pause there because I don't want to take off the stage. 6:52 And I want you to ask questions that you think 6:54 your audience are going to want to know about. 6:56 Well, talk to me 6:57 a little bit about more about PSA, because that is so confusing for people. 7:01 You know, they think PSA directly correlates 7:04 with their, you know, aggressiveness of cancer. 7:07 So if you see it go up, then they think, oh, cancer spreading everywhere. 7:12 And here you're saying that essentially 7:15 if you are then on hormone therapy your PSA is going to go up 7:20 because testosterone is needed to produce a TSA. 7:24 But it doesn't mean that cancer in itself is advancing. 7:27 I'm I I'm understanding that. 7:29 Right. Correct. 7:30 We can have a whole show on PSA. 7:32 Michael, let me try to summarize that for you. 7:34 First of all, PSA stands for what we always joke patient stimulated anxiety. 7:41 I don't know of a biomarker 7:44 that induces more anxiety in men than PSA. 7:48 They can have cholesterol through the roof. 7:51 They could have triglycerides through the roof. 7:53 These are biomarkers for heart disease 7:56 that will not cause the anxiety that PSA does. 7:59 It is remarkable when I analyze this. 8:03 What's the story with PSA? 8:05 Let me break this down for you. 8:06 PSA overall is a good prostate 8:10 health biomarker, 8:13 is not a great biomarker for prostate cancer okay. 8:19 So when PSA goes up is telling you something about the prostate. 8:23 And if it does go up rapidly and if it does go up with a high velocity, 8:28 the changes like this last patient we just spoke about without the Tati 8:32 Tati aside, that would be a red flag and something is happening. 8:36 So it's good, is inexpensive, is accessible. 8:39 So I don't want to throw you never want to throw the baby out with the bathwater. 8:42 It's good.
Understanding PSA and PSA Density 8:44 But it's not great for prostate cancer. 8:46 So some people come to me with a PSA of 100. 8:48 They have prostate cancer. 8:50 And they're telling me, well, PSA doesn't matter. 8:52 I know it's 100. 8:53 No, it matters matters when it's that high. 8:55 So anywhere between zero to about 20 it may or may not matter. 9:00 So the patient has a PSA of about 20. 9:02 It could be for other benign reasons. 9:05 It could be BPH and enlargement of the prostate. 9:08 It could be that they are on TRT 9:09 or their testosterone to just rose for whatever reason. 9:13 It could be that there's inflammation around the prostate. 9:16 It could be that they, you know, 9:17 went for a bike ride for four hours and then right after they got a PSA. 9:21 Could be many benign reasons above 20. 9:25 And that's not to say that low PSA. 9:27 This is the other tricky point. 9:28 I've seen patients with low PSA. 9:30 I'm talking about 1 or 2 with advanced prostate cancer. 9:34 Okay. 9:35 So it could it's a full spectrum. 9:37 It's about how to interpret it correctly. 9:39 And there's other biomarkers now available that you can say that you can tell 9:43 whether it is prostate cancer driven or, or driven from some benign reason. 9:48 Lastly PSA density is very good. 9:51 PSA density is a very good biomarker. 9:53 Again, inexpensive for the most part. 9:55 What is PSA density? 9:57 You take the you take the PSA divided over the size of the prostate. 10:02 So you do need an MRI and PSA density. 10:04 The cutoff is roughly 0.15 okay. 10:08 So you take the PSA over the size of the prostate. 10:12 Cutoff is about one five. 10:14 If it's above 0.15, it suggests 10:18 that there might be prostate cancer related. 10:21 If it's below 0.15, it suggests that the high end PSA, 10:26 or the rise in PSA is related to some other benign reason. 10:30 I like my cutoff to be about .10. 10:34 So between 0 and 1.15, because I don't want 10:37 I don't like to drop the ball on any patient 10:39 if I need if I need if they if I need to find out. 10:42 And if they do have clinically significant prostate cancer, I want to know. 10:46 So I kind of have my own methodology to figure those things out. 10:49 But PSA is good, not great good for prostate health. 10:54 And it is is good, not great for prostate cancer. 10:59 And this is something because I know when patients come to me 11:03 and they've been to their urologist, none of them talk about PSA density. 11:08 So do they have to request that from their urologist. 11:12 Or how do they go about getting that measurement? 11:16 These are the things that make me scratch my head. 11:19 And probably I've lost my hair due to the stress 11:22 of these kind of things happening in the world. 11:25 Let me give you an analogy. 11:27 Cardiovascular disease. 11:28 If you want a nonintervention 11:30 way of determining if you're at risk for cardiovascular disease 11:34 is not cholesterol, is not even LDL might be part of the equation. 11:38 But is Apple lipoprotein B right? 11:41 Isn't there enough evidence to 11:44 I mean, are we practicing evidence based medicine or are we not? 11:48 If there, how can you not order an April lipoprotein beat? 11:51 Well, I see tons of lab work without a protein 11:56 be right, even from their cardiologists. 11:59 PSA density is that. 12:01 What are we doing? 12:03 What are we doing? 12:04 Unless they they don't have an imaging. Right. 12:06 Because you do need and the imaging should be from an MRI, not the ultrasound. 12:11 So the 12:11 the volume and the size of the prostate should be from an MRI, not an ultrasound. 12:16 It's just more accurate. 12:18 So either they just haven't had an MRI and and they should. 12:23 But even after they had have an MRI often saw 12:26 oh oftentimes I see and you see the PSA density is not part of the equation 12:30 where this is a, you know, low hanging fruit. 12:33 This is like come on, this is way better and more accurate than just PSA alone. 12:39 So why is that happening? 12:41 I don't know the same thing with that. It's happening 12:43 with cardiology and AP protein B I don't know why that's happened. 12:47 Yeah it's fascinating. 12:48 And you mentioned other terms like pirates and grade and what I mean 12:53 keen navigate to go through that a little bit so people understand. 12:57 So there's so the pirate score is a score 13:00 from the MRI that really the MRI is trying to tell you. 13:05 Should you biopsy or not. Do you need to biopsy this guy. 13:08 Of course people come to see me like they don't want a biopsy. 13:11 So I have a system in place. 13:13 So to help them navigate through that and say, well, you do need one, 13:16 there's no other way. 13:17 Unfortunately. 13:17 Or this other piece of well, no, we can. 13:20 You don't need it. 13:21 The MRI pirate score is a scoring system from 1 to 5. 13:26 If the higher the number, the more likely 13:29 that there is clinically significant prostate cancer in them that they should, 13:34 you know, figure out, screen for or get a biopsy. 13:37 So if it's a period 1 or 2, you typically leave these guys alone. 13:42 It's highly unlikely that they have a clinically significant prostate cancer. 13:48 If it's a three it's like a neutral thing. 13:51 It depends on other things. 13:52 So this patient 79 years old pirate score three 13:57 I want to leave them alone and plus everything else. 14:00 And certainly after we found out that he was on TRT, 14:02 I would have probably not even biopsied him. 14:04 So three is like maybe, maybe not. 14:07 And oftentimes they're left alone for than five are more significant. 14:11 And these guys need to be looked at more closely 14:14 to find potential clinically significant prostate cancer. 14:19 And then we 14:20 have things like Gleason score and also, 14:23 you know, staging and grade, you know, but where do they play a role. 14:28 So that's from biopsy pathology. 14:30 So after they get a biopsy they get a greeting system. 14:34 Really the grading system that it's there's Gleason scores there. 14:38 But a lot of times is Gleason grade 1 to 5. 14:41 So Gleason grade one is, you know, very indolent. 14:45 They found something very indolent, 14:46 likely a Gleason score six, which is very low grade. 14:49 Leave these guys alone. 14:52 Gleason grade two is low intermediate risk. 14:55 So the Gleason score is they combine two numbers and they add them up. 15:01 So the Gleason score seven for example it could be a three plus four. 15:06 So they find more patterns of in this case three than four. 15:11 Or it could be 15:13 a Gleason score of seven four plus three. 15:16 So a Gleason scored three plus four is low intermediate risk. 15:21 And typically that's Gleason grade two. 15:24 Gleason Gleason grade three is high 15:27 intermediate risk or more sort of aggressive intermediate risk. 15:31 And that's a four plus three. 15:34 Then Gleason score for Gleason 15:36 grade four is eight. 15:39 And Gleason Gleason grade five. 15:42 Gleason grade five is typically a Gleason score. 15:44 That's nine or higher. 15:46 So the higher the Gleason score, the more aggressive the the disease is. 15:52 And that is essentially from the biopsy. 15:55 And seeing how many of those when they do the biopsy, 16:00 how many cancer spots are cancers that they're identified. 16:04 Correct. 16:05 That's correct. 16:05 And it's very important to reinforce that you only get this Gleason 16:09 grading system from a biopsy. 16:13 What do I say that sometimes I get reports 16:16 that somebody did an ultrasound on me and they gave it a Gleason score. 16:19 That's not accurate. 16:21 You could only get a Gleason score from the pathology from a biopsy. 16:25 And people have a lot of concerns when the second needle into an area 16:29 that there may be cancer. 16:31 And I hear you have that, you know, seeding, 16:35 you know, from the needle and you're triggering inflammatory response, 16:39 you're kind of opening up 16:40 and encapsulation that, you know, the cancer has been kind of capsular. 16:44 And I opening up a whole into that. 16:47 Yeah. Can you speak a little bit about those concerns,
MRI PIRADS, Biopsy, and Seeding Concerns 16:51 the seeding question, Michael, I wish I had $10 16:54 every time I had that question asked, because if I did, I'll probably 16:59 be doing this interview from the Caribbean on a beach somewhere. 17:04 That is the million dollar question. 17:07 Seating and spreading of cancer from biopsy. 17:11 Here's the bottom line. 17:12 The bottom line is 17:15 that in for the next 17:18 probably decade, it is unlikely 17:20 that one can diagnose a patient for prostate cancer without a biopsy. 17:24 So it's not going anywhere. 17:26 So if you're really interested in knowing if you have prostate cancer 17:30 and what type you have, then you're going to have to undergo a biopsy. 17:36 That said, there's this seeding concept where if I put this needle 17:40 to this tumor, seeding and this sticking of the cancer 17:43 cells are on the needle and as I pull the needle out, 17:46 is going to bring some of that cancer out of the out of the prostate. 17:50 And then that is potential that creates a potential to spread cancer. 17:56 I think that is a reasonable theory. 18:01 It's a reasonable theory. 18:02 I think that there's more evidence with that, if I remember correctly, 18:06 from other cancers, maybe breast cancer, and in animal studies 18:09 that that is potentially possible. 18:13 So I don't rule it out 18:15 because, you know, everything starts from a theory. 18:17 And Michael, let's be honest here. 18:19 Who's going to study this and why. 18:23 Why would we ever study this. 18:25 Right. 18:25 So we have to look at it that way. 18:28 That said, I've seen 18:31 now many patients post biopsy 18:34 and I personally cannot say or have a good argument 18:39 that because of this biopsy, this bread or not spread, I don't I can't say 18:42 I've seen that or has been that evident to me, but I can't say it hasn't either. 18:48 Right. 18:49 And some cases where there's a recurrence and things like that. So 18:54 what do you 18:55 do or are there different protocols, something for people 18:58 that are concerned about it, whether it's theoretical or actuality? 19:02 Yeah. 19:03 Absolutely right. 19:04 Yeah. Who's going to spend money on studying this. 19:06 You know, nobody. 19:08 And they come up with a different type of way of, you know, diagnostic way. 19:13 Then, then maybe at that time in order to be able 19:16 to push this other way of diagnosing. 19:18 But until then, probably not. 19:20 So are there certain protocols that you suggest for 19:24 people that are concerned about this issue during a biopsy? 19:28 Or, or do you just kind of say, hey, we you're going to be okay? 19:33 You know, we we don't have proof about this. 19:35 And, you know, please go ahead and move forward with the biopsy. 19:39 I put all these patients on protocols right away. 19:42 Even before that, it's all to me. 19:46 It's all about 19:46 creating an unfavorable hostile environment to cancer cells in the body. 19:51 Right. Cancer cells like certain environment. 19:54 You want to make it not that right unfavorable. 19:57 And that starts at the time where the say is high and you are 20:03 undergoing a biopsy. 20:05 So that starts there. 20:07 We could get into those details in a little bit 20:09 because there's nothing specific to around biopsy in my mind anyway. 20:13 There. 20:14 And I know there's protocols out there that some people use around biopsies. 20:17 I don't just because let's get you right on the right protocol 20:21 that that you would do if the biopsy result comes back positive. 20:25 Let's get you on it right away. No harm, no foul. 20:28 And you're going to feel better anyway. 20:29 So that's we can talk about those details in a second. 20:32 But let me say this. This is interesting I don't know. 20:35 And I've interviewed quite a few people around this on my podcast, that doctor 20:39 O prostate podcast. 20:41 And I always ask a question, is there a future that where a biopsy 20:46 is not needed, that we can use other things to determine that cancer? 20:51 Why do I ask that question just to be provocative? 20:53 No. In Germany they did a study, very elegant study, 20:58 that they looked at a group of patients without biopsy. 21:02 They looked at their MRI and a Pet scan, no 21:05 biopsy versus a group that did not do biopsy. 21:08 And they tried to determine if there was any difference in finding 21:12 significant prostate cancer after after they got either imaging or biopsy. 21:18 And there was actually no difference. 21:20 It's a group that did the same, a Pet scan and the MRI. 21:23 And so doctor Mark Burton, professor emeritus from London. 21:28 Brilliant. 21:30 And he has a lie. 21:31 He says he promotes. He's huge around imaging. 21:35 I've had him on twice. 21:36 So good. 21:38 He says if it talks like a duck 21:40 and walks like a duck, it's a duck. 21:44 If the imaging shows that is both a Pet 21:47 scan and MRI combined, if it shows 21:50 if it lights up to a certain degree, 21:53 then it's likely prostate cancer, right? 21:58 So is there a future without biopsies, prostate biopsies? 22:02 I asked another guy. I said, you know, is there a future? 22:05 He says, I don't know, because from the tissue you actually get good information. 22:10 Also, you get all this genetic information that's useful. 22:14 But there is a future, hopefully sooner than later, 22:17 where the technology and the imaging is so good 22:21 that they won't have to do 24 snips or cores, or 12. 22:26 They could do probably 1 or 2. 22:29 So it so there's a higher likelihood 22:33 that there would be less biopsy course 22:36 taken in the future than no biopsy at all. 22:41 Yeah. 22:41 Because he's still like you're saying the you're looking at the genetic 22:45 mutations and genetic or different drivers. 22:48 You can gain a lot of that information obviously 22:51 from the biopsy which will then determine 22:55 even from us as doctors, 22:58 we can then kind of form a protocol, you know, 23:02 to put pressure on these genetic drivers, you know. 23:06 So absolutely. 23:08 Yeah. 23:08 So yeah. 23:09 PS you mentioned PS A you know, what is that something that 23:14 every urologist does, or is that something that 23:18 the patient have to kind of push for a little bit, 23:21 kind of like that, that the PSA density test, it's all about self-help advocacy. 23:27 And so it's very interesting because we are at a stage 23:30 and phase where there's a lot of discussion on shared decision 23:33 making between the patient and the decision. Right. 23:36 That's a very interesting concept. 23:37 I believe in the empowerment of the patient 23:40 so that they ask better questions when they come into the office. 23:44 Right. 23:45 And had another patient come in this past week 23:48 who said, I have this my PSA high for his age. 23:51 He's 52 years old. 23:52 His PSA was nine, which is high. 23:55 No urinary symptoms. 23:56 But the pirate score on the MRI is a pirate two. 24:00 And my urologist asked, what do you think? 24:03 You know, he says, what do you want to do? 24:04 It's like, why are you leaving it to me? 24:05 The patient says, you know, you're the doctor. 24:08 So it's interesting because sometimes you do want to the doctor to just say, hey, 24:11 this is what we need to do, and other times you don't. 24:13 I think at the end of the day, it behooves the patient and and regular people. 24:19 We are, you know, at an age where you can find information more easily. 24:23 Yes, you can find inadequate and accurate, accurate information as well, 24:28 but there's also ability to find good information 24:31 where you can ask better questions and be part of that shared decision. So 24:37 the patient went back to your PSM. 24:40 In my perfect world and my perfect world, 24:44 I would get an MRI and 24:47 scan in every patient even before a biopsy. 24:52 That's not what's done. 24:53 It can't be done because then you're going to have to 24:56 battle with your health insurance. 24:57 So pay for the PSM, Pet scan health insurance will pay for PSM, a Pet scan 25:01 after you've been biopsy, and sometimes not even it sometimes is. 25:06 If there's a recurrence. 25:08 They have prostate cancer. 25:09 They get treated PSA recurrence rises up again, then PSM a Pet scan. 25:14 And that's when a lot of health plans will actually pay. 25:16 And only that circumstance I would like to know before what I have 25:21 can it be overkill sometimes. 25:22 So maybe the PSA is low. 25:24 Parrot is not that high from the MRI. 25:27 And look PSM apex can which really tells you 25:31 if there is anything outside of the proxy that we should be concerned about. 25:35 Maybe in some circumstances 25:37 there's little likelihood that there's something outside of the prostate. 25:40 But the PSM, a Pet scan shows it seems to be really good to tell us 25:45 what's in the prostate as well, not only with what's outside the prostate.
Future of Imaging and Treatment Decisions 25:49 So if you can, 25:52 you get a PSM, a Pet scan and an MRI. 25:55 Patients are willing to pay for it out of pocket, which is worth it 25:59 if you can afford it. 26:00 Otherwise you can kind of battle it out with your insurance company 26:04 for them to cover it for you. 26:06 But it is a very useful other biomarker along with MRI 26:10 to determine number one is anything is outside of the prostate. 26:14 Number two, even with what's in the prostate, 26:17 it could give you some idea of how clinically significant it really is. 26:23 And then now 26:24 when you have a good understanding of what's going on, 26:27 you've done the imaging, you've done the biopsy, 26:30 you had your score, you have all of this information in front of you. 26:34 And now there's a question, what should I do? 26:37 Yeah. 26:37 What is the appropriate type of of course of action. 26:41 And you know, you get and different forms of radiation, you know, whether it's 26:46 kind of the whole floor or you're going after it very, very targeted. 26:50 You have surgery, you have androgen deprivation therapy. 26:54 And then obviously there's always chemo if something is really gone wrong, 26:59 you know. 26:59 So how in your mind, I mean, when you are then 27:03 presented with the evidence of what's going on, 27:06 how should you then navigate, like you're saying, that kind of 27:09 shared responsibility, 27:10 how should a patient think about what would be the prudent thing to do? 27:16 So the the answer of course, is it depends. 27:19 Right. 27:20 So the patient high PSA without a biopsy, they already want to go 27:25 into the conversation of well if if I do a biopsy and it's positive what do I do? 27:30 Then I said, buddy, I can't tell you that because it depends. 27:34 And it could go and you know, really depends what you have. 27:38 So let's go through the full spectrum. 27:42 If you have low risk 27:45 prostate cancer, you highly unlikely to die from it. 27:48 And you actually are more likely to die from a heart attack than prostate cancer. 27:53 So they they you should be on active surveillance 27:56 or what I call pro active surveillance. 28:01 That is intensive lifestyle interventions, which we can go over and be like, 28:05 but you do these things to create an unfavorable ecosystem 28:10 to the tumor environment or to the prostate environment. 28:13 Right. 28:14 So that's number one. 28:15 Let's just say it's low intermediate risk. 28:17 Listen, grade two should I do something. 28:20 Maybe maybe not. 28:22 There is 28:23 evidence showing that those with low intermediate risks we're talking 28:27 at least in grade two Gleason seven three plus four 28:30 that they many of them are unlikely to die from their cancer as well. 28:35 And they may be an A candidate for proactive surveillance as well. 28:39 Right. 28:39 And many of my patients I have are in that situation. 28:46 Once you go above that two Gleason Gray three and so forth, 28:49 I would say that a treatment should be applied, a medical treatment. 28:56 The other thing is this 28:59 many of the research shows very clearly that in patients and active surveillance 29:03 who choose treatment, don't do it for biological reasons, 29:07 don't do it because of the biology of the prostate cancer and is progressing. 29:10 Do it for psychological reasons, right? 29:13 So once the cat is out of the box for some patient personalities 29:18 and they say and the word, the C word comes out, 29:21 that is just way too anxiety provoking. 29:25 And they get treated like I need to get rid of this, right. 29:30 So and I'm okay with that. 29:31 I just want patients to make an educated, well informed decision. 29:37 I'm the same. 29:38 I mean it because sometimes it's just you have that monkey on your back, 29:42 but the C word and you mentally, you just want to get rid of that 29:46 mic on the back, whatever that means, you know? 29:48 And so then you just honor that, whatever that may be. 29:52 Absolutely. 29:53 I'll give you a quick breakdown of the options because there are many. 29:56 I just came back from a Michael is amazing. 29:59 I'm getting asked to speak at these very conventional medical prostate cancer 30:03 conferences, which it only took 20 years to get those type of invitations. 30:08 That's all it took. 30:09 But man, they are they are all in with what we do and they want to learn more. 30:14 It is. I keep pinching myself. 30:16 So I just came back from a focal Therapy prostate cancer conference giving a talk. 30:21 All right. Vocal therapy is one of them. There's tons of them. 30:23 What is focal three focal ablation therapy. 30:26 What does that mean? 30:27 You leave the prostate intact and you only treat the tumor 30:32 itself with a little margin around it. 30:35 Right. All sorts of technologies to do that. 30:38 You have heat in the form of ultrasound, whether it's transfer 30:42 throw through the penis or through the rectum called Haifa. 30:45 You have you have cryo, which is you freeze well with cryotherapy. 30:51 You don't freeze the tumor and the margins. 30:54 You freeze half of the prostate. 30:57 So it's you, you you freeze the whole half. 31:00 You're not treating just. 31:01 But it's still considered focal ablation therapy. 31:03 So you leave the other half alone. 31:06 You have IRA electrical 31:09 paresis, which you actually electrocute the tumor. 31:12 So you put for prawns around the tumor. 31:14 You actually electrocuted it there. 31:17 There's many therapies. 31:18 So that's focal therapy for the right candidate, 31:21 which is not the higher grade yet. 31:24 I think it is. 31:24 I just introduced the thought a couple of thought leaders on that. 31:27 And I'm like, come on, tell me for higher grade that this is available please. 31:31 Because this is it has to be it doesn't make any sense. 31:34 It's like, not yet. 31:34 We we have to study it. 31:36 I said, well, okay, it's not study yet, but I'm a patient. 31:39 I'm Gleason nine. 31:40 I'm not going to do anything. 31:41 Doctor so-and-so, would you treat me? 31:44 I'll take my chances. 31:45 What do you think? I asked them, what do you think? Is it? 31:47 He says, I do think that it's going to be 31:49 if they make a well informed decision that you can treat 31:51 a Gleason nine, assuming that there's nothing else else outside, 31:54 but they're not ready to move forward with vocal therapy in 31:57 that treated with focal therapy with higher grade disease. 32:01 Then you have radiation. 32:02 Radiation has come a long way. 32:03 Now there's a possibility of just treating the prostate. 32:07 It used to be that the external beam radiation around the whole pelvic area, 32:11 which now you're exposing the radiation 32:13 to healthy tissue, which brings about other problems. 32:16 The problems are on the bladder called radiation cystitis, where now 32:20 you have all sorts of urinary symptoms, secondary cancers from that. 32:24 Now they've done a very good job of treating just the prostate 32:27 without hitting the rectum, because they put a spacer 32:30 between the rectum and the prostate to separate it, to hit only the prostate. 32:34 So radiology has come a long way. 32:36 And of course, as removal of the prostate, which I have to say, 32:41 there's just a lot of good surgeons out there. 32:42 But I'm in a homogenous situation. 32:44 I'm faculty at NYU, I'm in New York. 32:46 Everybody from across the world, globally, come to some of these institutions 32:51 to get their prostate removed. 32:52 Because these are high volume places. 32:54 There is a 32:55 chance that you go to a low volume place and the results are not going to be 32:58 the same. 32:59 So buyer beware because it really the learning curve 33:03 could be 50 about 100 before you become really good at this. 33:07 And you know the guys that the the surgeons that I'm familiar with
Treatment Options: Focal Therapy, Radiation, Surgery, and ADT 33:11 have done many thousands that said 33:15 that's come a long way with the robotic surgery 33:18 where they can spare nerve so you can still have your erections afterwards. 33:22 That's come a long way if you go to the right surgeon. 33:25 So those are the big three. 33:27 And later 33:28 more advanced prostate cancer than we took in hormone deprivation therapy. 33:33 We're talking about taxol as a chemotherapeutic agent. 33:37 We're talking about things like 33:40 which is like radio particles 33:42 type of treatment and immunotherapy, all sorts of things that come way later. 33:48 Triplet therapy, where they do hormone therapy under deprivation therapy, 33:52 and those and Taxol that comes way later on, more advanced disease. 33:57 And then there is hardcore chemo drugs like any other cancer, 34:02 if it's very advanced or what we call neuroendocrine prostate cancer. 34:08 And so talk a little bit about the androgen 34:12 deprivation therapy or hormone blockers. 34:15 When should they be incorporated. 34:16 Because it seems like that is an option that is thrown 34:21 quite early on for for an individual sometime 34:26 hormone deprivation therapy is chemical castration 34:28 where your testosterone goes down to zero, almost zero. 34:31 No, no man really likes that. 34:34 Okay. You you you are feeling different. 34:37 More fatigue a little bit, perhaps more emotional. 34:40 I always say, Michael, I always say, you know, being witnessing. 34:43 Right. 34:43 So two daughters that went from, you know, not having mentees 34:47 when they were very younger to older and then a lovely spouse 34:50 who went through her menopause and then seeing a lot of guys. 34:53 On Andrew deprivation therapy. 34:56 My conclusion, Michael, is that 34:59 you become more of who you really are 35:02 when there's a big shift in hormones, whether it's very high or very low, 35:07 you become more of who you are. 35:09 So if they are the angry type, they're going to be more angry after home. 35:14 You would think they're going to be everybody's the same. 35:16 No, they're going to be more angry. 35:17 If you're the emotional type, 35:20 don't watch that sad movie with your family 35:22 because you're going to be bawling. 35:23 That sad scene with the father loses it. 35:26 So whatever it is, you're going to ball, right? 35:29 So you, you become more of who you really are. 35:32 So hormone deprivation 35:35 therapy comes with a kind of stalling because there's so many elements. 35:39 I've been through a few people now as hard questions not to be provocative. 35:43 I just we need to know. 35:44 Hormone deprivation therapy oftentimes go in tandem 35:47 with radiation depending on their how their risk of disease. 35:51 So if it's higher risk based on a few tests 35:54 then it's hormone deprivation therapy. 35:56 And with the radiation, 35:58 the question that the patient needs to ask is very important is this 36:03 standard hormone deprivation 36:05 therapy around radiation is two years. 36:09 And I've asked a question why? 36:11 Why two years? Why not one year? When not six months. 36:14 Why not three months? What are we trying to accomplish? 36:16 Is it that the hormone deprivation therapy is making 36:20 the tumor more radio sensitive? 36:24 Right. 36:25 So now the tumor is more vulnerable because of the home of deprivation 36:29 therapy? 36:29 Or is the hormone deprivation therapy doing its own thing? 36:32 Because if it's the form or not the latter, 36:36 why two years? 36:38 The answer that I've received, these are the thought leaders in the field 36:42 is, well, it used to be three years because there was a study 36:45 that studied it for three years and out of Europe, 36:49 and then there was a study that studied it for two years. 36:51 And so it became two years. 36:53 Now there are studies that are suggesting one year. 36:56 So I'm saying, okay, so based on what 36:58 you decide to study, right, this is what you do. 37:02 So why not six months or three months since we seem to be heading in 37:06 that direction? And if it's around the radiation, 37:09 then how long 37:10 is the radiation therapy effective after the actual treatment? 37:14 Let's do it around that. Why not three months? Four months? 37:16 What do I say to that? 37:17 I say that because it is a reasonable conversation 37:21 to have with your decision 37:24 about, hey, can I do this for three months? 37:27 Can I do this only for four months? 37:28 Not two years or one year? Very reasonable. 37:31 This is not unscientific at all. 37:34 So that's number one. 37:35 Patients need to know that 37:37 with more advanced disease, oftentimes they leave them. 37:40 They leave patients with around EDT 37:43 for a longer period of time, two years or so. 37:47 The the number one question I ask my patients 37:50 to ask their oncologist is the following. 37:54 When would I when will I be off of 37:56 of the radiation of the ADT? 37:59 When will I be off? 38:00 One year, depending on what? 38:02 What are you looking for? Here's why. 38:04 The longer you stay on these hormone deprivation 38:07 therapy treatments, the higher number one, 38:10 your quality of life may be diminished because you don't have testosterone. 38:14 But number two, there's a higher likelihood of creating 38:18 castrate resistant prostate cancer, where now the hormones are not working. 38:23 The longer you're on these, the the the higher likelihood 38:26 is for the patient to be cause cancer resistant prostate cancer. 38:32 You want to try to avoid castrate resistant prostate cancer 38:36 by any means necessary. 38:37 One of the ways to do that is by doing intermittent ADT 38:41 if you needed in the first place, intermittent on it for a period of time, 38:46 things look good off of it, and depending on how things progress, PSA 38:49 or whatever, then we'll put you on or not put you on. 38:52 So there's protocols that I have for patients 38:55 who were on it, no longer on it, that are natural. 38:58 And in order to try to keep off of it for as long as possible. 39:04 Yeah, a lot of that, a lot of that. 39:05 And just kind of to wrap up a little bit. 39:07 So lifestyle wise, you know, what do you suggest? 39:11 You know, what are kind of some of the first initial changes 39:14 that an individual should, should go through. 39:18 All right. 39:19 So there are six six elements to the soil or the eco system 39:23 or on the tumor that I'm trying to target. Right. 39:25 So number one is the nerves. 39:26 The nerves are part of that microenvironment in prostate cancer. 39:30 You remove the prostate with the nerves. 39:32 You see by the way, 80%, 80% 39:36 of the biopsy tissue of the pathology tissue that's observed 80%. 39:41 You see it on the reports. 39:43 The pathology report shows her neural invasion 39:49 80% of the time. 39:51 The urologist is going to say, and I'm not knocking the urologist 39:54 because I don't think they know. 39:55 They're going to say, well, that's an incidental finding. 39:57 It's not significant. 39:58 Not when you ask the natural, holistic guy is this just doesn't make sense. 40:03 What have they found in prostate cancer? 40:06 In states that have cancer, 40:09 the nerves are thicker and more dense versus 40:13 those that don't have cancer are smaller and less dense. 40:17 Right. 40:18 So the nerves around the prostate is part of that microenvironment. 40:22 So how do you manipulate that? 40:26 How many people have you seen Michael. 40:28 Just again yesterday. 40:30 Patient from Tennessee 15 years ago. 40:34 You were 50 years old. Yeah. 40:35 Pretty advanced cancer. 40:37 15 years later he was doing great. 40:40 And what happened man, what a horrible divorce. 40:43 Horrible divorce. 40:44 You know, my 40:45 I'm a pilot and my come back home and I find out that my wife is cheating on me. 40:49 And then we have a daughter. 40:50 And it was brutal. 40:51 And I had to pay all these lawyers and. 40:54 Right. 40:55 That's the nerve around the prostate being affected. 40:58 Right. 40:59 So nerve nervous system regulation is how you deal with that. 41:03 And I think people can just there's a lot of information out there on that. 41:06 There's a gut microbiome very important to keep that healthy. 41:10 There's the immune system. 41:11 Keep all these T cells 41:13 and natural killer cells nice and healthy, ready to go right in. 41:17 Lowering chronic inflammation is another part of treating the soil.
Lifestyle, Exercise, and Finding Dr. Geo 41:21 So that's so we're dressing these things. 41:24 Then the question is 41:27 how do you address all these things. Right. 41:28 So in my mind the pillars are nerve system regulation. 41:33 It's good sleep to better sleep because everybody's like good sleep 41:38 I struggle with that. 41:38 I'm not saying for you to sleep eight hours a night overnight 41:41 a little bit better, a little bit better each night. 41:44 Sleep, exercise, prescriptive exercise. 41:48 I'm not talking 10,000 steps a day. 41:51 That's not fitness. 41:52 That's good. It's not fitness. 41:55 We need to be fitter and and so that this microenvironment thing 41:59 is more favorable towards you and your longevity and not the cancer, 42:03 nutrition, food and nutrition. 42:04 I don't call it diet anymore because I just don't like that word. 42:07 And I don't like the first three letters of that word anyway. 42:09 So I call it food nutrition and 42:12 and targeted supplementation, targeted dietary supplements. 42:17 Michael, if you ask me. Right. 42:20 I want to give the most bang for my book. Right? 42:22 I want the most bang for my buck with what I do. 42:25 What is the one thing that hits all these things? 42:29 The gut microbiome better, immune system lower. 42:32 What is the exercise? 42:34 We're not moving beyond exercise. 42:36 If you cannot exercise the way I'm asking you to, 42:40 Michael. 42:41 And this is going to sound crazy to a lot of listeners. 42:44 We're not even touching diet. 42:47 If you cannot exercise a certain way. 42:51 Right. Diet if the exercise is a problem. 42:53 But tell me about die or is it 42:56 50% less of what you already do? 42:58 No, no, no. But what are the foods? 43:00 He has a food rating system that I created. 43:02 But can we get deeper and we're not getting deeper. 43:04 You need to exercise and move your body because that hits everything 43:09 and everything gets better, including your sleep. 43:12 If you exercise a certain way, we're not doing it. 43:15 And that's sometimes the choke point for many patients. 43:18 And then targeted dietary supplements to here would deal with the inflammation 43:22 and immune keep the immune system strong and things like that. 43:26 But that and I seen you in the gym doing your deadlifts, you know so you 43:31 I know you walk your talk so walk by talk. 43:35 That's right, that's right. Deadlifts and barbell squats. 43:37 Well you know all the comments. Watch your back. 43:39 Be careful with your back. You're going to hurt your back. 43:41 No no no no no no no. 43:44 Stranger in my back. 43:45 Yeah exactly. 43:46 The fear is what keeps. 43:48 First of all you don't want to do it. 43:50 And second of all, now you have fear around this. 43:53 So why would you do it? No, no, no, you got to overcome that. 43:56 And you got to get in the gym and you have to do it. 43:58 And it's non-negotiable. 44:01 Love that. 44:02 Well, you obviously the amount of information that we can go through 44:06 and pack is I mean, you have your own podcasts, 44:10 so where can people find you and kind of listen more to what you do? 44:15 Well, you're very kind, Michael. 44:16 And again, thanks for the invitation. 44:18 Doctor geo.com. 44:19 So Dr. 44:20 geo.com everything is there. That's the hub. 44:23 So you can find information on the podcast. 44:25 Newsletters that I have are three Thursdays every Thursday 44:27 to put something out relative to 44:29 for the most part prostate cancer, prostate problems and male longevity. 44:33 And a podcast is Doctor Geo the Doctor Geo Prostate podcast. 44:38 Thank you so much, Michael. 44:40 Well thank you I'll always always a pleasure. 44:43 Thanks so much.
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