The Future of Prostate Cancer Treatments & Non-Invasive Techniques with Less Side Effects | Dr. Sanjay Mehta

24:37So I could create a tumor, I mean, I could create a ball of radiation that looks exactly like the shape and size of the tumor, even if it's got a little Mickey Mouse ear sticking off one side, I can do that too, while simultaneously shaping it to stay away from all the normal tissue. So that's where you get the advantage is basically what we call the therapeutic benefit where you're radiating what needs to be radiated, but you're not radiating and damaging the normal tissue. And do all, I mean, there's various types of cancers. Do all cancers respond to radiation? So the short answer is yes. And I won't bore you with too long of an answer, but it's a little, there's always a little more nuance to it than that.

25:14So yes, there is no cancer that cannot be destroyed by radiation. The limiting factor is the human being around that cancer. So I got to be cognizant of the normal tissue. So if you took a tumor in a Petri dish, anything can be radiated and it's going to destroy those cells. But let's just say it's a, you know, a tumor in the tip of your pinky toe. There's not much around that I don't have to worry about a kidney or, you know, or an eye or something like that. But if it's a brain tumor, I have to be very worried about what I'm treating to the normal brain tissue, the dose that's going to the lens of the eye, things like that.

25:46So depending on which part of the body it's in, the surrounding normal tissue will dictate how much radiation I can safely deliver. And it doesn't affect the dermis. You can just go right through the skin. Great question. So based on that energy, so if I have a skin cancer, I will use an energy of radiation or a type of radiation. One is called electron beam, which will literally only go in a few millimeters. So I can treat that superficial skin tissue and not affect anything deeper. Even if it's, I've treated like a squamous cell right on the temple of an old lady who was, she's a 90 year old who's on anticoagulants and she can't be off of her meds so they couldn't cut it out.

26:23So we just radiated it. But with electron beam, the x-rays stop a couple of millimeters deep into the tissue. But if I'm treating a brain tumor, I'm gonna treat the same area with a high energy x-ray that will, like you said, It'll spare the dermis. They won't even get a sunburn, but the energy will go deeper into the brain. Gosh, that is unbelievable. Yeah. Someone would not have to be opened. Correct. And not even burned. So that's the big thing. People are like, oh, am I going to get burned? And that goes back to your previous question about what are people concerned about? Everyone thinks they're going to get burned really badly.

26:55And that, again, is based on seeing all these horrible pictures from nuclear disasters. And with older radiation equipment, back in the 1950s and 60s, we had what was called cobalt-60, where it was just basically an actual chunk of radioactive cobalt that the patient was exposed to. It would burn the skin. And if you're trying to treat, say, a breast tumor, it would completely really burn or necrose the skin in order to get enough dose deep enough to treat the breast tumor. But now we don't use cobalt. We use these high-energy x-rays that are generated by a machine called a linear accelerator, or a LINAC for short.

27:29So the LINAC is our bread and butter machine that creates the x-rays, the high energy x-rays. Does everyone use a LINAC? Almost everyone. The other things you'll hear that are alternatives, being in Houston, we have MD Anderson up the street, they have proton therapy. So protons are different than photons or x-rays. So they have their own, what's called a cyclotron, which is essentially a particle accelerator to create protons, but that's a completely different topic. But most cancer centers do use a LINAC. So a linear accelerator can generate the low or high energy x-rays, depending on what I need to treat.

27:59So with a LINAC, I can treat a lung tumor, for example, and the surface of the skin will get a little dose, a little redness, but not a horrible skin reaction. And if it's a deep enough tumor with a high enough x-ray, sometimes the skin dose is almost undetectable. Like it's low, but not even enough. Like my prostate patients, they don't even get a sunburn. Maybe a little bit of a tan spot, but that's about it. Which they're definitely not looking for in that area. Right. Once you treat someone with radiation, obviously, it's a few treatments, a handful of treatments. And that's another big topic in terms of how much do you, because it's not just how much radiation you give, it's how frequently do you give it and how, how many pieces do you slice your pizza up into?

28:41Do you, what you get a, you know, when you get your pizza from Domino's, it has eight slices. If they, if you cut each one in half, you get 16 smaller slices. It's still the same pizza you're getting. So with, with radiation for someone with prostate cancer, you can do different protocols depending on, there's a lot of different data out there where you can give, say, nine weeks of treatment, or you can give four weeks or even one week. Now they're looking at different things, but it gets much more accelerated. You can give a higher dose per day. If you give a higher dose per day, there's a potential for more side effects.

29:10You have to be careful. The slower you give the radiation, you give a tiny bit per day and you stretch it out over many, many weeks, you have a lot less normal tissue toxicity in most cases. And is that all measured in grays? It is. So like, for example, a prostate patient, historically, if you asked me this 10 years ago, what do you give a prostate? We would give 81 gray, but given in 1.8 gray per day, which is 45 days. So 1.8 times 45. But that also requires the patient come in for nine weeks. It's a lot of visits. Whereas typically now we will use 70 gray. So it sounds like you're not giving as much radiation.

29:44but 2.5 gray per day rather than 1.8 you only have to give 28 days so 70 gray in 28 days is the equivalent of getting 81 gray in 45 days and it's a lot less visits to come in for it shrinks the cancer but does it cure it that's the key thing and so typically yes that's what we have to go for is that if we were just shrinking it then you would see these like for let's let's talk about prostate cancer the cure rates for prostate cancer are essentially the same whether you use external beam radiation or whether you have a radical prostatectomy. The cure rates are the same. They're literally the same, even though in one case you're surgically removing the tumor.

30:22On the other side, the prostate gland is never removed from the body, but the energy from the x-ray sterilizes the cells. So even though the organ is physically still there, if you were to do a prostate biopsy on someone after radiation, you would just get scar tissue out. So the physical gland on an x-ray is still there, but it's no longer active, viable tissue. So you are still curing the cancer. That's the goal anyway. And so an average prostate patient might have a 95 % chance of being cured with radical prostatectomy. It's basically the same with radiation. Oh, sorry. It's time to record an ad for the show.

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32:12Lyon and use the code Dr. Lyon to get 20 % off. I recommend trying their starter pack with all three different formats and of course their gummies, which are incredible. What are the side effects of surgery or radical prostate? The biggest problem with surgery is usually incontinence because when the prostate is removed, removed, the intraprostatic urethra comes out along with it. And then the urinary sphincter muscle gets damaged as well, because in the process of removing all that, there's always damage to those areas. There can be nerve damage as well that can lead to sexual dysfunction. That is the biggest one that I've seen.

32:51That and also, it's not talked about as much, but penile shortening, because they have to re-anastomose the penile urethra to the bladder neck in order to create a new pathway. The The intraprostatic urethra is gone, so that length is gone. And so I haven't met too many men who are okay with that either. You are the second person in all of my years of speaking with physicians that have mentioned penile shortening. It's just not talked about much. I don't think people even know about it. We had Dr. Tobias Kohler. He's a Mayo Clinic doctor. He runs the Men's Health over in Minnesota. and he was talking about if you don't use your penis over a three-month period of time, that you can shorten your penis by a centimeter.

33:37That's a lot. Yeah. And I think it's slightly reversible, right? If you start to have penile therapy, you can get some of that back. But if you have a radical prostatectomy, that's irreversible at that point. If you have a radical prostatectomy, which is removing the prostate, you can reduce penile length by how much? Probably a couple of centimeters on average. Because when you look at the anatomy, the prostate itself, depending on the size of the gland, you get BPH. Some men that are older have a really, really large 100-gram prostate. That's a lot of tissue to remove. And so the urethral length that's inside of that is gone after that.

34:18Now, that's not to say, to be fair to the urologist who may be listening and shaking their fists at us, There's plenty of side effects that potentially can happen from radiation too. But luckily in the modern era, this is called image-guided radiation. And because it's so much more precise, the traditional problems with radiation were cystitis or proctitis. You would be radiating the tumor, of course, but you're also radiating the bladder and the rectum. And that could cause blood in the urine with cystitis. It could cause severe diarrhea or blood in the stool. in some cases they were worried about you hear this in the it's all historical it doesn't happen anymore just to just to ruin the story but fistula formation you know a colovesicular fistula from the the scar tissue causing the organs to stick together and fistulize but that was in an era when we didn't have modern computer imaging we didn't have ct scans we didn't have pet scans so many times the bladder and the rectum got almost as much dose as the prostate did that's where radiation kind of got part of its bad rap was because this is in the 70s and 80s, there were some really bad side effects.

35:20Or like I mentioned earlier, cobalt-60 causing severe sunburns. But now that we have modern image-guided high-energy radiation, we can have the radiation beams concentrated. If the prostate is this big around, I can literally map the radiation just to that area so the dose fall-off, meaning the amount of radiation that's delivered just outside of that is very sharp. So you have a nice sharp fall-off to where you're not getting a bunch of low-dose radiation to all the surrounding tissue. It basically goes close to zero, and therefore, you're not causing the cystitis and the proctitis like we used to.

35:53So that's gotten much better, but the one thing about radiation that people have to keep in mind is when you, and this has been discussed quite a bit whenever you're discussing the pros and cons, even though we don't cause the impotence and the incontinence the way surgery potentially can, many patients, if they have a more aggressive prostate cancer, the data shows they have to be on testosterone blockers along with the radiation. So that in itself, androgen deprivation, you hear it called ADT, testosterone, basically a medicine like Lupron that suppresses the body's ability to make testosterone.

36:27That is a potential side effect from radiation that many surgical patients don't have to deal with. And so you deal with hot flashes and decreased libido and all the usual, because you're not just lowering their testosterone, it's going to go close to zero. And I think it from talking to our mutual friend, Dr. Mohed Cara and Abe Morgenthaler, both of which have been on the show. The joke is I have the number one men's health podcast and YouTube, but we'll save that for another day. Yeah, I'm not in their league. They're both the kings. Well, I don't know. You've got Sunday. You've got some pretty extraordinary skills that are very unique to a small subset of physicians to be able to really treat arthritis and things of this nature as well as cancer.

37:10but certain prostate cancers they do well with testosterone therapy it all just I guess it just depends isn't that interesting and Mohit is he's obviously on the forefront of all the research they've done despite all of that and all his data is very valid we still the standard of care we still use for aggressive prostate cancers we deprive the body of testosterone for a period of several months to even several years and that still has shown a survival advantage in those situations. Now, the good part is, once they're cured, their PSA goes down, Mohit can put his patients back on testosterone, which in the old days, that would be a big no-no, is no T for life.

37:48But now he's shown that it can be brought back. But there is a temporary window with radiation, even though the radiation might only be six weeks, if it's a more aggressive prostate cancer, they might need six to 12 months of androgen suppression. But in the big scheme of things, that's all reversible. And there's better drugs now, too. Some of the modern oral LHRH agonists, they don't cause as long or as severe of the hot flashes as the old Lupron shot did. And so it's gotten better. But for some of the lower grade patients who don't need the androgen suppression, if it's just radiation alone, extremely well tolerated.

38:21They really, the only thing that patients have is a little frequency or urgency. We're in Texas, so they eat their spicy foods, maybe a little bit of dysuria as you're passing the spicy chemical, the capsaicin route out of the urethra a little bit. But that's really minimal stuff. Patients are thrilled because they can go through their life. I have guys, I have bodybuilders that are, they're still training for competitions and they're coming in for their treatment. They get their treatment, go right back to whatever they were doing. We got retired guys. The same day? Same day? The same day. Same hour.

38:48I mean, literally 15 minutes, head straight from my clinic, straight to the gym. We got older guys that head straight to the golf course, straight to the, you know, back to whatever they were doing. They go, my dad, I actually treated my own father and he rides his bike three miles a day. And the only thing that was bothering him was his hand was getting sore and I fixed that too. Is there anyone who would not be a candidate for radiation therapy? For example, prostate, breast? Very few. There are rare situations. Like there's certain hereditary disorders of DNA repair, like zero derma pigmentosum and stuff that you probably haven't heard about since med school.

39:25I don't even think I've heard about it then. Yeah, it's like those are, you know, there's, you'll hear about a case where a patient can't be out in the sun at all. And so zero dermapigmentosin, these patients have no DNA repair. So even the minor amount of UV exposure, they'll have horrible like sunburns and things like that. So in those, and again, I don't think I've ever seen one of those people in real life, but theoretically, there are cases like that. And there's individual situations like not an absolute contraindication, but a relative contraindication could be an active autoimmune disease, like really bad rheumatoid arthritis or Sjogren's disease.

39:56Any of those things might cause the radiation type of the DNA damage caused by radiation to be more severe. I've still treated people with all of these things. And as long as you do it properly, and you modify the dose appropriately, it's still very doable. But that is a potential issue. Or if they've had a previous tumor in the same area been previously radiated, we have to be very careful. It's not an absolute contraindication. But relatively speaking, I have to make sure that my dose doesn't overlap with what was previously treated and things like that. It's that time again, man flu season.

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41:12And let's face it, there's a lot of stuff on the market, and it's important to get clean products. Go to thisisneeded.com and use the code Dr. Lyon for 20 % off your first order. That's thisisneeded.com. Is radiation the standard of care for all cancers? No, that's probably a little too much of a blanket statement. As much as I'm a believer in what we do, there's many, many different situations. So depending on what part of the body it's in, if it's a cancer that has a metastatic potential, like a lung tumor or maybe a lymphoma or something where it's more of a systemic disease, chemo and radiation are many times needed.

41:54There's many situations where chemo alone can work. Because as you know, cancer is not just one disease, it's so many. So for certain diseases, radiation alone works very well, like prostate cancer. But for most other ones, radiation is more of a part of the multidisciplinary approach. So in many cases, it may be chemo radiation and surgery sometimes surgery first followed by chemo radiation in other cases like for a rectal tumor the randomized data shows that chemo radiation combined will shrink the tumor enough to where then the surgeon can go in and remove it and reduce the risk of them losing their sphincter or things like that so many different scenarios so hard to make a blanket statement and i really appreciate that because we've moved into an era where we are very radiophobic and to frame that up for the listener the viewer other than my dad who might be i think he's the only one that watches youtube but hopefully we're changing that here's what i've heard okay don't use ipods those apple ipods because it's going to create radiation for your brain right do not stand near the microwave i've had patients who don't want to get mammograms because they are afraid of radiation.

43:08Other patients that are afraid to go through the security line and will request an opt-out, especially if they are pregnant. Did I miss any more other additional common? I think as a child of the 70s and 80s, when I was growing up, it was always don't sit too close to the TV. The TV? Yeah. And so let's address one of those. Don't put the computer on your lap. Don't put your cell phone in your pocket. That's right. And so all of these things are different. Some of them have more credibility than others. So the TV part, the microwave oven, or the AirPods, the iPod, those are all non-ionizing radio waves and microwaves.

43:50So going back to what we talked about previously in terms of the electromagnetic spectrum, when you're on the non-ionizing low energy side, those are not harmful. So the headphones, the AirPods, the microwave ovens, none of that stuff is going to damage your tissue. And we know that those are strictly non-ionizing. Correct, correct. Because ionizing radiation is much more tightly regulated. So like the mildest type of ionizing radiation would be ultraviolet. That's less of a strong energy than x-rays and gamma rays, which is the farther end. But even like a tanning bed, for example, those are now regulated by the FDA.

44:27You don't want to be in it. I mean, tanning salons are obviously big business, but those are ionizing and they can cause skin cancers and things like that. But on the other hand, as you mentioned, the lady who's afraid of going through an airport scanner because she might be pregnant, that is ionizing radiation. It's a very low dose to get an x-ray to security area, but that is an x-ray. X-rays, by definition, are ionizing, and if I had a chance of being pregnant, I wouldn't go through it either. I think that's a very reasonable thing. Wait, wait, wait. This is really important for the community.

44:58Yes. Going through the, is it the machine that you stand up that scans you or is it the, what is it? Yeah, so there's different types. There's like, I'm not an expert on this by the way, but there's a millimeter scanner, but they all do use x-rays. It's very low dose. It's probably not a big deal, but why take the chance? In theory, it is low, low doses of ionizing radiation, like any x-ray, and that if you have enough of them, now if I wasn't, if pregnancy was not an issue, I wouldn't think twice about it. But for a pregnant person, why take any chance? There's a principle we have called ALARA, A-L-A-R-A, and that stands for as low as reasonably achievable, A-L-A-R-A.

45:41And that's one of the things, the tenets of radiation safety, where no matter what we're doing, why not minimize things as low as reasonably achievable? Why put, even if there's a 0.01 % chance of damaging a fetus, why not make it zero and just not do it? That makes a lot of sense. But if it's not a pregnant person, those doses are so minimal. And that's where, getting back to what we talked about earlier, radiophobia is a real thing. And when you have high doses of radiation or whole body radiation, those effects are potentially lethal or at least very much damaging. But at very low doses, this is the point I wanted to make, at very low doses of radiation, it was always thought that even super low doses could cause DNA damage and therefore potentially cumulative effects over time.

46:23And I would agree with that. Like for someone who's pregnant, that's a different scenario. But for a non-pregnant and a non, like a child who still has multiplying cells and is still, you know, growing, we try to basically keep the radiation dose at zero. But for adults who are fully grown, it has now been shown that these super low doses of radiation are not only not damaging, there may actually be a hormetic, a hormesis effect. Which you said, again, that I think we're not really thinking about in that way. So these super, super low doses, like the amount that they use for an airport scanner is tiny.

46:55It's so little. if I was pregnant, I still wouldn't go through it. I don't blame her. But otherwise, it's nothing for the average person to be concerned about. Where else would we be exposed to radiation like that? Would that be the red light, those red light beds, just also the red light panels, which by the way, I use all the time, so you better tell me. Yeah, no, red light is visible. If you can see the light, it's not ionizing. But is there some light that, again, that maybe is being produced that we're not seeing? My smart ass answer to you would be everywhere. Living on Earth is where we get exposed to radiation.

47:27That's because there's radon gas in the atmosphere. Of course, you have UV radiation from the sun, which is absolutely everywhere. And depending on where you are in the country or in the world, the elevation you're at makes a big difference. So people in Denver, mile high, get way more background radiation than we do here in Houston at sea level. But an interesting point about that, even though they get far more radiation, the baseline level of cancer incidence, Colorado versus here, no difference, undetectable difference. Even though we get far less exposure than they do, it's still within that small amount to where it's not a problem.

48:06People who are either astronauts, for one thing, get a ton of radiation. They're beyond the atmosphere. But even people in the airline industry, pilots and airline people, they do get a relatively high dose because you're up in the air all the time. But even in those populational studies, I haven't seen any data showing that they have a higher incidence of cancers than those of us that stay on the ground most of the time. And is it the location of where someone is? So the higher they get up in the atmosphere, the higher the – is it because it's closer to the sun? Yeah, you have less shielding from the Earth's magnetic field and also from the atmosphere.

48:38Less shielding from the Earth's magnetic field. even though you're in a plane where you're not really being exposed to light. You're still, because it's not, it goes, the plane itself is made out of metal and that will shield a certain amount, but a lot of it still goes through. Have you ever, okay, don't make fun of me. We're friends, so don't make fun of me, Sanjay. But there, and again, I did this while I was pregnant. There were blankets that were EMF protector blankets. There were shields of placing my computer on an anti, you know, they call it this anti-EMF, anti-radiation tablet. Talk to me about that.

49:14Yeah. So that's all, all the electromagnetic frequencies and all, that's all non-ionizing. So it's not of any danger. So you're saying I wasted my$150. You know, again, there's a lot of things. I'm not trying to say modern medicine knows everything. And it's your own child you're talking about. Why not be a little extra cautious? I would probably agree with everything you did. As to whether it helped or not, it certainly didn't harm anything. Maybe it harmed your pocketbook a little bit. But, you know, electromagnetic EMF is not going to – like you could have a television and a radio and a microwave on all the time and it's not going to do anything.

49:49It's a really important conversation because there's a lot of misinformation out there. And, frankly, it's confusing for me as well, which is why I bought an EMF blanket and I used this tablet. that I put my computer on. But if it's not accurate, then I think that we have to, the whole point is to have... Did you ever see that, it was a viral video probably 15, 20 years ago when viral videos became a thing about the cell phone in the bowl of unpopped popcorn. And then someone would dial that number and the cell phone would ring and all the popcorn kernels started popping and becoming popcorn. Everyone used to ask me about that.

50:27Like, oh my God, if this cell phone can pop popcorn. Of course, it was a joke. It was a hoax. It was completely fake. But even if it wasn't, the popcorn kernels, what makes them pop? It's heat. It's just thermal energy. It's not radiation that does that. So there's a lot of that type of stuff that's out there that unfortunately is a multi-billion dollar industry with misinformation. Same as we see with all these liver cleansers and all these, you know, there's no end to this sort of stuff. Hydration isn't just about drinking Coke Zero or other sugar-free sweetened beverages like Red Bull. Now, I'm saying this for a friend.

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52:17Lion to claim yours. That's drinklmnt.com slash Dr. Lion. Stay hydrated, stay strong, and as Goggins would say, stay hard. What about the idea of grounding or this change in electrons? Have you heard about that? You go out, you walk. Yeah. Static electricity. That's actually important if you're putting gas in your car because a little spark can cause a big kaboom with the evaporating gas fumes. So that actually, that's why you don't want to be talking on your phone when you're putting fuel in your car. I didn't know that. That's actually a real thing. Okay, what? You got to tell me. Super rare.

52:57Wait, you should not talk on your phone? What if you're using an iPod? Yeah, so it's extremely rare, but there have been a few explosions at gas stations. People are, an iPod is probably fine. No, no, no, no. You got to tell, I mean, listen, I do not want to get blown up. The only time I've heard of it, because think about what's happening. When you're on your cell phone, it's basically like it's a fancy walkie-talkie. It's a radio. So there's radio waves that are going back and forth, but there's a little tiny amount of potentially static electricity, which we generate just by touching the ground.

53:28On a cold day, barefoot on the carpet, you zap yourself. And so that same sort of thing can happen with an electronic device. No big deal, but when you're putting gas in your car, some of that gas is evaporating and so the gas fumes are highly flammable so that's a situation where if you i'd get off the cell phone i don't think they taught i don't think they teach us that yeah and maybe some people don't agree with me on that but that was an actual thing and i know that actually you'll see at some gas stations there'll be a sign saying yes turn off your cell phone another thing is they turn off your car when you're filling it up because the ignition source of your car the actual spark plugs that are igniting your engine to keep it running in theory could ignite some gas fumes that's a whole that's nothing to do with radiation okay but okay we're gonna go back to radiation don't let me start talking about cars but i will say that i actually got into a fight with my husband about turning off the car yeah while you're pumping gas yeah yeah he told me no no he was right he said you have to turn off your car i said well why on earth would you have to do that and uh having said that i know plenty of people who when it's hot and 100 degrees in the summer and houston and your spouse is in the car you don't want them to bake for 10 minutes.

54:35Yes, you do. Yes, you do. Let's talk about how your treatment, what your low dose radiation treatment is, especially around musculoskeletal injuries. So this is really a new paradigm for America. The situation is that typically we always use radiation to kill cancer cells. It takes relatively higher doses to kill a cancer cell versus low doses of radiation, which it turns out will actually stop inflammation. So if there is inflammatory cells in the body, if there's a part of the body where you have a painful joint or something, that's essentially white blood cells, macrophages, that have migrated to wherever the area of pain is, and they secrete cytokines, interleukins, and different cytokines that create the inflammatory cascade.

55:23It turns out that very small doses of radiation, not enough to affect the rest of the body, But very small doses can stop those white blood cells from living. It basically kills them and stops them from migrating to the area of pain. And so it's the same effect as a cortisone shot. Cortisone is an anti-inflammatory drug. Radiation, the same radiation we've been talking about, when given in very small doses, it wipes out the white blood cells that cause inflammation. And therefore, it actually can stop the pain in a joint. And this is something that the rest of the world has been onto for 125 years.

55:56not just a couple of years, a decade. We're talking about since the late 1800s. And Americans also used to use this. So this was a very commonly done procedure to treat joints for arthritis, even in the U.S. up until the 1960s or 70s. But since that time, America decided, it wasn't a formal decision, but America just gravitated towards using drugs, cortisone shots. Then, of course, when ibuprofen became a thing, if it was a prescription at first. Everyone got ulcers. Do you remember there was a time, you may be too young to remember when ibuprofen was a prescription. And so at that time, it was a big difference.

56:30When that first came out, then you had all the other, the COX-2 inhibitors, the Vioxx and the Celebrex. All of those drugs, they worked really well for pain. Now, granted, they had all kinds of other side effects, but Americans kind of gravitated away. Doctors stopped using radiation. They just used drugs for this. Whereas the Europeans and a lot of the rest of the world, Asians as well, but especially in Europe, the Germans and the British continue to publish studies and use low doses of radiation for various joints. And now they have very robust hundred-year-old data showing that it's safe and effective to stop joint pain, whether it's osteoarthritis, whether it's tendinitis, whether it's bursitis, plantar fasciitis in the foot, any type of an inflammation, radiation can stop that inflammation chain reaction and let the body heal and really cause, really help the patient in terms of pain reduction.

57:22Prior to the 1960s, when was this first utilized and who was delivering it? Was it, you know, was it the orthopods? Was it physical medicine and rehab? That's a great question. So in the earliest days, so this actually goes back to, let's maybe talk for a second about the history of radiation. Dr. Rentgen was the doctor in 1895 in Germany that first described what an x-ray, he gave it the name an x-ray. And so when they were x-rays were first discovered, that was 1895. When he first published, you've probably seen that iconic picture of the of the hand with the bone showing. And there's a big lesion on the fourth finger, which I asked my med students, you know, what is that?

58:01And they're like, Oh, is that an osteosarcoma? Like, no, it was his wife's wedding ring. But that was the very first x-ray that was ever done, that was 1895. By 1898, there were already publications in the scientific literature showing radiation being used for all kinds of things, for cancer, for one thing, but also for ankylosing spondylitis. It was given in the spine. And so those were done by, those were essentially, there weren't even any radiologists yet because it wasn't even a discipline yet. So this was just a general practitioner that had access to an x-ray machine. But as the years went on, then it was, there were no radiation oncologists.

58:34We weren't a thing. My discipline is relatively new. It's Yeah, about 50 years or so. That's exactly right. And so in the earlier days, it would have been done either by an interventional radiologist who had done some kind of fellowship or just there was really no regulation. So, you know, dermatologists were using them for skin lesions, but you didn't have a LINAC. Remember the term linear accelerator? Those are all highly regulated, very complicated, expensive machines that are really part of the modern era. But back then they had superficial radiation machines or even an actual radioactive isotope.

59:06Like, for example, you can have a tiny little piece of a radioactive chemical called strontium. Oh, yeah. And that could be applied directly to the cornea for a pterygium, and it would make the pterygium go away. You know, you can take that orally. Right. Did you know that? Yeah, I've heard of that. You probably know more about it than I do, but I've heard of it. I mean. I don't know what you'd use it for. But it is used. Like, there's liquid forms that can be instilled in various parts of the body, like to try to cauterize, like a hemangioma maybe or something like that. Radiation was given, but it wasn't utilizing a Linux machine that is able to target where it's going.

59:39It was very crude. Crude. But it worked. But did it cause damage? One of the things that I want to really offer people is a solution. Right now in the U.S., someone has plantar fasciitis or, you know, I've had, God knows, I've had a ton of bursitis. what you will be recommended to do is take an ibuprofen or take something else lay off of it and you can't do any work for a while or go get a cortisone injection yes yep what about living next to an electrical tower or that's that's emf again and so that's electromagnetic frequencies that that's not are not able to damage your dna no but is that radiation no but radiation okay so So this is like a whole, I'm not a physicist.

1:00:24I could probably explain to you better if I got a physicist to back me up. But the electromagnetic spectrum does include electricity and waves. There's electricity and there's magnetism. And the two combined, electromagnetism is what powers everything in here. But those are not waves that are able to eject an electron off of a nucleus. Because it's the radiation that disrupts atoms. So when you have just, let's say, a water molecule, H2O, you got two hydrogen atoms and an oxygen atom. When ionizing, and we're mostly water, we're just bags of water, right, with a little bit of salt. Seek through salt.

1:01:00Yeah, well, you're more water than the rest of us because you're more muscle. The more muscle you have, the more water you are as opposed to fat. And so when you hit, when a little x-ray comes and hits a water molecule, it will eject a hydroxyl ion, an HO ion, and a free radical. You know, all about free radicals. And so that creates an ion. So where you had a stable H2O molecule, now you have an OH hydroxyl group and a proton that comes off of it. And so when that happens, the ion can zip around and hit a double helix DNA molecule and damage it. And that's DNA damage, which is what you're trying to do in the case of cancer.

1:01:39And what I didn't mention I probably should have, when you're treating cancer cells, their DNA, the cancerous DNA is fragile to start with. It doesn't have the ability to re-anneal and form the double helix back when you damage it. So that's the beauty. When I radiate someone's tumor, the cancerous part will fall apart more readily than the normal cells that still have the repair mechanisms in place. But non-ionizing radiation can't do any of that. Is there any positive benefit of non-ionizing radiation? You know, I think like in the psychiatric realm, they're doing tests with like, they're using, have you heard of like, what's it called?

1:02:14TMB or what's that? ECT or transmagnetic stimulation. Transmagnetic stimulation. So I think with the magnetic fields, they've seen changes in brain activity. That's not my area. We use that for the military operators. Yeah, yeah. That sounds amazing. But I know nothing. I'm an ignorant person about that. But in that situation, yes. I can just treat cancer, but whatever. Yeah. but there again this is this is something that a little bit of knowledge seems to really affect people including me because i bought all that stuff yeah yeah but someone made good money off of those emf blankets it's kind of like those people that sell the copper bracelets and all that stuff why are they selling that is that for arthritis or inflammation why why do people why do actual professional athletes pan to like new genics or what are those when you watch tv you see all these ads for these medicines that make you think more sharply and all that they're not even fda approved they're completely untested they're all over actual tv not just social media and there's zero data walgreens will sell you all this junk for the copper bracelets let's talk about what works for arthritis yeah not those but arthritis is is definitely something that can really impair someone's ability to live right right big time and especially you're i mean as you've been a huge proponent of exercise and muscle building and all that.

1:03:32If you're sitting around and you can't do anything because you're in pain, it affects your whole body because you're going to lose muscle mass. You're probably going to develop type two diabetes, you're going to gain weight, hypertension, you know, the whole cascade. If you can't do all the things that you're such a huge proponent of, and rightly so, your joints can stop all of that. So it's a huge quality of life issue. And traditionally you would either have physical therapy, which again is the best thing. You exercise, you do this sort of thing. But when you have a chronic joint inflammation, That's not going to get better with just that.

1:03:59It requires an intervention, which is most commonly going to be a steroid shot or just being on NSAIDs. Can we talk about the trajectory of arthritis? It doesn't just happen, right? You don't all of a sudden wake up one day and have arthritis. If it's low-grade inflammation, does that happen in stages? And so I think arthritis is a very broad term. Let's maybe focus on osteoarthritis because rheumatoid arthritis is an autoimmune disease. And osteoarthritis is just essentially friction in the joint from a lot of use, whether it's an athlete who's really used it up or just an older person that's been using their joints and living their life.

1:04:35You have basically two articular surfaces of two bones that are protected by a layer of cartilage. And as time goes on, maybe it's an injury-related thing or just from chronic use, the cartilage wears away, it compresses, and eventually it can be completely reabsorbed and it's bone on bone. So that's like grade four osteoarthritis. But in the earlier stages, when it hasn't gotten that bad yet, when you have this inflammation and this irritation of maybe a rough bone surface and the friction, the body's own immune system will come to the rescue, as it always does for any injury. And the macrophages, the white blood cells, will be sequestered to that area.

1:05:10They'll come through the capillaries, and they'll sit there, and they'll release cytokines and interleukins. And that's what leads to the redness and the warmth and the pain, which is what we know as inflammation. but radiation in very low doses will selectively kill the weakest cells that you aim it at. And the weakest, most fragile cells are going to be the white blood cells. So by giving tiny amounts of radiation, you're not hurting your normal tissue at all, but the white blood cells go away. They basically die off. And that's what stops the inflammation without having to, excuse me, without having to deal with a cortisone injection and the potential, either you're going to have side effects from the steroids itself or the actual physical injection, all those sorts of things can cause problems.

1:05:53I was my own first patient. I think I may have told you that story. My Achilles tendon was killing me. Cortisone worked a little bit, but you do too many of those. And as you know, you can rupture a tendon if you get too many shots. Plus, it was really not pleasant to have an injection in my Achilles tendon. So I decided to use the radiation like they do in Germany. And I did it. And you just went into the office one day. I was like, you know what, I'm just going to try. Actually, I should give proper due credit. There was a buddy of mine who's a radonk in Florida who tweeted about doing it on his Achilles.

1:06:21And I'm like, I have one of these machines. Why am I only treating cancer when I'm limping around like an old man when I could be treating myself? I said, let me try it. I knew based on, I'd never treated anyone, but I've been treating cancer for 25 years. I know what the physics and the physiology is. And so it made sense. And the German data was quite compelling. So let's just give it a shot and see what happens. Were there protocols in place, the gray number, what? Exactly. So we use half a gray. So just to give you that, we talked about earlier, in case you may have missed the earlier part or your listeners might have missed it.

1:06:50High doses like say... 81 grays. You're very good. Exactly. Good memory. 81 grays for a prostate. A breast might be 50 gray or 40 gray. A brain tumor could be 20 to 60, just depending on what we're treating. So high doses in the double digits treat cancer because you need a higher dose to damage cancer cells. But these inflammatory cells, the white blood cells, you need half a gray. So 0.5 gray. And the typical protocol is usually six treatments. So like Monday, Wednesday, Friday, every other day for two weeks. So half a gray times six is a total of only three gray. And it's to a peripheral part of the body, meaning there's no vital organs.

1:07:25You're not treating centrally. So whether it's a hand or a leg or a hip or whatever it is. You wouldn't treat, say, a costochondritis inflammation. You could. Absolutely you could. And it would work just fine. and half a gray even to the thorax is not going to hurt anything. That's an unusual situation, but there's no reason you couldn't. And in the last year and a half, almost two years since I treated myself, now I'm getting this deluge of all different types of things. So even spine, spinal degenerative diseases, I have people with low back pain that have gotten better. So you can treat any articular joint in the body.

1:07:57Does it have to be inflammation? Now, when I think about inflammation and I think about, say, plaque and arteries, There's a reason why that plaque builds up. It's a physiological response. Yeah, absolutely it is. Are you, when you're using low-dose radiation, do we want a little bit of inflammation early on? For example, as I think about my hamstring, we put PRP in there to increase the white blood cells, increase the inflammation to hope for some kind of healing. Right, right. And that's a good point because every little trauma you have, your body is going to heal it that way through the inflammatory pathway.

1:08:34And then normally the inflammation will pass once the tissue is healed. But what I deal with is chronic inflammation. So when it's someone that's had this, you know, you have a, I actually had a knuckle that was bugging me. I just, I don't know what I did to it. It was hurting when I knocked on the door. Driving cars. Probably. And it was three or four months and it was getting to the point where I was like, this is going on for quite a while, but then it got better on its own. But for the people who are dealing with this for years, and then you do an x-ray and you can see in the joint articular surfaces where there's actually evidence of what they, the radiologist will actually have criteria that this is arthritis.

1:09:05That means it's not just a short-term inflammation due to an insult that normally, most of these things heal themselves. This is for the long-term arthritis, tendinitis, fasciitis, where it's just, it's not healing other modalities haven't worked. And at some point, the inflammation is no longer a good thing. It's certainly without inflammation, we wouldn't be alive. It's part of the healing process. But when it goes out of whack, and especially when you have a lot of joints or a lot of tendons, in the case of my Achilles, there's very poor perfusion. You don't get blood flow to your tendons. That's where PRP comes in, in theory, that will give you all the healing factors.

1:09:39But even that seems to be only somewhat effective. It's not like it's 100 % effective. But with the radiation, that will allow the actual energy of the x-rays will stop all the inflammation without having to resort to injecting a drug into it like cortisone which is more effective cortisone or you know i think about don my best friend don layman he's a world-class phd protein researcher he doesn't listen to this podcast so i can talk about him he loves tennis okay his knees bother him yeah and i was telling him about you i said you know don because he comes quarterly and we record the podcast i said well you gotta is see yeah sanjay yeah and he's been doing cortisone treatments sure which if someone is early on or like if we were to take two scenarios my dad has terrible hips he will go to get a cortisone shot probably needs a hip replacement but right that is late stage challenges someone who is maybe early on and and they're getting arthritis or right it's kind of early on in their disease process, could they come in and pre-treat, treat early with the - They could.

1:10:55So there's two different scenarios there. One was, I guess the first question is, is it better than cortisone? And, you know, whenever I, as a physician, especially as an oncologist, when you're trying to compare two modalities, you want to nerd out and have randomized clinical trials, prospective data that really shows that X is better than Y, it's been thoroughly tested. And we don't have that level of like a direct cortisone versus radiation comparison. The few randomized trials that have been done were not particularly, they were done in Europe and they weren't particularly well designed and well powered.

1:11:28Probably they have different machines. They do. But what we do have is a lot of observational data. And so what I can tell you from what, and I've seen this mirrored now in my own couple of years of doing this. I'm still relatively new at it. But even doing a couple of hundred patients, you start to see trends pretty easily. and me myself being the first one, the cortisone usually works faster because you get that instant anti-inflammatory. And also a lot of times I think the pain docs, when they do the injection, they have a cocktail, they'll put a little lidocaine or something else in there, which gives you that instant relief as well.

1:11:57And I had that done as well. So the radiation typically doesn't work as quickly, but it seems that it has a more durable response where the cortisone might wear off in a few weeks or a few months. What seems to happen more often with radiation and And this, it seems to be more durable. And the reason seems to be - What do you mean by durable? Durable meaning that the pain doesn't recur as quickly or necessarily at all. And what we've seen based on the European data is five years out, half the patients who've had radiation are still pain-free or nearly pain-free. That's extraordinary. And I don't think cortisone shots ever last even a year, much less five years.

1:12:35And what it seems to be happening is that both the radiation or the cortisone might stop the initial inflammation, but the cortisone is very short-acting, and the inflammatory cells will come right back in many cases. Whereas what happens with the radiation on a microscopic level, the way these macrophages get into the area in the first place is through the capillaries. Now, you have microvasculature that delivers the white blood cells to the joint, but with the radiation, it seems to reduce the permeability of the microvasculature, so you don't get the next round of macrophages sequestering there again.

1:13:08It seems to inhibit them from coming back, and therefore you get more of a durable response. And that's what I'm seeing. In my case, I treated my Achilles almost two years ago now, and I'm still... And so the way the protocol works is the German protocol, which we follow, you do six treatments, as I mentioned earlier, half a grade times six. Then you actually wait 12 weeks, and if necessary, if there's any residual pain... You do the first six treatments? Two weeks in a row. So Monday, Wednesday, Friday, two weeks straight. Six days over two weeks. Wait 12 weeks and reassess. And in Germany at that point, they would say I think roughly a third to maybe almost a half of the patients decide to go for a second course.

1:13:45And that sometimes gets your results even closer to 100 % in terms of pain reduction. In my case, I just did the first course. I never had to do it again. And out of my 200-ish patients we've treated, I'd say maybe 10 to 12 of them have even come back for the second course. And those that do have, most of them have been happy. The only people I've seen who don't respond well when it gets really bad, as you mentioned, a really severe, like a grade four osteoarthritis where there's bone on bone, they still seem to see some benefit. They still feel good that they did it, but it's not a replacement for a joint replacement or something like that.

1:14:18but you mentioned that, I'm sorry, were you going to say something? I was just going to ask about, is there any possibility of disease reversal? So it depends on what the disease process is. So for an earlier stage, like you mentioned earlier, you're asking, can this be prophylactic? Not truly, like I wouldn't radiate it in absence of any symptoms, but if you have this low grade kind of festering thing, that's like a, they grade osteoarthritis on a scale of one through four. So four being like bone on bone, really end stage, zero one being very minor stuff. Typically this is offered to people who grade two, grade three, if it's just chronic and maybe it's not really debilitating, but it's just annoying for long periods of time, this works.

1:14:54And again, whenever I offer a patient a treatment, whether it's a cancer patient or an arthritis patient, or no matter what any physician does, obviously you want to weigh out the risks and the benefits. And if there's not a favorable risk-benefit ratio, you're not going to do it. So although the radiation works extremely well for most people, even in some of these fringe cases where maybe it works, maybe it doesn't, And the benefit may not be as clear, but the risk is also essentially zero. So when there is no risk or very low risk, I'm more apt to offer the treatment because it's not like you're going to be injecting medication or doing something that's going to have systemic effects.

1:15:29The low dose of radiation can, like, for example, for a hand or a foot or an ankle, it can take 100 times more radiation than what we're using. And that's within safe limits. So even if you use six gray and you do it or three gray and you do it every year, you know, 0.5 times six, which is three gray, you could do it every couple of years and still be well within the tolerance of that joint. So, you know, you're not going to cause problems. So that's why we do that. Is there any application for muscle, muscle law? I mean, obviously it wouldn't affect hypertrophy, but you see a lot of these machines doing various things.

1:16:05Yeah. Yeah. I think, you know, typically when you have, for an athletic person, the muscle, you know, as you're rebuilding your muscle, if you're working out, that's all more of a temporary thing. But the tendons and the ligaments that are nearby, it's sometimes hard to differentiate, like a bicep tendonitis. It's not really the bicep, it's the tendon, but the whole area hurts. And so I've treated people like that where I'll maybe treat the AC joint on halfway down their arm just as it radiates down there. And it does tend to work. But if, you know, someone who's just sore after a really heavy workout session, you're not going to use it for that.

1:16:38Yeah, that would be overkill because first of all, yeah, it probably would make them feel better, but so would a few days of not doing anything and you don't want to overdo this sort of thing. But one quick thing you mentioned earlier, which I wanted to touch on, you asked about, I think it was your dad's hip, you said. One thing that I've suddenly, that I've noticed now that I was not paying attention to for all these years, but now that I'm so tuned into it, I treat so much prostate cancer. The prostate is in the middle of the pelvis. The different beams we use, they actually go through the hip to get there.

1:17:05I've had multiple people over the years that I didn't really pay attention to who told me their hip pain got better, which was an unexpected inadvertent side effect, but it truly was a big thing. And one of the guys I just treated recently told me that, and now that I'm doing all this arthritis, I'm looking back, I'm saying, you know, I've seen a lot of that actually, where people's hip pain got better. Now we know why, but as radiation oncologists, our title is oncologist. We just were never focused on this in America, but the Europeans knew about this. And it seems as if they're still doing it.

1:17:33And it's quite frequently used if you look in the literature. Yes. Seems as if it's used. Oh, yeah. In Germany, in the UK, Spain, like most of the big, the leading minds in this who've done it for a while are all European. And the data is very robust. So there's really no downside. One of the big things people are always afraid of is secondary cancers, or I shouldn't say secondary because there is no primary cancer. This is just cancer from radiation-induced malignancy. But at these very low doses, unlike with high doses, there is no evidence that cancer has even caused decades later because we have decades of information.

1:18:05Now, I wouldn't treat a child. Obviously, you don't make sense. You don't. It's just common sense. But even someone in their 20s or 30s, we've treated teenagers with keloid scars forever. And we've never seen an incidence of secondary cancers from that. And no damage to the surrounding tissue. Yeah. Or very, when you say no damage, maybe a transient redness, like a little erythema for a few weeks, but no permanent damage. And I know that we're talking about osteoarthritis specifically, but rheumatoid arthritis. Can we just touch on that? Sure, sure. And so this is one area where I probably differ a little bit from some of the European doctors that I've talked to about this, where they typically don't treat any other type of arthritis on a routine basis.

1:18:45They save this just for osteoarthritis. But what I've seen and what a few of my colleagues in the US who I've chatted with have seen is that the difference is osteoarthritis is a local disease, whereas Whereas rheumatoid or psoriatic arthritis, those are systemic diseases. So you're meaning for the non-medical people, that means the whole body is affected because your immune system, in the case of rheumatoid arthritis, your immune system is attacking the joints. So radiation won't be able to stop that. We cannot stop the whole body effect. But what's more important is from a quality of life standpoint, many folks that have systemic, you know, have rheumatoid or psoriatic arthritis, they may have one particular area of the body that's really bothering them.

1:19:23and the radiation to that local area, it's a local effect. It's not a full body effect. They may still need to be seeing their rheumatologist for regular doses of, there's all kinds of different drugs now with immunotherapy and that sort of thing. But the radiation could be a great adjunct to just get that one painful spot and it improves their quality of life. I mean, I have to say, I think that that sounds really, really innovative and important because you get these patients that they're suffering with rheumatoid arthritis. And even if it's a systemic disease, if you're able to treat these joints and you're limiting pain, because again, I care about muscle.

1:19:58Right. And I don't care about muscle in isolation. I care about it from a metabolic perspective, quality of life. All things point back to muscle. That's right. I mean. Muscle centric, right? That's right, sir. Muscle centric. And if we limit someone's ability to move in a meaningful way, then maybe not immediately. We change their aging capacity and make it very poor. But it's going to happen. What about post-operatively? Okay. Like what type of surgery? I don't know. I'm just thinking post-surgical, post-hip replacement, post-shoulder replacement, any of those. You bring up a great point, which is on a slight tangent, so I won't go too far off on it.

1:20:42But my first exposure, and most radiation oncologists like me who do cancer for a living, in residency training, this is something that we did see a fair bit of, which we don't see in the private practice setting, but post-traumatic. So if someone has had a motorcycle accident with a hip, like a broken hip or even a shattered pelvis that's been reconstructed, one of the common problems that they get once they are reconstructed and they get back to normal life is heterotopic ossification or HO. And that's basically where you've got this chronic inflammation, like, for example, in the hip, in the acetabular area, where the body will lay down calcium.

1:21:17You know, that's part of the inflammatory process is laying down of calcium, and it can literally lock up that hip joint when you have a calcium, like a bone bridge that forms between the pelvic bone, the iliac bone, and the greater trochanter, for example, and it can lock it up. So early data, this data goes back to probably as old as the arthritis data from 100 years ago. They found that if you give a low dose of radiation just after the surgical intervention, that you will prevent that inflammation from occurring, and therefore the heterotopic ossification won't lock up their hip. So I was actually doing that way back 20 years ago, but that's only in a post-traumatic setting.

1:21:56It wouldn't be for like a C-section or something like that. But when there's an actual bone trauma, if you radiate that area, it will prevent heterotopic ossification. That reminds me of we were talking earlier about keloids and we're talking about scarring. And again, I joke and say that we have the number one men's health podcast. And a man can essentially, I don't want to say fracture his penis. But over time, if an individual gets scar tissue that creates curvature, which is known as Peyronie's disease, can be really painful and uncomfortable for men. For sure. Can you use low-dose radiation to potentially treat that?

1:22:38It has been done. There are publications on it. I haven't done it personally. But when you think about the physiology of it, it's the same thing. Fibroblasts lay down scar tissue. and normally the body regulates that and stops the scar tissue from overgrowing and things like that but the same way that a keloid forms or the same way you get a pterygium in your eye peroni's disease response to a penile trauma will cause a scar tissue to form and radiation can help stop that it can help to soften existing scars and keep them from getting worse because the problem is it's a self-propagating thing where it keeps continuing to get worse the most common scenario i'm actually seeing it in now is Dupuytren's contractures of the hand, which is essentially scar tissue forming just under the skin, not in the tendon itself, but near the tendons for your hand.

1:23:26And these contractures develop to the point where they can cause irreversible bends of the fingers. And some people even get amputations from that because it's gotten so bad where they've tried to fix it. And when they do what they call a needle aponeurotomy, that's a common hand procedure, where they release the scar tissue and straighten it out, unfortunately, the actual surgery stimulates more scarring. So by radiating those areas after they've been operated on, that allows the scar tissue, which keeps the scar tissue from forming again. And so Dupuytrens, and then there's actually a foot equivalent of Dupuytrens, which I wasn't even aware of until I started reading, but it's called leader hose disease.

1:24:00So you can get plantar fibromatosis, which can be very painful if you're trying to walk on these things. And it's not plantar fasciitis, it's actually just scarring, and you get these big thick nodules on the bottom of your foot, which would be terrible for trying to be active. And so the radiation is an alternative to surgery for that as well because it'll soften up those areas. Now, if you have a really bad one where you've got a finger contracture, you've got to have surgery. You have to have surgery. But in these earlier cases, it's used a lot. And Peyronie's is a similar type of disease, so it should work similarly.

1:24:29And I have seen some data. I was talking with some of our urology colleagues about it, but we haven't done it yet. Not yet, but you never know. You could be one of the first in the area. The data is there. The data is there. But what's holding back the U.S. from adopting more of these practices and how many physicians are doing and using radiation to treat these itises? Sure. So, you know, about 50 years ago or so when this was a new field, it was actually referred to as radiotherapy. and as a profession, a lot of the early, what we now call radiation oncologists, they actually really lobbied to be called radiation oncologists.

1:25:09So oncology is in our name and therefore everyone is so focused on oncology, which is the study of cancer, that all these benign diseases for the most part got left by the wayside in the U.S. Now, many other, basically any other country you go to, there is a much higher utilization of these sorts of things for benign diseases, whether it's keloids or arthritis or any of these things but in the u.s it's been highly highly underutilized but i think we're at the very precipice of this changing you're starting to see i was i was really not even it wasn't that i was a non-believer we just didn't focus on it but now that i treated myself i became a believer instantly i'm still not limping two years later and now that we've seen a couple hundred patients i'm seeing the true trends of how well it works i think a lot of other doctors like myself are starting to maybe start to pick up on it.

1:25:57When I talk to my colleagues all the time, I'll tell them what to do. And I'll get emails from people all over the country and say, you have somebody in Montana or somebody in North Dakota. So I'll talk to the local doctors and explain to them. Most of them are still not doing it. But I think we're getting to a point where that's really going to change. And to be clear, it should be a radiation oncologist. It has to be. No other doctor is trained with the radiation safety techniques and knowing exactly what to do. Even in the situation where you may have like a dermatologist that only treats skin cancer, they may have a machine in their office that can just treat superficial skin lesions.

1:26:37They still have to have radiation oncology supervision to do that. I think that you're really innovating and I'm grateful for you. And I know that many of our mutual friends are, you are providing a solution that is critical because we have to be able to treat these challenges for people so that they can go on with their life. And it's exciting. It really works. And people think you're a hero because you've eliminated their pain almost instantly with no side effects. It excites me. It's just fun. Like I have a good time going to work every day. I mean, there's nothing better than being able to positively impact someone's life.

1:27:13Right. It's for all these years, my the the dopamine came from telling people they were now cancer free that their cancer is, which is also a huge thing, obviously. But now we're seeing the same thing in the pain space where you're pain free. And that usually happens even faster. So instant gratification. And if people want to come see you, obviously, we'll include the link, Where can I go? Yeah, so my website is drsunjaymeda.org, D-R-S-A-N-J-A-Y-M-E-H-T-A.org. And on there I have a phone number and an email you can reach me on. But my clinic is right behind us here on South Main. So it's 9150 South Main Street right across from NRG Stadium.

1:27:52And they can call anytime, 713-630-8181. And your practice takes insurance? All insurance, basically all insurances. and of course most patients are Medicare age. So that's the typical what we see the most of. But yeah, most insurances. Well, Dr. Sanjay, I'm excited to be a patient of yours. Looking forward to it. I think we can help you. It's going to be great. I will report back. Thank you so much.