Prostate Cancer (Part 3): Surgery, Radiation, and the Reality of Side Effects

19:00Dr. Wayne Brisbane:It's a good question. We don't think it does, but that's one of the things we need to study prospectively long-term. And that's why focal therapy is not yet on the guidelines, because those very, very critical questions have yet to be answered over 10 year time. And we really need to answer this for guys over 10 to 15, 20 years, because our alternative therapies of surgery radiation are validated over 10 to 20, 20, some of the surgical data is out to 32 years. And so we really need to, we really need to do that for focal therapy prospectively. What I will tell you is the other concern that people have about focal therapy is that it's billed as an alternative with less side effects, you know, less sexual dysfunction, less urinary dysfunction.

19:49Dr. Wayne Brisbane:and the main sequelae that it means something is the erections not being as hard, the ejaculate volume decreasing or going away, and then urinary urgency and frequency. Those are the things that people oftentimes see after focal therapy. It does anecdotally, meaning that when you talk to people who do a lot of focal therapy, it does seem like that's lower than the alternative of surgery and radiation. But we haven't, until recently, we haven't compared them head to head. There have been some recent comparative trials that were retrospective, meaning we looked at a bunch of guys who got surgery, but looked at a bunch of guys who got focal.

20:27Dr. Wayne Brisbane:And we said, hey, it looks like the guys who got focal therapy do do better as far as side effects. But that's retrospective. And there's a lot of flaws in that design. But it has yet to be done prospectively. There's a couple of trials that are enrolling, but they haven't reported their results quite yet because they need to do so over a prolonged period of time. Thank you.

21:18Dr. Jesse Mills:medications like semaglutide and terzepatide, including both name brand options and personalized compound versions when appropriate. So you have choices backed by clinical oversight, not guesswork. It's a simpler, more supportive telehealth experience designed around people who want clarity, care, and confidence in their weight loss journey. And your medication is delivered directly to your home in discrete packaging. So your experience stays private from start to finish. Do your research. Ask the right questions. Then visit orderlymeds.com slash podcast for an exclusive offer. Again, that's orderlymeds.com slash podcast.

21:53Dr. Jesse Mills:Individual results may vary. Not medical advice. Eligibility required. See site for details.

21:59Dr. Wayne Brisbane:Hey everybody, I'm Bobby Bones. Today we're talking about Thomas Rhett and the soundtrack to Life Tour. For over a decade, Thomas Rhett has delivered more than 20 number one hits and sold out tours. Inspired by his family and his Nashville roots, He's created songs that have become the soundtrack to our lives. From Die a Happy Man to Life Changes, you've heard his songs playing at life's special moments. Now it's time to hear them live. Round up your friends to catch Thomas Rhett on the Soundtrack to Life Tour. Get your tickets Friday at LiveNation.com.

22:27Dr. Jesse Mills:For period protection you can put on and forget about, nothing beats Nick's Leakproof Underwear, North America's number one leakproof underwear brand. Let's face it, life can be unpredictable, but your leakproof underwear shouldn't be. That's why millions of people choose NYX. For periods, for light leaks, for everyday freshness. NYX undies are super comfy, super absorbent, and made to handle whatever your day throws at you. Day two of your period? Covered. Your daily run? No problem. That big sneeze? You know the one. Yep, we've got you. And with styles like bikinis, boy shorts, thongs, and high-rise, plus sizes from extra small to 4XL, NYX makes it easy to find your perfect fit.

23:07Dr. Jesse Mills:Say goodbye to stress and leaks, and say hello to undies that work just as hard as you do, no matter the leak. Find the style and level of protection you want at nix.com and use code FLOW15 for 15 % off. That's K-N-I-X.com, code FLOW15 for 15 % off. Nix, for your leaks, for your life.

24:07Dr. Jesse Mills:We'll be right back. and earn an uncapped 1 % bonus when you transfer your portfolio. That's public.com slash podcast. Paid for by Public Investing. Brokered services by Open to the Public Investing, Inc., member FINRA, and SIPC. Advisory services by Public Advisors, LLC, SEC Registered Advisor. Generated Assets is an interactive analysis tool. Output is for informational purposes only and is not an investment recommendation or advice. Complete disclosures available at public.com slash disclosures.

24:39Dr. Jesse Mills:Yeah, and I would say anecdotally, as a surgeon and urologist that treats men for some of the quality of life issues that happen with prostate cancer therapy from incontinence to sexual dysfunction, it's an interesting subset of patients because I certainly see fewer of these men post-focal therapy. But the ones I see tend to be a little bit, I don't want to say angrier, but a little bit more disappointed. And I think part of it is because, you know, maybe they had the expectation that if the risks are so much lower, without really stratifying what those risks are qualifying, it happened to them.

25:12Dr. Jesse Mills:Whereas my men that are going through prostate cancer therapy, which, you know, Jordan and I are going to do a whole episode on how I prep a guy for surgery, how we make sure that we optimize their outcomes. post-surgery. We have really good protocols for that. With focal therapy, I treat those men the same way because I don't know, really, you know, that's the only playbook I have. But it's interesting psychologically when people are making these decisions out there for anybody that's listening that's struggling with this decision. Yeah, it ain't zero. I mean, you are, there's a reasonable chance that you may still have some sexual dysfunction or urinary symptoms, but it's also not 100%.

25:46Dr. Jesse Mills:And so with surgery, we know 100 % of the time we're going to do something to kind to muck around with the nerves and we're going to do our best to spare them. And, and again, that's a whole nother episode, but, but I think that's the, the important thing for physicians to do is set the expectations that, you know, that we don't know if it happens to you, we still have amazing treatments to make your sexual function whole again, improve your urinary outcomes. But, but I think the thing that I would, I would say in terms of now we're kind of halfway through active surveillance and focal therapy is tell me what, tell me about PSA anxiety, you know, because I think in counseling, I did this with my father-in-law years ago who had a low grade Gleason, but he was 50, 51 at diagnosis and he was an engineer and he dealt in a black and white world.

26:39Dr. Jesse Mills:And he said, you know what, if you're going to tell me you can do a therapy that makes my PSA go to zero, I want that, right? Because if you're going to tell me, keep an eye on it, but if my PSA goes from 2.7 to 3, I'm going to lose sleep, wondering if my active surveillance is all of a sudden, you know, become the front runner in the race, using your analogy. So how real is that when you're counseling patients on, if they say, doc, I just, you know, I just, just get it out. I just want to go to zero. Have you ever persuaded somebody to say, look, actually, you know, this is a very watchable condition, but yes, you have to live with that PSA anxiety.

27:16Dr. Jesse Mills:So unpack that for us, Wayne.

27:18Dr. Wayne Brisbane:Sure. Yeah. I mean, I think that it's active surveillance for three plus four is, you know, it used to be that active surveillance for three plus three, we were dealing with a lot of clinician, like patient anxiety, but also a lot of clinician anxiety. A lot of our patients reflect our anxieties. And so I think that that's important to remember that because the clinicians have become much more relaxed about 3 plus 3 active surveillance, the patients have as well. Obviously, there's patients who are very nervous about this, and 3 plus 3 can transform into 3 plus 4 and beyond and cause problems.

27:55Dr. Wayne Brisbane:But it is rare. And so statistically, it's unlikely to metastasize within a short window. There obviously are case reports, but it's very just unlikely. And so I tell guys, if you're comfortable, try active surveillance, even for six months, and we'll touch base. And if you look in the mirror every day, and you say, I think about this, I hate it, I really, really want to treat it, that's fine. That's totally fine. But give it six months. And a good majority of my guys after six months say, you know what, it was scary initially, but then it just becomes part of something that as long as as long as I'm showing up for my visits, I'm okay.

28:38Dr. Wayne Brisbane:And I also ask them, you know what, if you can transfer that concern to me and your only responsibility is coming on these visits at this time and I will make sure that this doesn't metastasize or spread under our noses. As long as you show up, I'll take care of that risk for you. And that is also, you know, that makes them a little bit more relaxed.

28:57Dr. Jesse Mills:Take the load off, put it right on me. Let's go, let's go.

29:01Dr. Wayne Brisbane:I love it, I love it. I will say for three plus four, it is a little bit more higher intensity. PSA anxiety is real. We've talked about PSA. It's just the thermometer for the prostate. And the thermometer can go up and down with multiple other events. And so you have to tell people, or I tell my patients, if your PSA goes up, I'm never too worried. And if your PSA goes down, I'm never too happy. So it's one of those, you got to just take it as it comes. And what you're looking for is consistent rises and changes on imaging. Those are really the things that I worry about.

29:37Dr. Jesse Mills:I love that. That's a really, really good point is that, you know, people look at that number and think, man, I had a great month. My PSA went down. So it's gone, right? It's gone. It's gone. Okay, but it ain't gone. All right. So you're a surgeon. You do operations. You love to operate. So tell me, what are the nuances? Well, how do you pick a surgeon? How do you pick somebody that if our man is saying, look, I do want a radical prostatectomy, it's a gold standard. It's been around for years. It's probably had some improvements. So tell me, how do you pick somebody? What do you ask your surgeon you're interviewing?

30:15Dr. Jesse Mills:And then walk us through what that what that surgery looks like.

30:18Dr. Wayne Brisbane:Sure. So let's say this guy, you know, we chatted with him about active surveillance, he says. And, you know, we'll give him a nice percentage of pattern for, you know, it's visible. So it's visible in imaging. You know that there's enough cells to cluster together that it's visible. You get your percentage of pattern fours and we'll say 40%, which is, you know, a good portion of the cores are coming back percent of pattern four rather than pattern three. So that's starting to get into the point where I start steering guys pretty aggressively away from active surveillance at that point, especially if they're willing to try something with treatment.

30:51Dr. Wayne Brisbane:We say focal therapy, and he's like, you know what? I don't like the idea. I'm a young guy. I've got decades left to live. I don't like the idea of this recurrence being an issue. I'd really like to treat it for good. I realize that maybe a little bit more steep sexual and urinary function up front. So let's look at surgery and radiation. That's kind of the conversation I'm having with the guy at this point. Now, surgery and radiation have been studied together for a very long period of time and found to be equivalent for cure. So you guys should know that if you're doing surgery or doing radiation, you're getting equivalent cures, especially in this three plus four sitting.

31:28Dr. Wayne Brisbane:But you have different side effect profiles. And so one of the things I think it's important and our guys and gals who love the guys owe it to themselves to speak to the radiation oncologist and the surgeons. And that's, I think, something very important. And you should, this is, again, we've said you can go to a wedding in Italy and you can also take some time to really sit with this. Don't rush into a decision. Find several people to chat about, even several people within the same specialty to chat. And if they all say the same thing, that means it's probably closer to the truth. So, you know, if you get consistency in these second opinions, that's actually a favorable thing.

32:04Dr. Wayne Brisbane:If you get a lot of inconsistency, then you should maybe seek a third opinion.

32:09Dr. Jesse Mills:Well put.

32:09Dr. Wayne Brisbane:So what I'll tell you is I think surgery is very important. And it's one of those things where it's kind of like it's a little bit more like sports than it is like engineering. So, you know, to train a surgeon is like training a basketball player, a football player. You know, we have to go through multiple repetitions. And so experience matters. OK, so there's an experience portion of things. And then I personally think technique matters as well. There's, you know, robotic prostatectomies have been done a single way for a very long time. And they've been perfected as far as the technique. But there's been new introductions of technique which spare the muscles over the prostate.

32:51Dr. Wayne Brisbane:It's called a retzius sparing or a hood sparing. And those sparing the muscles over the prostate is not conventionally done, but it can lead to much faster urinary recovery. So one of the problems with taking the prostate out is it sits between the bladder and the penis, and it's almost in the position of like a cork in a bottle. And removing it can lead to urinary leakage. Now, for many, many years, we thought that that was just inevitable, and that was just something that happened. But it's also, I think, because there's good evidence to suggest it's because the muscles over the top of the prostate are being disrupted.

33:27Dr. Wayne Brisbane:And so if you intentionally spare those muscles, guys can have much faster and more durable urinary control. So that's the way I prefer to do it. And then a lot of my partners here at UCLA use a hood technique where the vast majority of the muscles are spared. And we found that that's a really, really nice way of preserving guys' urinary control.

33:48Dr. Jesse Mills:So what do you tell them? Is it, you know, how long? So a guy has to, with a surgery, they have to have a catheter. And I think everybody kind of understands that deal for seven days, 10 days. Yeah.

34:01Dr. Wayne Brisbane:I think about it like it's like a cast for your urethra. You know, if you break your femur, you want a cast in place to have it heal in a straight line. The catheter is a cast for that urethra. Make sure that it heals in a straight line and gives it a scaffold.

34:12Dr. Jesse Mills:Yep. And then when the catheter comes out after your, is it about a week, 10 days? What do you do? Yeah.

34:17Dr. Wayne Brisbane:So I do 10 days with the RETC sparing ones. And then, you know, when out guys usually so. So 92 percent of my guys, this is the data that we just pulled, will find that there, you know, they are 92 percent of my guys are back to what they consider their baseline within three months.

34:37Dr. Jesse Mills:That's amazing.

34:38Dr. Wayne Brisbane:So but that's you know, there's still 8 percent of guys who prefer to wear a pad out for longer. And that does get better over time. but with this with this muscle sparing technique you're you're you're peeing pretty well pretty fast and i think that's a huge improvement talk about what techniques of his you know

34:56Dr. Jesse Mills:jordan and i are going to talk about this the the sort of the history of the nerve sparing prostatectomy yeah sure walsh so we'll we'll cover that in a different a different episode but but talk to me about how much better we are at sparing nerves does a robot because we're doing at a magnification, are there data to show that a robotic nerve sparing is superior? And is there anything else we're doing to even better image those nerves intraoperatively? Let's walk through that. And is that something that a patient can ask their surgeon if they're employing these techniques?

35:26Dr. Wayne Brisbane:Of course. Yeah. So a nerve sparing is pretty commonly done now. And it's the idea of, these nerves run very close to the prostate in kind of a lattice. And I tell people, When I think of nerves, you can think of these as like telephone wires, which are copper wires with an insulator. And there are nerves in the body that look like this. And there's also the alternative is like fiber optic lines. There's a bunch of glass wires that are running in. And each one sends a little bit of a luminescence. And it's the intensity changes that we're monitoring. These nerves, and Jesse, you know more than I do about this.

36:04Dr. Wayne Brisbane:but these nerves are much more like the glass fiber optic lines than they are like the copper wires. So we're not cutting these nerves. We're just trying to spare them and push them over to the side. But in sparing them, you can crack the glass fiber optics. Okay. And so the intensity of the light getting to the nerve receptor that opens the arteries to the corpora cavernosa, which is basically the functional element of giving you an erection, the light intensity, that goes down with time. So all of us, as we age, you're getting less and less light output, which if you think about the light as a direct function of how much erection you're getting, that is going down.

36:44Dr. Wayne Brisbane:Bite your tongue, brother.

36:46Dr. Jesse Mills:Bite your tongue. I know.

36:48Dr. Wayne Brisbane:The other thing is if you do any surgery, that's going to crack some of those wires, but it's going to be where you're sitting. So if you're starting with a little bit lower light output, it's going to be even lower than that. And that's important because we think that, you know, there's a lot of these nerves that come in at the five and seven o 'clock and can be pushed away. But there's some newer evidence, and it's a little controversial, but I believe it personally, that there's some nerves that cross right in front of the prostate. And so there's no way to get the prostate out without clipping those nerves.

37:20Dr. Wayne Brisbane:And so that's why you can have a very, very discordant amount of, you know, if you do surgery, even if you do a perfect nerve sparing surgery, absolute perfection, you're going to have to divide a small number of the nerves, what percentage, it's still unclear. But just to get the prostate to remove out of its slot, there's some nerves that are sitting across the prostate. And so you're going to have a decrease in erection. And so that's why I send a lot of my guys over to Jesse and his team in order to prehab them and also help them post-operatively in maintaining their erectile function. And he's got a great kind of a protocol to help guys really, really have a, you know, it's a part of survivorship, but it's a really, really important part.

38:06Dr. Wayne Brisbane:And they feel like they're well-counseled. And I think it's a real huge service that we provide here.

38:25Dr. Jesse Mills:Are you trying to get weight loss support through telehealth, but it feels overwhelming and rushed? Check out orderlymeds.com now. Orderlymeds.com was built to be different. Here, you connect with real doctors who take the time to understand your goals, review your eligibility, and guide you through a plan that's right for you. Orderlymeds provides access to proven GLP-1 medications like semaglutide and terzepatide, including both name brand options and personalized compound versions when appropriate. So you have choices backed by clinical oversight, not guesswork. It's a simpler, more supportive telehealth experience designed around people who want clarity, care, and confidence in their weight loss journey.

39:05Dr. Jesse Mills:And your medication is delivered directly to your home in discreet packaging. So your experience stays private from start to finish. Do your research. Ask the right questions. Then visit orderlymeds.com slash podcast for an exclusive offer. Again, that's orderlymeds.com slash podcast. Individual results may vary. Not medical advice. Eligibility required. See site for details. Hey, everybody.

39:27Dr. Wayne Brisbane:I'm Bobby Bones. Today, we're talking about Thomas Rhett and the soundtrack to Life Tour. For over a decade, Thomas Rhett has delivered more than 20 number one hits and sold out tours. Inspired by his family and his Nashville roots, he's created songs that have become the soundtrack to our lives. From Die a Happy Man to Life Changes, you've heard his songs playing at life's special moments. Now it's time to hear them live. Round up your friends to catch Thomas Rhett on the Soundtrack to Life Tour. Get your tickets Friday at LiveNation.com.

39:54Dr. Jesse Mills:For period protection you can put on and forget about, nothing beats NYX leak-proof underwear. North America's number one leak-proof underwear brand. Let's face it, life can be unpredictable, but your leak-proof underwear shouldn't be. That's why millions of people choose NYX. For periods, for light leaks, for everyday freshness. NYX undies are super comfy, super absorbent, and made to handle whatever your day throws at you. Day two of your period? Covered. Your daily run? No problem. That big sneeze? You know the one. Yep, we've got you. And with styles like bikinis, boy shorts, thongs, and high-rise, plus sizes from extra small to 4XL, NYX makes it easy to find your perfect fit.

40:34Dr. Jesse Mills:Say goodbye to stress and leaks and say hello to undies that work just as hard as you do, no matter the leak. Find the style and level of protection you want at nyx.com and use code flow15 for 15 % off. That's knix.com code flow15 for 15 % off. Nix, for your leaks, for your life. Support for the show comes from Public, the investing platform for those who take it seriously. On Public, you can build a multi-asset portfolio of stocks, bonds, options, crypto, and now generated assets, which allow you to turn any idea into an investable index with AI. It all starts with your prompt from renewable energy companies with high free cash flow to semiconductor

41:41Dr. Jesse Mills:Thank you. Member FINRA and SIPC. Advisory services by Public Advisors, LLC, SEC registered advisor. Generated Assets is an interactive analysis tool. Output is for informational purposes only and is not an investment recommendation or advice. Complete disclosures available at public.com slash disclosures.

42:06Dr. Jesse Mills:For sure. It's yeah, I think what it has a beautiful analogy, actually, I like the fibroactics. I say it's, you know, the technical term is a neuropraxia, where no matter what you do, you're going to get a little zinger to that nerve. And when you neuropraxia a nerve that controls the smooth muscle contractility of the penis, then it's not going to contract for a little while. And that's the goal is to steward guys through that time period where you're zinging those nerves and waiting for them to essentially not even grow back, but just get back to normal function. That's a beautiful, beautiful way to describe that.

42:43Dr. Jesse Mills:And now we have some degree of imaging or ways to know, you know, what, I mean, the fact that you even explained all of that is, you know, in the old days, with loops or with magnification, you could see kind of the main branches of those nerves. And, but now you really are able to visualize even those, some of those tiniest little fibers, which is just, I mean, as a surgeon, as somebody trained to do radical prosthetics, they haven't done one for close to 20 years. It's just beautiful. I mean, I hate to say, I don't like the word beautiful when it comes to anatomy and cancer, but it's pretty amazing.

43:19Dr. Wayne Brisbane:It's great. And there's, you know, there's a lot of this is built on the back of some of the imaging technologies that we have. So that's PSMA, micro ultrasound, MRI, and building these models to help us understand exactly where the cancers are in relation to the nerves. There's also this unfortunate reality that the cancer cells kind of use the nerve cells as a ladder to escape the prostate often. And so you can have the cancers that grow in proximity to the nerves. there's some reasonable data to suggest that there's actually nerve fiber factors that are almost calling to the cancer cells and pulling them out.

43:58Dr. Wayne Brisbane:And so you have to be very careful in doing the nerve spare that it's appropriate, but it can be very, very well done. And we have some really awesome imaging technologies to help us understand exactly when it's appropriate.

44:12Dr. Jesse Mills:I liked what you said earlier about, you know, I call this a hierarchy of survivorship. And you alluded to it, and it's going to segue into us, you know, walking us through the radiation treatment, which, of course, neither of us are radiation oncologists, but we know our way around it pretty well. But I talk about this, and I know you talk about it as well, but the three Cs of cancer therapies are, you know, everybody wants the first C is going to be cure or cancer control. Second is going to be continence. And then third is going to be coitus. And usually in that order, although I've had a few guys that say, doc, I want to have coitus well before continence.

44:51Dr. Jesse Mills:I don't care. Just give me my erections back. But usually in the way of how things recover, continence usually comes on board a little faster than coitus with radical prostatectomy. But is that sort of the way that you're, and you said it in a great way, is that you have curative intent here. We're going to do everything we can. You're probably going to be okay, even with this intermediate cancer, because we caught it early. So walk us through a little bit of what radiation looks like for a guy, but also who is a 55-year-old guy different than, say, a 70-year-old guy in terms of what you would say surgery versus radiation.

45:30Dr. Jesse Mills:And think of the 70-year-old guy as somebody that's going to be running the New York Marathon, has longevity, and tell us about who those guys are. And yeah, just let her rip on radiation for a little bit.

45:42Dr. Wayne Brisbane:Sure. And so radiation, I want to say that I'm a surgeon. I don't do radiation. And so, but I have excellent radiation oncology colleagues. I do help with the brachytherapy portions of things. And then from an academic standpoint, I'm very interested in how we help guys understand their choices and make sure that they get the best results that, as we said, that mirror what their expectations are. So radiation, you should know, is a phenomenal option for guys. And for three plus four prostate cancer, even in guys who are 55, okay, this is a still a very good option. Now there's some nuances that you'll hear about.

46:18Dr. Wayne Brisbane:And so I just want to address them to make sure that they're, you know, addressed here. So one of the things that you will hear about with radiation is that radiation always needs anti-testosterone therapy. There's a couple of terms that get thrown around. The most common one is androgen deprivation therapy, ADT, but Sometimes there'll be the drug names will get thrown around like Lupron. And so these are all the same term. But the idea behind this is radiation, what is it? Well, it's a bunch of either photons or protons that come in and they break DNA. So they break DNA and they separate them.

46:54Dr. Wayne Brisbane:And then cells that are dividing fast rely on those DNA as a blueprint. Now, cancer divides fast. So that's a preferential cancer cure. So if anybody is ever wondering like, hey, is there any like thing we can do that preferentially kills the cancer and leaves the normal cells behind? Radiation is that. That's what radiation is. It preferentially kills cancer and leaves the normal cells behind. However, your cells can repair themselves. That's what they do. And so testosterone is one of the mediated mechanisms by which cells repair themselves. And so with cancer, especially if the cancer is aggressive, we think that anti-testosterone therapy, also called ADT, will help make sure that radiation works and is durable, okay, so that the cancers don't just come back after they've had a chance to repair themselves.

47:42Dr. Wayne Brisbane:However, risk stratification, what type of cancer you have going forward, is very important. And so if you have intermediate risk prostate cancer, you probably don't need the endogen deprivation therapy. So that's a really nice out because you don't have to have that in conjunction. Now, if you have the more aggressive tumor subtypes, you probably need to add some ADT. And if you really have aggressive tumors, you probably need to add a lot of ADT. So that's an important caveat because when we're having this conversation of surgery, radiation, ADT, it gets kind of muddy. But what I will say is radiation and surgery often do very good jobs of killing the cancer.

48:21Dr. Wayne Brisbane:if you're going to do radiation oftentimes you can do it in about five treatments okay so they're they're good there's a lot of radiation options one is photons which would be cons it's called if you just think about beam-based radiation this is um this is regular radiation the other is protons and protons kind of come in and then they degrade instead of coming through they they almost degrade and you can think about it as the main benefit is a proton as it comes in and then it doesn't have an exit wound, right? It doesn't hit anything on the other side. So that's a benefit of protons. Photons, they do, but go all the way through the tissue and then they come out the other side.

49:00Dr. Wayne Brisbane:But one of the benefits of photons is they can be guided with MRI at this point. And so the margins are super tight and they can do a very, very nice job. They can also compress the number of fractions. And so the initial treatments that we would give guys for radiation would be 40 treatments. And so it'd be several months of treatments Mondays through Friday. And then they started experimenting because the technology at aiming got so much better. We started going to hypofractionation, which was 20 treatments. And then the technologies continued to improve. And now we have ultra hypofractionation, also called SBRT.

49:37Dr. Wayne Brisbane:And this is a beam that only takes five treatments and that's two weeks of radiation. And it's from our initial comparative studies, it appears that they work just as well as far as cancer control and side effect profile. So you can really, it's not your grandfather's radiation any longer. It's very, very, aiming at the prostate is very good. And the number of treatments has decreased considerably.

50:00Dr. Jesse Mills:And it's still Monday through Friday because there's a radiation oncology always tell us cancer doesn't grow on weekends.

50:05Dr. Wayne Brisbane:You know, I don't operate on weekends either, but that's... There you go. That's right.

50:10Dr. Jesse Mills:Yeah, it's, yeah. My mom's oncologist told us that years ago when I was just applying for medical school and she was going through radiation therapy. I got you. I don't know how I ended up in urology if I realized that. But, yes, it's truly actually close to miraculous in terms of the amount of time saved. Because, I mean, this guy is 55. He's working, you know. So to go to radiation for 40 treatments, five days a week, so you're there for two months in LA traffic alone, that would say, gosh, tell me something else because I'm going to take a half day off work every time I do this. I mean, I'd definitely go into Wayne's OR.

50:49Dr. Jesse Mills:Just get it done. Let me take a couple of weeks off. But now the time and the opportunity cost has changed pretty dramatically with some of these novel therapies for radiation. And cure rates are the same and side effect rates are the same with SPRT versus traditional radiation?

51:08Dr. Wayne Brisbane:So what you're getting for, you know, we talked about surgical side effects. And I will say surgery, you know, it does have side effects. They tend to get better over time. So that's with the urinary control. You know, three months is kind of your benchmark there. And then usually it's about 12 months. Your erections are slowly getting better for 12 months. And we do optimize that curve with some of these prehab and posthab that Jesse's been working on at UCLA. That said, radiation, you're going to get similar styles of side effects, but just a different twist on them. So from a urinary standpoint, you know, cancer or radiation kills things that grow fast.

51:44Dr. Wayne Brisbane:Well, what grows fast around the prostate? Well, the cancer. We said the cancer grows fast, so it kills the cancer very nicely. The urethra and the bladder also have a lining, a waterproofing layer that grows very fast. And so this results in what we call kind of a radiation cystitis. That's a very technical term, but basically it hurts to pee. And you can think about this as a sunburn in your bladder is the best kind of analogy I can come up with. It's not forever, but it is a transient thing where if you ever get a bad sunburn on your skin, you could think about, well, what would, what would it cost?

52:21Dr. Wayne Brisbane:Well, it hurts if you move, right? So if you, if you have to move the skin, it hurts. So as your bladder fills, that's your bladder moving. So you'd want to pee more often. So it'd be urgency. Okay. And frequency, you'd want to pee more often. The second thing is you'd also have some pain, right? Because sunburns hurt. And that's the same thing. You have burning with urination, that's called dysuria. And so urgency, frequency and dysuria are common, not durable. Often, you know, same kind of three months, they get spicy for about six weeks and then gets better. But just like in surgery, I said, you know, my urinary control outcomes in my personal series are very good.

53:00But in radiation,

53:02Dr. Wayne Brisbane:the vast majority guys get better, but there's a couple of guys who will have really, really bad urinary side effects where these kind of last for a long period of time. Thankfully, we do have tests to help determine who those guys might be. There's a prostatox genetic test where I think about it as kind of evaluating how pale you are in your bladder. Because, you know, I'm very pale. I love surfing, but I go in the middle and very early morning. So the sun is not up yet. And so I can avoid getting sunburned. But this is a test where you can kind of determine how likely are you to get a radiation burn.

53:32Dr. Wayne Brisbane:And so the radiation oncologist will use that to determine, can they give you these really, really hypofractionated doses or do they need to extend it out so you get a little bit of a dose each day?

53:44Dr. Jesse Mills:Or do you just – has it ever changed decision making for somebody to go towards surgery because of that?

53:49Dr. Wayne Brisbane:You know, it can. It can. So I tell guys, you know, if you already – we have guys like who come in and they're in their 50s and they say, you know, in my 40s I was doing okay. But now I pretty much pee before every meeting just to make sure that I can get it all out. And I get up two to three times a night. Those are guys who might have a lot of trouble with radiation. And we just chat about that because they're already having urinary urgency and frequency. And so this could be a really compounding effect. Occasionally, they'll say, you know, I'll take the risk. But it's important. It's important consideration.

54:26Dr. Wayne Brisbane:The other thing that I tell guys is there's some anatomic considerations. So some prostates grow pretty significantly into the bladder. And for the radiation oncologist to treat the entire prostate, they're going to have to extend the radiation field into the bladder quite a bit. And that can be pretty significant, cause some significant toxicity. Yeah.

54:47Dr. Jesse Mills:Well, and also, you know, I love your sunburn analogy as all of your analogies are so well thought out and easy to visualize. And so I would take you if you get a really bad sunburn, you also peel. And when your bladder peels, you can get hematuria or blood in the urine as well. Yes, absolutely. Sometimes we have to go in and do something about. So severe cases, which I will tell you, you know, somebody that still takes call as a general urologist, I'm not seeing as much as I used to. Yeah, no, definitely. I think radiation cystitis, because for severe cases, we even have to go in and actually kind of burn the bleeding spots in the bladder from that sunburn peel from radiation.

55:24Dr. Jesse Mills:Sometimes we even have to use hyperbaric oxygen to cure it. But it seems as if our radiation colleagues have done a really good job of mitigating those risks. And it sounds like also stratifying the right patient. Well, let me ask you this. You had your guy or my guy who I sent to you, 55, three plus four, because I probably conservatively start 3 ,000 men a year on testosterone therapy in this city. There's a good chance that that guy is on testosterone. So if you said, Dr. Brisbane, whatever you do, you're going to have to pry this testosterone syringe out of my cold, dead hand. Yeah, sure. Are you going to say, well, look, then why don't you just let's do surgery, keep on your testosterone therapy versus if I did radiation, not only am I going to pull that syringe out of your hand, but I'm also going to probably have to take your testosterone down for six months, two years, depending on the protocols, somewhere in between.

56:21Dr. Jesse Mills:Would that guide your management of this patient if he was actively on testosterone therapy?

56:28Dr. Wayne Brisbane:I mean, yeah, and we share patients. This is not a hypothetical for a lot of our patients. This is tomorrow for us. Exactly. So these are guys who are saying, I have cancer. My getting on the or my hormone replacement is very important to me. And I want to make sure that this is optimized. And in some ways, surgery can be a good option. It starts getting back into this risk of this recurrence issue. And I think that this is another thing that's very important is to say, well, if cancer comes back in the prostate after radiation, what are our options? And we actually have a lot of options. And one of the nice things about the emergence of focal therapy is we have now a lot of options.

57:07Dr. Wayne Brisbane:And it's almost another – that's a completely other conversation. But guys should know if they get radiation, they have recurrence, there are good options for them. The testosterone while they're getting treatment is oftentimes removed. I've actually, my radiation oncology colleagues get very nervous about actively getting TRT through their radiation treatment. Yeah, it makes sense based on what you just taught us. Yeah. But for surgery, we don't have that concern. Like if they want to continue the radiation or their hormone therapy, oftentimes they'll take a hiatus between the diagnosis and their treatment just because they're nervous about it, which is totally fine.

57:41Dr. Wayne Brisbane:But from a biological standpoint, that cancer has been growing under TRT up to that point. I don't have much of an issue having once the surgery is done, it should be it should be done. Now, if the cancer comes back outside the prostate at a later date, that would obviously be a time where we'd have to turn off their their testosterone. But within the prostate, the whole prostate is coming out. The cells that are cancerous should be coming out as well. So that that should be OK.

58:06Dr. Jesse Mills:Yeah. So, Jordan, we've got Dr. Brisbane here. We're kind of wrapping up this this trilogy. we have our patient who has four real options for treatment with his degree of prostate cancer and over from active surveillance through some kind of focal therapy, through surgery, through radiation. What are your thoughts? What did we miss? You know, you've had family members that have gone through cancer therapy and you've got a bit of a personal connection to this. So what are your, tell me your thoughts and what we can get out of Dr. Brisbane before I run off to the operating room and he runs off to cure more cancer.

58:40Dr. Jesse Mills:So you were literally in scrubs right now. I just, this is one of those moments when I wish that the listeners could see what I can see right now. No, I mean, this was an extremely optimistic conversation about a very scary, serious topic. And that's the sort of general sense as the, as the every person, lay person listening in right now that I'm leaving with. And, and the thing that I'm really glad you touched on, and I kind to maybe want to leave listeners with is, as you just said, cancer of unknown origin runs in my immediate family. And it's been kind of a shadow over my life with a lot of hypervigilance,

59:17Dr. Wayne Brisbane:this thing, you know, I didn't know when and where it was going to appear. So for me, as soon as

59:22Dr. Jesse Mills:there was any trace of it discovered, my initial knee jerk reaction would be get it out immediately. You know, I want this gone sort of here. And so I kind of want to go back to what you're saying about, you know, okay, sit with it for six months. If this is really ruined in your life, we can go in that direction. But I just thought that was such a fascinating take because me, somebody who has lived in fear of this for most of their adult life, that's not the most obvious response.

59:56Dr. Wayne Brisbane:And so I was very fascinated and very heartened, by the way, to hear you say that, that this is not something that's immediately a death sentence. You're probably going to be okay.

1:00:06Dr. Jesse Mills:Yeah, exactly.

1:00:07Dr. Wayne Brisbane:Yeah, and that's kind of what I wanted to leave the listeners with. Yeah. No, I think that it gets back into risk stratification. So to be clear, there are prostate cancers that are very aggressive, and we need to be very aggressive in response. But I also tell my patients that we should tailor your therapy to the aggressiveness of your cancer. or the funny way to say that is we should treat the cancer how it's asking to be treated. And so if it's an aggressive tumor, we need to mirror that by being aggressive. If it's a non-aggressive tumor, we need to mirror that by not being aggressive. But the vast majority of prostate cancers are less aggressive.

1:00:43Dr. Wayne Brisbane:And so I think that that's an important consideration is, you know, patients need to say, I have cancer, but what type, what flavor? And is my treatment effectively mirroring the cancer aggression and as the side effect profile that I'm being offered consistent with my goals. And then, you know, you should be able to achieve what you want.

1:01:05Dr. Jesse Mills:As Sean Connery said, don't bring a knife to a gunfight.

1:01:08Dr. Wayne Brisbane:That's right.

1:01:09Dr. Jesse Mills:I love it. Well, Dr. Brisbane, you delivered on the mailroom, but before I let you go, you also are the pinnacle of men's health. You're a dad, a husband, a researcher, a surgeon. I don't know how you do a barista. I don't know how you do all that you do in a day. But one thing I have to ask for all our listeners of all our guests is what do we learn from you that makes Wayne Wayne? What do you have to do every day so that you can be this world-class surgeon, world-class researcher, and just all around, you know, amazing person? What is your must-have when you wake up in the morning? You're like, this is what I got.

1:01:46Dr. Jesse Mills:This is how I have to be me. Talk to me, give me your tip.

1:01:50Dr. Wayne Brisbane:Yeah, sure. I mean, I drink a lot of coffee, but I do, I do work out not every morning, but most mornings I work out and it's, and I do it because it's fun. I'm not, I'm not David Goggins. I do it. Like I do the things that I enjoy. So that's, that's, that's surfing going. I, you know, I go to a very bougie gym here in LA and I, and I sit in the steam room for at least half the time. So I enjoy myself, but I, that, that just makes me feel good for the rest of the day.

1:02:16Dr. Jesse Mills:I love it. Inhaling a eucalyptus towel. I'm getting chills. I was at that bougie gym last night. And yeah, there's something about that.

1:02:27Dr. Wayne Brisbane:Well, I'm grateful.

1:02:29Dr. Jesse Mills:I mean, yeah, I really put you to the test. I've never had a guy on for three consecutive episodes, but this is such an important topic. It's so common. You know, to recap, I mean, prostate cancer, should anybody die from it? I mean, this is the highest death rate of solid organ cancers in men. People are still dying from it. So leave us with an optimistic, can we get to zero prostate cancer deaths at some point in our career?

1:02:56Dr. Wayne Brisbane:I think we can. I think we can. It's probably going to be a screening effort. And there's some super exciting clinical trials undergoing with optimizing how we diagnose prostate cancer early. And this gets to the point is, can we screen for things? And if you can screen for things and find them early, prostate cancer is one of those very curable diseases. The problem is, is, you know, we tend not to find the more aggressive cancers until it's too late. And we find some of these non-aggressive cancers when they never need to be found. And so we're optimizing that. I know you had the team from Grail out.

1:03:34Dr. Wayne Brisbane:That's very exciting. Um, and, um, and then we're also in a similar vein using genetic proclivity here at the UCLA's Institute for Precision Health, um, to see if that is a better way we're using imaging and novel ways to screen. Um, and, uh, and then for those guys who are unlucky and get, um, a diagnosis with advanced disease, we now have multiple medications to, at least of them have come out of UCLA and, And some of our efforts with the PSMA drug therapies have also been pioneered here. So obviously a shameless plug. This is a great place to get your cancer care.

1:04:14Dr. Jesse Mills:It's amazing. I mean, it gives me chills to think about it and just the luminaries we have in the field, you included. So Wayne, thanks so much. Get out under the waves. Be you. And Jordan, thanks again for a fantastic episode. Thanks to our listeners for tuning in and caring about this. And again, this is a podcast for men and the people that love those men. So if you're listening and you have a brother, a father, a son, go out, talk to them about this and make sure that they know their numbers are getting some kind of access to care. So thanks, everybody. We'll listen to you next time.

1:05:04Dr. Jesse Mills:Let's talk about it.

1:05:07Dr. Wayne Brisbane:Let's talk about it.

1:05:12Dr. Wayne Brisbane:Let's talk about it. Let's talk about it. Let's talk about it.

1:05:19Dr. Jesse Mills:The Mail Room with Dr. Jesse Mills was a production of iHeartRadio. It was executive produced by Jordan Runtog. It was edited, mixed, and mastered by Bahid Frazier. and the theme was provided by Long Transit. If you like what you heard, please subscribe and leave a review. For more podcasts from iHeartRadio, check out the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows. This program is intended for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment.

1:05:54Dr. Wayne Brisbane:Consult your health care provider for any medical or other related questions or concerns. The views and discussions aired on this podcast are those of Dr. Mills and do not represent the official positions of UCLA or UCLA Health.

1:06:28Dr. Jesse Mills:We'll see you next time.

1:06:37Dr. Wayne Brisbane:That's orderlymeds.com slash podcast. Individual results may vary. Not medical advice. Eligibility required. Seasite for details.

1:06:46Dr. Jesse Mills:I'm U.S. Transportation Secretary Sean Duffy. The sound of a seatbelt. It's one of the most important sounds in our car.

1:06:55Dr. Wayne Brisbane:It means everyone is ready and everyone is safe. The more our kids see us put on our seatbelts, the more natural it is for them to put theirs on too. Make it a priority. Buckle up every time. Hear the sound? Make it a habit. Paid for by NHTSA.

1:07:16Dr. Jesse Mills:Are you a fraud-paying American? One in four tax-paying Americans has been a victim of identity fraud. With LifeLock, if your identity is stolen, they fix it. Guaranteed or your money back. Last year, billions in refunds were stolen. Could be from your salary, overtime, or second job. Gone. But this year, you don't need to stay a victim. Because this tax season, fraud-paying American is something no American should have to claim. Save up to 40 % your first year. Visit lifelock.com slash iHeart. Terms apply. If you love high-stakes competition and incredible food, don't miss America's Culinary Cup, premiering Wednesday on CBS.

1:07:54Dr. Jesse Mills:16 of the most decorated chefs in the country go head-to-head for an unprecedented$1 million prize. Hosted by Emmy-nominated food expert Padma Lakshmi, This is a high-pressure arena where every dish matters and one mistake sends you home. America's Culinary Cup premieres Wednesday after Survivor on CBS and streaming on Paramount+. This is an iHeart Podcast. Guaranteed human.