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

26:38If you get a lot of inconsistency, then you should, you should maybe seek a third opinion. Yeah, well put. So what I'll tell you is, I think surgery is very important. And it's, 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. Okay, so there's, there's an experience portion of things. And then I, I personally think technique matters as well. There's, you know, robotic prostatectomies have been done a single way for a very long time.

27:16And they've been perfected as far as the technique, but there's been new introductions of technique, which spare the muscles over the prostate. 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 that happened.

27:52But it's also I think, because they are, you know, there's good evidence to suggest it's because the muscles over the top of the prostate are being disrupted. 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. 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.

28:28And I think everybody kind of understands that deal for seven days, 10 days. Yeah. 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 a heel 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. Yep. And then when the catheter comes out after your, is it about a week, 10 days? What do you, what do you do? Yeah. So I do 10 days with the RETC sparing ones. Um, and then, um, you know, when out guys usually, uh, so, so 92 % of my guys, this is, uh, the data that we just, uh, pulled, um, we'll find that there, you know, they are 92 % of my guys are back to what they'd consider their baseline within three months.

29:10That's amazing. So, but that's, you know, there's still 8 % of guys who prefer to wear a pad out for longer and that does get better over time. Um, but, uh, with this, with this muscle sparing technique, you're, you're, you're, you're peeing pretty well, pretty fast. Um, and I think that's a huge improvement. Talk about what techniques of his, you know, 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.

29:43Does a robot, because we're doing it at 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? Of course. Yeah. So 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.

30:17And 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, 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. And so the intensity of the light getting to the neuroreceptor 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.

31:09So 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. Bite your tongue, brother. Bite your tongue. I know. The other thing is if you do any surgery, that's going to crack some of those wires, but it's going to be, you know, where you're sitting. So if you're, if you're starting with a little bit lower out 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.

31:50And so there's no way to get the prostate out without clipping those nerves. 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.

32:30And 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. And they feel like they're well counseled. And I think it's a real huge service that we provide here.

33:10For sure. Yeah, I think what it has a beautiful analogy, actually, I like the fiber optics. 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.

33:46And 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.

34:22It'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.

35:02And 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. 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 C's of cancer therapies are, you know, everybody wants the first C is going to be cure or cancer control.

35:44Second 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 be, I want to, I want to have coitus well before continence. I don't care. Just give me my erections back. But, but usually in the, in the way of how things recover, continence usually comes on, on board a little faster than, than coitus with, with radical prostatectomy. But, but is that, is that sort of the way that you're, and you said it in a great way is that you're, you know, we're, you have curative intent here. We're going to do everything we can.

36:14You'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. 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 sure yeah no so radiation i want i want to say that i'm a surgeon i don't do radiation and so um but uh 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 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.

37:12And for 3 plus 4 prostate cancer, even in guys who are 55, this is still a very good option. Now, there's some nuances that you'll hear about. And so I just want to address them to make sure that they're 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. The idea behind this is, you know, radiation, what is it? Well, it's a bunch of either photons or protons that come in and they break DNA. Okay, so they break DNA and they separate them.

37:49And 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.

38:32so that the cancers don't just come back after they've had a chance to repair themselves. 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.

39:07But what I will say is radiation and surgery often do very good jobs of killing the cancer. If you're going to do radiation, oftentimes you can do it in about five treatments. Okay, so there's a lot of radiation options. One is photons, which would be, it's called, if you just think about beam-based radiation, this is regular radiation. The other is protons, and protons kind of come in and then they degrade. Instead of coming through, they almost degrade. And you can think about it as the main benefit of the proton is it comes in and then it doesn't have an exit wound, right? It doesn't hit anything on the other side.

39:47So 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 but one of the benefits of proton or photons is they can be guided with mri at this point and so the 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 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 hypo fractionation, which was 20 treatments.

40:25And then the technologies continued to improve. And now we have ultra hypo fractionation, also called SBRT. 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. And it's still Monday through Friday because there's a radiation oncologist always tell us cancer doesn't grow on weekends.

41:01You know, I don't operate on weekends either, but that's... There you go. That's right. 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 this guy's 55. He's working. So to go to radiation for 40 treatments, five days a week. So you're there for two months. And 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.

41:43I mean, I'd definitely go into Wayne's OR. Just get it done. Let me take a couple 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 SBRT versus traditional radiation. 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.

42:19And 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 bit a different twist on them. So from a urinary standpoint, you know, So radiation kills things that grow fast. 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.

43:01And you can think about this as a sunburn in your bladder is the best kind of analogy I can come up with. with. It's not forever, but it is a transient thing where if you get, if you ever get a bad sunburn on your skin, you could think about, well, what would, what would it cost? 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.

43:35And 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, my urinary control outcomes in my personal series are very good. But in radiation, 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.

44:10I 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. And so the radiation oncologist will use that to determine, And 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? That's a tool. Or do you – has it ever changed decision making for somebody to go toward surgery because of that?

44:42You 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 consideration.

45:19consideration the other thing that i tell guys is there's some anatomic considerations so if 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 well and also you know when you 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.

45:56Sometimes 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. Sometimes we even have to use hyperbaric oxygen to cure, 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.

46:27Well, 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, if you said, Dr. Brisbane, whatever you do, you know, you're going to have to pry this testosterone syringe out of my cold dead hand. Yeah, sure. Yeah. 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.

47:14Would that guide your management of this patient if he was actively on testosterone therapy? 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. Getting on 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 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?

47:55And 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. 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.

48:26Like 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. 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.

48:55The cells that are cancerous should be coming out as well. So that that should be OK. Yeah. So, Jordan, we've got Dr. Brisbane here. We're kind of wrapping up 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've had family members that have gone through cancer therapy, and you've got a bit of a personal connection to this. So 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.

49:33So 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 every person, lay person listening in right now that I'm leaving with. And the thing that I'm really glad you touched on and I kind of 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, this thing, you know, I didn't know when and where it was going to appear.

50:13So for me, as soon as 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 hear. 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. And so I was very fascinated And very heartened, by the way, to hear you say that, that this is not, you know, something that was immediately a death sentence.

50:58It's probably going to be okay. Yeah, exactly. Yeah. And that's kind of what I wanted to leave the listeners with. Yeah. No, I think that, you know, 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. So, but I also tell my patients that, you know, 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.

51:33But the vast majority of prostate cancers are less aggressive. 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 is 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. As Sean Connery said, don't bring a knife to a gunfight. That's right. 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.

52:11You know, 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. This is how I have to be me. Talk to me. Give me your tip. Yeah, sure. I mean, I drink a lot of coffee.

52:46Hell yeah. But I do work out, not every morning, but most mornings I work out. And I do it because it's fun. I'm not David Goggins. I do the things that I enjoy. So that's surfing. I go to a very bougie gym here in LA, and I sit in the steam room for at least half the time. So I enjoy myself. But that just makes me feel good for the rest of the day. I love it. Inhaling a eucalyptus towel. I'm getting chills. I was at that bougie gym last night. Yeah, there's something about that. That's nice. Wayne, I'm grateful. 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.

53:30Yeah. 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 If you can screen for things and find them early, prostate cancer is one of those very curable diseases. The problem 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. You know, when guys hear advanced or metastatic prostate cancer these days, they're picturing what it used to be like years ago. And, you know, it's just not really the case anymore.

54:06It's not the conversation I want to have. You know, we've got guys living full, active lives, and they're on these hormones for years, and they're still kind of doing what they need to do, right? And a lot of these PSMA treatments, even some of those guys who would be considered advanced metastatic diseases, they still qualify for some of these precision options based on their genetics. And so even those guys have hope, right? And I think that's the thing that we have to take home from this is that there is still a lot of hope. and we're really changing the way that we think about prostate cancer and a lot of former what we'd almost consider death sentence cancers into chronic diseases i mean that's huge so even though we can't say hey this is a cure we can say we got this you know this is something that we can manage and hope that guys can optimize however many years they have left but but that's the way we're looking at it now is kind of years right not just oh man that's it end of the line so so i think that's an important thing for guys to think about is if they get this diagnosis, they just have to know that that toolbox is a lot bigger than it was even five years ago.

55:09I know you had the team from Grail out. That's very exciting. And then we're also in a similar vein using genetic proclivity here at the UCLA's Institute for Precision Health to see if that is a better way. We're using imaging in novel ways to screen. And then for those guys who are unlucky and get a diagnosis with advanced disease, we now have multiple medications. Two at least of them have come out of UCLA. 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. It's amazing. I mean, it gives me chills to think about it and just the luminaries we have in the field, you included.

55:58So, 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.

56:43Let's talk about it. Let's talk about it in the mailroom. Let's talk about it. Let's talk about it in the mailroom. The Mailroom with Dr. Jesse Mills was a production of iHeartRadio. It was executive produced by Jordan Runtog. If you liked 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 was independently created by iHeartRadio. Novartis Pharmaceuticals Corporation is the exclusive advertising partner. It is intended for educational and informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.

57:31Please consult your health care provider for any medical or related questions or concerns before making any treatment decisions. The views and discussions aired on this podcast for those of Dr. Mills and his guests and do not represent the official positions of UCLA or UCLA Health.