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Presented by the El Paso County Medical Society and hosted by Kathrin Berg.

New and continuous research lead to significant advancements in individualized and specialized cancer care.

We're going to talk about progressive technology in the areas of prostate cancer, bladder cancer, and along with new diagnostic imaging in the cancer world.

And how does AI factor into all of this?

This evening's program is underwritten by Rio Grande Urology.

Also, the Rio Grande cancer specialist you're known as both.

And thank you so much.

The El Paso County Medical Society for sponsoring this program since 1997.

I'm Kathrin Berg, and this is the El Paso physician.

Neither the El Paso County Medical Society, its members nor PBS El Paso shall be responsible for the views, opinions or facts expressed by the panelists on this television program.

Please consult your doctor.

Good evening.

Thank you for joining us today.

We're going to be talking about significant advances in cancer care, new options and new hope.

And we have three veterans with us here this evening.

Thank you so much for being here.

We have Doctor Jeffrey Spier who specializes in urology.

We have Doctor Travis Mendel who specializes in radiation oncology.

And we have Brian Nabhan who is kind of in charge of the center, so to speak, of the Rio Grande Urology slash Rio Grande Cancer Center.

I love saying it that way.

So, Doctor Spear, I have photographs of you and I doing this show together.

I'm not kidding you.

About 29, 28 years ago.

It's been a while.

So on that note, he looks at me.

Okay, I'm older than you.

I think you're thinking of vulgar weed, but.

Oh, I take it he was involved at that time too.

But on that note, you being here today, what is the hat that you're wearing?

I know you're you're like the IT guy, at Rio Grande Urology.

Like, literally.

I came by the center yesterday and toured the world, and you start walking by the Doc Travis.

Same thing.

Right.

So for today, what do you do all day, every day?

I'm a general urologist.

I have taken an interest in sort of the administrative role for the group.

It's a big, big organization now.

I mean, we're up to about 30 providers and 175 employees, so it's a big group.

I have a huge administrate of staff.

It helps me, but it's been just an honor to, and really the, you know, fantastic opportunity to help grow the organization.

So I'm CEO and president, and I run the, Advanced Prostate Cancer Center.

So a lot of hats, but very fulfilling.

And I'm lucky to be surrounded with people like this.

You have a great staff.

And just kind of watching and seeing everybody do their thing.

Yesterday was was quite impressive.

Doctor Travis Mendel.

So radiation oncology, and also radiation that isn't always necessarily hooked to oncology.

Like, there's been a lot of different programs that we've done.

But in the course of today's show, what is your all day every day?

So so basically I use radiation to treat cancers.

You know, these days our treatments and become much more focused.

So where we're able to deliver the radiation within millimeters of what we're trying to target.

So day to day I see patients, I design plans, and I kill cancer, and I kill cancer is Batman.

I kind of love that.

So, Brian, let's take a use of Brian.

Thank you for kind of helping put all this together and navigate this.

So Brian Nabhan slash RTT.

So first of all, I have that here on my piece of paper.

What does that mean to everybody at home.

And then let's talk about what you do all day every day in today's context.

Yeah, absolutely.

So the RTT, that signifies my credentials as a radiation therapist, meaning, I mean, in, in, in this conversation, doctor Mendoza, radiation oncologist who prescribes a treatment to be delivered to cancer patients.

In my capacity as a radiation therapist, I would give that treatment.

I would operate the equipment and work with the patients on a on a daily, basis to deliver those treatments.

But my role, now is, I pulled back from clinical responsibilities, and I'm an administrator for the group.

As the, director of oncology.

And, you know, like Doctor Spear, I suppose I may.

I wear many hats, and the the one I think that's that's most relevant or most significant is that I, quite simply do everything I can from a leadership standpoint to make sure that we're able to offer, is as many services to as many patients as we can in the community.

So as we're going through a lot of the technical medical staff, I'm going to stop every now and again and again because the tour yesterday really opened my eyes into all kinds of stuff that you're doing.

You're kind of in two separate buildings that are the same building.

It's sit in essence, and then I'm building in in the middle.

That's going to be surgical.

I'd like for you to just kind of have in your head as we're bouncing back and forth to interject what these two are going to be three facilities are going to be doing again, it's all on one campus, so it's all right there.

So I love the idea of that.

And I feel we've been doing the show for almost 30 years, and prostate cancer screening is always in question and not necessarily in question.

Things just change here and there.

And so, Doctor Spear, I would love for you to take on that question as I probably thrown to you every single time we've done a program together, because it is here and there.

And so the question is who, when and why with prostate cancer screening.

Perfect.

Well, thank you for all you do and thank you for coming by yesterday.

I think it was important for you to just to kind of see what we're doing.

Maybe I'll just take you through sort of a scenario, a patient scenario.

And this is for the for the audience.

Understand, when a man goes and sees their primary care physician or internal medicine physician, they get screened for prostate cancer.

And one of those screening tests is a blood test called the PSA.

When that blood test is, abnormal or the internal medicine doc or the referring physician feels uncomfortable, that's when they refer to the urologist.

And that's what what I do.

And so PSA screening remains sort of the foundation for prostate cancer screening along with a digital rectal exam.

But things have started to change over the last ten years or so.

And really, it takes us through that story about the U.S.

Preventative Task Force that was established probably in 2008, but in 2012, they came and they graded the PSA as, what was being described as a grade D, which is a low classification.

I remember that, and that created a bit of chaos.

So PSA was started.

You know, people were frowning upon it.

At least practitioners were, and they began not to screen as much.

And what we've seen is this influx of more advanced disease because of it.

I told the President Biden's story the last time.

It's a really good story for the audience to hear.

Let me, let me let me recap.

It's not a good story, but it's an important story for the general public to understand because, it's no one's fault really.

But because of those guidelines, his PSA was probably not checked later in life.

So I'm a believer that you look at the age.

You also look at how long these patients are going to be on this earth.

So I usually keep checking PSA if there's a 10 to 15 life expectancy.

So if I have an 85 year old that comes in, we check it.

That's going to live a long time.

I mean, I'm a believer in that, but what what the basic screening for PSA is that what you know, first of all, it's a protein that's excreted from the prostate, right.

It's a biomarker.

So that the blood sample can be looked at.

And so we do have some ages that we start screening.

And the typical age that we start for, for African-American men and patients that are at high risk are between 40 and 45.

We usually recommend, I start I start telling my friends and patients that, you know, you should probably screen close to 50, 45 to 50.

And at 50 for sure, everyone should be screened.

And so now there's been some updates to the task force as far as between 50 and 69, where if patients have a low PSA and it's steady, there's some flexibility there.

Some will check every two years.

I believe that we should check it yearly and then after 70, that's sort of a shared decision model with, with, you know, with your doctor.

So, that's really important.

But even I think more important is the idea that the primary care docs have always thought of 4.0 is sort of their cutoff, whether you're 55 or 85, you know, and so there's really as this depicts a sliding scale of sorts on PSA.

And I don't want everyone to get too uptight about the numbers.

But essentially, if I have a young man who's 45 and his PSA is 2.5, that's going to create a little bit of, a discussion.

And if I on the flip side, if I have a 74 year old and his PSA is 5.8, you know, I just don't know if we need to worry.

So as you can see from that sort of age adjusted scale, you can see sort of, you know, a kind of a summary of what I look at.

And so, you know, it also kind of depicts what's taking place with the new task force ruling in 2018.

So our job is, again, we see a patient with high PSA.

We check it.

The other point I want to make that's very important is I don't just go by one PSA.

If a patient comes in and they're super nervous, I try to calm them down and say, okay, your PSA is 5.9.

You're 62.

It's a little high.

Let's take a deep breath and let's repeat it because PSA can be elevated for many different reasons.

Go for it.

That's exactly the question I was going to ask, because I learned this from you several years back, that there could be an activity or two that you did that day, or the couple of days prior or after that can affect your PSA numbers.

And so I love for you to bring some of those just regular everyday things that can affect it that so it doesn't freak people.

Sure.

Yeah.

I mean, sitting on a park bench for five hours before you came and saw your doctor, your urologist or your primary care, really hard airplane seat on how to fly, how about bicyclists?

I mean, so, you know, I try to tell my patients, let's not, you know, let's it's not a hair on fire moment.

No, no.

Also, there's fantastic technology now to include MRI technology, which I am, and implementing just about all the time, which basically the radiologists I don't want to get technical looks within the prostate and can tell if there's some lesions that look suspicious and if they do that can sort of be added to the PSA and potentially even other biomarkers to make a decision on prostate biopsy.

We do not want to do harm.

So we're not looking to biopsy everybody.

And that's what the task force was worried about.

Because you go down a slippery slope, they can get infections from the biopsy.

So we tried to put all of that information together and make an educated decision.

And I do want to bring this up to because it's not always in an elevated PSA means that there's cancer and because as a urologist, gentlemen that come to you that may not want to do their PSA or want to do this because they're afraid of the idea of cancer or what have you.

What else could be going on if it's not cancer, but you have an elevated PSA?

It's a great question.

I think I'll try to go with the most common, which is benign prostatic hyperplasia.

BPH, obviously job security for the urologist.

Right.

Prostates are there's there's a few prostates out there.

And so men come in with urinary complaints, their prostates getting larger.

That can elevate the PSA just from the volume or the size of the prostate.

Okay.

Also infection prostatitis, we call it inflammation a urinary tract infection, trauma.

Like we talked about bicyclists.

The list kind of goes on and on.

So you know, again it isn't just an indication of a carcinoma.

Right.

Those are some examples for you I love that.

And you mentioned also to the radiologists, I know you're a radiation oncologist, not a radiologist.

However, I think that's a nice transition when he was talking about the radiologists can go in there and see specifically what's going on, and if we can kind of turn that into a little bit of where you come in in this stage.

Yeah, for sure.

So, so one of the things that I comment on patients are, are very fixated on their PSA.

It is like that's the first thing we're talking about whenever they come in, you know, if if it's a new diagnosis or even for a screening or a patient on active surveillance, they're coming in and they're they're very fixated on the PSA.

But everyone just needs to realize that the PSA, it's designed as a screening test, right?

It's not like gospel.

The PSA can bounce all over the place.

And I make the joke that if you eat a Snickers bar, it can go up, right?

So it's like, it's not it's not this like, tell all test.

And I think one of the, the most important things for guys when they get their act is repeating.

It is a great, you know, great advice.

Jeff is talking about but also the trends like if your PSA is five, that doesn't mean you have cancer.

You know, if you have a PSA that's five for ten years, you probably don't have cancer because cancer grows.

And one of my one of my attendings when I was in residency, he's he's a very strange guy.

But one of his, one of his quotes was there's only three guarantees in life death, taxes and cancer growing.

Oh, God.

And so and so like for the third one, it's going to grow.

So like if, if it's trending up then you know something's probably not right.

So that's that's why I think it's really important to start PSA screening early.

And you don't need to jump the gun the second you get a PSA.

Because it's five.

Definitely recheck it and trend it before you do anything invasive for the patient.

So the way that we've we've been identifying cancer was basically DRE PSA.

And then we going into a template biopsy which is I talk about what a DRE is explain it.

So it's basically a digital rectal exam.

So you know 80% of the prostate cancers are going to live in the back portion of the prostate.

It's called the peripheral zone.

And so it's very easy to just put your finger in there and you can feel.

And cancer is firm.

It feels almost like a, like a marble or like a very like dense like of those bouncy balls, like the super bouncy balls.

It's very dense.

And so you can, you can feel that there's something different or something, you know, abnormal on the prostate just with your finger.

I think that that's still a very important component of screening.

But you don't want to have get your like a digital rectal exam and then go get your PSA right after.

That's a bad idea.

You don't have intercourse right before you get your PSA because it's it's going to be high riding a bike.

There's different things that can kind of irritate the prostate.

That can raise your PSA.

And those are the kind of things you want to avoid.

Or at least let your, your, you know, PCP or urologist, you know, let them know, like, hey, this is what happened before.

Do you think that could have changed my results?

And so that they kind of prompted to check it again.

And so there's a lot of this coaching that that usually doesn't go on before patients are getting their PSA checked.

And so I think that's why we're seeing, you know, it bounced around quite a bit right.

Anyways.

So so you know now that we have these imaging capabilities.

it's imperative that you get an MRI for your prostate nowadays before a biopsy, I think I think it's just like you have to have that information because it allows us to make better decisions rather than going in there, and then kind of like randomly, you know, I guess systematically sampling the prostate.

We can do that and to make sure we're not missing anything.

But if there's something in there that looks abnormal, then it needs to be interrogated.

And I actually just had a guy today who who?

He was on active surveillance.

He'd been on active surveillance for maybe 2 or 3 years.

Got an MRI, and there was a lesion in the transitional zone.

And I like a lot of these times I see these things and I'm like, tell me, what transitional is that?

So it's it's the center part of the prostate where we usually see.

And so you can get these BPH nodules and they masquerade as prostate cancer.

And so they look exactly like prostate cancer on the MRI.

But they're in that area that you usually don't see prostate cancer.

And I do I do prostate biopsies myself as well.

And I every time I see that I'm like, I there's almost no chance this is going to be a prostate cancer, you know?

But I'm, you know, I need to make sure that it's not because they're calling it on the, on the read.

We use a special, pyrite scoring, which is kind of tells us how likely the likelihood of this being prostate cancer.

And so a lot of times I'll, I'll even tell a patient I'm like, look, this is probably not something you need to be worried about, but you need to interrogate it just in case, because there is maybe a 10% chance it could be.

And it's usually not a dangerous cancer.

So this guy, I remember doing his biopsy because I just wasn't I wasn't convinced, you know, I did it anyways.

And it came back as a high risk cancer.

It was a bad cancer.

And so, you know, that just like just today kind of, you know, rewired my, my thinking on these things because I'm like, yeah, I'm glad I did that biopsy.

Know I didn't talk the patient out of it.

And so now, you know, he's, he's he's going to get treated.

He's going to be fine.

But these are the kind of things that, you know, even clinicians can be confused about.

And like sometimes you just just got to do it.

Yeah.

You just got to do it.

I like to kind of go sure.

Basic for a moment.

We have a great slide that shows this to the anatomy of the prostate.

Right.

So what does the prostate do?

We have a we have a great picture we're going to throw up on screen.

But you were talking about being on a bike for five hours.

Why would that affect the PSA to us having sex right before.

Why would that affect.

So describe the the purpose of the prostate where it's located in in it helps with the pressure.

Sure.

Well, the picture kind of depicts the location of the prostate and it's very, you know, there's a lot of pressure that's put on it.

For example, when you're bicycle riding, because it sits in the pelvis right below the bladder, it's a gland and it's a useless gland for the most part.

It's just it, you know, it produces a lot of problems and it also produces the ejaculate.

So it's where sperm basically join the the semen or the fluid so that they can make it to their destination.

It has all of the nutrients, the fruit so useless.

Go ahead.

We can't have baby.

So let me refer a phrase that it's pretty it's pretty important isn't it?

Right.

But as far as what it for men, it's all it does is caused consternation, to be quite honest.

You're talking about like we talked about BPH and prostate cancer.

And so it's, it's really, you know, a gland that, it creates a lot of, frustration for men.

And so, as Travis said, I can't, you know, I have to just piggyback on what he said about the location of cancer.

It's it's on the periphery.

That's why we can feel it with, digital rectal exam.

And that's why it's so unusual for it to be in the transition zone.

That's where enlargement of the prostate lives.

So that's important for the anatomical side.

It squeezes the urethra.

And that's where BPH comes from.

The benign prostatic hyperplasia because it sits almost like you know, it's it's like squeezing the hose.

And that's why men have trouble urinating.

And so I think the MRI is an important topic.

And so what happens after the PSA or there's a worry that it's high and you have an MRI that's suspicious.

We go for biopsy.

And the days of the 12 core biopsies that some men on this program or the audience will know are slowly fading away.

It's traumatic.

Now.

We have targeted techniques.

He pretty much does my my targeted biopsies because you confuse the MRI with the ultrasound and do two, three, four biopsies.

There's other techniques that have have really made a difference in diagnosis.

And then we can start talking about what happens from there as far as the severity of the disease, the treatment modalities.

But I'll leave that to you know, I think that's great.

And I think this is a nice transition over to Brian, because I'm thinking about all the equipment that I saw yesterday.

I mean, these are rooms full of, yes, treatments, but also screening, detection, how to find different types of cancers here.

And there is a Brian talk a little bit about how the acquisition of all of these pieces of equipment comes about.

What are you all looking for in this center?

And the really nice thing too.

And I'd like to bring this up to you all are a private entity, which is really nice when it comes to the world of red tape and bureaucracy, etc.

etc.

that you guys are far more nimble and throughout the program I'd like you to talk about that as the Rio Grande Cancer center.

And I said it wrong.

But my point is, how is it that you find the equipment?

Why do you buy it, etc.

kind of taking it as the administration of the center and how that all works?

I'm sure that's a quick conversation.

It's it's a quick eight hour conversation that you're going to have to dwindle down.

That's true.

Yeah.

You know, that it always seems to start with a very poignant question, for this group.

And, and the question is, is this something that's going to benefit the community, right.

The the partnership is comprised of physicians who have direct ties to this, to this community, either they were born here.

Doctor Mendel grew up here, went to school here.

Doctor spear, they both graduated from Coronado.

I went to Paso High.

Is that were troopers?

Yeah.

That's right.

Yeah.

So there is that, there's always that desire to make sure that we are doing the, the most that we can, the best that we can for the community.

So all of our initiatives generally start with that question.

How is this going to further our ability to provide quality, high quality health care to our community?

We're very lucky in that we have great vendor relationships, right, where we've been able to in the past, identify, these vendors that we want to work with, over and over, because they share that same passion about helping us provide that high quality health care.

So we look, we find that there is a need, let's say, for a piece of equipment, we're able to go and work with those vendors and negotiate a deal just like you would for anything else.

Right.

Buying a car or a new couch.

Right.

Although considerably more.

More expensive in some cases.

But the nice thing too, is I, if I'm understanding it correctly, too, you see something that you want and this as a private group, you you go for that versus waiting for permission and having to go through different checks and balances in order to get a piece of equipment.

That's what I think is so nice about what you all do in your practice.

You know that that's the flexibility that we have as a as a privately owned company.

That of course, has, you know, some limitations to it.

We have to be a little more cost conscious.

But, because we, we don't have, you know, the coffers of maybe a large group or a hospital on group, but, so you can be very specific and I love that.

So.

So I wanted to make a comment here, Doctor Mendel, so I can kind of give you a story that gives kind of the, the mentality and kind of perspective of the group.

So and what makes it kind of like beautiful to work there.

So, so we're a group of physicians and we care about the community.

And when we're making decisions.

The problem with medicine right now is it's a business, right?

Right.

It's a business.

Like I got to keep the lights on.

And when you're when you're billing for different procedures or imaging or, you know, whatever you're doing, you're the billing code that you use, it doesn't necessarily matter what kind of equipment you're using, right.

So you can buy some equipment that's 20 years old, used for like dirt cheap and get the same reimbursement that you're going to get if you buy a new machine that's obviously better.

It had better technology.

It's, you know, it's it's faster.

And so in the group, we always have to make these kind of decisions where it's like to we want to make more money or have the better ROI, or do we want to do the right thing for the patient?

And this guy is is the one who's kind of leading a lot of this.

And I so remember when I and I've told this story multiple times and he was probably so can be telling it, but but I remember sitting in his office when I like first started and I, we were we're trying to figure out like kind of make things work.

And I wanted to bring us some, like, new treatment paradigms that didn't reimburse as much.

But they were they were obviously better and more modern.

And he he didn't even like flinch.

He was like, look, do the right thing for the patient and good things will come.

And he was 100% right.

And that's like the mentality of the group when we're doing when we're thinking about things and trying to figure out where we're going to like deploy capital and make investments.

It's always patient centric and like trying to like, figure out how to do the right thing.

And that's how we that's how we do things.

And it's it's been it's worked out really well so far.

And we're just we just keep doing it and we keep growing.

And it's it's been great.

And it's just a really, really like amazing place to to work and have like the same mentality with, with like a partnership like that and it just like percolates to the staff and everything.

It's really the patients.

I mean to the patients, I can see them.

It's like, you know, they're involved from step one.

You're talking about you do the biopsy, you can you can sit with the radiologist as he's reading a lot of the results here and there.

So you guys are all in it together at any given time, which I think is fantastic.

I don't want to skip this part because I know time's going pretty fast, but let's talk about robotic surgery.

In prostate cancer.

We don't have to spend a lot of time on that.

I know it's been going on for a while.

Is there, some new inroads with that over the last couple of decades?

Well, let me just kind of tell you what happens after the cancer diagnosis is made, because there are options and I'll try to move and I try to make pretty quick.

But for the audience, they're going to want to know.

I mean, the basic isn't about surgery versus radiation.

Sure.

We can get that into this question.

The bottom line is, if it's advanced, this is all about it's not necessarily, you know, not only the Gleason score, what we call the pathology, the pathology, but it's really the grade, the grade group and where they are.

So if it's a low grade, I tell patients all the time and friends, if you have a very if you're in a very low risk grade group, we're not doing anything.

So I want to make clear that that was active surveillance.

Active surveillance.

Very good.

And so patients can be watched for the rest of their lives.

They're going to die most likely of something else.

And so we do I mean, I think about 55% of my patients are on active surveillance.

That's sort of the number that is pretty familiar to me.

Okay.

There's radiation therapy and there's surgery.

I'm going to let Travis and Brian kind of hit on the radiation side.

But on the surgical side, robotic prostatectomy has become standard.

When I was training, it came out in 2003 or 4.

And, you know, it was little hoax.

And it was it was a disaster.

I mean, you know, it was very dangerous and everyone was nervous and everyone went into fellowship training to learn how to do the robot.

That's just not necessary anymore because the general urologists are doing it.

We have fantastic roboticists in our group that I feel super comfortable having my patients go see.

I'm getting old, so I'm not doing those fancy procedures anymore.

I'm passing it along.

But we've got great young, roboticists that do it.

The incontinence rates and the erectile dysfunction rates have improved over the years.

And those are the two big side effects that we tell all our patients is that we have to take the prostate out, reconnect the urethra to the bladder neck.

And so incontinence can happen because you've lost one of the two sphincters that control your continence.

And then for men that already have erectile dysfunction, we tell them it's going to be a hard road here.

I mean, no pun intended.

It's going to be a longer road for recovery.

But they can have therapies that can help with that as well.

And they try to do what it's called nerve sparing techniques.

So we have that discussion.

And what I typically do is if it's apples to apples, I let the patient see Travis and his team, and I have them see the roboticist to talk about surgery and let them make the decision because the data is clear, there's really been no data to show that one is better than the other.

But there definitely needs to be decision making because the side effect profile and such needs to be discussed.

So priorities.

That's kind of where we are now.

There's focal therapy.

I don't want to get into that.

A lot of your audience have looked into high foo or high intensity focused ultrasound.

There's different types of therapies that can treat just the lesion, but it's not ready for prime time in my opinion yet, although it's gaining some traction.

Okay.

That's a great transition into the pace versus Sbrt.

Well yeah sure.

So I'm just going to make another another comment about all this.

And just kind of explain the dynamic of the group.

So, so a lot of and it's not like this everywhere.

So because of, because of business purposes and so a lot of a lot of providers, they'll see a patient and that's like they're patient, you know, like they're going to treat them like that's that's that's you know, it's their patient.

The way our mentality is, is we're trying to figure out like you have to balance things.

So you know, what does the patient want to do.

Does the patient understand all the treatment options.

You know, does the providers understand all the treatment options.

And so the way that we work is, you know, say Speer as a patient, he's not thinking, okay, how am I going to treat this patient.

My clinic, you know, he's thinking, how am I going to get this patient information that they need in order to make the decision that fits for them?

Right.

And so that's why the patients are always wondering why they're seeing all these people.

And it's because we want to make sure that they understand all their treatment options to the team, so that they can make an informed decision, because there's not a right or wrong answer.

Right?

Right.

Like a lot of times the patients, they can go on active surveillance, they can get treatment with surgery, they can get radiation and all those are all appropriate decisions.

But they need to understand kind of the pros and cons of those things.

And so that's the beauty of our setup is where we're able we're not climbing over each other to get patients.

Everyone just wants the patients to get like be comfortable with their decision and have a good treatment option.

And so that's what makes it like a great place to practice because we're not we're not fighting each other.

We're just trying to help our, our patients.

Right.

So that's number one.

But number two with the radiation.

So I there's the slide that I put up here.

It's in radiation.

It's it's just every year we're continuing to evolve or become the treatments are becoming more precise.

They're becoming more personalized.

And we're we're just we're getting smarter at it.

And so my, my, my mentality for radiation is I don't want the patients to need to leave El Paso like I want them to have the best care possible that they can here, and that you can get the same care here that you can't anywhere else.

And we're very good at it.

And so in order to do that, you have to bring on these new technologies.

And sometimes I'm like one of the first people in the country trying these things out.

And Sbrt is something that's been around for a long time.

And what we've started doing is doing a lot of these, like, kind of nerve sparing techniques, which is very similar to what the urologists do, where they, they, they avoid cutting the nerves that are allowing patients to have erections.

And we do the same thing now we're we're able to carve off the carve the radiation dose and not damage the nerves because our precision is at that level at this point.

And this this study didn't study that, but it's it's just one of the one of the studies where we're comparing, you know, the differences between surgery and radiation.

And I'm a I'm a, I tell the patients, like, if I'm 50 years old and I have, you know, a pretty aggressive cancer, I'd probably do surgery and I'll tell them that to their face, even though, you know, I'm a radiation oncologist.

But once you get to your 60s and 70s, it's really, you know, you know, flip a coin and it's you're going to have the essentially the same outcome.

But these, these studies, it's it's nice to have them and show the patients where it's like, you know, this is what you're going to be dealing with when you have surgery.

Like, you're, you're you're changing the plumbing inside.

And so you're going to have diapers for a little bit and things like that.

And radiation is the opposite.

It's going to cause a little swelling.

So you're going to have a little urinary obstruction.

And so these conversations are really just educating the patients on like, you know, the outcome of what they're going to have to deal with.

And then in their mind they can think about, well, I'm working.

You know, I have to work full time.

I can't I can't stop working around now for six weeks.

And so then a lot of those patients will choose, like the more and more noninvasive option that allows them to continue doing what they're doing.

And then some patients choose the opposite.

But it's a very personal decision, right?

So it's just like everyone's a little different.

They think differently.

And so you just have to kind of our job is more of like like we're guiding.

We're not telling them what to do anymore.

Back in the day, 30 years ago, that's probably what we were doing.

But now it's more of like educating the patients and giving them the context to make that decision.

And so another one of the slides that we have right after the PACE is, is a new spacing technology.

And so in radiation, we've been doing spacing for a very long time.

Where we push the rectum out of the high dose of the field.

And so the prostate gets the majority of the dose.

And then we're limiting the toxicity like rectal bleeding and things like that.

Proc Titus from, from receive like after the rectum receives high doses of radiation.

This is a new technology that is is up and coming and not not too many people are using it yet, but it's actually a balloon that we're inflating between the prostate and the rectum.

And, and it creates a massive amount of space between, between those two structures.

And so that allows us to be, you know, obviously get higher doses, but also limit more of the, radiation exposure to the rectum.

And so these are things that you just have to learn and continue to evolve.

And I think, you know, in, you know, with Brian in our center, we've been we've been very good at it, trying to bring down these new technologies to El Paso so people don't have to leave to go get them somewhere else.

That's kind of the summary of it in a nutshell.

Like I said, we can we can go hours and hours on this.

But we're kind of hitting the 20 minutes till we're ending.

Mark.

So I do want to touch base.

I feel like bladder cancer doesn't get talked about enough.

It's like the non sexy cancer that exists.

It's there, but nobody really talks about it.

I don't know why, but let's let's at least touch base on it.

So as a urologist bladder cancer I don't know if you have statistics out there.

If not, that's fine.

Of about how common that is.

Is it more common in men or women, etc., etc.

and just some trap or doctor mentorship talking in Travis.

Sorry.

So at the New Frontier, you said, you know, bladder cancer is the new frontier.

So talk a little bit about what bladder cancer is, and then talk about the new frontier of how the treatment and, and diagnosis of it.

We'll, we'll go through it briefly because when we now want to go, we wanted to get to our, you know that their analysis and such.

But suffice it to say that it's certainly not as common as prostate, but it's we miss prostate Cancer Awareness Month and it's now, October.

But I believe it's prostate Cancer Awareness Month every month.

So but we also did want to talk about bladder cancer, which gets a little bit I wouldn't say ignored, but it gets pushed to the side because it's not as common.

But it's out there and it's much more dangerous.

I must tell you.

I mean, in a sense that if it's not caught at a certain time, it can be, patients succumb.

So I think it's really good for your audience to ask the questions.

It usually presents with blood in the urine.

Maybe some pelvic pain.

Irritated, voiding cyst symptoms, which I know is common, but it needs to be discussed with your doctor.

And then a workup transpires by the urologist to look in the bladder and get an image called the CT scan.

Part of what we have at our facilities too is a CT scanner.

So we are able to move quickly.

But a really the crux of the conversation is the excitement that's going on.

Like Travis said, he titled it The New Frontier because there's muscle invasive and there's non muscle invasive.

And I'll start with non muscle invasive.

And that's when the cancer hasn't gotten deep into the muscle or the roots haven't spread.

And there's a much better outcomes with that.

And we only had one therapy in the past called BCG which is a it's basically an attenuated virus or a dead tubercular TB virus, tuberculosis virus that basically lives on, lives on the surface of the bladder with an infusion of fluid and, and what happens there is your immune response reacts to it.

It's found in the 80s.

I mean, it's been around forever, but it's still the standard of care.

But now we have all these new therapeutics that are out in that space that is just changing.

It's a paradigm shift for sure.

So I think for the audience, it's really, you know, I don't want to get into the details of how the mechanism action works, but we have all these different therapies now.

So you need to ask the question and you have to be aware of bladder cancer.

And there's fantastic therapies even for when it gets deep in the muscle and metastatic disease.

We have new studies that have shown different therapeutics that are now working in that space as well.

So I think the message is not to mention radiation therapy that we can give our patients.

So we have systems that take out the bladder when it's advanced.

But all these therapeutics are amazing.

And so more details probably on another hour can be spent just on bladder cancer.

But I don't know if you have any other, additional comments.

Travis on it.

Yeah.

Just briefly, specifically for muscle invasive.

So, so basically, you know, your options for muscle invasive and bladder cancer is usually cystic to me.

But now we we started doing something called bladder preservation.

It's been a it's been around for a while, but now there's actually defined trials that are showing that it's actually a, a reasonable treatment option for patients who don't want their bladder removed.

Removing the bladder is a big surgery.

Yeah.

It's not just like, you know, hey, we're going to go to the, you know, the surgery surgery center and you're going to be there for an hour.

It's it's a long like playing a 4 or 5 hour surgery, a huge operation.

Sometimes they have to refashion the bladder.

And so in some cases those patients may not tolerate that surgery well.

So the another option is to do chemo radiation which is what.

But I do keep radiation.

You don't hear that a lot often together.

So what we do a lot for for cancers where we give we give I call it chemo light.

Yeah.

Okay.

It just sensitize us the cancer to radiation and we're able to treat the entire bladder, wipe out the cancer in the patients, able to to keep their bladder in their body, and have no bladder cancer.

But the the big thing with, with bladder cancer too, is the immunotherapy.

And so we now have all these immunotherapies that are able to basically harness our immune system, to attack the cancer cells.

And some of the immunotherapies, even like the cancer, cancer is, is hiding from your immune system.

It's not supposed to be there.

And actually we produce cancers all the time, but our immune system is able to go in there and eradicate that cancerous cell that forms.

And you know, it probably every day that's happening in our bodies.

But our immune system is able to wipe it out.

And the cancers, they they learn how to kind of cloak themselves from your immune system, and that's what allows them to grow.

And so we have these agents that are able to to allow your immune system to find those cancers.

Again, and these are all coming out and basically all the cancers that you can think of, we have these immunotherapies that are had been very, effective and bladders just the, the next one network that we're doing this on.

Okay.

Theranostics.

It's a big thing to talk about in the show.

So I want to get started on that, because I know we've got several things on there.

First of all, define theranostics.

So so theranostics it's a, it's a play on words.

So, so the idea was therapy and diagnostics.

So having like diagnostic imaging and then having a targeted therapy that kind of pairs with that.

And so instead of saying, you know like I don't know, you know how you like it, even word it with diagnostics, they just merge the words and they call it Theranostics And the concept is you have an imaging agent that's able to identify and allow us to see where those, the cancerous cells are.

It sticks to them and it glows.

And we can see it on the on the cameras that we make.

The technology is a little more complicated, and I won't get into it because I think it'll just freak everyone out.

But, but basically you're able to image the cancer cells inside the body, or tumors.

And then there's an agent that, that has the same, like, light in that's targeted on the cell, and you put a, therapeutic agent onto that same, ligand.

So the way that they just think of it very basically, you have an imaging agent that sticks to the cancer cell, then you have a therapy agent that seeks the same cancer cell.

And so, you know that when you give that therapy that it's going to go to that cancer cell because the same imaging agent just stuck to it like they're almost magnets.

And I like the way it's written down here.

It's target image treatment here.

Yes.

And the way you're describing it is great.

Like the piggyback.

I'm trying to make it simple.

Yes, but basically have an imaging agent and a therapy agent that we're able to to pair together and almost ensure that it's going to be, efficacious for that patient.

And you're able to tell if the cells, say, the patient has a metastatic cancer and we image them and it's not lighting up, you don't want to give that therapy because it's not going to work, because it's not going to stick to the cells.

And they're developing this.

We do this for prostate cancer and also neuroendocrine cancers.

But they're developing it for all other cancers.

So this is the field.

This field is in its infancy.

We're kind of at the cutting edge right now with it.

But we are it's it's going to continue to grow here in the next like 5 or 10 years.

We'll have more imaging agents, more therapy agents that will be able to deliver for all different cancers that patients have.

And I love that you brought that up because, again, I was kind of joking in the beginning of the show is real Grand Urology slash Rio Grand cancer specialist.

So you're dealing with urology, bladder, prostate, etc.

but you are also on this new frontier of a bunch of other cancers as well.

So I love that you're doing that.

So please continue to come back so we can learn more about that.

I know these shows go by so, so fast.

So aeronautics, before we move on to some AI that's always a question of the day.

Is there anything else you want to talk about there?

And the reason I was saying that we have a whopping 13 minutes left, so it's going fast.

Let me just comment real quick about Doctor for this, for everyone to understand, make it clear that this is when the disease this is about prostate cancer, not bladder cancer.

So we're back to prostate on theranostics.

We don't have anything yet in the theranostics.realm.

But this is when the disease progresses to metastatic disease.

So it's not for just someone who comes in with an elevated PSA.

So I don't want a bunch of people coming into my office saying, hey, man, you never told me about, Theranostics.

So it's, you know, and we have an advanced prostate cancer center.

That's when we shuffle them.

That's it's a totally different disease state.

And like I say it where we are, we treat from diagnosis to end of life issues.

So we the whole continuum is what we do.

But, so at the end of the day, this is about advanced disease, that Theranostics.

So sorry.

I just want to make that clear because I know that my partners will be like you did.

You know, I've just got a patient again that came in that has an elevated PSA and wants Plavix.

So that's the name of the medication.

So we got to be careful.

It happens.

It happens.

Yeah it does happen.

Yeah.

So just just to be clear.

Gotcha.

Advanced disease.

And that's what you saw today Kathrin with the PSA scanner that's in-house which is state of the art.

What you asked about Brian about everything we you know, we try to have everything on campus.

What I say on campus where it's just, you know, the urologist or next to the radiation oncologist who was next to the theranostic center They're not to patients.

I mean, really, everything's all in one place, which is really nice because they get to know the staff.

And that in and of itself adds a comfort level.

That brings everything in the question of the day, the question of the year.

The question going forward, though, is AI.

And so AI is great.

But at the same time there's insurances that you want to use with AI.

So I want you to touch base on that because I feel like every medical show we're doing right now, we have to somehow touch base on that.

And you're looking at me with a smile on your face like a little kid.

So, you get to handle that one?

Oh, yeah.

So I'd love to.

So I'm heavily involved in this.

Okay, so.

So the concept with AI is an umbrella term, right?

Right.

AI's in everything.

It's not.

It's like we've we've been using AI in medicine for decades.

It's in a lot of the tests.

It's it's just they're the the fear that people have now though is, is a is a different type of AI.

So what people are scared about and what's all the tumor is and everyone, you know, talking on YouTube and stuff.

It's it's about generative AI.

It's not I like that we use and like our pathology, you know, reports and things like that.

That's just is kind of helping us analyze things.

Generative AI is is the new is the new frontier for AI.

And basically the way it works is they have these models, the LMS, the large language models that are running on on these chips.

And basically it's a bunch of probabilities that are inside the model.

And they train these, they train the they train the model on text.

And so what, what the generative AI is doing is it's actually predicting what it what it thinks you want to hear.

Okay.

So whenever you talk to ChatGPT or Claude or, or Gemini or all the other frontier labs and different models, it's predicting what it wants you to hear and that that becomes a little bit scary because, you know, you how does it know what you want to hear?

Right?

So it's it's basically all these weights.

And there's the parameters.

They call them parameters or weights.

There's trillions of them now.

And so you can't go in and inspect that.

There's trillions of the weights in.

The human cannot go in there and you know see what's going on.

So it's like a magic box that's producing predictive text that we're using to to talk to and make decisions and things like that.

And this is really not like prime time in clinic right now.

We're not like most most places are not using generative AI to to make decisions or have decisions made for them.

We use it to research things and research decisions and so we don't miss anything.

That's starting to become like kind of commonplace in clinic.

But the the whole concept of, of AI and the things people are scared about are the language models and then generative AI.

Is this totally different than the AI that we've had from like 10 or 20 years ago.

And the big thing now is something called agent tech AI.

And so what they've done again, agent tech, they call them agents.

Okay.

The AI agents.

And if you want, we can do a whole hour long thing on this because I, I'm going to understand I can go and like deep dive into this.

How does this so so the agents the, the new thing is agent AI and what they're doing is, is putting the limbs in what's called a harness and so that it can actually do work for you.

And I have like it can click around on your computer screen, you know, do PowerPoints for you, all kinds of things.

And what the concern in medicine right now is you don't want these LLS replacing the, the physicians like, because we're the ones sitting here, like thinking about things and kind of taking in all that context.

And the big fear in medicine right now is that this is going to come in and basically replace the like the, the context of the physician.

And, and for me, what I've been trying to do nationally actually, is, is try to teach people like, hey, you don't this is this doesn't it doesn't need to replace anyone.

But it can definitely be a good wingman.

Yeah.

There you go.

You know, like someone someone that like, like that helps you not miss things.

Because medicine right now, there's so much information being thrown at us, studies and the patients, and everyone's becoming more and more busy.

And it's it's hard to keep track of everything.

And I can really help with that.

And make sure that you don't miss anything, but you do not want it to make decisions for you because it can be wrong.

If I may just I just really has a lot of a lot of time.

And he's it's amazing what he's doing for our practice.

But in the pathology world, it's it's in play to help the pathologists look at slides.

In the radiology world, we're dealing with radiologists.

Now that are saying, look, it's helping us with our reads.

It's not going to replace physicians.

And that's and they hope it doesn't replace, you know, others with within our organization.

Of course, on the clinical side, there's ways that we can implement it.

But I think one of the messages is is here we're trying to keep up with the technology.

And, I it certainly is exciting.

Yeah, sure.

I mean, hearing AI is here embrace.

But it's not going to replace, you know, that's a it's a whole different way of looking at things.

But it again, it's something that everybody's talking about all the time.

With such small amount of time left, I do want to talk about what's new at Rio Grande.

Cancer specialist.

And Brian, I'm going to throw that your way.

And I'd love for you to to kind of bounce back and forth on what's going on, what's coming up and what is new.

Yeah, absolutely.

I mean, in terms of, what's new At the practice, technology is constantly evolving, of course.

And, and the techniques that we use to treat patients is constantly evolving.

I think we do, a an amazing job, clinically, of making sure that as, you know, the the industry goes through these evolutions that we are, absorbing the best of those evolutions and and putting them into practice.

One of them, I think that that I'm, that I'm very proud about is that we've employed a, a surface guidance program, which monitors patients and automatically shuts off the radiation beam if they fall out of a tolerance.

That that's programed into it.

In terms of, the, quality of treatment delivery, that's very important.

Equally, if not more important is the patient safety factor to that.

Right?

In radiation oncology, the one of the biggest worries is, and, and, and how we design our treatment plans is that we want to deliver radiation and, almost exclusively to that, that treatment volume, wherever that tumors living.

And we have to give some radiation to healthy tissue around it, but we want to minimize it.

This is one of the tools that that helps us to do that.

No.

And, and and it was a significant investment, but I think it shows how, I can comment because right time, I think our, our radio ligand therapy program is, is state of the art.

When the only ones in the entire region that's the victim.

That's our PSM scanner.

We have, a radio pharmacy about to pop and open where we'll have a radio pharmacist's where we will deliver the the radio ligand and make it in our office, in our clinic setting so that patients can have quicker access to it.

We have an ambulatory surgery center that's soon to come.

And I think it just kind of speaks to the team that that we've, that we've built.

I mean, we're independent, but we're able to, like you said, I love the word, the word nimble.

We're we're able to pivot and try to keep up with what's going on nationally.

So proud of what we built.

And it just keeps coming, you know, just quickly about the surgery center like that.

That blew me away yesterday when I it's it's we're looking at several months away.

You know, going into that that everything is going to be done on campus.

Who wants to take that.

Yeah.

I mean it's the focus really is going to be most of the our patients that are having procedures done if they're listening.

Now I'm sorry that we, you know, created some trauma for you in the past.

But we're going to be able to put them under sedation for prostate biopsies, for cystoscopy, for smaller procedure as well as procedures that are outpatient, they're not going to be able to stay overnight.

So a lot of our clinic procedures will pivot and and transfer over to that.

That sort of space.

And so it will be easy for the physicians to, you know, it'll, it'll help with, with their sort of sequencing of patients throughput, adding more patients to our, our, you know, our days because the surgery center will take care of all those procedures in clinic.

And I just think it's super exciting for everyone.

I think it's going to be solid care, for sure.

And it goes back to a doctor Mendel was saying about you, it really is all about the patient.

And I just see it just being there.

I'm just thinking, man, if I'm getting treated, I want this all to be on a campus where I know everybody.

I can see you around.

I can just see everybody else around.

So I think that's phenomenal.

Before we do a closing, Doctor Mendel, do you have anything else you want to add about?

I was just going to make a comment on a lot of these kind of initiatives.

We have, you know, the population in the US is aging, and so there's a lot more cancer being diagnosed.

Mostly.

You know, people are getting better at finding it.

But also just the, the, the majority of the population is aging into that cancer age.

And so what's happening here, especially locally for physicians is where are you like almost getting overrun by patients because there's so many patients.

And and this is why a lot of times patients are having to wait months sometimes to see a provider to get a procedure done in the surgery is just one of those things that we, we decided was going to make it more efficient for us and the patients to where we're able to get more, do more things, get more things done, do it in a more comfortable setting that's more efficient, and then the patients aren't going to have to wait as long.

They're going to get diagnosed sooner.

We're going to be able to get them on treatment faster.

And so this is all kind of symbiotic.

And we're really trying to to do our best effort to, to make it to where we can serve the community is the best way that we possibly can.

And this is just like one of the things that we're doing.

But there's, you know, ten things going on all at once.

And this guy has to deal with most of it.

And then there's obviously going to be more things in the future.

And so it's just it's we're always just trying to stay ahead of the game.

But it's it's hard.

Yeah it is.

It's not.

But I will tell you again just watching you all in action, every one of you are so personally involved in what's happening, what's going on and involving our patients and all that.

And so I think that's fantastic.

And if you're just tuning into this right now and you missed part of the show, it's okay.

There's hope for you.

In three different places.

So this program is significant advances in cancer care, new options, new hope.

We talked a lot about prostate cancer and just in general new and just advanced imaging that's happening.

But you can watch this program again on PBS El paso.org.

You can also watch it on the El Paso County Medical Society site.

And that's the EP, CMS site and that's dot com.

And then also YouTube, youtube.com.

All you have to do is if you're watching this in the month of October or November, you can go straight there and this program will pop up.

If you're watching it during any other month, just type in the, the, the, El Paso Physican into the search engine and you'll see significant advancements in cancer care in this program will pop up for you again there I want to say thank you.

So much, Doctor Jeffrey Speer again, Doctor Travis Mendel and Brian Nabhan, you guys have been fantastic.

Thank you so much for letting me tour your facility.

If there ever any issues and give them a call.

I mean, it's really a fantastic place to be.

Again, this Rio Grande Urology and also Rio Grande cancer specialist.

Thank you so much for joining us.

I'm Kathrin Berg, and this has been the El Paso Physician.