Navigating Prostate Cancer: A Conversation with Dr. David Grew

Navigating Prostate Cancer, Interview with David Grew, MD

[00:00:00] David: Clinical trials are so important. Clinical trials are really what they, they really are the engine that's driving the leading edge of medicine. If we don't have clinical trials, we don't get things like, immunotherapy, targeted therapies, combination chemotherapy, more advanced radiation techniques that shorten the course of treatment and give higher doses, we would never be able to, uh, test and establish the safety of these kinds of really amazing new drugs that have.

Completely changed the lives of countless people 

[00:00:39] Leah Sherman, ND: Hey Tina,

[00:00:39] Tina Kaczor, ND, FABNO: Hey, Leah. I just finished listening to your interview with Dr. David Grew and I loved it.

[00:00:46] Leah Sherman, ND: this. it was a really good talk. so, Dr. Grew is a radiation oncologist who has created these free resources for patients. It's really for anybody. 'cause I think it would be great for medical students, um, just providers to help to show their patients, what different cancer treatments involve.

 he has resources that are these, like, very simple illustrations that explain cancer.

 ,cancer process, a clinical trials. I think that part is really important

[00:01:22] Tina Kaczor, ND, FABNO: Mm-hmm.

[00:01:23] Leah Sherman, ND: and I got to speak with him about that. His company is known as Primer and imr, right? Right. Yeah. Yeah. There are links in our, um, Uh, so where you can find him, he is all over social media I was really excited to talk to him about, um, these resources. And we also talked a little bit about prostate cancer. there has been prostate cancer in the news and there have been some misconceptions.

And so I wanted to kind of clear things up and we just covered the basics. We talked about, well, especially because it's Men's Health Month, 

[00:02:01] Tina Kaczor, ND, FABNO: June?

[00:02:02] Leah Sherman, ND: this.

[00:02:02] Tina Kaczor, ND, FABNO: Yes.

[00:02:03] Leah Sherman, ND: June. Yep. so we covered the guidelines for prostate cancer. We talked about, you know, when you should consider getting checked out, um, the different treatment options.

you know, if we all have someone in our lives who can be affected by prostate cancer. And so I think it's really important,

[00:02:21] Tina Kaczor, ND, FABNO: Because sometimes it is the partner, spouse, wife, sister, good friend that finally gets someone to go, go see the doctor because they have symptoms of what looks like like BPH or benign prostatic hypertrophy, which is really common as people age, they end up with symptoms of benign prostatic hypertrophy, which mimic the symptoms of, um, prostate cancer.

So it, it has to be looked out. It has to be checked out.

[00:02:51] Leah Sherman, ND: And, and we go into that. So, just because somebody has symptoms, does that mean that they have cancer or not? You have to tune in and listen. but 

Before we get to the interview, I wanna cover some things. I want to thank Kathy for her membership. Uh, she joined as a petal patron Thank you so much for joining. We also had somebody sign up for monthly support, so they didn't join the membership, but they did sign up to give a monthly coffee So all of this helps us to keep the podcast going and to keep bringing you this high quality content, as we always say. 

[00:03:28] Tina Kaczor, ND, FABNO: Yeah. And ultimately, you know, long time ago when you and I were just dreaming this up, creating community was a big piece of it. 

[00:03:35] Leah Sherman, ND: right.

[00:03:36] Tina Kaczor, ND, FABNO: It ends up being the, a little bit more of a challenging piece. I mean, it's easier for us to turn on camera and record for, for the last four years. but now we're at the point where we really want to gather people, like-minded people and talk about what can be done and kind of a supportive environment.

So yes, I'm glad that it's finally happening, that we finally are putting our membership out there and I look forward to meeting some of our listeners.

[00:03:58] Leah Sherman, ND: Yeah, and some of the perks of membership include, um, you know, it's, I think it's ever evolving. We keep adding things. As extra perks, but we're just now gonna be adding, episode cheat sheets. So especially with the side effect, um, and survivorship episodes depending on what level you are subscribing, there'll be downloads so that you have something that's more tangible so that you don't have to like sit. And take notes during the podcast. If you wanna keep

[00:04:24] Tina Kaczor, ND, FABNO: Yeah.

[00:04:25] Leah Sherman, ND: repeat the podcast and take notes, go for it. But,

[00:04:28] Tina Kaczor, ND, FABNO: Right.

[00:04:29] Leah Sherman, ND: you join the membership, you get these, the access to the downloads.

[00:04:33] Tina Kaczor, ND, FABNO: 

it's, it's not becoming a. like a resource library of sorts. So we we're gonna formalize that now.

Um, so yeah, that's a, that's a great perk. And then there's, there's our live q and as on YouTube,

[00:04:44] Leah Sherman, ND: So just go to our website, uh, the cancer pod.com and click on join us. Uh, there's a button off to the right and it's that easy. And then just pick a level and the perks that interest you.

[00:04:56] Tina Kaczor, ND, FABNO: Oh, and You can gift this membership to somebody who you think could benefit from hearing not just the podcast, but maybe the q and a sessions with us or some of the other perks and benefits that we're gonna be sending out.

[00:05:07] Leah Sherman, ND: Yeah. That's an awesome idea. 

[00:05:09] Tina (2): I'm Dr. Tina Kayser, and as Leia likes to say, I'm the science y one. 

[00:05:13] Leah: And I'm Dr. Leia Sherman, and I'm the cancer insider. 

[00:05:17] Tina (2): And we're two naturopathic doctors who practice integrative cancer care. 

[00:05:21] Leah: But we're not your doctors. 

[00:05:23] Tina (2): This is for education, entertainment, and informational purposes only. 

[00:05:28] Leah: Do not apply any of this information without first speaking to your doctor.

[00:05:32] Tina (2): The views and opinions expressed on this podcast by the hosts and their guests are solely their own. 

[00:05:38] Leah: Welcome to the Cancer Pod.

[00:05:42] Leah Sherman, ND: I'm here today with Dr. David Grew. 

 Dr. Grew is a board certified radiation oncologist working in Connecticut. He earned his Masters of public health at Tulane University and completed his residency training at NYU School of Medicine. He is also the founder of Primer, a company that creates short digital videos, which are free resources for patients that explain the basics of cancer workup, treatments, treatment risks, clinical trials, and more. Thanks for being on the Cancer Pod.

[00:06:12] David: Thanks for having me. I'm really excited Leia.

[00:06:14] Leah Sherman, ND: I invited you because I really wanted to speak with someone to talk about prostate cancer. We don't typically focus on one particular cancer, but I thought you were the perfect guest because you also have these videos that explanations of all different kinds of cancers. so I think that would be a great resource for a lot of our listeners.

[00:06:36] David: Yeah, thanks. I can tell you a little bit about how that all started, just to give some context for your audience, but basically it, it's. I mean, I've always been sort of a visual learner, so even when I was in medical school and even as a pre-med, I would just sketch out different things that I was trying to remember for tests and exams and things like that.

 and then that carried through medical school and, uh, for a little extra money. During med school, I was teaching undergrads how to prepare for the MCAT test to get into med school. And part of that. Job was to stand at a whiteboard and, and take these complex concepts that these undergrad students had to understand for the MCAT and turn them into simple visuals that would be easy memory hooks and different ways to like recall these complex concepts when it came time to sit for the test.

And so I just really got in the habit of. Trying to convert these complicated things into simple and easy to understand images and carried that habit right through med school residency and into my practice now in Connecticut, where when I explained to my own patients what their cancer is, where it is, what the treatment options are, and then obviously from there, what are the risks of treatment, what are the side effects and the, the complications and things like that.

I just have always found that pulling out a piece of paper or even just drawing right there on the exam table is a great way to take this. Otherwise just purely verbal explanation and turn it into something visual that most of us are actually visual learners. We're animals after all, so it's an easier way for most patients to.

Ultimately kind of understand and, and absorb this complicated information. And then what happened was during COVID patients started asking if they could keep that little scribbled drawing that I had made, and I would ask them why, you know, this isn't, this is just kind of scribbles here. By the time I'm done with it, it's a mess.

But they said, you know, I, I, when I go home, my family's gonna ask me. What the doctor said, and, and I really did understand it when you just explained it. So if I take this piece of paper home, that will maybe jog my memory. And enough people had asked me that to finally, the light bulb went off and I said, well, maybe I should sort of digitize some of these common explanations and common illustrations that I'm making over and over for my patients.

 and because there was a lot of time on my hands during lockdowns and things like that, uh, I, I kind of went nuts with it and just. Made this massive library of common cancer explanations across, like you said, breast cancer, prostate cancer, brain tumors, lung cancers, all these different diseases where there's usually some mystifying element to it that a simple Google search is not gonna really solve for patients.

And so I'm trying to fill those gaps where, um, gaps in understanding to help patients understand with visuals and narration. 

[00:09:43] Leah Sherman, ND: I have to say, I did, um, of dive into some of your videos in preparation for, for today, and I, what I love about them is that they're just, they're brief, they're just these little kind of sound bites they're so succinct and no, it's, it's such a great resource. I think even for, you know, like you were saying, like medical students, I mean, it just really, because they are so brief and so simple. you, you really are turning these complex, um, ideas into something that, anyone can really absorb. It's, they're

[00:10:17] David: Well, I noticed that, you know, like when I walk into a patient's room, they're often, like all of us are passing idle time on our phones. either like scrolling through reels or TikTok or something. And so our brains have, uh, for better or worse, really adapted to consuming or, or doing knowledge transfer.

With short form video. And so yes, I could easily have like just taken my entire spiel for breast cancer, which is probably 20 minutes and made it into a long form thing, but I. no one's gonna watch that, number one and number two, that's not even really how I think about the explanations I give my patients.

It's actually it. It generally runs about 20 minutes of this explanation, but that 20 minutes has probably, I. 30 different two or three minute pieces, and I'm hand selecting each of those unique pieces to construct a unique or like a more bespoke 20 minute explanation. And so. I just decided to take each of these individual two minute pieces and create all of them, and that way a patient can kind of find their own journey through the content and say, well, well, I, I was node negative, so, so this one isn't for me.

This, this kind of radiation won't be what I get. Or I was node positive, so I actually need to think about this kind of surgery and, and this kind of radiation treatment. And so I try to kind of leave the crumbs so that patients can kind of understand their own path and, and then even beyond that, if they, they wanna understand the other side of the coin, um, for a certain treatment and say like, well, what if I didn't have this?

Or what if I did have that? They can kind of go down that path and, and consume content that will educate them about an alternative path too.

[00:12:09] Leah Sherman, ND: And I really love how you also have videos on clinical trials because I think that is such a mystery to patients in general, like. know, whatever attitudes they may have, um, about clinical trials. Like just having something that simply explains, I think, I think that's a fantastic resource.

[00:12:26] David: Clinical trials are so important. Clinical trials are really what they, they really are the engine that's driving the leading edge of medicine. If we don't have clinical trials, we don't get things like, immunotherapy, targeted therapies, combination chemotherapy, more advanced radiation techniques that shorten the course of treatment and give higher doses, we would never be able to, uh, test and establish the safety of these kinds of really amazing new drugs that have.

Completely changed the lives of countless people in, in the United States if we didn't have clinical trials. but I also understand there's a reluctance and for, for many patients that reluctance is for completely legitimate reasons. And I think that the only way that you can even can have a chance to overcome some of that reluctance is to establish trust.

So the way that we're approaching it is trying to deliver value to patients in the form of education, uh, and, and taking that complex clinical trial and turning it into a, a short educational video that's between maybe two and a half to three and a half minutes. And. Whether the patient's gonna enroll or not, they really, if they consume that video, they're gonna understand their disease a little bit better.

Even if they're not a good fit for the trial, they're not interested, they'll understand, okay, this is the general approach that doctors currently take to this disease. This is an open question that doctors don't understand yet, and if I enrolled on this trial, it's set up to safely and accurately answer that question about some new drug device or technique or something.

And so there's no pressure, there's no coercion. It's really just if you wanna understand a little bit deeper level about your. Your situation, you can watch this video and if you're interested, then you take the next steps to speak about the trial with the, with the care team and everything.

[00:14:41] Leah Sherman, ND: Yeah, it's a great introduction so that when they go to speak with the care team, um, they already have an idea of what's going on. 

[00:14:48] David: Yeah, our, our work in the clinical trial space really came from the doctors who lead the clinical trials. They're called principal investigators or PIs for short. I. And they were describing this problem. They had seen some of our content about general cancer situations and they described this problem that they had where not only is it hard to explain their new trial, which is like super complex and it involves these new like genomic tests and um, new complicated treatments and things, but they were trying to do that exact.

Treatment at scale across many, many clinical trial sites, hospitals, all over the US and Canada, maybe 45 sites. And they didn't have a great way to ensure that the explanation that a patient was getting at site A was gonna be the, you know, have the same caliber and quality at site B and C and so on. And so content is a great way to establish a benchmark of quality to establish.

Basically like a minimum, uh, standard of quality of explanation. And so they basically approached us to say, could, could you help us create that minimum standard of quality and actually elevate the patient experience across all of these sites by using kind of multi multimedia in person, but also flyers and also video that they consume on their own phone to just sort of enhance the overall experience.

[00:16:25] Leah Sherman, ND: like I mentioned, I would love to talk to you about prostate cancer. There's a lot about prostate cancer in the news these days, and I think people have questions. Um, everybody somebody with a prostate, you know. So I think that this is, something that maybe it doesn't apply personally to one of our listeners, but it may. Be something that can affect a loved one, a friend. Um, so I think that this is really good information to get out there. Um, I guess we can start with what is a prostate,

[00:16:59] David: Great place to start. So the, yeah, the, the prostate is a gland deep in the male pelvis that, uh, is, doesn't play any, um. Like vital function, but it does, it is involved in producing some of the fluid that's in semen. So I guess in that sense, for procreation, it is a vital function.  but it, it sits right in front of, this is a place where I, I wish I had my little visual aids, but it sits right in front of the rectum and right below the bladder.

And so that makes it not easy to. To access or remove because there's other sort of organs in the area that can, uh, have some collateral damage with the treatments, which I think we'll talk about later. But, the good news is that it produces, um, a chemical, a molecule called PSA. And so even though it's not a very easy organ to access it, it it has, it produces something that's easy to measure.

In the blood with a simple blood test. And I'm sure most or almost all of your listeners have heard of PSA. It's basically a, a simple blood test that, uh, patients can undergo usually on an annual basis. Men start doing this at least around age 55, but I see more PCPs starting to get PSAs even for younger patients.

And, You can track it over time. And so there's a normal range and, uh, even if it's in the normal range, if it's rising, we can track the speed or the velocity with, with which it is rising. And if it, if it rises beyond a certain threshold, then that can trigger additional tests. That usually would be how we would start the workup for prostate cancer.

[00:18:54] Leah Sherman, ND: And a rising PSA. Is there anything else besides cancer that can cause to rise?

[00:19:01] David: Really great question. Yes. And, uh, simple things like prostatitis inflammation, benign inflammation, uh, of the prostate gland or, uh, prostate infection. So a bacterial infection of the prostate can produce a higher PSA and sexual activity. Just recent sexual act activity. Ejaculation can, we believe can probably elevate PSA.

Um, so we've sometimes we'll see patients who. We're following the PSA very, very closely, and any change is pretty important for their, for their plan of care. And if they have one outlier where the PSA is higher, we'll probably take a deeper history and try to figure out they have an inflammation right now, are they having an infection?

Uh, and if they don't have any of that, did they, did they have recent. Sexual activity and we may just repeat the test after putting them on antibiotics or having them abstain from sexual activity for a week or so, and then repeat the test.

[00:20:07] Leah Sherman, ND: I don't know if, um, if it's well known about the digital rectal exam, but that would be another exam that patients would undergo. And so what are the guidelines for, for getting one of those?

[00:20:21] David: one thing about the guidelines is there's not wide agreement. The, the government guidelines from the U-S-P-S-T-F, the United States Preventive Service Task Force, um, are generally pretty conservative and recommend sort of late start to screening and early finish to screening.

And then there's other guidelines that come through, uh, the A UA, which is like the American Urologic Society and others. Which are a little bit more liberal. They kind of open up, open up the goalposts and recommend screening earlier and you know, continuing screening later. But all of them generally point to a shared decision making process between the patient and their family and the doctors where there's a discussion around.

Um, the why we do screening, what we might do with that information after and so forth. And so the digital rectal exam kind of comes in as part of that conversation for shared decision making, and it should really be done in a. Combination with the PSA blood test and, but on its own isn't thought to be a, a great screening tool, but in combination with the PSA.

If you have a rising PSA and a digital rectal exam that shows a nodular prostate, that can be pretty convincing and lead to some additional tests.

[00:21:37] Leah Sherman, ND: Is it possible that you could have a rising PSA and an unremarkable. digital rectal exam.

[00:21:46] David: Yes, it's possible. And it's in fact the most common situation

[00:21:51] Leah Sherman, ND: Okay.

[00:21:51] David: that you have a digital rectal exam that's totally unremarkable. It's a smooth prostate. There's no discernible irregularities or anything, prostate. Feels fine, and then usually the next step after that is an MRI and an MRI is far more sensitive than the digital rectal exam, meaning it's more powerful at picking up.

Prostate cancers than a digital rectal exam. Um, so the MRI in combination with a rising PSA starts to paint like a broader picture of like, what, what's going on. So if we have a rising PSA and an MRI that shows a nodule that looks suspicious on an MRI, that would sort of provide a very good rationale for then going and getting a biopsy to look for cancer.

[00:22:40] Leah Sherman, ND: And are there people who are considered more high risk than others?

[00:22:44] David: There are some, uh, there's family history is a key driver and it, uh, prostate cancer is thought to be more prevalent in African American men. And so those two groups in particular are usually a main focus for who we want to make sure we're, we're getting, getting screened at at the appropriate time.

[00:23:04] Leah Sherman, ND: Okay. Or do you do an earlier age as well for people with a family history?

[00:23:09] David: I think, again, that goes back to that shared decision making process. There's, there's definitely not like a, uh, hard and fast or like a concrete cutoff for age for screening. There's, there's a lot of controversy around what is, uh, the, the optimal age to start. But, um, I think that generally falls to the primary care physicians who are.

Talking to with these patients probably in their early forties to start, you know, if they have, if they have a known family history to start talking about doing screening.

[00:23:43] Leah Sherman, ND: And then a cutoff for, um, on the other end, like know that's pretty controversial as well as to when to stop, um, screening.

[00:23:52] David: Quite con controversial. So the right now the government, recommendation from the U-S-P-S-T-F is they recommend against screening starting at age 70. So they only recommend screening up to 69 and at 70. It's not that they're saying we're not, um, we're not endorsing. Screening, they're, they're going a step further and saying, we recommend against it.

 which sort of implies, in my view anyway, that they believe that there's some potential harm. They're saying don't do it. Um, and so then you might scratch your head and say, well, what would be the harm? And the best we can tell their argument is that. The harm is over-diagnosis and overtreatment.

And so if you, the scenario to just give a concrete example would be like a 75-year-old patient who has a very low risk prostate cancer, um, and, and then decides to go and have surgery or something, and. Gets an infection or has an MI or something in the postoperative state and then, and then they, they die or they have significant morbidity because of the treatment that they did for a cancer that was very unlikely to ever be life-threatening for them.

So that is an extreme example and we have, a lot of other treatment options now that are far lo lower risk to patients in that cohort. But, I think that is the, the rationale for I. Recommending against doing any form of PSA screening in that age group?

[00:25:26] Leah Sherman, ND: You talked about low risk, so if we talk about kind of staging and Gleason score and you know, what is considered low risk,

[00:25:33] David: Yeah,

[00:25:34] Leah Sherman, ND: versus more aggressive prostate cancers,

[00:25:36] David: sure. So we, we, prostate cancers kind of get categorized on a spectrum of risk from very low risk. Then on the other end, very high risk. And then there's everything in the middle. Um, and the things that we look at to place a patient somewhere on that risk spectrum are primarily, or historically, it, it was three things.

So it would be their PSA blood test the size of their tumor, which could be assessed usually on the digital rectal exam and whether or not it had spread outside the gland. So that gives us a sense of how big it is. And then the biopsy results. And with prostate cancer, historically there was this kind of funky, uh, biopsy staging sy, not staging, but grading system.

And so it was called the Gleason score. And basically it gave two numbers that were basically describing how aggressive the cancer looked under the microscope, and then those numbers were added together, and then there was a final number. That number would range from six to 10. So it was sort of a dizzying and confusing system for patients to understand.

But um, that score was the other element. So it was PSA, the size of the tumor, how big it was, and I. The Gleason score more recently for the risk group. We've also added in additional in information that kind of helps us really refine how we place patients in terms of like the, the spectrum of risk. One thing, so we have advanced imaging tests, so their CT and bone scan, which are kind of like the historic standards, more res recently.

MRI has become pretty routine. And then even more recently, something called A-P-S-M-A PET scan has been used much more commonly. So all of those combined help paint a more, like a fuller picture of a. How advanced the disease is, how aggressive it likely is to behave. And then another new category of information that helps us sort of refine or place patients on a risk spectrum is genomic testing.

So genomic testing is, is not testing the genes of the patient. It's testing the genes of the cancer. So that's an important distinction. But what they basically do is take the biopsy specimen and send that cancer from the specimen off to the lab, and a lab processes it and creates a map from that person's cancer and the map.

Sort of cr uh, it, it maps out a certain pattern of genetic mutations in the cancer, and then it, it understands the exact sort of pattern of those mutations and it matches them to similar patients who have had those kinds of mutations with their cancer in the past. And so then we have a new patient who's now been grouped.

On a genetic basis with similar patients, and then you can look at what happened with those patients in the past who had genetically similar tumors, and you can see what happened with them. So you, it helps you kind of understand or sort of look in a crystal ball from a genetic standpoint to better predict what what might happen with this patient in front of you.

Uh, you know, with this kind of genetic signature, and that has been extremely helpful, especially for patients who are thinking about doing active surveillance, which is where, you know, you're not doing any real treatment, um, because genetic information can maybe push you one way or the other on that.

[00:29:26] Leah Sherman, ND: And that's what, that's what I was gonna ask. Ask about next. explaining what active surveillance is, when somebody would consider that versus going towards, another treatment such as radiation or surgery.

[00:29:38] David: Yeah. So thi this has become a really empowering, uh, approach for patients active surveillance because in the right kind of patient, and this would be a patient who has a low PSA less than 10, a Gleason score of six, which is the lowest Gleason score and a small tumor that's not spreading outside the gland.

Um, and then if we do genomic testing, they also have a low genomic. Test score. Uh, so for them, there's a extremely low chance that that cancer would ever become a life-threatening problem. Over the next 15 years, that patient would probably have a less than 1% chance of dying of that cancer. So it doesn't get much lower risk than that.

And so. For them not doing nothing, I don't like to say that, but doing no active treatment, uh, which basically entails getting a PSA every six months and then every 18 to 24 months, another MRI and biopsy. Um, and there's even some clinical trials that are adding in A-P-S-M-A PET scan into the active surveillance program, but basically these patients are able to avoid the risks and complications of surgery or radiation.

And still we keep an eye on their cancer. So if it, if it mutates or it changes or it progresses, we detect that with the PSA and the biopsy, the MRI, but for about half of them in some trials, they're able to avoid treatment completely forever. And so they don't have to endure the risks and the complications of these kinds of treatments.

And the cancer never becomes a life-threatening problem.

[00:31:18] Leah Sherman, ND: Are there any lifestyle recommendations that you give to your patients while they're in active surveillance to kind of help to reduce the risk of recurrence or like that? I.

[00:31:31] David: That's a great question. nothing honestly comes to mind other than just stressing the importance of continuing with follow-up. I think the big, the highest risk activity that they could participate in is not getting their PSA or, or not getting, uh, the follow-up MRI or biopsy. Um, so just. It's kind of more, you know, the, the beauty of it is continue as you are, you know, continue with your life, live your life, and, um, and so I just encourage them to do whatever they like.

I, I'm not aware of any, uh, specific environmental or behavioral things that patients can do that would further w will basically reduce the chance that they would need to in the future, convert to an active treatment. 

[00:32:18] Leah Sherman, ND: the reason I asked is I worked with a, a urologist and he would talk his patients, um, he would talk to his patients about, incorporating more plants into. Or diet and kind of doing more, not necessarily go vegan, but just doing more of a plant, plant forward diet.

[00:32:33] David: Interesting.

[00:32:34] Leah Sherman, ND: yeah.

[00:32:35] David: I, I hadn't heard that, but, um, yeah, I mean, I think the, you can never go wrong by leading a more, um. Sort of natural, unhealthy lifestyle.

[00:32:46] Leah Sherman, ND: Yeah, and I think things like, you know, like managing stress and,

[00:32:49] David: Mm-hmm.

[00:32:49] Leah Sherman, ND: of, all of those kind of holistic things, I think those can all be, I. It'd be helpful for, for really anybody.

[00:32:57] David: Uh, totally. And One thing that I, I sometimes worry about my patients on active surveillance is do they feel like a constant threat following them around because they know they have been diagnosed with cancer and they have not had treatment for some patients. That is not an issue. Like they do not want treatment.

And psychologically it's not a huge hurdle for them to clear to, if someone is saying, Hey, we can safely watch this. They're good. They're, they're gonna go on and live, live a normal life. But some patients psychologically are not able to get to that space and. They demand treatment even by doctors who are reluctant to put them through it, even because they understand just how low risk they are.

Um, and that's okay. I mean, there is a, it's not wrong to treat those patients. We try our best to educate them and nudge them towards an active surveillance program. I never have withheld treatment from a patient who had very low risk prostate cancer, who demanded treatment. They do have cancer and you know, it can be treated.

[00:34:04] Leah Sherman, ND: Yeah, I think, for some people just the idea of having cancer in you. It's just like, just, just get it out. You know?

[00:34:10] David: Exactly. Exactly.

[00:34:11] Leah Sherman, ND: a common thought. Um, okay. So, um, I guess the next level would be someone who would be considering surgery or radiation or both.

[00:34:23] David: Yeah. So typically that, that decision, uh, that's a big fork in the road. So if we, if the first fork in the road is, do we need treatment or not, uh, then the, and if the answer is yes, we need treatment, then the, the next fork in the road is surgery versus radiation. There are other focal therapies that is the category.

 Those are mostly, in my opinion, investigational. We haven't seen great long-term data from those. Those would be things like HIFU and cryo and things like that. In my view, that should mostly be done on a clinical trial until we have better long-term data. But, uh, what I think we should focus on are the sort of mainstream treatments, which would be surgery and radiation, and so patients.

Would meet with a urologist, or a urologic surgeon to talk about. The main surgery is a, a radical prostatectomy. Typically these days that's done by a robotic radical prostatectomy. Um, and then the other option, radiation is done by a doctor. Which is what I do, which is radiation oncology. So it's a specialist who's gone through training in, uh, precision delivery of radiation therapy.

And, um, we use high technology, machines that basically deliver high energy x-rays directly to the prostate. so you, you pick one or the other out of the gate if you pick surgery. The hope is that you'd be able to avoid radiation, and that that would certainly be the plan. But if, let's say in the scenario where you do pick surgery, the key way that we understand whether or not the surgery worked is to check the PSA again, so that that same blood test that we used for screening in the first place is extremely useful after treatment too.

 after a patient's had a pros prostatectomy. The prostate gland is what makes that chemical normally. So if the prostate gland has been removed. And the prostate cancer has been removed, then there should be no PSA. And so we expect the PSA to go all the way down to zero shortly after surgery.

And in fact, that's what the surgeons do. They order a PSA test and they wanna see it go quote, undetectable. I. Which is zero registration on the, on the PSA scale. And so, and then they follow it over time. It's every three to six months for a year or so. And then after that, probably every six months. And uh, if it never rises, we're good to go.

That's a cure. Uh, but, uh, sometimes it will go from undetectable to 0.02 and then 0.1, and then we're concerned that. This patient, even though they've had surgery, there's there, there may be some cancer cells that were not fully removed and are still down there. And that's the case where radiation can be used after surgery.

That's called salvage radiation. Um, and so I. That that's a scenario where you've had surgery as a cure. But then if it comes back, we can use radiation at that point and have a decent chance of cure. Usually about two thirds chance, 60 or 70% chance of cure at that point. Um, and then I. The other scenario is if you don't choose surgery, if you do radiation upfront, that's a, that's a very common treatment, especially for folks who are over age 70 who wanna avoid the risks of surgery.

And that's, that's primary radiation. Meaning it's radiation for cure as an alternative to surgery. And so there are several different ways to deliver that kind of radiation. All of them are. Approximately equivalent in terms of cure and approximately equivalent in terms of side effects. But they have different schedules.

Some of them are many weeks over nine weeks. Some of them are five and a half weeks. Some of the more advanced techniques are only five days. So when we meet with these patients, we're usually presenting them with a variety of these radiation technique options.

[00:38:09] Leah Sherman, ND: One. The things that I noticed, over my career is when I was initially in training back in 2009, 10, 

 I would see patients with a lot more side effects than when I went on to work at CTCA. Um, it just, the advancement, especially, you know, in radiation therapy. Um, just really being able to focus on that, you know, that

[00:38:32] David: I.

[00:38:32] Leah Sherman, ND: area. It, it was remarkable and how we would be making recommendations for, you know, reducing the risk of all of these side effects and. I don't know if it was what we were recommending, but I think a lot of it was more just the, the precision

[00:38:49] David: Yes.

[00:38:49] Leah Sherman, ND: so much.

And then also patients, you know, they knew someone, they had a relative who had had the same procedure and they were just, just really worried about getting those same side effects. Like the, just the advancements I think are incredible. And it, I mean, it's across the board in a lot of cancers, but really I noticed it with, uh, prostate cancer patients.

[00:39:10] David: Absolutely. You're, yeah. What you observed is a, is a real phenomenon. Where over the last say, well certainly over the last two decades, The, the changes in technology have occurred at kind of a breakneck pace relative to the prior two decades where not a ton had changed. Um, and it, it is all about precision.

And that, not to get too technical, but it, it mostly, it has to do with two things. One is, um, the way that doctors are able to accurately. target the radiation at the gland. So there's a lot of things that they're able to do when the patient is actually laying there on the table. Before we start the treatment, we can do a very quick CAT scan to make sure that the prostate, the bladder, the rectum, are all in the same place where we expect them to be.

And if they're not, we can actually adjust in real time to make sure that the treatment is going to the exact right spot. So that was a. Big advancement that allowed us to shrink the size of the fields and to go to higher doses. So that meant less side effects and higher curate. The other thing that that was a big advance was the way that we're able to shape the beam.

So there was a major advancement called IMRT, which stands for Intensity Modulated Radiation Therapy. It's a fancy way of saying it's just kind of like. Sort of bending the high dose of radiation in a very customized way so that you can create a custom plan for that exact patient's prostate gland, and, and avoid the other structures in the area like the rectum and the bladder, and these.

Two kind of breakthrough technologies occurred at the same time and allowed us to kind of take a few leaps forward with the, the precision of radiation to, and basically resulted in like higher cure rates and lower risks, which is awesome. Usually we can only get one of those things. We gotta choose one or the other.

[00:41:05] Leah Sherman, ND: so let's talk about more, more aggressive prostate cancers. I guess my first question would be how could be diagnosed with an aggressive prostate cancer With really no, no symptoms or no, you know, no prior, you know, PSA that was elevating like how. How does that happen? How does somebody just diagnosed with a more aggressive cancer?

[00:41:31] David: Well, I think there's, there's probably two. Different ways that that can happen. One is, uh, if that person, or if that person's doctor was following the U-S-P-S-T-F guidelines and that person's like in their late seventies or early eighties, they may not have had a PSA for a decade, and it could easily be that their last PSA that they had drawn was normal.

And then in the intervening. Eight, 10 years. The PSA had just been slowly climbing and then went off the charts, um, that I have seen that happen. It's, it's really unfortunate because it leaves you kind of wondering. What if, what if we didn't stop? And what if we actually got this when it was, went from four to to eight, uh, you know, eight years ago or 10 years ago, and delivered surgery or radiation at that time and, and took care of this problem.

 so that's super frustrating for everybody. Uh, we, we can't stand it and it's obviously extremely upsetting for the patients and their families. The other thing that can happen, which we don't have much defense against, to be frank, is that the, if we go back to that risk spectrum and the Gleason score, so the very high Gleason scores, remember it goes from six to 10 Gleason nines and tens, they, they can be so aggressive and they basically, they mutate so much that.

They no longer even make PSA at high levels. prostate cancers are, are creating a lot of PSA as they grow and spread and metastasize to other parts of the body. Very mutated high grade we call them, or very aggressive prostate cancers sometimes cannot make much PSA at all. And so you could be doing the screening test with the PSA.

It could look fine. It may not even be elevated, but in the meantime, the prostate cancer could be in the bloodstream spreading to bone and kind of spread all over the body right under our nose, and we don't even know about it because it's not creating a lot of PSA.

[00:43:49] Leah Sherman, ND: Yeah, I've had patients that, um, like their primary complaint was lower back pain.

[00:43:54] David: Hmm.

[00:43:55] Leah Sherman, ND: You know, it wasn't necessarily, or maybe they dismissed their urinary symptoms as, oh, I'm getting older. This is what happens. But they sought treatment for like. this nagging back pain. And then, you know, they were surprised by the, the cancer diagnosis.

[00:44:11] David: We unfortunately see that a fair amount in the hospital. I work at a city hospital and, um, you know, for one reason or another, patients don't make their way into the sys into the system until they, they have a, um, a big. Painful problem. And, and that sometimes, unfortunately that's, that's how we discover these kinds of prostate cancers and they've already spread into bone.

And that's not to say there aren't treatments, uh, many of these kinds of prostate cancers will respond to hormone therapies and you can have a kind of a pretty dramatic response actually. Um, and so it's not that there's no treatment, it's just that there isn't a realistic. Cure treatment, curative treatment, and so that's what makes it so frustrating.

We can offer them treatments, but we've missed our chance of cure.

[00:45:01] Leah Sherman, ND: So I guess maybe I should have started with this, um, what would be symptoms that somebody would be looking for? What are. Things that they might be experience that, um, would cause somebody to, you know, seek out a doctor and, and, get further testing.

[00:45:21] David: It, it's a great question, but, um, I should highlight before I even go into the list of things that they can look for, that the vast majority of patients who are diagnosed with prostate cancer do not have any symptoms at all. So I don't, so there's two sides to that. One is I don't want to give anybody a false sense of security if they're not having symptoms that they can't have prostate cancer.

And then the other side of that is that. Some of the symptoms of really advanced prostate cancer are much more common with like non-cancer related, uh, problems. And so let, let's, so let's talk about like, when patients do have symptoms, what are the symptoms? You, you kind of refer, reference this, but like.

Urinary symptoms. So the prostate is intimately embedded in the urinary system. And so, um, symptoms of either blood in the urine, or really a hard time getting started with peeing or, or lots of urinary frequency urgency, what we call hesitancy, like inability to. Get it started and then, um, weak stream, just not having that same powerful stream that they were used to back when they were 18 years old.

 so. The thing is, all of those symptoms that I, that I just mentioned, except for maybe the blood in the urine, um, are all the most common symptoms of BPH benign prostatic hyperplasia, which is a benign condition that's extremely common, especially in men in their sixties, seventies, and eighties. So there's not, BPH has nothing to do with cancer and those symptoms that we just discussed are the symptoms of BPH.

So if you just pluck any patient off the street who has those symptoms, by far more likely that they have BPH than a sort of life-threatening prostate cancer. But when we see patients who are symptomatic of prostate cancer, those are the kinds of things they get. The other thing would be what you described, which is, a sign of very advanced prostate cancer, which could be bone pain usually in the spine.

 and, and that's unfortunately a situation that's, that's tough to, uh, reel in, in a, in a curative way. Um, so. Those are the patients who, you know, it's already left. The prostate's gotten into the bloodstream, and from the bloodstream it got into the bones, which is where prostate cancer tends to spread or what we call metastasize.

And so pain in the back, especially in the lower back, is, is, is a possible presentation with that, that said. The most common cause of, of low back pain is not prostate cancer. It's of course like, you know, osteoarthritis and other spine related issues. So, um, I would just kind of encourage everyone to have, you know, not panic.

If you experience these things, it's far more likely it's a benign or non-cancer thing. But, um, in combination with A-P-S-A-I think that can be tho keeping those things in mind can be useful.

[00:48:22] Leah Sherman, ND: Is there anything else that you want to mention before we, before we wrap up?

[00:48:29] David: Yeah, I mean I, one thing I see happening a lot now is patients are feeling a lot more empowered because this is a disease, unlike some lung cancers and pancreas cancer, where, there really are not gonna be a lot of options. If you want cure, then you need to have surgery. And, and maybe even additional treatments after prostate cancer is different.

There are several different ways to treat this disease with approximately equivalent cure rates. So I always encourage patients to do their own research, but then probably also seek multiple opinions before they make a final decision. That may even mean talking to multiple surgeons and certainly talking to.

At least one surgeon and at least one radiation oncologist. Um, to just make sure that they understand both, both of those options pretty thoroughly. So I guess that's, that's my main thing is, uh, if there's a diagnosis of prostate cancer, make sure you, you spend the extra couple of weeks getting opinions from multiple specialists.

[00:49:32] Leah Sherman, ND: And I'm a huge fan of second and possibly third

[00:49:35] David: Mm-hmm.

[00:49:36] Leah Sherman, ND: because it does, it does give peace of mind to patients. I am so glad that you made the time to, to join us here at the Cancer Pod. Um, and I encourage listeners to check out your videos. I'm gonna post a link

[00:49:51] David: Oh, great.

[00:49:51] Leah Sherman, ND: your social media, your YouTube channel, all of that, your website. and yeah, no, this, this has been really informative and I just really appreciate you, you joining me.

[00:50:03] David: I, I really appreciate the invitation and thank you so much for having me.

[00:50:07] Leah Sherman, ND: And maybe we'll find another, another subject to, to cover at a later date.

[00:50:11] David: I'd love to be back.

[00:50:13] Leah Sherman, ND: well that was awesome, Leia. Thank you so much for, uh, doing that interview with, with Dr. Grew.

his resources are gonna be so helpful to our listeners. I actually forwarded his website to a couple of doctors that I know who still work at the cancer centers that I worked at, so hopefully they'll be able to use them with their patients,

[00:50:33] Tina Kaczor, ND, FABNO: Yeah, it's super cool that he makes it available

and free. I mean, I just love that. I love it. I love I, and I think he's right. I think we are highly visual learners, most of us. I am. I mean, there's always cartoons in my head

[00:50:49] Leah Sherman, ND: And

[00:50:49] Tina Kaczor, ND, FABNO: much.

[00:50:50] Leah Sherman, ND: Love the simplicity of the illustrations and his explanations. And like I mentioned, like they're just these short little blurbs. And so it ca it captures your attention. Like we've all kind of been ruined by social media and these short little video clips, but it works, it works great to helping to, you know, retain that information.

We don't normally cover one particular cancer, but I think that this information is important.

The, the risk of prostate cancer goes up with every year of life. So, um, if you live long enough, the risk is, is pretty high. Um, so it's good to be

very aware

[00:51:24] Tina Kaczor, ND, FABNO: I think everyone should be very aware of the symptoms of any, any impending. Disease

because 

early diagnosis.

is in your favor. And so yes, I'm a big fan of reminding everyone of the basics of cancer early.

[00:51:37] Leah Sherman, ND: and the guidelines, you know, there is a cutoff age according to certain guidelines. And so really having that conversation with your doctor, if there are additional risk factors, um,

Just because there's a guideline doesn't mean that you can't. Continue getting tested. You know, you weigh the risk benefit as, as he mentioned. So, um, really, really good information. 

[00:51:58] Tina Kaczor, ND, FABNO: And I think of that on both ends of the age category for prostate cancer, because while the, while the risk goes up with age, if you have a family history

[00:52:07] Leah Sherman, ND: certain ethnicities and much higher risk

in earlier in your life. So maybe you should be

[00:52:13] Tina Kaczor, ND, FABNO: be

[00:52:14] Leah Sherman, ND: tested at 50 years old

[00:52:15] Tina Kaczor, ND, FABNO: if you're, you know,

[00:52:16] Leah Sherman, ND: at a higher risk.

[00:52:17] Tina Kaczor, ND, FABNO: So

[00:52:18] Leah Sherman, ND: I can't,

[00:52:18] Tina Kaczor, ND, FABNO: check is something that

[00:52:19] Leah Sherman, ND: that been debatable.

[00:52:20] Tina Kaczor, ND, FABNO: because, uh, there was an argument that finding it didn't help the overall prognosis.

[00:52:27] Leah Sherman, ND: Um, I still don't think that that's the case in my mind, I

[00:52:31] Tina Kaczor, ND, FABNO: I think

[00:52:31] Leah Sherman, ND: knowing something like better than,

[00:52:32] Tina Kaczor, ND, FABNO: than not knowing something.

[00:52:34] Leah Sherman, ND: So again, having that conversation with your doctor and, um. And, you know, doing what's best, you know, for your particular situation, I think is important. as I mentioned at the beginning, we will have all of these links in our show notes and on our website.

 the website for primer. It is primer med.com, P-R-I-M-R-M-E d.com. And then I also wanted to. because this is on YouTube. Refer, uh, our listeners and watchers, viewers. Viewers to his YouTube channel and its Doctor Grew Explains Cancer 1, 2, 5, 1.

And so again, that link will be in our show notes. It'll be on our website. And also on our website are going to be the visuals that accompany. This in case you're listening to it. and not watching it on, on video. you remember, because it's

[00:53:29] Tina Kaczor, ND, FABNO: easy to remember

[00:53:30] Leah Sherman, ND: the same as the podcast.

[00:53:31] Tina Kaczor, ND, FABNO: name.

[00:53:32] Leah Sherman, ND: It's the cancer pod.com 

 And also, we're including some resources for prostate cancer clinical trials that are out there 

There'll be so many links and you're gonna want them because like I said, these resources are helpful for everybody.

[00:53:46] Tina Kaczor, ND, FABNO: again, thanks. I think, is excellent and, uh, hope everyone can let

[00:53:51] Leah Sherman, ND: How they

[00:53:52] Tina Kaczor, ND, FABNO: felt, rate us, review us. it always helps to have few

star review

Apple gives us a little love, or Spotify or wherever else you're

[00:53:59] Leah Sherman, ND: and, and YouTube. Drop a comment, um, down below and as we mentioned before, when you sign up for our membership, 

So depending on the level that you sign up for, you'll have access to us and you'll be able to ask us questions. Although we will not be able to give you medical advice because we are not your doctor, and you have other perks too. So go to our website, hit that, join us button, and sign up for the level that appeals to you most.

[00:54:25] Tina Kaczor, ND, FABNO: Yes, and we look forward to meeting you.

[00:54:26] Leah Sherman, ND: And on that note, I'm Dr. Leah Sherman.

[00:54:28] Tina Kaczor, ND, FABNO: And I'm Dr. Tina Kaser.

[00:54:30] Leah Sherman, ND: this is the cancer pod.

[00:54:31] Tina Kaczor, ND, FABNO: Until next time,

Thanks for listening to the cancer pod. Remember to subscribe, review and rate us wherever you get your podcasts. Follow us on social media for updates, and as always, this is not medical advice. These are our opinions. Talk to your doctor before changing anything related to your treatment plan. The cancer pod is hosted by me, Dr.

Lea Sherman. And by Dr. Tina Caer music is by Kevin McLeod. See you next time.