Age Prostate Cancer

psa screening. what's a guy to think? so, why have screening tests? so the purpose of a screeningtest is designed to find at-risk individuals beforethere are problems. you want to find at-risk populations. you want to identifythe disease early. you want to prevent the lateoutcomes, such as illnesses, fractures, metastasis,death even. you want it to be costeffective, you want it to be

simple, and you want to limityour false negatives or your false positive. when your test comes up, ding! you want it to be that it'sreally ding, and not maybe it's not and maybe it isn't. and so, how do you designa perfect screening test? and think about someof the ones we have. colonoscopy, well, theyhave to drink that stuff. you have to poop a lot. you have to go have a telescope. maybe a half a percent ofthe time there can be a

rupture of the colonduring the colonoscopy. you know, that's some work justto find early colon cancer. and women go for pap smears,and you go for mammographies and then they want you to get theultrasound, and then they want to do the needlebiopsy, and what percent of those are really positive?so people will go through a lot of process for the sakeof a screening test. so psa, how beautiful is that, right?it's a blood test. could it be any simpler thango get your blood drawn

and maybe this gives you someyes or no answers? so in theory, a psa is a greatscreening test, and actually, probably even less scary thansome of the other things you can do. so, before you makeany decisions about psa. that sounds pretty convincing. you have to have a foundation. you have to understand thebasics of prostate cancer, so you have to lay that foundationand take it from there. so, prostate cancer, youhave to know, is a slow, progressive disease. it kills people maybe in 10 years,

maybe in 15 years,maybe in 20 years. so, it's not a life or deathimmediate kind of a problem. really interesting, if you doautopsies on guys, something like a third of guys at age60 you might find prostate cancer in their prostate.they didn't know it. they died of something else. maybe half the men at age70 have prostate cancer. and maybe, you know therule of thumb we always talk about is 90% of men atage 90 have some

cancer in their prostate,if you checked. and actually, interestingtrauma studies have shown that something like 15%of 30-year-olds have prostate cancer. you know, people have somehorrible car wreck and they do an autopsy study and, oh mygosh, we find prostate cancer. so, it's there, right. andit's, and it's not necessarily actuallykilling people. and, it's not necessarilykilling everybody because

90% of men are not dyingof prostate cancer, if they live long enough. the current us incidence,roughly, it's like one in six. that's 16% of men in the uswill be diagnosed with prostate cancer. the death risk ofprostate cancer is about 3%. so that's not really asignificant death risk compared to the incidence. it is however, the numberone solid cancer in men. the only cancer that's morecommon in men is skin cancer.

there's a whole staging system. i don't know if you guys,anyone's ever had a friend or yourself been through any kindof malignancy, any kind of cancer. you know, how nasty is it? where is it? what's the stage? how spread, or howcontained is it? so, most us men are stillin a really early stage. t1 is basically you found duringsome kind of a screening test, like psa. and 85% is still alljust there in the

prostate. so localized atdiagnosis is still just hanging out in the prostate andhasn't spread yet, okay. in our world, we talk aboutagain, how aggressive this disease is. and some ways topredict how aggressive it might be, is somethingcalled the gleason score. you can look at the cancer underthe microscope, you say, alright and if it looks kind of likethis, you call it a six, and if it looks kind of more likethis, you call that a seven. and if it looks more like that,you call that an eight,

and there's ways torank these things. in theory the scalegoes from two to ten. no one uses two toten, so six to ten. six is the least aggressive,seven is a moderate, eight, nine, ten gets clumped togetheras the most aggressive. and we look at the psa, and howspread or contained is it when someone shows up. howhealthy is the patient? you know, the guy who's gottwo heart attacks and the oxygen tank and comesin in a wheelchair,

prostate cancer's not his risk. and how old is the patient? odds are, if you made it to 80,you've got a better chance of making it to 90 than me. because you've already made it to 80. you've already proven something. but, let's face it. people don't live forever. and so, in oldergentlemen, maybe the 10, 15, 20-year cancer is not reallyyour biggest concern. alright, what is psa? (prostatic specific antigen) actually, it's not designed to make urologists busy,and pathologists busy.

it's really designed, it'sactually liquefied semen. turns out that, it's alsofloating around your blood stream, and it's in all men. various things will makethere be psa in your blood. you can have anenlarged prostate. every guy, if youlive long enough, gets an enlarged prostate. and the symptoms are mild orhuge, depending on the guy. but everyone's going to havesome enlargement of their

prostate, which means everyguy's going to have some rise with their psa as they age.it just happens. prostatitis, or inflammation,could be infection, could be a viral thing, could be a catheterwent past, anything that makes itis, anything that makesan inflammation, will make the psa go up. of course, cancer of theprostate will, urinary tract infections, bladder infections,trauma, you had a foley catheter, you landed hard,blood down there, even sexual

intercourse will make thepsa go up a little bit. medications, finasteride,proscar, avodart, things that shrink the prostate help guyspee better, that'll make your psa go down, and then whichcompany's psa test you use will also make somedifference in the values. so if i use the hypertech, itcould be actually be 25% higher than if i used the worldhealth organization version. and so it's not just psa, onesize fits all, things will affect it. there are normal values.

we say less than four isnormal, but the median, what's the middle mark? you have 99 guys, whatis the middle number? so the middle number, not theaverage, but the middle number for men in their forties is 0.7. that's pretty low. actually i never see those,because they never come to the urologist, the primary looksat it and goes this is fine and they never even get to me. and you see the median, themiddle of the road number

kind of goes up as people age. so your prostrate gets bigger,it makes a little more psa. alright so, prostratecancer right. in the psa era, sincewe've been using psa. people die less often. so in the early 90s, 45,000 guysa year died of prostate cancer. and now, it's about 30,000 guysa year die of prostate cancer. and i have to tell you,there's a lot more older guys. right, so the numerator gotsmaller, the denominator got

bigger. there's less guys dyingof prostate cancer. that's great. roughly one insix guys in 1990s presented with stuff alreadyall over the place. and we can't stop that.we can slow it down but we're playing catch up. and now that's like one in 50. so now one in six guyspresented it with really advanced disease and nowit's one in 50 guys present with really advanced disease. and there's actually this areain austria, the tyrol region.

so the tyrol regiondid this trial. every guy in tyrol, austriagot their psa screened. as opposed to the restof austria which didn't. and, the tyrol's had a lot lessdeath and prostate cancer than the other, the rest of thecountry for about 10 years, until the rest of the countrystarted doing psa, then they caught up. so wow, ifyou do large mass readings you really decreasethe death rate. in the us, the death rate fromprostate cancer has dropped

about 4% every yearsince this started. 40,000 down to 30,000,45 down to 30, whatever. it's been a significant dropand there's more older guys. mortality's lower, morbidity, orsickness, or illness is lower. isn't this great? and everything kind of fell apart, from a scientific or from a study standpoint in 2009, when the new england journal of medicine, they had two articles that said, "don't screen for prostate cancer." and there were two trialswith a lot of people in them.

so this big european trial had182,000 men, and did a psa every four years, and theyhad nine-year results. the united states trialhad almost 80,000 men, they randomized to screening with apsa every year to no screening, and they had seven-yearresults, so not nearly as long. and what did theeuropeans showed? and they showed that there wasan 8% cancer in a screened group versus almost 5% in the controlgroup, which means they were getting found otherwise, butnot through the screening test.

there's at least, atleast, a 20% reduction in death from prostate cancer. this is the way they said it. you have to screen 1400 menand treat 48 guys with prostate cancer to save one fromdying of prostate cancer. that doesn't soundso good, right? that's not so good odds. you've gotto treat almost 50 guys to keep one from dying from it? what happens to the 45,000 to30, that sounded pretty good five minutes ago, nowit's not sounding so good.

suddenly it sounds like we'reover treating a bunch of guys. they've actually since gone backand cleaned up the numbers and there's, there's probablymore like 20 to one. 20 to one is still kind ofa lot of guys, you know? if you say we're going to getrid of that group, we're going to get rid ofthat group. we're going to pickjust these guys. we try to make thedata a little cleaner. it's probably more like 20 toone, which is still a pretty big

ratio of guys to treatto save that one. unless you're theone of course, right? and that's always the catch. and then if you look at theselittle graphs, another way to look at it is to run them outof years, so at nine years we're starting to see that the red armis different from the blue arm, but if you look at some of theguys that had the mid at the 14. you know the difference betweenthe non-screened versus the screened, that graph isreally starting to spread.

and so, if you got a diseasethat doesn't kill people for 10, 15, or 20 years, you know one ofthe concerns, without being too defensive is that well maybe wejust didn't wait long enough to see what happens when those,when you get more time. what if those thingsare really diverging? wow, that is a bigdifference then. so, we have to listen to whatthey said and then you got to think at whether you reallywant to use all that data or is there, you want to lookat it more carefully.

now the us trials, statisticallythere's no difference between the screened andunscreened, no difference. at seven years there'sno difference if you got screened or didn't.well, not so good. another study, out of sweden, sothey randomized men aged 50 to 70. they had a20-year follow-up. 20 years, that's more likewhat we're looking for. they screened every sixth man,did a digital rectal exam and they found no benefit toscreening at 20 years.

alright, well there's anotherlike nail in the coffin for the screening test. so, these things reallyspeak against screening. you also want to look at bothsides, and there are some really big problems with these studies. in europe, just for starters,every four years really may not be often enough, or frequentenough to pick up the cancer. you wait two, four yearsand you miss that window. the window opens to findit, you wait four years.

oh, too late. they'vealready shut. so, four years mightnot be frequent enough. now, this is, i think thebiggest problem with any of these trials, was the us trial. there's supposed to be screeningversus no screening, except half of you guys snuck over and, andgot into the screening thing. so, at least, at least 50% ofthe don't screen control arm, got screened, by theirprimary care doctors. so it wasn't screening versusno screening, it was pretty good

screening versus almostas good screening. always, if you want to tell thedifference between groups, you have to have twodifferent groups. they didn't have twodifferent groups, and both really didn't wait long enough. so, again, if you want to havesome understanding whether this'll make a difference at 20years, you have to be able to run out the statistics, somewhatcloser to 10, 15 to 20 years, not seven years or nine.these things really raise

some significant questionsabout over-detection. maybe we're just findingtoo much of this cancer. less people dying, but remember,it's almost in everybody. so maybe, maybe unfortunately,the psa is finding those guys who are going todie with it anyway. and the estimated risk ofover-detection is maybe, half the guys at age 75, we didn'treally want to find it. you've detected cancerthat really wasn't going to risk their health.

that's a lot of, remember i saidearlier a screening test, you want to find stuff, but youdon't want to have too many positive that aren't real, andtoo many negatives that aren't real. so that's a lot of false positives. and recently, since i made thistalk, a big us preventative task force group has come along andthey basically said because of the risk of over-detection,the us preventative task force services group says don'tdo any psa screening. so they just went from basically screeneverybody to screen nobody.

so, i have to say i think ingeneral, that someone just chucked out the babywith the bath water. i appreciate, and i understandand i don't want to over-treat my male patients. but i kind of don't want togo back to the old days when someone sick showed up with bonemetastases and we're playing catch up because we never do. that's not so good either. so, can we try to nuancethis a little bit? can we use this better?

alright, so first of all,i have to say detection really should notequal treatment. i think there has been a realmove in american urology to not treat everybody, and thatreally started to grow about five, six, seven years ago. and unfortunately it doesn'tquite get recognized in that task force recommendationnot to screen anybody. because what they say is ifeveryone gets detected and everyone gets discovered to haveprostate cancer, goes on to get

treatment, you're going toover-treat a lot of guys. and they say if that'sthe assumption, then, yes, we're over-treating alot of people and we shouldn't dopsa screening. if that algorithm has changedsome, and we are finding prostate cancer but some guyswe're treating it some guys we're not, are we trying topick and choose who is going to benefit from it, thenmaybe psa's still helpful. so, detection shouldnot equal treatment.

there are definitely sometypes of prostate cancer that don't need to be treated. so another big swedish trial, 15year data, by picking out guys under age 65 to get treated,because they have the longest life expectancy and have thegreatest potential risk for dying of prostrate cancerbecause again it's kind of slow. if you pick out guys under 65. this swedish study shows thatyou would need only seven men to treat to save one life.

and quite frankly, that's verymuch in line with the colon cancer screening numbers, andthe breast cancer screening numbers and a lot of theseother screening numbers. so, seven to one, may soundlike it's still a bunch of guys getting treated, but that'sactually, in the scheme of epidemiology, andscreening type of studies. that's pretty good. alright,well maybe we're just going to have tofinesse who we find and who we look for and whowe treat. a pivot trial.

they got a whole bunch ofva patients, and they try to randomize it to surgery,or they got randomized through surveillance. we're just going to watch you,and if something bad happens we'll treat you. they found eventually 700patients, but they had to screen 14,000, because no onewanted to go into the trial. because every guy who wants to,says, "i don't want someone else to decide if i get watched ortreated, i just want to

make my own decision." it took them forever to getanyone who actually agreed to be randomized to have someone elsemake that decision for them. you know, it's america. you can't tell me what todo, so no one wanted to be in that trial. i don't know that i would haveeither, but no one wanted to be in, so it took a long time. but essentially there is nobenefit to treating guys

with low-risk disease. and remember, when wetalked before, what makes it risky or not. one of those big thingsis that gleason score. so guys with a low gleasonand not too much of it. that's low risk. and if youtreated them, you weren't going to make them livelonger than if you just watched them. alright.at least it's starting. it got really fuzzythere for a while.

we're starting to, things arestarting to come back into focus a little bit more about whowe're going to search.there's some mild benefit to moderatedisease, and there's definitely a survival benefit for treatingguys with higher risk disease. psa was higher, thegleason score was higher. your biopsy 12 slivers, tenof them have cancer in it. duh, that's a fair amountof cancer in there. so, again, it's starting tocome a little more into focus. if you look at what'schanged over the years.

if you look at attempts athaving more scientific trials. i think there's some reallystrong implications that we don't have to ceasescreening entirely. and actually those trials andthat discussion improves what you have to talk aboutwith your patient. and it improves some of thescreening techniques and maybe it's going to help us improvesome of the treatment decisions. so, how do we take it fromthe monkey up to the guy walking upright? and how do weevolve this psa test?

well a guy walks in theoffice and his psa last year was two and now it's five. and maybe ten years ago let'ssay, alright, so you went from two to five, we'regoing to do a biopsy. well, no. now the next step is "why don'tyou come back in six weeks we're going to check the psa again."and you know, sometimes it goes down, it'sback to 2 and a half again. alright, so something madesome itis, something made some inflammation insidethat prostate and the

numbers came back down again. alright, great, you didn't havea biopsy, isn't that great? we checked your number again. we can age adjust these numbers. you can cut off 2 and a halfif you're in your forties. you can watch how quickly thesenumbers rise over time, and if i went from two, tofour, to five, to six. boy, that curve isgetting a little steep. then the velocity can maybehelp predict who needs a prostate biopsy. you all knowabout good and bad cholestrol?

right, well there's, basicallythere's good and bad psa. so the free psa is the good psa. you have to have atleast 25% of that. so you can look at the free psa. if there's a lot of it: great. if there's a really lowamount of it: not so great. if it's in between, it's in thestandard, classic gray zone. hard to know what to do with it,but the extremes of the good psa can be helpful. you can look athow big the prostate is. if you've got a gigantic gland,you expect you're going to have

more of a gigantic baseline psa. a little harder to do becauseit'd require having an ultrasound through the rectumto measure the prostate, to really get a verydefinitive prostate size. so, as a screening test, notgoing to put everyone through a transrectal ultrasound justto do a screening test. baseline psa, let's say you'rein your forties, or you turned 40, we check your baseline psa. if your baseline psa is 0.86or 0.4 at age 40

you know he's in a low pool. he's got like a 5% risk ofever getting prostate cancer. come back at 50. come back at60, we'll check it again. so if you start really low,you're starting really low and your risk is goingto be really low. if your baseline numberis two at age 40. well, you know, okay, wemight actually check you a little more often than if youstarted really low. if you look at people's baselinenumbers, so a 50 year old guy,

a normal rectal exam. zero to two, he's got 10%risk of prostate cancer. that's pretty low. greater thanten, that's almost 50-50. so you can look at baselinenumbers as some risk assessment of how closely i needto really follow some guy. so maybe everyone doesn'tneed an annual psa. maybe we just need to kindof have some check-ins as to how frequently it is. the american cancer society,they still say basically offer

screening to men at age 50. offer the screening to men. not everyone should have itbut, "sir, we could screen your prostate." the us preventive services taskforce actually, they used to say, "do not screen over age75." it's now don't check at all. american urologicassociation says, offer baseline to men in their 40s. and that baseline number will tell you whether you're at some risk in the long term or not. consider regular screeningfor men over age 50.

you should have at leasta life expectancy of more than 10 years. and most of the primaries arereally pretty sharp, but every now and then i get aguy come in the office. he just looks, he's old and he'ssick and he's really worn out, and he's had areally rough life. he's got the diabetes,he's got the hypertension. he's had two heart attacks.and his psa is 4.2. what do i think about it?you should go have lunch.

you don't need to check that. that's just not what his risk is going to be. go check your sugars. really pay attention to yourother health things, because that's what's going to riskhis health, not a prostate cancer ten years down the road. so you can look atpeople's life expectancy. and we're not bad at kindof getting some assessment when you sit down look atpeople's medical records. that's what you think thechance they'll make ten years.

and there's a whole bunchof things we can check. and you go into the aua websiteand you read the recommendations and it's just like this flurryof things you should all take into consideration when you wantto decide if you want to check psa. you want to do prostatecancer screening. so the future, and this is awhole bunch of medical labels, but there's actually some really interesting new tests coming out. and every few monthsthere's some article on my trade journal saying, "there'sthe pca urine marker.

there's the dna methylation." and there's been 200 guys whohad this new test and it looks pretty good for determining whoreally has prostate cancer, and who really might havethe progressive stuff. but it's 200 guys. no one's going to change theentire practice pattern for 300 people in the united statesbased on a 200 person study. so there are really excitingfuture things coming out that are not quite readyfor prime time.

so, a couple of things,remember, detection does not equal treatment. just because we find it doesn'tmean we have to treat it. we really should bescreening with some thought. "hey if i found something,would you really even consider having it treated?" we have to screenwith a better filter. i think there is some utilityfor looking for prostate cancer. we love the fact thatdeath rates have dropped.

but it does bother us thatwe have essentially over-treated tens ofthousands of guys per year. and then we're really goingto be watching for new developments. there will be better tests. and hopefully better teststhat really can separate the wheat from the chaff. we're much more discriminatingabout who really needs to be followed and who we just letpass on the prostate issue. it's hard to talk about this inhalf an hour and it's certainly

hard for peter jennings to giveyou the 30 minute story and have you understand why the taskforce recommendation to stop completely i think is abit over shot. but the task force really did bring upsome really good points. we have to be careful thatwe don't over treat guys. questions from you guys? (man) i'm just curious, youcited the two different studies that were out there. in the context of validity orof value, what would

you say makes a good test? (dr. pietrow) so, whatmakes a good study? you know, that's like the goldstandard often times, in medical studies, is you want it to haveto be randomized, and you want that trial to be controlled. and you want to look fordifference that is real. so, the problem with the ustrial was that it wasn't controlled. youhave this absolute contamination ofthe control arm.

essentially, there's very largeportions of people who weren't supposed to be screened,got screened anyway. so, you want it to be clean,you want it to be well set-up in the first place. you're looking for differencethat's going to be measurable. so, how long people live, howpeople, how much mortality there is, how much morbiditythere is from it. so, we'll never getthe perfect psa study. you can't. it's just too hard,because it's so hard.

it's hard to follow people for20 years, and it's hard to get a... i can tell you how goodstrep throat treatment is. you can get 100 people withstrep throat, and you check them, and within a week you knowwhether they're cured or not. should we use amoxycilin, orshould we use augmentin. fine. you get some pretty quickfeedback whether that is working. so we will never havethe perfect psa screening test or prostrate cancer trials,because it takes so long to follow patients to reallyprove that you're not just

too early or you're notgetting contaminated. so they are limited. but they're not worthless,they're just not as black and white definitive aspeople want them to be. so i think there is someutility to psa testing. but i think the every guy who'sover 50 guy gets a psa test and just painting that entirewall the same color is really not appropriate. and that's what i'm trying topromote is a more nuanced and a

more rational use of "whoshould i even screen?" and patients have to bepart of that process. they have to be willing to asksome questions, and have some philosophy questions. "do i really want to bescreened? will i treat it?" if you might, then it'sworth getting the test. yes. (woman) they have a lot ofpeople that i've heard of who've had psa's up. and the first thing they want to do is a biopsy. because youdidn't talk much on that part.

is that something that'spart of the testing? because you had mentionedthat a lot of times you want to wait and see what happens. (dr. pietrow) check it again. see if it's really elevated. so if we decide we're going tocheck, and we think this test may be positive, what's next? well, we really kind of startthis whole chain rolling. sometimes you reach in andyou feel the prostate and you know that's kind of ugly.

you still want toget some tissue. you want to get a sliver sothe pathologist can tell us how aggressive is this. and that's done through aprostate biopsy, which is done through the wall of the rectum. so it's an ultrasound, kind ofabout as big around as a finger, slides into the rectum. typically we'll use some novocaine, or lidocaine, and inject that next to the prostate and numb it. and then once we're there, then

we can get our samples,which is usually 12 needle slips. slip, slip,slip goes through the wall of the rectum into the prostate. there's a little springloaded thing that goes zip, zip and, and takes a sliver. the biggest risk of a prostatebiopsy is about one or two percent risk of infection. we tend to use cipro. we give a dose of cipro beforeand then that day and then that night, and it's worked prettywell for a decade or two, except with the indiscriminate useof antibiotics, including by

urologists and other physiciansand in the feed lots. there's a growing ciproresistance, so we're now having to come up with new ways toprevent that infection rate and still keep it down to thelow one percent or so. yeah? (man) when do you recommend thepsa for one of your patients? (dr. pietrow) so, first it hasto be at least a guy who has a long enough life expectancy. so, it has to be worth looking for a disease that might hurt them in ten to 20 years. so, they have to least have tobe healthy enough to think

they can live that long. so that's step number one. i think that certainlyguys who have a family history should be screened. i think that african americanstend to have a higher rate of prostate cancer, and it tends tobe a little more aggressive as well. so african americans,people with family history, guys with a good lifeexpectancy, people who might actually consider treating it ifwe found it. those are people who it's reasonableto do a psa screening on.

(man) how do youdetermine their treatment? (dr. pietrow) essentially, i'mgoing to over simplify. but there is four ways to thinkabout the new patient sitting there in front of me that justgot diagnosed with prostate cancer. not all prostate cancerneeds to be treated. remember my comment aboutdetection doesn't equal treatment. so, let's say the guy has onesliver of gleason 6 prostate cancer. that's the least aggressive.

and it's only onesliver out of 12. and it's maybe only5% of that sliver. not the entire core,but one part of it. that's a pretty low-risk biopsyand that guy should probably just get treatedwith surveillance. which means, we're notgoing to treat him. no active treatment. that's the kind of prostatecancer that he's more likely to die with. that's that 90 year old. 90% of 90. that's that guy.

well, we just discovered, oops,i just discovered the prostate cancer that i didn'twant to discover. but if i can recognize that,i'm not going to treat the guy. so, it doesn't mean you justwalk out the door and come back if anything ever goes wrong. generally we'llfollow some psas. we might repeat a biopsyat one year or two years. maybe at four, dependingon whose protocol you want to follow.

if nothing ever really changes,essentially as the guy gets older, and if it never reallyshows up as five cores and gleason 7 and later, you willprobably never treat that guy. so, that's kind of one extreme. the other extreme is the guy whoshows up and he's already got pretty advanced disease. he shows up because hegot some rib fracture. by the time they get sent to us,we find out he's got prostate cancer, but it's already spread. and i can't cure that guy.

so that's the kind ofguy you might treat with hormone deprivation. essentially we turn offtestosterone in the body. and turns out that by deprivingprostate cancer of testosterone, you can make it shrink. and it doesn't cureit, but it stalls. and you can buy years. you can buy years of time. almost always the prostatecancer finds a way to out-sneak the hormone deprivation,the hormone suppression

and progress, and get worse. so, people with moreadvanced disease are people we just want to stall. he's 80, but he's got a lot ofprostate cancer and, i just try. i know i'm notgoing to cure him. i just want him to nothave a bad bone fracture from his prostate cancer. so, i'm going to treat him justto stall things so he can die of something else,may use stalling tactics.

hormone suppression. now, if we're talking aboutcuring, kind of in between doing nothing and stalling, there aretwo mainstays, and there's a couple of sub-flavors withinthat, but the two mainstays for treatment are either surgeryto take out the entire prostate gland, or radiation. you keep the prostate, but wetreat that tissue with radiation so that the cells die. and youcan do radiation with a beam. you go every dayfor 45 days.

because if they were to give youthat entire dose of radiation exposure, it'd be too tough. you'd have too much burnto the skin and it's just too irritable. so they take that entire doseof radiation they want to expose you to, and they give you alittle bit, little bit, little bit, little bit, little bit. by the time you're done,you've had 45 little bits that adds up to that entiredose that you want.

and that's thestandard x-ray therapy. people can implantradioactive pellets. and people say "i don't wantthat radiation, i want the seeds." it is radiation. it's just radiation seedsversus radiation that you get exposed to in a beam. but those seeds, theyget implanted surgically. you go to the o.r. and we put needles in and you drop these pellets in the tissue.

and essentially theyburn themselves out. so they release their energy,they release their energy, and then they kind of... the half-life of radiation. eventually they're notproducing any energy anymore. the seeds stay in, butthey're no longer exposing the tissue to the energy. those are the two mainstaysof radiation therapy. surgery used to be an incisionfrom belly button to above the pubic bone, then they starteddoing smaller incisions, then

they started doinglaproscopic surgery. and now, 85% of people, ifthey're going to have surgery, have, essentially therobotic laproscopic surgery. there's a machine called thedevinci robot, and it's not like the ford motor company whereit reaches and just does it. you know, somebody's telling itwhat to do at all times, but the surgeon sits at a console. cool little 3d thing you sit atand you're watching these two telescopes and you're movingyour fingers over here and over

there are these robot arms thatyou've placed inside the belly. so, when i move over here, thearms over here go like this. so it allows you to getinto the really narrow spot. it's easier to manipulate, butit's still just surgery, right? it's just a fancy tool. so the mainstays for treatmentare either surveillance, if we think the guys alow risk disease. if you think this is gleason 7,he's had a bunch of cores, and this could be a threat to hislife expectancy, you might

either do surgery or radiation. and if you think that, "boy it'sreally advanced or i just want to stall," you might dohormone therapy or suppress it. so, the next question:"surgery or radiation? what of those are better?" and there is no right answer. part of that truly ispatient preference. some guys since you have tojust sort of decide what side effects they're mostwilling to put up with. surgery has theimmediate surgical risk.

you cut out the prostate, youput the urethra and bladder back together again, and now youhave to learn how to control that muscle. andguys leak right away. now most guys get theirbladder control back, but it takes some time. radiation has what i call theinnocent bystander effects. they can aim that beam rightat the prostate but it's never just the prostate. it's the nerves that goout to the penis as well.

so erections get worse,just like with surgery. and the rectumsits right behind, and that sees some ofthe energy. and the bladder sits above andthat sees some of the energy. so part of deciding which of thetwo curative, if you were to do that, is really deciding whichof the two side effects, which of the two recoveriesam i more willing to do. historically we've done moreradiation in older patients, and we've done more surgeryin younger patients.

a 55-year-old guy, youfigure, he can recover better. he's got more strength. he'sgot more reserve. but there's really no hardand fast rule in how you treat it if you're going to doa curative approach. any other questions? alright, thank you.