How can we treat prostate cancer while still protecting the heart? Dr. Alain Bouchard explores this subject with expert guests Dr. Michael Bivins, a urologist at Urology Centers of Alabama (UCA), Dr. Mollie deShazo, a medical oncologist at UCA Van Scott Cancer Center, and Dr. Carrie Lenneman, director of the Cardio-Onocology program at the University of Alabama in Birmingham.
Learn more about how to treat prostate cancer and protect your heart here.
About the Host
Dr. Alain Bouchard is a clinical cardiologist at Cardiology Specialists of Birmingham, AL. He is a native of Quebec, Canada and trained in Internal Medicine at McGill University in Montreal. He continued as a Research Fellow at the Montreal Heart Institute. He did a clinical cardiology fellowship at the University of California in San Francisco. He joined the faculty at the University of Alabama Birmingham from 1986 to 1990. He worked at CardiologyPC and Baptist Medical Center at Princeton from 1990-2019. He is now part of the Cardiology Specialists of Birmingham at St. Vincent’s Health System, Ascension.
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This is the My heart dotnet podcast. This show is produced by Dr. Philip Johnson in conjunction with Lydell engine.com. Please welcome your host, Dr. La Bouchard of cardiology specialists in Birmingham, Alabama at St. Vincent's medical center part of ascension. Welcome to our podcast on how to treat prostate cancer and protect your heart at the same time. And with me today I have a good friend of mine, Michael Bivins, who is a urologist at urology centers of Alabama. We have also Molly DeShazo, who is an oncologist, medical oncologist also at the urology centers of Alabama. And of course, Dr. Carrie Lindemann, who's director of cardio Oncology Program at the University of Alabama, at Birmingham. And then there's me, who has a prostate and had some concern you know about the state of prostate cancer. So hopefully we can talk about it. So welcome on this beautiful Sunday. Thank you very much for agreeing to do this. Mike and Molly, and Carrie will try to discuss you know, briefly during this podcast. Today we'll we'll discuss about the problem with prostate cancer. Mike is going to help us also talk a little bit about the PSA, what does it mean? And when do we need to be concerned? We'll discuss what is a localized prostate cancer, we'll talk a little bit about this the treatment which is the mainstay of treatment of prostate cancer, which is the androgen deprivation therapy or ADT. Finally talk about the advanced prostate cancer. And we'll finish up with Carrie and discuss maybe some of the side effects that are cardiovascular risk and patients that we treat with prostate cancer. So welcome, you know, Carrie, who just join us, thank you for being here today. In between softball games and soccer practice, and whatever what goes on, on Sunday afternoon. Thank you for being here. Mike, let's get started. And, you know, it seems like, you know, if you're a guy, if you don't die from the heart, the prostate is gonna get you tell us a little bit about the prostate cancer and seems to be a growing problem. Well, I think first of all, to take a step back and say what is the prostate, the prostate gland is a gland that only made half this this in the pelvis, and the whole purpose of the prostate is a fertility, Oregon. So if a man did not have a prostate, he could not fertilize. And so and that's, that's the whole point, purpose of the prostate gland. We know that as men get older the gland can grow. And it can cause symptoms and more with just symptoms, obstructive symptoms, but you know, there are a certain subset of populations that are prone to prostate cancer. And so as we look at prostate cancer, to really, really understand where we are today, we really have to understand where we came from. And if we look at, we'll take a stroll that, you know, 3040 years, when you look at prior to 1978 1980, you know, the vast majority, we didn't have any great screening tools. And we know that in all cancers, and Molly probably can attest to that, that that survival is definitely linked to good screening screening protocols. And so what we found was that you had a significant number of men that were advanced stage at diagnosis, and their five year and actually if you look at prostate cancer prosecutes is really unique. In that typical cancers, we as you measure them, they're typically measured on five years of Bibles, where today prostate cancer now is measured over a 20 year old standard 15 years. Wow. And but if you go back 30 years, it was also measured on five years. Wow. So if you look at part of it at the five year survival was 70 80%. Reason for that is because you didn't have great screening tools. And so it was showing up when they had symptoms. And we all we all know that when if you wait or symptoms and prostate cancer, then it's going to be more advanced then around in the mid 1980s that the slow tests that came about called the PSA. And that was a game changer. And so you saw the survival curves just totally shift me it would be in screen meaning will be cancels with being found early. And so you took that 90 That that 70 80% five year survival and it went to 90, almost 100% and so and so what a PSA is, is a chemical made by the prostate gland and it should be in a certain range. And when it goes above that range, and we'll talk about potentially I didn't tell you what that range was at this point. But but when it goes above that range, then it's like an alarm going off in the house. You need to figure out what's going on. We don't want at that point. And so and so then, as you scroll through the history around 2012, you know, the United States Preventive task force came out said, wow, you know, they addressed screening and prostate cancer. And that was, again, the game was changed, because they ruled, they came out against screening for prostate cancer screening using the PSA screening test for prostate cancer. And they had a huge effect, because what happened was you start looking at and family medicine practices and associations, you look at them that surprise Association, and associations, basically, they stopped screening. And so what you start to see was you started to see that curve starting to shift back, we saw that. And since then, what we realized what we had to do was, in order to come up with better screening mechanisms, and it's reflected in most of the different associations with Smith kiss association was meant for a large Association, and most of the verbiage that comes out now since shared decision making. So that's sort of kind of the historical, you know, sort of journey that we've taken with PSA. When you look at the PSA, people always ask, well, what is normal PSA? And I think that again, that's a little bit of a complex question. But, you know, typically, we like to see it in a certain range, we know that the chances of cancer, your chance of diagnosing cancer increases as a PSA increase. So historically, that number has been four. And then there was some data that suggests that in certain populations, typically your risk of cancer, maybe you'll find cancers or in certain populations that cancer risk could be higher in PSA is less than four. And I think if you just take four and four to 10. And I've seen several papers that look at what's your risk of cancer between a PSA of four to 10. And I've seen it anywhere from 15 to 25%. So four became sort of the hallmark number. And then there was a study that I believe was at University of North Carolina from not mistaken and I think they looked at it to know in the military that you can find an African Americans and people and people were that have family histories, that even a PSA is less than four between 2.5 and four, that there are a significant number of cancer that can be missed. And so that sort of kind of changed the way we sort of address PSA screenings here at urologist soon as we typically because people want to know, okay, you can give me all this data. But but give me something Get Help me Help me evaluate my patients. And what we typically do is we come up with and again, this is just urology centers, and trying to look at and look at all the data and try to help different associations try to help our patients figure out, when should we screen we typically use 2.5. And what we use is 2.54, or less is normal, or 2.5 or greater, is considered abnormal. And again, I think you got to take into account a lot of different things, your family history, what happened. And so the second question is, when do you start screening. And so traditionally, historically, that's been a man age 50. But again, when subsets for populations and looked at when you start looking at patients that have family histories, maybe genetically and the cancers or when you look at different populations, such as African Americans in those faces, we found that even in in less than 50, you can miss a significant number of cancer. So typically, we use age 14 For those people at higher risk. And we know those people higher risk when you take African American two times the risk, when you take people with family history, they can be up to three times the risk of cancer. So to summarize all of that, PSA, we do believe in PSA as a screening tool, we know that it's effective in saving lives, we use a PSA of four or four or greater, unless you at higher risk. And typically, with men that are higher risk, we use 2.5. And we started screening those men at high risk of age. Well, that's a that's pretty good self introduction, right there might. So let's say for example, I'm you know, I'm 60 years old and, and I have a PSA that turns out that you know, six, and I go see the urologist and refer to you what happens after that, I mean, we're trying to decide, you know, is this inflammation or is this cancer or what are the steps that you take there? Great question. So the first thing I'm going to do is take a good history if you have any signs and symptoms of inflammation, then I will typically say well, let's just try to treat you with some antibodies try to try to tease out that prostatitis and then repeat it, you know, maybe that show up. I typically will probably repeat that PSA anyway, and then confirm that it's elevated before I take them down a biopsy. Again, it's got a good detail history, something as simple as we know, it's amazing. Some people would have you know, of course, you know, before they come in to get that PSA test or night before then I would Tell them wants to come back in a week or two and just repeat it. Because we know that that can affect the PSA. But let's just assume all that sees out, let's assume that this six is realistic. Let's assume that I repeat, the PSA is still elevated. And then what are the next steps? And so historically, the next steps would be well, we'll just proceed with a biopsy and what a biopsy is we're trying to sample the prostate to see if there's cancer present. And the other thing that you can find out is, you know, a lot of times you also can see if inflammation is on a tissue, and that will certainly help put you at ease. So this could be the driver of an elevated PSA. Now, you know, more recently, we've started utilizing MRIs. To to get a better picture of the architecture of the prostate, we try to assess, are there lesions that are concerning when we look at them. And, you know, historically, insurance companies did not pay for screening MRIs. But more recently, they are starting to pay for those. So there's a certainly that is going into the entire screening process, being able to utilize MRIs, even but again, you know, it still makes us all feel better when we get tissue to be able to rule in or rule out if cancer is present. So even even with a MRI, it may guide you as to where you need to focus on during a biopsy, but it doesn't rule out a biopsy. So if you have a true true elevated PSA, as you just stated with a gentleman that's 6065 years old, and his PSA is six, then that person if it's confirmed to be that, then that person is one of the labs. So let's say for example, you repeat the PSA, my God, it's 10. And, you know, a physical exam was okay, you get an MRI that is abnormal, you do the biopsy and it's positive. How do you determine okay, we're now we're dealing with prostate cancer, and you're trying to determine how do you determine whether it's localized? Or what do you call localized prostate cancer? What do you what do you call more advanced prostate cancer? And then we've been talking about treatment and maybe try to bring Molly along. Yeah, maybe. Okay. And so, you know, you know, Molly, she probably is definitely it was she's an expert in prostate cancer. And here, he is probably a little bit more advanced prostate cancer, typically urologist will deal with more localized and again, localized to finding out is cancer that's confirmed to be in the prostate gland, and not spread outside the prostate gland. And so let's listen to a PSA is elevated, we do a biopsy biopsy comes back and the patient has case well, I think, you know, from taking a detailed history, you know, what, what if a patient comes in, and he has five brothers that have cancer, right, or if he has a father and grandfather has prostate cancer, there's some genetic link to that prostate cancer, and those typically can be more aggressive, right. And so probably that patient is probably going to show up earlier. And we know that when cancer shows up earlier, they're typically more aggressive. And my thought process is probably going to be this patient needs a treatment outside of active surveillance. So that's one thing. So detailed history, you know, we will likely assuming, again, you've done it, you've done an exam, the prostate feels normal, we call that clinical, T one, two, T one T one C, which means it's localized to the prostate gland, assuming all that's normal at that point, MRI, MRIs, it's tough in this space, because you've already done a boxing. So if you've already done in boxing, you don't have an MRI, then getting an MRI at this point is going to be not useful because it's gonna have so much inflammation from the body, and you probably can't get an MRI for six months. But if you have an MRI that that you got prior to the biopsy, and that may be useful, because that can help determine whether this cancer is localized or not, or are there significant, aggressive lesions on the MRI. The other thing that we can do to help us is is genetic testing. We have multiple genetic platforms that will assess risk based off of the type of genes and the type of genetic pathways. So you know, if we have one of the genetic testing that shows that this patient is at high risk for if left untreated, or if this patient is at high risk for spread and just faces a high risk of death, then likely not treating this patient is would be a good idea or active surveillance probably would not be a good idea in this space. However, if this patient has genes that had that set of consistent with indolent cancers, then active surveillance would be a good option for those patients. And you know, interesting we did a we just did a review of all our patients with localized treatment. And actually we have more patients now in urology centers that are actual active surveillance. I didn't I wouldn't about that, but we actually do and integrate that again, genetic Genetic testing genetic scoring is key as well as part of that process when we evaluate patients, but let's say that you do all of that you got a patient, you know, and you are you still can have it, you still can have a patient that have low genetic scores, and they have low grades. And the great tells you how it looks, it's what a pathologist looks at it, and you grade the architect of that cancer. And when you do that, that tells you how aggressive that cancer is. And usually, typically, historically, we use what is what we call a Gleason score, and to not get too in detail on the Gleason score, but it gives us a gives us a pathway to tell just, you know, again, how aggressive it is. And when I talk to my patients, I typically say the combined score between five and 10, five and six, a low grade, slow growing cancers, whether it's nines and 10s, are aggressive. And these are the ones that are going to spread and become a problem. And then everything in between. And say you can have a patient that has low grade, the genetic score is low, and you got you got to take into account some patients and you can you can even suggest active surveillance, you can have only one core small amount of cancer. And I know this cancer likely won't be a problem for this patient over his entire life and they're looking acid that's still got cancer, right? Like yes, well, I can't, I can't live no one I got cancer inside of me. And so that in and of itself, even though you recommend that, you know that, that this cancer would not be a problem over time, you still have to take that into account because they you know, it's a mental aspect of them living with it. Well, let's say that you got a genetic score that's a little bit higher. Or you got you got a patient with a higher Gleason score higher PSA. And when you that's another thing, so risk stratify no PSA, when you when you evaluate is you have low, medium and high risk. So PSA less than 10 is low risk. PSA between 10 and 20 is intermediate risk and PSA greater than 20 is high risk. So those patients that are intermediate high risk, they probably need a little bit more aggressive treatment plan, ie probably active surveillance is likely not the best option for them. And then you can consider treatments such as surgery. And, you know, robotic prostatectomy is I don't think many people in the country still do an open prostates. But if they find a prostatectomy, or radiation, and I will tell you radiation, it's just it continues to get better and better, more precise, whether you're talking, you know, intermediate, you're talking IMRT, or you're talking proton beam, or you're talking whatever form of radiation you're talking, they're all good options. Breakey therapy where you play CS and in some instances, patients that get combination Breakthrough Therapy, which is C therapy, and then IMRT or proton beam, there are other options such as cryo therapy, you got high food, which is High Intensity Focused Ultrasound as an option. And so suddenly, we go through all of these options with the patient, and we try to come up with the best option as well as treatment. So Molly, now I've got this localized cancer, you know, it's, I've got some high risk, and you want to do, I'm concerned about the cancer in there. Particularly cancer may be possibly growing and, and metastasizing. So how do you even though it's a localized cancer and an increased risk? What do you recommend to the patient? I mean, what is what are the options? I mean, Mike has mentioned prostatectomy as mentioned radiation or their medical castration method as well. So, definitely, when the patients get to me, they don't they don't come to me. First of all, thanks so much for having me on this podcast. I'm really excited to be here. It's probably not as entertainment entertaining as my favorite podcast smartlace But our language was it was probably cleaner than that that podcast but so you know when my calls me when I'm getting involved is not in early stage prostate cancer. So early stage prostate cancer, like he has said is treated by either surgery or radiation. They pull me in when you have more what we call locally advanced a bigger prostate cancer or a prostate cancer that is the margins are a little bit hazy either the surgery didn't go as we hoped there, which is usually when there's a surprise when they get in there and there's more disease that all of our imaging told us before the surgery or there's a lymph node that looked negative and oh, we get in there and it's positive and that can happen even in the best surgeries hands or imaging is only so good. So he pulls me in If the tumor is worse than what they thought, or it was what they thought but they thought they had they had to get it out anyway because a man was having a lot of symptoms from his prostate, meaning symptoms they often have is obstruction having problems pee, they're having pain. So that the guys I see have a little bit more advanced prostate cancer or they have nodes that were positive. Or in some cases, they have patients that might install and unfortunately, from the get go, they knew that the cancer was already in the bones or had already spread. So I see you there locally advanced. So you know, the ones who are in lymph nodes are people who are metastatic, which is a fancy word for saying it had spread outside where the outside the prostate. So there for the locally advanced cancers, the the therapy has changed a lot, even in the last five years. So we have some fairly blunt instruments for using oncology that are old and we've been using for years and we have some much fancier and newer technology that I think is going to change the landscape of prostate cancer probably even in the next five years. How I treat prostate cancer is drastically different than how I treated it five years ago and way different than how I treated it when I was trained 20 years ago, so when patients come to me what drives past most prostate cancers, what drives them is testosterone. And testosterone is actually a friend for our bought for bodies as they age for women and men. People don't realize that women have testosterone to protect our bones protects our heart. And I think Carrie will get into that a little bit more. But what drives prostate cancer is testosterone. So the first very blunt instrument I have is to take away testosterone. If I take away testosterone and most men that's going to slow the progression of disease, the data is very good for that, that lowering testosterone makes people live longer. So that's what we do, we can do it by shots or pills there. There's pills now that block testosterone, there's shots that have been around for decades that blocked testosterone, what has changed in the landscape of prostate cancer not to get too much into it because it's it's a little bit complicated and could have a whole hour podcast on itself. But is that we used to just do we would start testosterone blockade and do that for a while and then eventually the prostate cancer cells are smart, and they're like, oh, I don't care that you're taking away my testosterone I'm gonna grow anyway. So then we would add on another test different type of testosterone block A, which we call now novel androgen blockade novel androgen receptor blockade, we would do that for a year, and then the test stops, and then the prostate cancer is like, ha ha, ha, I figured that out too. And I'm going to keep growing, whether you did this new fancy therapy or not, then we would use chemotherapy. And that would work for a period of less than a year, and then patients would die. And so this, that progression could last anywhere from, you know, starting the testosterone blockade, doing the fancy testosterone blockade, then doing the chemotherapy that could last from two years to 20 years between where you started at point A to point C and then death unfortunately, now we have moved all those therapies like most oncology, up to the front, where we hit the cancer with everything up front. And people do much better just like kind of like antibiotic resistance that if you use multiple antibiotics at the front, you have less resistance, we're realizing that that cancer cannot get as smart as quickly if we hit them from all angles up front. So we call either that doublet therapy or triplet therapy, whether or not we use chemotherapy upfront. The problem is which carrier we'll talk about is taking away someone's testosterone has risk. The risk that the men don't like is hot flashes, essentially turning them into a menopausal woman, which no one wants to be ever. So you they'll have hot flashes, fatigue, bone, increased risk of osteoporosis. It's of the stuff as an oncologist I do 10 being the worst ever been the easiest. It's about a three or four but I'm not a man and I haven't had my testosterone taken away. So I don't know how that feels. They don't like it it but it works. When we add all these other therapies, we increase toxicity. So novel androgen blockade increases the risk of cardiovascular side effects and all the side effects I just mentioned. So it's a numbers game as an oncologist, like Mike was saying, I have these blunt instruments, and I have these fancy instruments and genomics, which we're not going to go into which he was talking about these hereditary, hereditary things that help that I can direct therapy to that we test from the blood that's going to change the landscape. That's what's going to happen in the next five years, we're going to be much more directed in therapy depending on treating Mike's cancer instead of just all men who have the cancer the same. We're not totally there yet. We're getting there. But my instruments are better but there's still very blood in my opinion at this point. Molly Fahad have a an advanced prostate cancer and, and you know, you remove the prostate and you hit me with you know, the triplets in therapy, you know, And what's my chance of survival in the next 10 years. So advanced has different connotations, so that locally advance, you can live, you know, at least a decade, if you have metastatic disease, meaning prostate cancer outside the prostate, then survival when we used to do that I'm talking about a decade ago was three to four years now we're four to five years now we're five to six years. And that's median survival. So there are men who have advanced, not not just locally advanced, advanced prostate cancer who can live a decade, I mean, the the curve is continues to shift. And even men who are what we used to say, covered up with cancer can still you get live years when they walk in the door with me, which was not possible a decade ago, I would say, you know, two to three years if you were covered up with cancer everywhere, liver disease, bone disease, that was that was that was a hope. And now that that is a reasonable expectation at this point. Well, I'd like to engage Carrie now a little bit, and thought maybe expand a little bit on these side effects of the androgen deprivation therapy, and particularly when it concerns you know, in a cardiovascular patient, I have a lot of patients with prostate cancer, you know, is it actually is your treatment or your approach the same in someone who's had bypass surgery previous, you know, myocardial infarction or heart failure? At Alan, thank you so much for having me that again, I think, sort of like we were saying, I think prostate cancer definitely has evolved and changed in the sense of patients are living longer. So we need to think about their cardiovascular risk and, and health going forward. Because as Molly was alluding to, we take someone's testosterone away, and major things happen. And from a cardio metabolic standpoint, major things happen. They have glucose intolerance, they get central adiposity, they can get sarcopenia, and muscle muscle atrophy. So you see a whole sort of landscape change as far as the metabolic parameters that are occurring in individuals. So when you have a patient that's got an underlying cardiovascular risk, if those risk factors are not well controlled, or they've had a recent, you know, mi or recent bypass, you may want to be just very aggressive at engaging the patient, to be very aware of, you know, really good glucose control, blood pressure control, make sure their medicines are really well optimized, of course, making sure they're on a statin to help sort of calm down the inflammation and help their lipid profile, and engage them to let them know to about exercise and how important that is to help mitigate their cardiovascular risk. And then obviously, in a very high risk patient, there are like Molly was saying, there are a lot of new tools that are out. And we think some of the older tools, the gonadotropin releasing hormone agonist, the like Leuprolide, that probably if there's a way to maybe maybe move away from that one and look at some of the newer gonadotropin releasing hormone, antagonists, like dog a dog a Rolex or relative go likes mouthfuls. Those actually have the current data shows they may have a little better cardiovascular risk profile than compared to some of the older agents. So sometimes we'll have we'll have a discussion and we'll we'll have a dialogue if someone is very high risk, especially if someone's had a recent MI, or recent bypass in the last few months, and we're really worried about their aggressive cancer, and we need to go ahead and get them on therapy don't have a window of time, those agents may be maybe more favorable from a cardio metabolic standpoint. And then, you know, also we do know that Enzalutamide, which is an androgen receptor blockade, and then AB erode AB, AB rotarod. The androgen synthesize inhibitor, those two can cause some fluid retention and hypertension. So if I have a patient that's going to be started on those agents, again, I really just sort of engage them about education about saying, hey, I want you to start looking for swelling fluid, I want you to weigh yourself, let me know if you're having fluid or swelling, so I might need to start on a diuretic. And we know that the hypertension is well associated with these two agents as well. So again, I just sort of engaged them empower them to be checking their blood pressures at home. And we know that hypertension that occurs with those two agents are actually independent of independent of steroid use. I mean, we think steroids cause some of it, but it's actually studies have shown that it's actually independent of steroids itself, because steroids are often used with as agents have a patient they would have been treating for, you know, his, his hypertension and hypercholesterolemia and ended up with prostate cancer treated with Leuprolide or Lupron and, you know, is concerned that, you know, five years into this, you know, trying to control his blood pressure, trying to control his cholesterol that is seeing some, we're seeing some progression. You know, on the CT for example, there's more calcium developing, you know, what do we have studies actually a kind of, you know, study looking at this, you know, what is the best way to treat a cardiovascular patient who end up with prostate cancer? Yeah, I don't know, they're actually prospective studies that show that, especially in on sort of older therapies like Lupron how to it how medical therapy mitigates risk, although we know it probably does. But if it's already known, and we see it progressing, I guess that might be a time to maybe talk, talk with their medical oncology team to say, Do we have other agents that we think could be potentially used because I'm seeing calcium progression in their aorta, or I'm seeing calcium progression and their CTS that they're getting, if that is a concern, and if they're on optimal medicines, you know, high dose, high intensity, statin and their blood pressure is well controlled, and their glycemic index is well controlled, I think it's hard to know. And again, from a cardiovascular standpoint, they're newer agents like stLt, two inhibitors and things like that, we don't really know what that would do in a prostate cancer patient, you know, someone who has underlying heart failure, underlying coronary disease. So hopefully, as as we are adding newer, more novel agents to our cardiovascular profile for patients, we're hoping that it'll improve, improve their outcomes. This is where it becomes so crucial for us to interact with our cardiologists. I'm Carrie and I know each other from UAB. When I was there, more and more were discussing, you know, having regular cardiology referrals for these patients, to be honest, it didn't matter 10 years ago, even 15 years ago, because they would die of their prostate cancer. And so these were not issues that were on our on our brains. And now that people are living decades with advanced prostate cancer, we have to start weighing the pros, am I going to kill them from what I'm doing to them? Or am I? Or is the cancer going to kill them? And that's a really hard way to think about it. But once again, we have very blunt instruments, and we have to use them very carefully. So you know, when a patient comes to me, and they have horrible diabetes, and they just had an MI, and and you know, they have prostate cancer? What, what's going to really take their life, is it going to be their horrible uncontrolled cardiovascular disease and their diabetes? Or is it gonna be their prostate cancer, I don't want to make their diabetes and heart disease worse and cause that to be the end of their life. Sometimes the prostate cancer has to take a bit of a backseat and get their other cardiovascular disease under control first, before I start making it worse with what I'm going to do to them. So, you know, interdisciplinary care of these patients is becoming more and more relevant. I don't know, half the drugs that carry talks about anymore, these new new new hypertension are hypertensive and stuff. And I can't be expected to know all these, that's why I need her. And I need cardiologists to help me navigate this. And knowing the drug interactions with the drugs that all these drugs are metabolized in different ways. And so the cardiovascular medicines are metabolized in different ways. And if we don't coordinate care, then we may be, you know, shooting, shooting ourselves in the foot thinking I'm actually treating something in the medicine she's giving is, is making my drug metabolized in a way that it's not helpful. So this is getting you know, as all medicine getting more and more super specialized. Here we are, again, a very complicated drugs and their interactions with each other. Seems like when a patient with prostate cancer, the prevention methods are, you know, prime importance and working on their blood pressure, their diet exercise, Mike. Yeah, I got a quick question. You know, so we now when you start looking at costs, with these drugs that we have, that can be very costly and co pays can be very costly. And we've seen a trend where patients are opting more for organic. And so Kerry, one question I would have is, where does horkey activities fall on that cardiac race? Yeah, sure, Mike. I mean, you know, I don't know they're grounded in a whole lot of studies when we do an orchiectomy to help basically blunt the testosterone production. But in general, we still know that there's cardio metabolic profiles change that, you know, when you rapidly remove an organ that helps produce testosterones that we do see patients end up having glucose intolerance, they develop, you know, unfortunately, As Molly mentioned, the hot flashes, all the other kind of acute kind of menopausal type symptoms. And then, obviously, they have like these central adiposity, weight, weight gain those typical things which are really hard and challenging for individuals. So I think usually unfortunate patients don't come to me, they usually come to me saying, can this person undergo an orchiectomy? They don't really say is, you know, orchiectomy versus ADT for patients or I haven't yet had that experience, but I guess that could be a potential for some individuals, especially if they had before Whatever reason their insurance want to prove some other, the other ADTs that are more cardiovascular favorable than others, that might be an option. Well, you know, I still I see a lot of patients, when you look and you say, Well, you know, a three months Lupron shot is going to be 200 bucks every time. And, and that's, that's significant to them, and then the conversation or go weeks may be, you know, 100 bucks a month and then they're like, Well, you know, what, do you have anything else cheaper, because with gas prices going up and food prices going up, that's significant. And whereas you could do a one shot pop, no pun intended, and handle the ADT, you know, ablation portion with with a procedure, I am getting people that that are opt in for that, you know, and I can do it, okay, that to me leave epidemis. And for these guys, that's mentally like, I don't have anything in my scrotum, they can still feel something in their scrotum. And they'll opt in for that. And so, you know, I just didn't know where the cardiovascular with one and that up is that something of counseling, you know, something that I need to also think about, in addition to just counseling on Add ADT treatment, I think it's great, I do think that we do know, their cardio metabolic profile will change with that. And then just again, maybe having them engaged with their primary care team or their cardiologist, they're seeing one, just say what, hey, you know, when we do this, just like as if we did ADT, we know that these things will change, we just want to make sure you're plugged in, and that you know, that you're getting, you know, follow up care, because we're really working hard to give you longevity and good life expectancy for your prostate cancer. But we want to make sure that we're not, you know, turning you into a horribly controlled diabetic or someone who's going to be crippled by heart disease. But I think that's a great point. Like I honestly don't get patients really with at that decision point. But I think where you're coming from, from your viewpoint, that's very, very valid. And I could see that as a good option. I mean, we haven't discussed much the quality of life of these patients and all the stuff we do to them. I mean, this is not, it's not fun, what they're going through here, and Mike touched on the mental aspect of just feeling something in your scrotum. I mean, I had a professional football player, who the weight game just undid him. I mean, he was he was a big, muscular guy, his whole life part of his identity. You know, he played professional footballer, and he gets sarcopenia muscle wasting breast growth. And, you know, it became clinically depressed from everything we were doing. And at some point, we just had to pull back because he just could not live like that. And he didn't want to live like that. So this is it's hard, hard work that these men do till to be around. And we I think sometimes it's negated because men just don't complain a lot of times about all the horrible things we're doing to them. And we need to really be careful about asking them. To that you could have a podcast on the mental aspects of prostate cancer and prostate cancer and prostate cancer treatments. Absolutely. What do you think we're going to be five years from now? Where's the research going? With medical oncology? It's amazing. I think we do genomics now. So we're testing for what we call homologous recombination repair problems. So genetic defects were that we can target with drugs. So this is breast cancer research has a lot of the same thing. So you hear the braca mutation that Angelina Jolie had, you know, and she had, these are people who have hereditary breast and ovarian cancers, we were a little late to the game and prostate cancer understanding that there is a significant portion of men who have these ah, hrr mutations, who we can direct care with a lot of the same drugs that we're using for breast cancer treatment for men with prostate cancer treatment. So already in the last, you know, year and a half with new data that I talked about, at this doublet and triplet therapy using all of our drugs up front, like we discussed earlier, I think in you know, a year or two, maybe even three, there's multiple trials that are using drugs to target these ha HRR mutations that are much fancier and makes much more sense. And other mutations we're finding that are common, and there's drugs in development to target more specifically. So hopefully, our our therapy will be less and less blunt as we go forward. Man, I think that I think that, you know, it's something that's just kind of, you know, high on my radar is personalized medicine, this person is, is figuring out how to, to address these individual bases, and I think genetics and genomics are central to it as well as mileage state. You know, and I think that as the things that we have now, we keep moving them forward, we keep moving them you know, anytime you introduce a new thing, like you introduce new therapy, they're actually introduced at the most advanced stages. But I think then you continue to move forward. So we'll continue to move some of these novel therapies forward. I think we'll figure out who who needs to be screened, we'll figure out who excuse me who needs to be screened, who needs to be treated, we'll get better imaging will get better genomic understand cancer better, even though we have what we have today is still we still tip of the iceberg on understanding genomics. And I think that's where this personalized minutes so that's where things will go will get better technology on going and taking out an operating and radiation will get better radio radio therapies are targeted therapies, if you will. And we'll get better focal therapies, whereas you don't really have to, to to basically operate, remove the whole prostate ready to hold prostate, you know, ultrasound, the whole prostate. So that's, I think, we'll be able to go there, I think, you know, immunotherapies will probably continue to move forward. And, you know, I always, you know, at solving to my partner, Dr. Berg and I were talking about I said, I just asked myself, if you got diagnosed prostate cancer, would you just pay for immunotherapy upfront? And we both say, Yeah, we probably would we just go ahead and get the probate upfront. And now there's no studies on that. You know, but I think you'll start it makes sense. And I think you'll start to see things continue to move forward earlier, only disease. Interesting time we have and I do agree with model. We are totally treating prostate cancer, different than we did 20 Well, five years ago, but certainly 1020 years ago, and it's still evolving. So we'll see. Maybe we're not going to die anymore, either from the heart or for the prostate. How to treat prostate cancer and protect your heart. Thank you very much, guys, Mike Bivins and Molly DeShazo, Carolyn Carolina man. Always a pleasure to get together and particularly on a beautiful Sunday afternoon. Enjoy. Thank you so much. Thank you. All right, take care. To learn more from our team of cardiologists, please visit us at my heart.net You can also follow us on social media by searching my heart.net on Facebook and Twitter. And be sure to subscribe to this podcast. So you don't miss our next episode.