Anything else about another scan besides PSMA you want to say because I'm just going to finish up
the last minute or two with PSMA unless there's something else we missed about the bone scan, the
MRI — we talked about gadolinium ad nauseam —we've talked about the other types of PET CT scans.
Anything else you want to talk about on those scans because I'm done talking about them.
Yeah, I think we covered it very well Mark, It's nice that we can have a whole section focused on
this because it's all about, in the past we had to use things like Gleason score, how high the
PSA is, how big the nodule is, and we would do a statistical projection and do a guesstimate,
"Well, we think there's probably a one out of three chance that there's disease in the lymph nodes. We
don't know for sure because all we've got is this crappy CAT scan to to try and determine
if there's any cancer." Sometimes the surgeons would use this as an argument and say, "Well we
just don't know about the lymph nodes, so we want to do surgery on you so we can remove the lymph
nodes and look at them under the microscope," as if that's justification for, you know, lifetime
mutilation but it's a — this whole issue is so so important because now instead of using these
projections, these guesstimates, we're actually getting a scan and looking. Now, does it mean if
your PSMA scan is clear that there's absolutely no risk of cancer out there? No, it doesn't.
All it does is reduce the likelihood of their cancer being out there by at least 50 percent.
So, if you have someone with high-risk disease and you do all these calculations and say, "Sir
you have an 18% chance that there's metastatic disease outside your prostate,
but now we did a PSMA PET scan; it's clear. So, if you have something it's obviously very small
and the chances now that there's something out there is at least fifty percent lower." So you go
from an eighteen percent risk down to maybe a nine percent risk. Is that going to change the way you
treat that person? Are you going to consider not giving them one and a half to two years of Lupron
because you've got a lot stronger evidence that there's nothing spread? I think you are. The other
talk that we're going to get into with Dr. Higano, I mean that was — if i was seeing that for the
first time and looking at what all the problems that hormone blockade can cause for men...
Yeah.
...I'd say, "Wow how do I get out of that jail? That's a big deal," and so these
PSMA PET scans, I think, offer a window of opportunity for men with high-risk disease
that have negative PSMA PET scans to consider maybe for shortening that that routine
recommendation of 18 months of hormone therapy — maybe just do what you do for intermediate-risk,
maybe four to six months would be more plausible in someone with a negative scan.
So just to the audience, when when Dr. Scholz is talking and sometimes I
start laughing when he says some things, some negative things, about some type of surgeons,
I laugh because I've known him as long as I've known probably some of my brothers, so you know,
we're sort of Cain and Able at times but also very close, so I just laugh because I know who he is.
I think the audience realized — they realize that you're just disrespecting me Mark,
but you've been up to that for years, you know, you have other good qualities,
but being the son of a urologist, we understand that you've got a blind spot. I mean, that's okay.
I love surgeons; I think they do an amazing job, and you and I are gonna go to our grave fighting
this, but I just sometimes laugh because I met you when you were a serious guy and now
you have this humorous side. Whenever you make a joke—it's like Thomas Hope—whenever
you make a joke I laugh, so I want the audience to understand it's based on
the relationship. It's like talking with your brother of 20, 30 years.
No, no, no, you're not laughing at the joke;
you're laughing at the fact that Scholz told a joke. You're saying, "What?!"
That's true; that's well said. That's better said — it's like yeah, Scholz told a joke? Man,
someone lock and load that thing in; let's put that on the wall as a quotation.
Okay, let's talk about PSA and PSMA. PSA, it was the limiting factor of past scans; you've got to
admit that. Here's the nervousness: PSA is going up and other PET/CTs are saying just let it go
to one, let it go to one and a half, let it go to two, and I'm going, "Oh my gosh!" So, PSMA now can
possibly pick up at 0.2, and so is that's — can you again elaborate on that? For someone that's
waiting and they're watching their PSA slowly move up after primary therapy and it reaches that
threshold, are you confident that the 0.2s, 0.3s, 0.4s people should be talking about PSMAs now?
Well you know, now that someone has to write a check for three thousand dollars, we try and
spend their money judiciously. When this is FDA approved, people are gonna get a scan right at 0.2
because it'll be covered by insurance, and you say, "Why not? Let's look." That'll be
routine. There is a better chance of finding something is say 0.5 to 0.7 than there is at 0.2,
so if someone has to write a check for $3,000 and they want to spend their money wisely,
they may wait for it to rise a little higher. There's data in the radiation literature
that suggests that, you know, people that get treated with radiation around 0.5
do better than men who get treated with radiation at higher and higher levels. That means that the
disease is more likely to be localized at 0.5 then if you allowed to go higher. So, the maybe it'll
turn out around 0.5 is the sweet spot. We have a a lot of men that are going to be wondering what's
happening after radiation — modern radiation, you know, historically they would—remember they
would say—that if your PSA goes two points above the lowest amount, then you're having a relapse.
I don't think that's going to be a modern standard with these PSMA PET scans. I think
what you're going to tell men after radiation (seed implant, IMRT, proton therapy) that if
your PSA starts going above 0.5 you probably need to get a scan and look and see if, god forbid,
there's some cancer coming back. And people say, "Oh that's such a low level!" That's the beauty of
these scans; you get rid of this guesswork that we've been dealing with for decades.
That's where you get "control;" that's where you
get "cure;" that's where you get the words that people want to use, right?