Dr. Ted Schaeffer: All Things Prostate Cancer, Urology, & Men’s Health

Dr. Edward Schaeffer is a world-renowned urologist, pioneering robotic surgeon, and Chair of Urology at Northwestern University. This conversation explores the complexities of prostate health and cancer care. We discuss the latest advancements in early detection and treatment and the importance of proactive health management for men. Dr. Schaeffer shares insights on interpreting PSA tests, the role of genetics in prostate cancer risk, and the revolutionary impact of robotic surgery. Along the way, we debunk common myths about prostate health, address the controversies surrounding mass screening, and examine the interplay between lifestyle choices and cancer risk. Dr. Schaeffer is a pioneer in his field. The conversation is enlightening and potentially life-saving. Enjoy! Show notes + MORE Watch on YouTube Newsletter Sign-Up Today’s Sponsors: AG1: Get a FREE 1-year supply of Vitamin D3+K2 AND 5 free AG1 Travel Packs 👉drinkAG1.com/richroll Peak Design: 20% OFF sleek carry solutions 👉PeakDesign.com/RICHROLL Squarespace: Save 10% off your first purchase of a website or domain 👉 Squarespace.com/RichRoll On: Enter RichRoll10 at the checkout to get 10% OFF your first order 👉on.com/richroll Meal Planner: For customized plant-based recipes 👉meals.richroll.com Check out all of the amazing discounts from our Sponsors 👉 richroll.com/sponsors Find out more about Voicing Change Media at voicingchange.media and follow us @voicingchange Learn more about your ad choices. Visit podcastchoices.com/adchoices

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:01Speaker 00

  Hey, I'm a 50-year-old guy. Should I be thinking about screening for prostate cancer? These days, around 35,000 people a year die from prostate cancer, which is a low number, but it's still the second-leading cause of cancer death. Men's relationship with health care is very different than women, and they really only engage later in life when a problem becomes apparent. I mean, cancers don't read rulebooks. They get this diagnosis, and it's not on their 2024 agenda. We can screen guys and pick up cancers early and curable. We can do this more modern surgery, and we can actually improve the outcomes for men with prostate cancer. It's not a sign of weakness. It's a sign of strength when you can talk about these things publicly. You just want to understand your individual risk

• 0:45Speaker 00

  and understand how close you need to be followed.

• 0:51Rich Roll?

  Hey, everybody. Welcome to the podcast. Today features an important and very comprehensive conversation about an all-too-under-discussed, underappreciated, and often misunderstood topic: prostate cancer, a disease that afflicts one out of every seven men and is second only to lung cancer in cancer death lethality. My guest for this discussion is Dr. Ted Schaeffer, one of the world's leading experts in the diagnosis and treatment of prostate cancer. Dr. Schaeffer is the chair of urology at Northwestern University's Feinberg School of Medicine. He has over 430 peer-reviewed publications to his name and is a pioneer in robotic prostatectomy,

• 1:34Rich Roll?

  the most advanced surgical procedure available for the treatment of prostate cancer. Today, we demystify all things prostate and all things prostate cancer. We discuss risk factors, including TRT therapy, and the importance of early detection. We go into detail on everything you need to know about testing, including PSA screening, MRIs, and biopsies, and we discuss the various treatments for prostate cancer, as well as many other important topics related to urological health. It's all coming up quick, but first...

• 2:19Rich Roll?

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• 3:03Rich Roll?

  It's kind of an amazing thing. For listeners of the show, all you special people, we're offering an exclusive $20 off an annual subscription right now. To get it, go to meals.richroll.com, take your quick personalization quiz, and enter promo code RICHROLL20 at checkout.

• 3:25Rich Roll?

  Okay. Not only is Ted just the absolute man when it comes to this field, he is a genuinely good human, and I'm just beyond grateful for him to take the time to share his wisdom and expertise with me and with all of you today, which I consider to be a masterclass and a true public service announcement. So, without further ado, enjoy.

• 3:49Rich Roll?

  Ted, thank you so much for doing this. I guess the first question I have for you, though, to just kick this off, is when you decided to go into urology, was it always your plan to end up on the Howard Stern Show?

• 4:04Speaker 00

  You know, my path to urology was kind of multi-dimensional. My father's a urologist who happens to be a prominent academic urologist. And when I was in high school, my dad's dad died. And we would, there was this whole journey where every single weekend, we would go see him over years. I saw this individual age and slowly decline and I didn't know what he died of at the time, but he ended up, it turns out, he died of prostate cancer. And so during my medical training, I kind of came to the realization and understanding of what he died from and that really solidified my interest in doing urology. A different kind of urology than my father and what he did, but a urology that was very

• 4:47Speaker 00

  hyper-focused on helping others in the future kind of diagnose their cancers early and treat their cancers early in a way that we could extend meaningful life for those men.

• 4:58Rich Roll?

  Yeah, yeah, that's a great little kind of context for what we're going to talk about today. The joke around Howard Stern being that Ben Stiller was your patient and you treated him and he made this decision to be public about it as a real public service, really, to raise awareness around this issue, which is often kind of unspoken or perhaps not as widely understood as it should be. And it's part of why I wanted to have you here today, because I want to sort of cast a spotlight on something that a lot of men don't talk about or is kind of talked about off to the side, right? Not in a public forum like this.

• 5:41Rich Roll?

  And I think it's the more that I looked into the work that you do and trying to better understand prostate health, like I'm embarrassed to say that I've never been screened. Like I'm immediately going to go get screened, you know, after this experience.

• 5:55Speaker 00

  Yeah, I think men's relationship with health, their health and healthcare is very different than women and their relationship with their health. And I think it has to just do with, as a generalization, you know, women have doctors that they kind of, you know, grow up with as they go through puberty and then into young adulthood and so forth. And men don't have that. They kind of, you know, as a boy, they'll see their pediatrician and there's this large gap and they really only engage. Traditionally, health care providers later in life, when a problem becomes apparent. So I will just, you know, throw it back at you and say that, you know, the work that you're doing and kind of, and our good friend Peter Attia, what they do in terms of bringing to the forefront, this idea that men can engage in their, their overall health and

• 6:40Speaker 00

  their wellness in a very proactive way versus being reactive, I think is just a huge benefit too. And so I'm honored to kind of be able to be here to talk about it because it is a great thing. And Ben really did lead the way and really bring it to the forefront where it's not an embarrassment, it's not a sign of weakness, it's a sign of strength when you can talk about these things publicly.

• 6:59Rich Roll?

  I want to dig deeper into the PSA testing and talk about the nuances there, but let's put that aside for a moment and start with some real basics. What is the prostate? What does it do? Why is it important?

• 7:15Speaker 00

  The prostate...

• 7:16Rich Roll?

  This is as basic as it gets.

• 7:18Speaker 00

  Let's do it. Yeah. No, the prostate is this very small, about the size of a golf ball, sexual gland. And so it sits just below the bladder in men and it produces semen. Okay. So its job is to basically produce a fluid that keeps sperm alive while that sperm is trying to go find an egg and basically fertilize an egg. That's the job of the prostate. And without a prostate, you really can't effectively reproduce by natural, you know, kind of techniques. Now, it sits just below the bladder. So, and the tube that men urinate out of, the urethra, that's where urine comes out of when you empty your bladder every

• 8:03Speaker 00

  three or four hours. And that's where semen comes out of when you have an orgasm, when you ejaculate. So that tube actually runs right through the middle of the prostate. So the bladder's above it, you pee through the tube, and the first part of the tube is the prostate or the prostatic urethra. So... The most common issue that the prostate has for men is just it enlarges. The channel that you urinate through kind of gets compressed and you have urinary symptoms. Weak stream, you don't empty all the way. These are common. Seventy-five percent of men over the age of 50 actually have urinary bother because their prostate gets larger and kind of compresses off their ability to urinate normally.

• 8:45Speaker 00

  So although prostate cancer is very common, actually the prostate itself causes lots of issues for men, mostly because it gets bigger and it causes obstruction.

• 8:55Rich Roll?

  Which is not necessarily cancer.

• 8:57Speaker 00

  Yeah, most of the time that urinary bother and those urinary symptoms are not from a cancer. They're just because of natural or normal kind of aging out kind of phenomenon. So prostate sits at the very bottom of your pelvis. It sits just below your bladder. It's there for sexual reproduction and that's its function. And but it causes a lot of issues for guys.

• 9:20Rich Roll?

  Yeah, so it's going to naturally grow no matter what as we age. That's going to cause some problems. It's not necessarily indicia of anything terribly wrong other than just aging up. During your time at Johns Hopkins, you had the privilege of working underneath what I gather to be the godfather of how we understand the prostate, prostate cancer and how to treat it, this guy, Pat Walsh. Can you talk a little bit about him and why he is such a legend and what you learned from him and how you picked up the baton and kind of ran with it in the wake of what he kind of represents?

• 10:00Speaker 00

  Yeah, Pat Walsh is one of the icons in my specialty in our field and there are many of those icons at Hopkins, which is what made it such a special place. He had a passion for really, really doing deep dives into understanding, you know, how to diagnose and then subsequently treat the disease in a better, safer way with improved outcomes for men. And so he was really a pioneer in developing the surgical techniques. To, you know, at that time, allow people to have an operation and actually survive because the death rates from the surgery itself were quite high at that time. And then refine the technique so that there's improvements in overall function of individuals after their prostate cancer surgery. So he did that.

• 10:45Speaker 00

  And that by itself, developing the technique and then really disseminating it. So he wasn't someone who developed a technique and then kind of kept it to himself. He published videos, he published books, he published and invited people to his OR to help them disseminate, like this is how you can do it better. And he did that with a surgical technique that was with what was an open approach where there's a bigger incision below the belly button to kind of get access to the prostate. And then when I was training surgical robotics, minimally invasive surgery really came online. And so I wasn't the first individual to do it with a minimally invasive approach, but I would consider myself to be an early adopter with that approach.

• 11:27Speaker 00

  And then I was really able to take and translate all these special observations and surgical techniques that Pat Walsh, my mentor, developed and deploy them with kind of a minimally invasive approach. And so it was a great time to come up and train under him and then a great time to kind of be in practice. And I was honored to be his first and only partner through his career.

• 11:51Rich Roll?

  Did the robotic procedure, what's it called robotic?

• 11:54Speaker 00

  Well, the company is called Intuitive and it's called the DaVinci is the machine that we use to kind of do the technique. So it's a very sophisticated toolset. But you can't just, you know, you don't just need a sophisticated toolset to do a great job. You have to understand the anatomy and understand the implications of each move that you make when you're doing the operation to be able to kind of result in excellent result, you know, excellent outcomes for the patients.

• 12:21Rich Roll?

  Pre-robotics and pre-Pat Walsh, paint the picture of what could be expected for somebody who had contracted metastasized prostate cancer. It wasn't a very pretty picture in general.

• 12:37Speaker 00

  Yeah. So in pre-1990 effectively.

• 12:41Speaker 00

  Forty to fifty percent of men who came into an office where when they were diagnosed with prostate cancer was metastatic, as you said, which has spread throughout the body. And there is no cure for that. You can suppress the growth of metastatic prostate cancer by blocking, you know, the production of testosterone and there's a variety of ways to do that. But effectively, that's a very, you know, difficult process to, you know, survive because you feel very bad, you know, testosterone is the kind of predominant male hormone. It makes you who you are and makes me who I am. And so you take your normal testosterone and you bake it zero. It's basically like immediately inducing kind of menopause in a man.

• 13:25Speaker 00

  You have a lot of side effects from the medication and then if you have metastatic cancer, you often have side effects from the cancer itself. So it's this kind of double edged sword of like, you know, you, you, you have a medicine that can make you suppress the cancer from growing because you feel bad from the cancer, but the medicine makes you feel bad too. So that was kind of pre Walsh era was this idea that fifty percent of guys ballpark, forty percent of guys came in with incurable disease. And those guys that presented with curable cancer, there was really no effective treatment. Radiation was very kind of broad. It wasn't focused and there was a lot of side effects, burning of the skin, burning of the rectum, burning of the bladder when you tried to treat prostate cancer with radiation.

• 14:06Speaker 00

  And when you did surgery, you know, bleeding would be very high. It was a high risk of, of just dying when you're on the operating table. And then the side effects from the treatment, total incontinence, total impotence, erectile dysfunction after the surgery. In many ways, the, the cure was worse than the disease. And so Walsh really took those observations and said, let's, let me try to develop a technique to make the outcomes from the surgery better. And then a variety of people, there was a urologist at Stanford, Tom Stamey, who made this observation that you can use this blood, there's a thing in the blood called PSA and you can actually measure that. And he made the observation, you can measure that and gauge how you, how your

• 14:51Speaker 00

  How well controlled your cancer is. And there's a guy named Bill Catalona, who's one of my partners in Chicago, who made the observation that, hey, we can use this PSA blood test to actually check men and pick up prostate cancers while they're in their infancy, while they're much more curable. And so the two things that really revolutionized the field was Pat Walsh's development of better surgery and kind of this deployment with Bill Catalona of like, hey, we can screen guys and pick up cancers early and curable. We can do this more modern surgery and we can actually improve the outcomes for men with prostate cancer. So if you fast forward today to today, only about 4% or 5% of men are diagnosed with metastatic prostate cancer at their initial kind of diagnostic screen.

• 15:35Rich Roll?

  And what is the difference in lethality between then and 2024?

• 15:40Speaker 00

  Well, yeah, so these days around 35,000 people a year die from prostate cancer, which is a low number, but it's still the second leading cause of cancer death.

• 15:50Rich Roll?

  I think something like 250,000 people are diagnosed every year.

• 15:54Speaker 00

  Yes, so the numbers are going up in terms of diagnosis, but that's just a side effect of the idea that the baby boomer is aging up.

• 16:03Rich Roll?

  And also perhaps early detection because there's more testing?

• 16:07Speaker 00

  When the PSA blood test was approved by the FDA for screening for prostate cancer in the 1990s, a number of cases just went through the roof. That's because, you know, you just started screening a huge population of men. And so we picked up the most prostate cancers then. Once you kind of screen out the population where you're not just screening everybody who's over 50, but you're just screening men that go from age 49 to 50, right? Then the numbers came down and then they were kind of, they were steady. The total numbers right now are very high because of the boomers. But if you look at the incidence per 100,000, the rates are pretty steady. So, so we're able to kind of identify cancers now early. A lot of times we don't actually have to treat them right away. We can just map them out and follow them.

• 16:52Speaker 00

  But when we do pick up a cancer that needs to be treated, that's aggressive enough to require treatment, we have a lot of really sophisticated technologies and approaches to do that.

• 17:00Rich Roll?

  Yeah. When do we be concerned? Like, when do we know that something is off and we need to go see a urologist or get proactive about some interventions or some testing?

• 17:11Speaker 00

  Yeah, so, most of the time, you know, urinary symptoms in men are not from a cancer, but they are symptoms that can affect their overall quality of life. They can have profound impacts on their sleep habits. And so, one of the common things that people will have, men and women, but men, as they age out, you know, nighttime urinary frequency. And so, if you're having those issues and those symptoms, you should definitely see and engage with the urologist because there's medications that are very straightforward, they're safe to take, that will make you feel better. In terms of when should men engage with urologists, in terms of thinking about the C-word, or, you know, cancer, we generally would say,

• 17:53Speaker 00

  if you don't have a family history of cancer, if you're an average US citizen, so to speak, we would suggest that you engage with and start getting checked at age 50. Doesn't have to be with the urologist, it can be with your primary care physician. But again, I think men should start engaging with and developing a relationship with the primary care physician, starting around age 40. That's when things like blood pressure, cholesterol, you really have to kind of start thinking about those. And you can also start thinking about cancer screening. That includes prostate cancer screening, and in individuals, also colon cancer screening.

• 18:28Rich Roll?

  Are there lifestyle choices that we can or should be making to care for the prostate?

• 18:35Speaker 00

  Yes. The short answer is yes. But the problem is in part that the lifestyle choices that many men will say, "Hey, I want to do these things to improve my urinary function or reduce my cancer risk." Those are things that you had to really engage with early on in life. So, the life of a prostate really begins around puberty. So, let's start, let's say, age 15-ish ballpark, right? And so, it's what happens to your prostate over those decades, 15 to 25, 25 to 35, etc., that have major implications for your overall prostate health and your prostate cancer risk later in life. So, it's hard to say, at age 50, I'm going to make radical changes in my life or my lifestyle that will...

• 19:17Speaker 00

  Significantly impact the subsequent 10 years of their life. And in my mind, it's really what you do early on in your prostate's life. When you're, you know, kind of postpubescent, that really has a big impact on your future risk for cancers. Why do I say that? If you look at kind of retrospective data from different countries. Individuals who traditionally were from Asia, you know, not new, modern kind of China with all the westernized diet and all that. But if you look at more traditional East Asian cultures, their risk for developing prostate cancer is very, very low. Much, much lower than any westernized country, US or European.

• 20:01Speaker 00

  So if you say, well, what's different about those cultures? It's what they ate, right? They didn't eat a lot of meat. They had a lot of, you know, just vegetable-based, plant-based stuff, food. And then the volume of food they ate, which was substantially less because it was effectively a peasant lifestyle. And so those things, I think we've shown just historically can really lower your overall risk for developing cancer. But you really have to think about deploying those early on in life, I think, to have the biggest bang for your buck. It doesn't mean that you can't change later and have a profound impact on your overall, you know, lifespan or health span because you can. But do it early if you really want to focus on, you know, enhancing your, reducing your

• 20:46Speaker 00

  prostate cancer risk.

• 20:47Rich Roll?

  And there's nothing specific about the prostate. I mean, that's counsel you would give anybody to sidestep your, or at least ameliorate some risk of cancer generally and other lifestyle illnesses.

• 21:00Speaker 00

  Yeah. Yeah. And, you know, there's a lot of similarities between prostate and colon in terms of like the foods you eat and the impact on the foods that you eat vis a vis your colon cancer risk and your prostate cancer risk. So processed meat, charred meats, meats in general, those things are going to have a, they're associated over a long, long period of time, decades. They're associated with higher risk for developing those cancers.

• 21:26Rich Roll?

  Yeah. Well, let's talk about prostate cancer.

• 21:28Speaker 00

  Sure.

• 21:29Rich Roll?

  I mean, prostate cancer is the second leading cause of cancer death behind lung cancer. It's the number one cancer diagnosis in men, correct?

• 21:38Speaker 00

  Yep.

• 21:40Rich Roll?

  One in seven men will get this diagnosis. We mentioned earlier about 250,000 diagnoses per year. Why is this particular type of cancer so prevalent and so devastating?

• 21:57Speaker 00

  We don't really know why it's so prevalent. It varies a little bit based on genomic ancestry, so where your ancestors came from. But in general, the risk for prostate cancer is quite high and is directly associated with how long you live. So the longer you live, the higher your risk for developing prostate cancer, which is kind of unique among cancers where there's much earlier onset for other aggressive cancers like breast cancer women. So we don't exactly know. It's what we would consider to be polygenic, meaning there's many little individual genes that if you sum them up will increase your risk for developing prostate

• 22:39Speaker 00

  cancer. At this point, there's probably over 250 different little individual markers that you can actually attribute to an increased or decreased risk for developing prostate cancer. And there are tests that you can actually obtain, blood tests, that will calculate your polygenic risk, and they'll give you a score. And they'll say, well, okay, Ted, you have a low score. Your overall risk for developing prostate cancer in your lifetime's low. Or no, Rich, your score is high and your overall risk for developing cancer is elevated. So you can obtain those tests. It doesn't tell you individually that you're going to

• 23:19Speaker 00

  get a cancer or not, but it gives you a relative risk. Beyond that, there are very rare, specific genetic mutations. So there are these genes that are associated with breast cancer, BRCA1 and BRCA2. They actually are associated with ovarian, breast, and prostate cancer. So if you have a family history of breast cancer in your family, a strong family history of breast, ovarian, prostate, you may want to consider getting checked for those. They're very rare. Less than 1% of the population harbor those. But if you have them, you definitely are at a specifically increased risk for getting prostate cancer, and it's genetically related versus, let's say, environmental or other factors.

• 24:02Rich Roll?

  Is prostate cancer unique in its relationship to age versus other cancers?

• 24:08Speaker 00

  It is.

• 24:09Rich Roll?

  Like this idea that you do get it older and there is that kind of common trope of if you live long enough, you're going to get a prostate cancer, you know, diagnosis at some point.

• 24:18Speaker 00

  Yes.

• 24:19Rich Roll?

  Like what is it about this particular type of cancer that connects it with age?

• 24:24Speaker 00

  Yeah, I think it's just the kind of, it's the longstanding environmental exposures that just happen over time. And so we know, for example, that like smoke inhalation is a strong, you know, inducer for lung cancer. So if you stop that exposure, then you reduce that risk. And then for prostate, there are, as I mentioned, known kind of, you know, dietary-based exposures that, you know, are traditional in Western diets that will increase your risk for developing cancer. So it's this kind of daily, you know, small little ping that I think over time is a cumulative risk for developing a cancer. So it's true, if you're young and you get prostate cancer, you know, it's a real bummer, right?

• 25:09Speaker 00

  But the older you get, the cancers you develop are almost always more aggressive. And that's because you develop them after all these little cumulative hits in your kind of, on your prostate genome, so to speak.

• 25:23Rich Roll?

  The other interesting thing here is that symptomology only occurs in, I think you said, 5% of people that have it. So it's not something that you would necessarily intuitively know that you have unless you're proactively testing.

• 25:40Speaker 00

  Yeah, so here's the uniqueness of prostate. So we said 250,000 approximate new diagnoses this year, 34,000 deaths. If you look at pancreatic cancer, it's like 30,000 new diagnoses, 29,000 deaths, or something like that, right? So there's a very tight correlation between diagnosis and death. And the reason is because we don't have an early test to pick up pancreatic cancer while it's still curable. Every time you're diagnosed with pancreatic cancer, you will almost certainly die from it. So the, one of the big differentiators in prostate is that we have this test, the PSA blood test, we'll get into that in a sec. That PSA blood test is a way we can screen for early cancers.

• 26:24Speaker 00

  Not every single prostate cancer is lethal. Many men will die with and not from their prostate cancer. So, one of our jobs as urologists is to identify those individuals who have a prostate cancer that if left alone, it will become a problem for those men. But almost everybody we screen now has no symptoms of their cancer. Whereas if you have lung cancer, you're often, you know, you're coughing up blood. If you have pancreatic cancer, there are specific symptoms of it. We don't, we screen for men early. Those men don't have any symptoms related to their prostate cancer on average over 95% of the time. And so we're really just picking them up early. Then our job really, our important job as urologists is to say,

• 27:07Speaker 00

  you know, person A needs treatment, person B can be followed. And, you know, and that strategy is, is definitely something that we do a lot of these days. That's a pretty strong argument for getting tested. Yeah, because we, you just want to understand your individual risk and understand how close you need to be followed. So, to, to take it back for the audience, how do you screen for prostate cancer? It's a blood test. That's simple. The test is basically looking at this molecule called PSA, our prostate-specific antigen. That's something that's produced by the prostate and is normally in the semen. So that's part of that, that, that, the, the semen that keeps sperm alive and helps it impregnate or infertilize an egg.

• 27:51Speaker 00

  That particular fluid, that, that particular molecule can leak into the bloodstream. So it's supposed to be in the prostate normally. And it's in the prostate in levels that are like 100,000 nanograms per milliliter, super high levels. It leaks a little bit into the bloodstream and we screen for very low levels. PSAs in the bloodstream are often one, or two, or four, or eight, or 10. So the relative amount that we see in the blood versus in the organ where it's supposed to be is very, very low. But we look at that low number and we basically can follow that low number over time. That's why it's good to engage with a doctor because you really want to track trends and look at that number over time to kind of understand your risk at the time you get

• 28:33Speaker 00

  your first blood test and to understand your risk over subsequent five, or 10, or 15 years based on how that number is changing or if it's stable.

• 28:42Rich Roll?

  Another argument to get tested early because you're getting a baseline, basically.

• 28:46Speaker 00

  That's right.

• 28:46Rich Roll?

  And then it's really about how are you, you know, how are the levels varying from that baseline?

• 28:51Speaker 00

  Totally. It's, I always like to tell patients, it's like, I want to take not just a single photograph. I want to take a bunch of photographs and make a movie. Because then if you have a sense for what's changing over time, you can identify the bad actors from the good actors.

• 29:05Rich Roll?

  Because even if it's low and comes off as a low-risk situation, if there's a sudden extreme jump.

• 29:12Speaker 00

  That's right.

• 29:12Rich Roll?

  And even if that jump is still within a reasonable range, that would be alarming.

• 29:17Speaker 00

  Over 70% of people in the US, when they get their blood test checked, will have a PSA below three. And that's a very safe kind of range for most men. If you're younger, when you get your first baseline PSA, so for a guy who's between 45 and 50, which is a good age to start getting a baseline PSA, as you said, your number should be below one for sure, and on average, it's below .6. So the median PSA for a 40 to 45-year-old is around .5 or .6. A median PSA for a 50-year-old is one. So for half of the male audience watching right now, that's really good news. If you're 50 and you get your PSA checked and it's below one, you don't have to worry. You know, you can still, you should still follow it, but you should not be anxious at all or worried at all.

• 30:02Speaker 00

  If your PSA is over one at a young age, if it's over one at age 50, it doesn't mean you have cancer. It doesn't mean you need to do anything at the time, except for closely follow it over the years. ever kind of reaches an inflection point, as you mentioned, where it goes up a fair a lot over a year's time. Or if it creeps up to a number where we're not comfortable, 2.5 or 4 are good kind of general cutoffs. Then you want to, you know, engage more with your urologist and say, hey, we got to do some further investigation.

• 30:48Rich Roll?

  When you talked about PSA leaking into the circulatory system in the bloodstream, this is the difference between what you would call free PSA versus bound PSA, correct?

• 31:01Speaker 00

  Yeah, well, so PSA will leak into the bloodstream. And how the PSA appears in the bloodstream, free or bound, varies if it's leaking into the bloodstream from a benign prostate cell or from a cancerous prostate cell. Okay? So, there's less free PSA around in the bloodstream if the cell that's making the PSA is a cancer cell. If the cell that's making the PSA is just a benign cell, as we've talked about, the prostate gets bigger as we get older, then there's more bound PSA, there's more unbound PSA, so the percent free is high.

• 31:40Rich Roll?

  Right, so as we age and the prostate gets larger, there's going to be more PSA in the blood.

• 31:46Speaker 00

  There's more PSA in the blood, but there's also a higher percent free PSA in the blood. If you, if you get, as you get older, if your PSA goes up, but your percent free PSA is low or goes down, that's the canary in the coal mine to tell you, you have a problem.

• 32:01Rich Roll?

  And that problem still isn't necessarily cancer. Could it be attributed to something else?

• 32:06Speaker 00

  It can be other things. It just warrants further investigation. So, ballpark.

• 32:12Speaker 00

  I think PSA screening at age 45 is good. Understand your baseline. There's very few men at age 45 that have prostate cancer. So for the audience out there that's scared, don't be scared. Just get it as part of your annual routine to get a PSA test. And just chart it. Don't rely on your doctor to chart it. Just do it yourself. Get it every single year. If your PSA rises, as you mentioned, more than half a point a year, that may be cause for concern. Or if it crests over the 2.5 or 4 threshold, those are causes for concern. So what do you do then? Then you can get this percent free PSA. It's a free test and you can look. If your percent free PSA is high, that means that you're, you shouldn't have to worry too much

• 32:55Speaker 00

  because it just means you're probably, your prostate's getting bigger as you're kind of getting older. If your PSA goes up and your percent freeze low and the number you want to think about is 16. So if it's below 16, you should be a little worried. If it's over 16, you're probably okay. Still follow it though. If you have any worrisome signs, what do we do? We don't just start poking you and doing biopsies. We do other tests and the test that we like to deploy is an MRI. And I always explain it to patients like, you know, these days you never go anywhere without checking Google Map. Right? And this is just a high resolution Google Map of your prostate. It gives us an amazing topography of the prostate and it will identify suspicious areas. If there's a suspicious area, that's when you want to go

• 33:40Speaker 00

  and you can do an MRI guided biopsy of that suspicious area to figure out what's going on. And again, if you have an MRI abnormality, it's not a guarantee that you have prostate cancer and it's definitely not a death sentence. Rather, these tests allow us to identify, think, rule out cancers in many guys, but pick up cancers while they're early and curable in many other men.

• 34:01Rich Roll?

  But the MRI only comes into play once there is a PSA value that is concerning enough to inquire more deeply.

• 34:09Speaker 00

  Yes, in my mind, you know, you can get MRIs and there's a lot of interest in whole body MRIs. At this point, it's very much on trend. In general, I don't think a whole body MRI makes any sense or a prostate specific MRI without a baseline blood test number. Because that test, the PSA test is so powerful at, you know, effectively your pre-test probability of having something that unless your pre-test probability is high, I wouldn't deploy the test, which is the MRI.

• 34:38Rich Roll?

  And in the context of the MRI, it's also important to have a qualified technician and diagnostician who knows how to take the right image and interpret that image.

• 34:50Speaker 00

  Yes.

• 34:51Rich Roll?

  Right? Because somebody who isn't necessarily as steeped in urology as yourself might miss something or might not have the right frame in the right place to properly interpret the result that you're trying to understand.

• 35:04Speaker 00

  Yeah, and you know, it's a team-based approach, right? So urologists are really the captains of the team, but we have to rely on like, super talented radiologists and other folks. They're the folks that really tell us, "Hey, is this MRI suspicious or not?" We put it into the clinical context, but they give us their initial assessment, "Okay, it's an A, or a B, or a C." We then put that in the context and help our patients make a decision about a next step.

• 35:30Rich Roll?

  Before the PSA, though, we all have the experience with the reach-around. Right? So the reach-around precedes the PSA typically with your general practitioner when you go in for your annual checkup or whatever.

• 35:44Speaker 00

  Yeah.

• 35:44Rich Roll?

  What is that all about? It's called a DRE.

• 35:47Speaker 00

  Yeah.

• 35:47Rich Roll?

  What do we, you know, is that still an effective, you know, indicator of anything? Or is that something we can just sidestep, just get your PSA?

• 35:57Speaker 00

  I mean, I do rectal exams on everybody, but almost everybody I see already has a cancer diagnosis. So for me, I'm doing it to get a sense of their extent of their disease. The benefit of doing a rectal exam in individuals who you're screening is very limited relative to the power of the PSA test. So I'm not saying that your doctor's a bad doctor for doing it. Is it essential? It's not essential, and frankly, if you can get a primary care doc who will map and chart out your PSA annually over time, frankly, that's, and there hasn't to do with the exam, that's fine too. One of the things I'll have, as many primary docs will just say, "I'm not comfortable. I don't do enough reps to do it.

• 36:42Speaker 00

  Can you just see this person?" And I will do it for them, but it's not essential. So if that's what guys are afraid of, going to the doctor for, then go to the doctor, get the test, and you're 98% of the way there.

• 36:53Rich Roll?

  The other ripple has to do with hair loss medication. If a patient is taking Propecia, Finasteride,

• 37:02Speaker 00

  Yep.

• 37:02Rich Roll?

  that is going to artificially reduce that PSA value, correct?

• 37:07Speaker 00

  Yeah. So these tests, these products will, A, help with hair loss prevention, but they are, they lower the PSA test by about 2 to 2.5. So if you, and it depends on the time that you start taking the medication. So if you start taking Propecia and you're a young man, then your PSA will be very, very low. It should be less than 1 for sure, less than 0.5 when you start the medication, if you're taking it in your 20s or 30s. And it will remain very low over your, your whole lifetime. It should never, ever move. So the point is, when you start the medication, your PSA will drop. And it drops between 1/3 and 50% on average. You have to just chart that out.

• 37:52Speaker 00

  And that's really the patient's job to do that. You've set that new baseline and it should never go above that baseline. The new baseline PSA, when you start these medications, is where you are and it should never move up. If it moves up, that means that you have a four or five-fold increased risk for actually having a cancer at that time. So the medication is very powerful at lowering the PSA and suppressing the PSA. If you ever have a bump up, you've got an issue. And the problem I see is that there's a lot of online resources for, for these hair loss medications. And men may not inform their family physician, their primary care doc, "Hey, I'm, I'm taking Propecia for hair loss." And they'll be, I see it in my practice. It's not a theoretical thing.

• 38:36Speaker 00

  I'll see it where a guy comes in, he's 55, his PSA went from 0.5 to 1 to 4 to 6. And it's too late before the primary care doc realizes it's not actually 6. It's 12 or 14 because you have to double or 2.5 x it. So that's when the real problem happens.

• 38:55Rich Roll?

  So a general practitioner may not know to ask that question, but any urologist is going to know.

• 39:01Speaker 00

  We ask, but it's, you know, the question is who's doing the primary screening? So there's a really well-done study done out of Southern California where they looked at individuals in the VA. And they looked at men, they said, is it safe to put people on finasteride or propecia? And the answer was that there was a much higher risk of death from prostate cancer in people on propecia or finasteride than those that were not. And the reason is because of what we just talked about. The primary doctors who are doing the screening, they're just not aware of the situation. And so the number starts rising and they missed the early detection.

• 39:37Rich Roll?

  Right. Another nuance to this is understanding PSA density. So if somebody has an elevated or a concerning PSA value, then you have to look at the density of that. And from what I gather, and please correct me, I could be totally wrong, this then becomes somewhat of a predictor of the aggressiveness of that cancer.

• 40:00Speaker 00

  Yeah, it's a difficult concept, but it's a very important concept. So as we said, the prostate, as we age, it gets bigger. And more PSA leaks into the bloodstream just from a regular, just increasing size over time. And so if you think about the average size of a prostate for a man who's 50, it's around 25 grams. And if you look at a safe PSA for a man at around 50, it's less than 2.5. So if you do that calculation, 2.5 over 25, that PSA density for that individual is 0.1. And that's kind of a safe PSA density for most guys. As you get older, your prostate gets bigger.

• 40:44Speaker 00

  So an average prostate size for a man who's 60, maybe 40 grams. So if your PSA is four and you have a... A 40 gram prostate, then actually that PSA density, again, is fine, it's .1. The problem lies in if your PSA is 5 and your prostate's still 25 grams, that means that there's a lot more PSA being leaked into the bloodstream relative to the size of that prostate. And that is a very strong predictor that there's some kind of cancer going on in that guy's prostate versus the other guy whose PSA is 5, but his prostate's 50 grams. That's just probably PSA being leaked into the bloodstream on average because their prostate's just bigger and it's just growing with time.

• 41:29Rich Roll?

  Right, understood.

• 41:30Speaker 00

  So, so you, it's hard to, you don't know your PSA density unless you've gotten an MRI or had an ultrasound. So usually the algorithm is we're tracking PSA over time. We're looking for the velocity change. How much is it increasing over time? Or is it remaining flat? And if it's increasing, or if it's increasing, we do something like the percent free PSA check and it's low and concerning, we get an MRI. I look at the MRI, say, okay, number one, what's the volume of the prostate? And I calculate the PSA density. And then number two, do our radiology colleagues see something suspicious in the prostate? And they'll rank order like how suspicious it looks. Those are the factors that I take with me to suggest, okay, we should do a biopsy or no, we should think about,

• 42:15Speaker 00

  we can just follow you.

• 42:16Rich Roll?

  Hmm, this is a pretty bulletproof case that you're making for, for testing, early detection. But there is a very persistent second trope in your world, which is, and I've heard this many times, like, oh, don't get tested. You know, if you get tested, they're going to find something and you're going to end up with an unnecessary surgical procedure because, you know, there's financial incentives for surgeons and hospitals to, you know, cut and also, you know, sort of litigation oriented incentives to make sure that you're doing everything you can. Can you speak to that controversy a little bit? Or I don't even know if it's a controversy, it's just a kind of...

• 43:01Speaker 00

  Yeah, I mean, it's certainly, so look, most people who get, most people don't have prostate cancer. And so getting a baseline PSA test will provide significant reassurance for those men.

• 43:16Speaker 00

  It's, you know, 90% of men at age 50 don't have an elevated PSA. They're in the clear. There's no problem. So it's just a select group of people that have an elevated elevation in their PSA. It's not everybody. It's a very, very narrow focus of individuals who have an issue and then require additional testing and may need to have surgery. In terms of the idea that urologists are, you know, making money doing surgery, well, the way our profession works on average is that we're paid for the work that we do. That's true for attorneys. That's true for hedge fund managers. Everybody's paid in general for the work that they do. So I myself, I'm not. I'm on a flat salary. But in general, that's the way that it works.

• 44:00Speaker 00

  However, I would argue that urologists spend a lot of, you know, the insurance company's money doing these sophisticated tests to really reduce the number of biopsies we do. MRIs are very expensive. They're five or $6,000. We deploy MRIs all the time to not lean us to do a biopsy, but actually to steer us away from doing a biopsy. So if you look backwards in the old days, before MRI, everybody with an elevated PSA got a biopsy. Now with MRI testing, about 2/3 of men who get an MRI, actually, we find out they don't need a biopsy. Then of the 1/3 that get a biopsy, and let's just say we pick up a cancer, about 40 to

• 44:44Speaker 00

  50% of cancers that we pick up today, we don't recommend treatment for. So we're actually monitor people over time, following their cancers rather than just cutting on them and, as the story goes, making a buck or two. So I think that in general, urologists are very good citizens. They're very cognizant of what they do. Why? Because unlike a lot of other surgical specialties, we follow our patients for life. So...

• 45:16Speaker 00

  When I have a patient who has prostate cancer, they have access to my cellphone number for the rest of my life and their life. So we follow them longitudinally. So we're very engaged in kind of survivorship with them. And so in that way, I feel like we, you know, we have a reasonable conscience to say, hey, we want what's best for our patient because they can track us down over time if we do something to them that, you know, they don't, you know, they have side effects from the treatment or something like that.

• 45:44Rich Roll?

  Right. You did say something that was quite alarming, though, which is no PSA number, no matter how low, guarantees that you don't have cancer. So even if you go through the rigorous testing that we just spoke about, there's still a percentage chance that you nonetheless have prostate cancer.

• 46:04Speaker 00

  Well, I mean, cancers don't read rulebooks. That's what I always tell my patients. When we get a great pathology report after a surgery, everyone's happy. I just say, we're still going to follow this. They don't read the rulebooks. So yes, there are no absolutes in medicine. Prostate cancer falls under that same, you know, general edict. There are no absolutes. And so you have to be a thoughtful, good doctor. And there are several, you know, prominent folks out there right now who are really battling publicly, and they're true champions. There are prostate cancers that don't always show up with high PSAs. But on average, this approach is safe for men to engage with their physicians. And it, generally speaking, allows for those rare individuals

• 46:49Speaker 00

  who have a cancer that needs treatment to get their treatment early and be cured. And for the vast majority of men out there, they can be screened and they can feel rest assured that there's nothing going on.

• 46:58Rich Roll?

  Mm-hmm. Hence the much lower lethality rate in comparison to diagnoses.

• 47:04Speaker 00

  That's right. So if you say there's 34,000 deaths a year, that means that there's 170,000 men who are surviving their cancer. And many of those men never got treatment. We're just monitoring them.

• 47:17Rich Roll?

  Okay, so, reach around PSA, MRI, all of these things are telling you that we need to know more, so the next step is the biopsy.

• 47:30Speaker 00

  Yeah.

• 47:31Rich Roll?

  And performing a biopsy on the prostate is not a small thing, from what I understand.

• 47:36Speaker 00

  We just finished a study where we just carefully tracked, in the modern era nowadays, how people do after prostate biopsy, how much does it bother them, and what are the results of the testing that we do. So, a modern prostate biopsy at our shop is with a kind of percutaneous approach. That means that we put the needle through the skin into the prostate. We do have an ultrasound probe in your rectum, and that's actually the most uncomfortable thing. The thing that guys don't like with the exam is the fact that there's a finger going in their rectum. We still put an ultrasound probe in the rectum, it looks directly up at the prostate and

• 48:18Speaker 00

  visualizes it, and then we can use software to kind of overlay the MRI onto the ultrasound image, and then deploy a needle from the skin into the prostate just above the rectum, and actually sample the suspicious areas within the prostate. What does that mean for men? It's about an eight-minute procedure at Northwestern. We know on a 1 to 10 pain scale that they report it's about a 3.6 out of 10. So, it's uncomfortable for about eight minutes, it's not painful. We deploy as much lidocaine as possible. We really max out the dose per kilogram of lidocaine and numb the area up.

• 48:59Speaker 00

  And with that, we can get the results of the biopsy. If you think about it, like, are we really doing this because we're incentivized to do biopsies? I would say the answer is no. About 50 to 60% of the men we biopsy, they needed the biopsy. We pick up a cancer that is something that we wanted to know about. So we're not overly biopsying people just for fun or for money. We're doing it when the clinical indications are appropriate. The procedure's done, awake in the office. It takes eight minutes. They leave the office on their own. The pain that they had at the time of the biopsy is gone within 10 minutes.

• 49:35Rich Roll?

  And that's going to definitively tell you whether a cancer is present or not.

• 49:40Speaker 00

  It tells us if there's a cancer that is significant enough for us to worry about on average, yeah.

• 49:46Rich Roll?

  And so from that, what is the decision tree around surgery?

• 49:51Speaker 00

  The decision tree is very complicated, but it's quite simple, to be honest with you. It's what's the age and the health of the patient? And how aggressive and how bulky is the cancer? It's those two things that really kind of weigh, we put into the equation as to whether or not the person needs treatment for their cancer. And if they need treatment, what's the best treatment for them? So about 40% of the cancers we pick up today are low-grade and they're small, and we monitor those. Historically, those individuals would have had surgery. When I was training, those men automatically had surgery. We've now learned that those cancers are indolent. They're not aggressive.

• 50:33Speaker 00

  They don't grow very quickly, and they can be followed safely for five to 10 years sometimes before an intervention's necessary. So those men, we follow, we call that active surveillance.

• 50:43Rich Roll?

  And is indolent the opposite of metastatic?

• 50:46Speaker 00

  Indolent is the opposite of like fast-growing and aggressive.

• 50:50Rich Roll?

  I see.

• 50:51Speaker 00

  So it just kind of sits around. It may change slowly. Indolent, low-grade cancers, at five years, about 40% of them.

• 51:01Speaker 00

  Flip and they start growing. At 10 years, around 60% kind of have flipped and start growing. And you'd say, well, that's not very good odds. And I would argue, well, if 10 years after a diagnosis of cancer, that 40% of men don't need anything, I'd say that's a huge win. When historically, everybody who had that got treatment. So that's 40% of guys who we do biopsies on have a cancer that we can follow. They don't need any treatment. What does that mean for the guy? It means that they can live their regular, healthy life and not have to worry about it, except for once a year when they come in for their biopsy.

• 51:35Rich Roll?

  So there's no pharma intervention or any other

• 51:38Speaker 00

  Nothing's needed.

• 51:39Rich Roll?

  ...treatment protocol?

• 51:40Speaker 00

  Yeah.

• 51:40Rich Roll?

  Other than just consistent screening?

• 51:42Speaker 00

  A heart, healthy lifestyle is the best thing for those guys. Of the men who have a cancer that, you know, needs to be treated, those men can choose to have surgery and/or they can choose to have radiation-based approaches. Again, in the whole spectrum, only about 4 or 5% of men that we diagnose have metastatic prostate cancer, prostate cancer that's spread to other parts of the body. So if you're getting a biopsy, 40% of the time, it's something that can be followed. What's the math? 55% of the time, it's something that we should probably treat and treatment will prolong your life. And 5% of the time, you get treatment, but it's intensified other kinds of treatment,

• 52:24Speaker 00

  not surgery and not radiation to really extend those individual slice bands.

• 52:29Rich Roll?

  But radiation would be the preferred treatment protocol for a metastatic version that has spread to other areas of the body, obviously, because surgery is not going to...

• 52:40Speaker 00

  Yeah. So when it's metastatic, we use two things. We use systemic therapy by medications that will aggressively block your testosterone levels to zero. Testosterone is the fuel for prostate cancer to grow. So you can suppress and really halt its growth significantly. And in many cases in those scenarios, we will also use radiation to kind of spot well any little areas that we see the cancer in. That's very effective for men with metastatic. For men with clinically localized cancer that needs treatment, then they can either have surgery or they can have radiation. In general, both are effective treatments. We usually will direct young individuals, individuals with a 20, 15 to 20-plus year

• 53:22Speaker 00

  life expectancy, towards a surgical approach versus a primary radiation-based approach because surgery in general is more durable. It is lasts longer than a radiation-based approach. So for young guys, we will usually deploy surgery. In general, for older guys, we will usually deploy radiation. But there's a lot of nuance and it's a very individualized, you know, decision process that we usually will work through with our patients to, you know, allow them to make the best decision for themselves.

• 53:53Rich Roll?

  And is that because surgical intervention in an older person becomes a higher-risk scenario?

• 54:00Speaker 00

  So the, you're really kind of measuring and trying to gauge and balance out the life expectancy of the patient and then the efficacy of the treatment. So in general, radiation is not as, doesn't have as many profound or potential profound side effects as does surgery, particularly in older men. So the main side effects with treatment are impacts on urinary function and impacts on sexual function. The impacts and then cancer control. So in an older individual who maybe has less robust muscle mass and less resiliency in their tissue, surgery may result in higher rates of urinary incontinence, for example, with surgery.

• 54:41Rich Roll?

  I see.

• 54:42Speaker 00

  Whereas with radiation, there are really effectively minimal or no rates of urinary incontinence. And if the radiation can effectively control the cancer for what we anticipate is the patient's life expectancy, then we'll go with radiation. There are a lot of nuances to it and variations in terms of what we select for individual patients. And so we, I will often really encourage patients to go see a radiation oncologist and learn more about the disease from their perspective before we make a decision about what's best for them.

• 55:14Rich Roll?

  Understood. So for the patient who is a good candidate for surgical intervention, the surgery is called robotic prostatectomy.

• 55:24Speaker 00

  Yes.

• 55:24Rich Roll?

  And I'm envisioning, I don't know what this looks like, you mentioned the DaVinci machine.

• 55:30Speaker 00

  Yeah.

• 55:31Rich Roll?

  But I'm imagining, you know, a large computer-based sort of thing where you have a high-precision joystick and somehow you're operating an arm, or there's a program that goes in that can do the cutting and the incisions, you know, in a very specific and targeted way.

• 55:51Speaker 00

  You claim that you're a layperson, but you're a budding urologist, you need to know it. Yeah, so that's basically, the best way to think about the robot from the, you know, the utilizer's perspective is like, it's like playing an organ in many ways. You have foot controls, so when I operate, I use my two feet and my two hands. So you control things, individual hand movements with each hand, and then you have foot pedals to also augment your ability to move things. The actual, the technology that really was the edge for Intuitive in terms of doing this was two things. One, their technology allows for something like the size of your pen. That's the size of the instrument that we put inside the human body.

• 56:35Speaker 00

  It's fully wristed and allows for seven degrees of motion. So exactly what my arm can do, the instrument that I put inside the body can do, it's just totally miniaturized. That was a huge, huge advance that Intuitive developed and came up with and patented. The other was that they came up with this idea that you could create a laparoscope, that's how we see things on the inside of the human body, that had two eyes. So previously, all the laparoscopes had a single lens or a single eye, and all you would be able to do is see two dimensionally. Their technology allows for processing of images from a right eye and a left eye, they're adjacent to each other, they're very close, but they can actually... Triangulate an image and they provide three dimensional views.

• 57:20Speaker 00

  So basically.

• 57:21Rich Roll?

  You can, you can understand depth.

• 57:24Speaker 00

  When you, when you put your head into their console, which is like basically the size of this table. When you enter that space, you are entering the inside of the human body in three dimensions. I mean, it is just like spectacular, spectacular stuff. So with that, you can see things that you could just never see with open surgery. When you're doing open surgery, it's your regular eyes, even if you wear magnifying glasses. You can't see things, there's much less bleeding when you do it with the laparoscopic robotic approach. So there's no kind of blood hiding the surgical field. So the, the view and, and the ability to do things, you just cannot do them with, with traditional instrumentation.

• 58:06Speaker 00

  And that is part of the skill of what makes a great, you know, prostate surgeon. And the other one is just understanding the nuances of the human body and how the anatomy varies. And it's just like, it's that old 10,000 hour adage, right? If you do lots of, because you can't, there's no automated program to just take a prostate out. Cause your prostate's different than my prostate and everyone else's out there. So that idea of understanding anatomy, I learned that from Pat Walsh. And that guy saw stuff that I only saw when I started doing robotic. I mean, he just had, he just understood the anatomy spectacularly. So it's the robot and that as a very sophisticated, very expensive set of tools.

• 58:46Speaker 00

  And then understanding the disease and really understanding the disease in the sense of skating where the puck's gonna go. And really anticipating what you're gonna see in that particular case. Um, that really make for, I think, a great prostate surgeon.

• 58:59Rich Roll?

  How long did it take for you to master this machine?

• 59:02Speaker 00

  You know, there's ways to kind of gauge that performance. And so how you do in your first 50, 100, 200, 250 cases. So when we looked, I was, I was, I was good out of the box.

• 59:15Rich Roll?

  Yeah.

• 59:16Speaker 00

  But, um, you know, you get better every time.

• 59:19Rich Roll?

  Those surgeon hands.

• 59:21Speaker 00

  I'm not sure what it is, but I did okay out of the box, but I always, we have this very sophisticated software that allows us to actually, we record every single case we do. So, I look at my cases and I look at how patients do and I can actually help, just like professional sports teams do, and my mentor did the same thing. He used, you know, VHS tapes. We have everything digitized and by the end of the day, my cases are downloaded to my virtual inbox of my surgeries and I can pull those cases and look at them, which is pretty awesome.

• 59:52Rich Roll?

  Like game tape.

• 59:53Speaker 00

  Game tape. Takes a lot of time, but you know, it's pretty amazing when you go back and look and you know, you kind of analyze and say, where could I have done better in this case, or what was it about this case that was a challenge? And that's kind of the fun part of doing it, right? You know, you can just kind of continually try to perfect your technique.

• 1:00:10Rich Roll?

  I think some of Pat Walsh's procedures are on YouTube.

• 1:00:14Speaker 00

  He has them. Yeah, yeah. He, you know, that was one of his gifts, you know, back was to say like, he really was the master and he owned the space, but he didn't, he really shared that space. And so, I, we have a YouTube channel at Northwestern. I put up many, many of my techniques and I'm always developing new techniques that I think will result in better outcomes and I put them out there so that other surgeons can, you know, all of our trainees are ultra talented. I train our, I train our residents, physicians, how to do my techniques, teach them the tools to learn them and to deploy them in their own practice and I put my videos out there so people can see them. It's not proprietary, it's so that everybody can be better, right?

• 1:01:08Rich Roll?

  How many of these DaVinci machines exist?

• 1:01:12Speaker 00

  Nowadays, it's hard to say. I think we have at our hospital 10 and in deployed, we have 11 hospital system out throughout Chicago. We probably have 25 different machines. They were the market share leader. They had the patents on everything up until this, just this past year. So they really have the ability to kind of be very proactive and develop really nice tools for us to kind of use for our patients.

• 1:01:37Rich Roll?

  But is it the case that every major hospital has one of these machines in their urology department?

• 1:01:43Speaker 00

  Well, they're used now for almost, almost all kinds of surgery. You can use the robot to kind of advance things. It was originally developed for cardiac surgeons because that's very precise suturing and you need magnification and it just wasn't adopted in cardiac surgery. Urologist is, urology is a specialty that's very kind of innovative. We're always kind of progressive and trying to do things better with, you know, new tools and new technologic advances. And so we saw this tool, deployed it in our space. We just started doing it on prostatectomy and now for almost every major surgical procedure we do, it's done with the laparoscopic robotic approach.

• 1:02:23Rich Roll?

  Every surgery requires an intense level of precision, but from what I understand, the prostate is particularly sensitive because of the, the density of the kind of vascular system there. Is that what creates the complications and the risks?

• 1:02:47Speaker 00

  It's the size of a golf ball. Everything surrounding it is like high-priced real estate. So you have to be very precise about dissecting the prostate off, all the structures around it. And there's something that those structures exist to do. There's no redundancy when it comes to where the prostate's located. So you have to be very precise about separating it off of something on all the different sides that it's kind of a budding. And then you have to reconstruct it. So you're disassembling things, you're putting them back together. And so, yes, the robot enables more surgeons to remove prostates, but you also have to be skilled in how you remove it and put it, put every, put the pieces back together effectively.

• 1:03:28Speaker 00

  And that's where, that's a big differentiator from a, a good surgeon to like an exceptional surgeon.

• 1:03:35Rich Roll?

  And does prostate cancer show up as a singular mass, like a lump? Or is it something that's sort of diffused across the prostate? Like, when you go in to take it out, is it removing one thing? Or lots of little things and trying to find where it's hiding?

• 1:03:53Speaker 00

  Yeah, it's a great question. And I like to explain to patients, like, it's a weed with roots. And those roots can kind of disseminate and infiltrate throughout the prostate. So even if you can see a spot on MRI, that may be the weed above the surface. The depth and the extent that the roots disseminate throughout the prostate is variable. And so you can't just go carve out and pull out the spot that you see on the MRI. Because the roots of that spot kind of do disseminate, not everywhere in the prostate, but they may go from the right side across to the left side. Or, in fact, grow outside of the prostate. And when you have roots of the weed growing outside of the prostate, that's where, you know, that's where part of the surgery becomes technically more difficult.

• 1:04:36Speaker 00

  Because there's no, everything around the prostate is really important. So you have to kind of gauge, okay, does the tumor have roots outside? If the prostate cancer has roots outside, am I clearing all those roots out when I'm doing the operation? Et cetera. And so that's where it becomes technically very difficult. And you're kind of processing this. The procedure takes around three hours. So you're, you know, you're in this machine. You can take a break and give your eyes a rest. But you are hyper-focused for three hours. Where you're really just focused on and doing this one particular craft. If you do that several times a day, it becomes, you know, like training, it becomes hardcore training to be able to do it, you know, for 10 or 12 hours in a day.

• 1:05:18Rich Roll?

  In terms of risk factors, you mentioned sexual dysfunction, urinary tract dysfunction. Are there other risk factors? And what is the incidence level of these risks showing up?

• 1:05:29Speaker 00

  Yeah, so those are the main ones. So it's really, we focus on cancer control. And how often, you know, are you removing the cancer at the time of surgery? Theoretically, it should be 100% of the time. A really excellent surgeon is removing the cancer, you know, 95% of the time when it's contained within the prostate. And that's kind of how I track my numbers and we're able to track your performance. And then rates of urinary leakage should be very low. And it's hard for me to say what other folks are doing. For me, you know, 95% of my patients are dry by three months after surgery. About 55% are that way immediately after surgery, like no leakage at all.

• 1:06:11Speaker 00

  And about 2% of guys, there's something else wrong in terms of their urinary function that requires them to have a small secondary procedure to be totally dry and comfortable. So overall, with an experienced surgeon, you should be looking at rates that are in the, you know, 1, 2, 5% range. Erectile dysfunction is not quite as good, and that depends on a lot of factors. So why is it that men have erectile dysfunction after prostate surgery? So when you want to have an erection, you get a signal from your brain. It goes all the way down your spinal cord. It goes through the nervous system into the penis, and those nerves run right adjacent to the prostate. These nerves are microscopic.

• 1:06:56Speaker 00

  You cannot visualize them. We know where they are, but you can't actually see them, and we have to kind of peel them off of the prostate. In doing that, they often will be damaged, and so they have to kind of recover from that damage. And that recovery rate is variable. It depends on, well, what's the function of the patient before the surgery? What's the age of the patient? So the younger you are, the more resilient your nerve tissue is. And then what's the extent of their cancer? Because one of the first places that cancers grow is just adjacent to the prostate, and that's how that happens to be where the nerve tissue is. So there's lots of variables that affect your ability to recover erectile function after surgery. So it's hard to kind of just say, okay, if you have surgery with Shaffer, 95% should be dry at three months.

• 1:07:40Speaker 00

  It's hard to give that equal number for recovering erectile function. And that's where, really, we're much more kind of individualized in kind of giving that patient's probability of recovering.

• 1:07:50Rich Roll?

  Urology and what you do is somewhat unique in the world of oncology because cancer doctors are constantly contending with death and they're combating a disease that eludes our ability to figure out how to cure, at least so far. And so there's a lot of tragedy around it. But you're in this situation where you're performing this life-saving procedure that is taking lethality off the table. So you have this rare opportunity and experience of treating patients and being with patients

• 1:08:31Rich Roll?

  on the other side of this surgery, like literally saving their lives, preventing this lethal cancer from robbing them of their lives too soon. I'm curious around what that experience is like for you when you go and visit the patient after the procedure, or you have the opportunity to look them in the eye and spend time with them afterwards.

• 1:08:54Speaker 00

  Yeah, it's a good question.

• 1:08:55Rich Roll?

  They have this new lease on life. They have this opportunity all of a sudden.

• 1:09:00Speaker 00

  Yeah, I think that being an oncologist or a cancer doctor has a lot of high highs and a lot of low lows. For me, it's a gift that I was given. This is my talent. So I feel grateful and I have a tremendous amount of gratitude that I can help with my gift to help other people. And I'm always, I try to be as empathetic as possible. These are people who, as we talked about earlier, they have no symptoms. They're living their regular, normal life and then they get this diagnosis and it's not on their 2024 agenda. And so although we can cure them, it's still a process for them to think about and to kind of work through.

• 1:09:43Speaker 00

  And last week, I took care of a 44-year-old man who has a four-year-old kid. So although I know that he's going to survive, it's still, if you just pause and think about that stuff, you have a family. It's remarkable and it's scary and very powerful. So I feel honored that I can participate in these individual patients' journeys with them. I feel that there's a lot of...

• 1:10:11Speaker 00

  I do have, you have a burden that you really have to be a cheerleader for them. You have to be a psychiatrist for them. You have to really try to be, you know, in this one moment in time, you know, a lot of things for them. And so for me, that, that heavy burden is fed forward and I get a payback from, for my patients, and you know several of my patients. And, and the relationships that I develop with them over time is, is really, it gives me kind of the energy that I need individually to kind of get back to the next 10 men who we, we help in their journey in life.

• 1:10:45Rich Roll?

  Yeah. I mean, one, one patient that I know of yours, you know, said basically like, suddenly, you think your life is getting stripped away, your life is returned to you. And this question comes up of, well, what are you going to do with this?

• 1:11:02Speaker 00

  Yeah.

• 1:11:03Rich Roll?

  And I would imagine, having done this for as long as you have and performed as many of these procedures, that you've seen people take stock in the inventory of their lives and, and make changes as a result, like to, not to say that there's a, there's, that this is like a, like a gift, but there is an opportunity in there.

• 1:11:26Speaker 00

  Yeah.

• 1:11:27Rich Roll?

  And I'm curious around like what you've seen people do with, with that opportunity.

• 1:11:32Speaker 00

  Yeah. I, you know, I, you're absolutely right. And it's, it's, it's the silver lining of the diagnosis is when you can see an individual really take that, you know, accounting of their life and perhaps how they've given back in whatever capacity they have and really being, making what they perceive as a negative into a positive. I know for me personally, I've, I've done that, I've taken stock of my own, you know, the gifts and, and accounted for what I've done. And it's made me, I think, a much better. You know, person, a much better husband and a much better dad. So that when I do spend time with my kids, I think about, okay, this is really, this, in this moment in time, what, how can we make it better?

• 1:12:15Speaker 00

  And so I, it's helped me, but it's also really nice to see patients, they've done just many, many things. It doesn't have to be that they start fundraisers for prostate cancer. I don't want, you know, a million people doing that. I want people to kind of, again, reengage with their talents and, and, and, you know, deploy those talents to make the world a better place. It sounds super cheesy, but it's actually, people do that and it's very, very powerful.

• 1:12:40Rich Roll?

  Hmm. Another trope that you see in movies and television is the surgeon with the terrible bedside manner, right? That's just all about like the cutting and, you know, getting on with it. The emotionally stunted, uh, you know, kind of overly materialistic, you know, uh, character. You're certainly not that. You strike me as a deeply empathetic person who's very aware of the role that you're playing. But within that, how do you manage, like from a psychological perspective, the toll of, of, and the heaviness of it all? Like, do you have to have certain kind of psychological boundaries?

• 1:13:22Rich Roll?

  So you're not, you're not like this porous membrane where all of this, you know, angst and fear and pain is seeping in? Like, you know, how do you comport yourself over the, the long term? So you can continue to do this and, and take care of yourself?

• 1:13:37Speaker 00

  Well, um, one, I bike ride a lot. So that helps me personally, just in terms of if I can get my blood, my, my heart rate over 150, that helps me a lot.

• 1:13:46Rich Roll?

  Yeah. Peter, Peter got you on a program? You have this, do you have the indoor bike? You're not out riding in Chicago in the winter, are you?

• 1:13:53Speaker 00

  Uh, I rode in February this year.

• 1:13:55Rich Roll?

  Did you?

• 1:13:56Speaker 00

  Because it was 70, right? But, um, in general, I'm indoors in the winter and I'm, I, I try to get out and bike commute in the summer best I can. But I would say that. It's definitely something I've thought about and to be honest, I will tell the patients to their face how I'm feeling and I will try to be as empathetic and say, "Listen, you know, I know this is hard for you and I feel for you" and you know, and I'll just tell them to give me a hug. And like, and that idea of being, having fewer barriers at that moment with the patient, I've actually found helps me a lot and actually helps those patients tremendously. And it's tough. I mean, you know, after doing surgery for 12 hours in a day and, you know, I probably lose five or six pounds in water weight

• 1:14:39Speaker 00

  just because the OR doesn't have humidified air and you just, you know, it's just, it's just an intense process. You know, it's hard sometimes to go and see these people, but you have to think about, I just try to think about how they're scared and how I do this thing every day. They do this once in their life. And so, I try to remind myself of that and then I have my wife to remind me of that too. So, she keeps track of me and makes sure that I'm good to my patients.

• 1:15:05Rich Roll?

  Yeah. Have you ever had any moments where you felt like you needed to step back because it was all too much or you're able to navigate it and kind of find a way to balance all of that?

• 1:15:17Speaker 00

  I think, you know, it would be too much, I'd be too macho to say that you don't have those. And you know, you have them when you have, you have, you know, you have, you're doing the surgery and you have a side effect, you have a complication and it's super duper hard to process and develop a game plan when you do have a complication. And the greatest surgeons in the world have complications. And there, then that's when you just need to rely on your friends, your colleagues, who are usually, I think, in your specialty, in your line of work to just decompress. So, I try not to decompress professionally with my family because I, I just don't want to be that guy, which is why I'll spend time on the phone on my drive home with...

• 1:16:03Speaker 00

  colleagues and just say, you know, I had a tough case or I had a hard day and it was or I had a patient who, you know, they're young or they're this or that. So I try to do that with my colleagues and I try to proactively reach out to them because I know that they go through that same thing. It's very much in the forefront of medicine, this idea of physician burnout and processing all these different, you know, outside stressors in your individual life and then your professional life and just working to kind of balance them. And it's definitely something that's a work in progress for me, but I think outlet through friends and then outlet through family and then outlet through high heart rate.

• 1:16:39Rich Roll?

  Yeah, I mean, the conventional idea that you would have would be you're modeling something different. Like there's this idea like, listen, I'm performing thousands of these procedures. Like, do you want me to do a good job? If you want me to do a good job, like I gotta mute out all the emotional stuff because all that does is is take up mind share that should be deployed in the process of performing the best surgery that I can. So let me just do that, right? To instead say, I'm going to give this guy a hug and I'm going to understand that they're in pain and there's a lot of fear here. And to have that, you know, gentler approach and to have that work for you is interesting.

• 1:17:22Rich Roll?

  I'm sure it's powerful for the younger doctors that are that are working underneath you. And, you know, knowing some of your patients, like it's appreciated. Like, these people are, you know, well, I just can't say enough amazing things about you.

• 1:17:38Speaker 00

  I try. I can always do better, you know, but I always try to be the best guy I can be for that. It's easy. When you put yourself in these people's shoes, it's like not, it's not hard to understand what somebody needs, you know, in their particular situation when they're confronted with a health event in their life.

• 1:17:55Rich Roll?

  Speaking of cycling. Every time I get on my bike and I'm out for a couple hours, I'm thinking, what is this doing to my prostate?

• 1:18:03Speaker 00

  Nothing.

• 1:18:04Rich Roll?

  Okay, good. We cleared that up.

• 1:18:07Speaker 00

  Yes, no issues.

• 1:18:08Rich Roll?

  Cycling, good, not, yeah, like, there's a lot of, you know, sometimes like, if my fit isn't right, I get a little numbness.

• 1:18:14Speaker 00

  Yes.

• 1:18:15Rich Roll?

  You know, down there.

• 1:18:16Speaker 00

  Yep. I mean, you know, as you know, fit, fitment is key. Speed comes from a good fitting bike, right?

• 1:18:21Rich Roll?

  Yeah.

• 1:18:22Speaker 00

  So, yeah, there are special seats, you know, there are nerves that, it's not, it's not the prostate, but there are nerves around the prostate that actually you can get compression, you know, injury to it and have, and have numbness. So, there are different seats that can kind of relieve that pressure in the area where the prostate lives and, you know, they can be significant game changers for those, some of those folks.

• 1:18:45Rich Roll?

  Yeah, I, I've found that the saddles that have the cutout in the middle and kind of an elevated rear, that's like right on the sit bones.

• 1:18:52Speaker 00

  Yeah, way more anatomics, 100%.

• 1:18:55Rich Roll?

  Yeah, yeah. The saddles have gotten a lot better.

• 1:18:57Speaker 00

  They have, and you know, and the tri bikes are often like the worst, because you know, the old tri bike, you're just really, you're really in it, you're right on.

• 1:19:04Rich Roll?

  You're leaning forward.

• 1:19:05Speaker 00

  Yeah, exactly.

• 1:19:06Rich Roll?

  You're not on the sit bones at all.

• 1:19:07Speaker 00

  Exactly. So, those ones where, that's where the seat is the biggest kind of factor, because you, you know, if you are on, if you're on a tri bike for a long, long time, which I imagine you've been, your prostate's not an issue, but you can actually have problems with the urethra, the tube that you pee through, because you can just compress it and cause issues with the blood vessels to it. So, fitment is key.

• 1:19:27Rich Roll?

  What is the relationship between prostate health, prostate cancer, and TRT, like testosterone therapy?

• 1:19:34Speaker 00

  Yeah, I actually think there's no increased risk for developing prostate cancer on testosterone replacement therapy. So, that's a very broad and maybe provocative statement, but there's a lot of good recent studies that have shown that that's not a major player. Peter and I are going to do a very deep dive on that coming up, so we'll have a really nice, super nuanced and detailed podcast about a big picture. Couple of recent trials came out, they gave men testosterone replacement, they, these were men had low T, they brought them on replacement to like just below low T, so not very good replacement.

• 1:20:13Speaker 00

  So, the quality of life for those guys wasn't super great, but with, you know, mild testosterone replacement, there was no increased risk for developing prostate cancer in general, I think. Testosterone replacement to relatively reasonable levels is not going to induce any cancer issues. It can cause your prostate to grow and cause more urinary symptoms over the long haul, but over a shorter term period of time, it's probably not a problem either.

• 1:20:38Rich Roll?

  Does it have any impact on PSA results? Is it something that the urologist needs to know about?

• 1:20:45Speaker 00

  Good question. It can bump the PSA, but in general, it's in the tenths of a point, so not major changes in PSA with testosterone supplementation. Again, normal ranges for testosterone, a low is considered to be below 300 and high ranges are 800 to 900. So if you're low and you go on replacement, you may have a subtle bump, maybe half a point, 0.4 of a PSA value rise, and then it should be stable. If you go in the thousands, you may have more of a rise initially, but then beyond that, actually, it shouldn't go

• 1:21:23Speaker 00

  up substantially. If on TRT, your PSA is rising, just like in every other space, if your PSA is rising, that's when you need to get an investigation with the urologist and get the work up we talked about earlier.

• 1:21:36Rich Roll?

  Are there other, any other kind of pharma that would have an impact on PSA values or be something that's contributing or creating a greater risk for prostate cancer?

• 1:21:51Speaker 00

  So there is some correlation with some of these very strong immune modulators that people take for autoimmune disease. So Crohn's disease and ulcerative colitis, which can be very catastrophic diseases of the colon, there are some very effective medications that can make those symptoms go away. And remember, Crohn's and ulcerative colitis are really profoundly catastrophic if untreated in individuals. The medications that you use to suppress those can raise your risk of developing prostate cancer. So again, if you have Crohn's or ulcerative colitis, On any TNF alpha blocking medication, so those of your audience that are on it, they'll know what I'm talking about.

• 1:22:35Speaker 00

  Just follow your PSA very carefully. Again, screening, the way we do it in America is pretty aggressive. And so it works, if you deploy it, it will work for most everybody to pick up something early. I would definitely not advocate for not taking those medications because you're taking them for a real disease. Just have to be careful in terms of following. So those medications for autoimmune disease can do it. Testosterone, Clomid, which raises testosterone, can do it. And then Finasteride, Dutasteride, Propecia, that protect your hair loss in general or your prostate from growing in older men. It can alter your numbers, and so you have to be cognizant of that, too.

• 1:23:12Rich Roll?

  What is happening in terms of new and developing science, in terms of better understanding prostate cancer? And where are we in terms of the possibility around a cure?

• 1:23:25Speaker 00

  Yeah, good question. So, a lot of the cancers that we diagnose, we diagnose them and we gauge how aggressive they are based on how they look under a microscope. And in the last decade, there's been a huge shift in terms of looking at the genomics, what drives those individual cells to look the way they do under the microscope. And when you look at, start looking at genomics, you can understand the fundamental kind of recipe for an aggressive or a non-aggressive cancer. And if you understand the recipe for an aggressive or non-aggressive cancer on a genomic level, you can then deploy more customized, more precise therapies for those individuals. So what is that, how's that impacted individuals who have a localized cancer?

• 1:24:10Speaker 00

  We're now learning that you can use genomics and probably will be able to kind of help titrate and tailor some of the types of radiation treatment you get. There's trials that are ongoing that will answer that. In terms of more advanced prostate cancers, for those men that are unfortunate enough to have advanced prostate cancer, genomics has really transformed how we treat the disease. So, we've identified vulnerabilities, developed and deployed medications to attack those vulnerabilities. So... We're getting there, and there's been tremendous progress over the last 15 or 20 years to like do newer, more customized, more precise and powerful medications. So less overall side effects, more toxicity to the cancer cells. They're not creating

• 1:24:53Speaker 00

  cures yet, but we're getting closer kind of every year, to be honest with you.

• 1:24:57Rich Roll?

  From a layperson's perspective, why is cancer, just cancer generally, such a challenge in terms of trying to figure out a cure? So many brilliant minds devoted their lives to trying to solve this and getting closer and closer and closer, but there's something missing that's preventing that from happening.

• 1:25:23Speaker 00

  Yeah, it's a good question. I think about it like, you know, the best example in medicine about where we probably would want to be with cancer is how we treat HIV. So we don't have a cure for HIV, but we have a very powerful cocktail medications that can suppress the growth of HIV virus and allow a person to live out a full, healthy life and die with, not from their HIV. In prostate cancer, we have a portfolio of super powerful medications, and our goal is to enable people, short term, to not die from, but die with their prostate cancer. And so I would argue that, yeah, it is very, very difficult to find that cure. And there are cancers we can cure, testis cancer in

• 1:26:07Speaker 00

  men, for example, is curable. Other cancers are just way more elusive because they're always changing over time. So we find something to attack them, and then they evolve and they develop resistance and they change. But I think if we get enough of those different new medications that we can kind of continually suppress and think about deploying them in cocktail formats like we do for HIV, you could actually suppress the disease and enable them to live out a full, healthy life. So for example, if a man's diagnosed with metastatic prostate cancer today... He can live on average eight to 10 years, median survival, eight to 10 years. That means that some people are living 15 or 20 years with metastatic prostate cancer.

• 1:26:49Speaker 00

  And there are some side effects from the meds, but in general, they're able to live out a nice, full, healthy life. So we're not there yet in terms of cure, but we're there, we're getting closer. And in the meantime, we can live, people can live substantially longer with, you know, limited kind of side effects.

• 1:27:06Rich Roll?

  What kind of advances can you reasonably anticipate in your lifetime?

• 1:27:12Speaker 00

  I think further ways to target, like testosterone is the main kind of driver for prostate cancer progression. So further, more sophisticated methods to suppress testosterone in individual cancer cells will be key. And then further deploying like immune-based therapies. So, you know, immunotherapy has really changed a lot of other cancers, melanoma, kidney cancer, bladder cancer, and enabling people to live longer. And I think we haven't yet cracked the nut as to how to kind of deploy immunotherapy within the prostate cancer space. So that's, I think, super exciting and on the horizon. And then in the localized space for most guys, you know, just refining, hey, who really needs aggressive treatment?

• 1:27:56Speaker 00

  And if you need aggressive treatment, should it be surgery? Should it be radiation? How do we fine tune and tailor that? Those are the kind of exciting things in the next five to 10 years that we'll have.

• 1:28:05Rich Roll?

  Yeah. As groundbreaking as the PSA test is, and as revolutionary as this DaVinci machine is, we're seeing such rapid technological advancement right now in robotics and diagnostics and like screening and, and with the advent of AI, like applying like, you know, hyperintelligence to massive data sets. It feels, again, from a very layperson's perspective, that we're on the precipice of being able to make some pretty astronomical breakthroughs in medicine.

• 1:28:39Speaker 00

  Yeah, we're, they're happening, you know. So AI is deployed in medicine already. We just don't, you know, it's, for example, if you get a CAT scan, you lie on that machine, I don't know if you've ever had a CAT scan, you lie on the machine, and it weighs you. And it figures out, it's just deploying very basic AI, machine learning, how much radiation you should get based on your weight and your body composition. Now we have, we have AI that can read x-rays for people that come through the ER. So that the doctor who's reading them is not overtired. And it's for reading them and screening them and identifying things at a much more, you know, precision than a regular physician. They're doing that in mammography, so for breast cancer screening.

• 1:29:24Speaker 00

  So we have a project looking at AI to read MRIs better perhaps and try to find the needle in the haystacks that maybe we were missing before. So again, lots of deployment in that space. And then also in terms of that kind of physician life balance, we talked about like, how can we use AI to actually give physicians a break? To allow them to not feel like the weight of the world is always there on their shoulders because they have, their patients are accessing them all the time with information. So using AI to actually improve wellness and decrease burnout. That stuff is very much what I think we would benefit from tremendously.

• 1:30:05Speaker 00

  So not just better medicine, but actually better care of the physicians who are delivering that better medicine.

• 1:30:11Rich Roll?

  I'm going to get practical here. So, look, it's pretty common as you, as you get older that sleep becomes a little more elusive and you might have to get up in the middle of the night to take a pee. Generally happens to me sometime between 2:00 and 3:00 AM, pretty regularly. Not multiple times, but generally one time during the night. A, should I be alarmed? And B, what can I do to ameliorate this or make it less likely that I have to get up and go to the bathroom in the middle of the night?

• 1:30:49Speaker 00

  Yeah.

• 1:30:50Rich Roll?

  Should I be worried?

• 1:30:51Speaker 00

  You shouldn't be alarmed. Most people get up, most people over 50 get up, men and women, get up one time at night to go to the bathroom. Usually that's not too disruptive for an individual person's sleep. When you get on to two to three times, that becomes incredibly disruptive and it's not effective in terms of your overall sleep habits and so forth. How can you mitigate it? You can do basic things like time, you know, when you stop drinking fluids. And, you know, so for you, that's like, are you working out later in the day and then having to rehydrate and, you know, excess fluid is coming off overnight, et cetera. And for the general listener, it would be the, the warning signs that you want to think

• 1:31:33Speaker 00

  about if you have nighttime urinary issues are what are, what other things besides your prostate could this be a sign of? The key thing is actually sleep apnea. It affects one-third, you know, 50% of individuals, not just men. Sleep apnea is when you stop breathing at night. I mean, you just stop breathing and you go apneic. That's like, it's scary to think about. And sleep apnea has a profound effect on so many different organs in our body. But one of the things that is a blessing is that it can actually cause you to urinate more at nighttime. And so if you're getting up a lot at night to urinate, you have a, you know, even if you're, you know, it's typical, the way to think about sleep apnea is like, oh, you're, you have a thick neck, you have a floppy neck.

• 1:32:17Speaker 00

  Risk factors for sleep apnea are male sex and men over 50. So it doesn't mean if you're, you're thin and you're fit, that you may not actually have sleep apnea as a problem. So sleep apnea is a key thing to just think about and be screened for if you start having increased nighttime urinary frequency. There's other cardiovascular things that you can have, I don't, you don't have, you individually don't have them, but a listener would want to think about. And so, yes, more than once at night is good to bring up with not just your urologist, but your primary care doc, because there may be other factors that precipitate that nighttime frequency.

• 1:32:51Rich Roll?

  What is the relationship, though, between sleep apnea and the urge to pee?

• 1:32:56Speaker 00

  Well, sleep apnea increases your urine production at nighttime. So some people have increased urine production at nighttime and therefore they have to get up to go pee. Other individuals just have an urgency to go to the bathroom at nighttime, but it's actually not related to... A tremendously increased amount of urine. It's just something that they're awoken and they get up and they'll do small volume urination. So that's something that is more in the urology space. But if you're urinating 20 or 30% of your total 24-hour urine volume at night, then there's a couple of factors that you may want to look into, you could look into to see, not just prostate specific, but hormonal and/or sleep apnea and/or heart-related.

• 1:33:38Rich Roll?

  What about compression socks? I heard that if you have this issue, wearing compression socks might be helpful. Not that I really want to put on compression socks.

• 1:33:46Speaker 00

  I have mine on right now. Even if you-

• 1:33:48Rich Roll?

  Once a cyclist, always a cyclist.

• 1:33:50Speaker 00

  I mean, it's there, you, once you just adapt to them, yes.

• 1:33:53Rich Roll?

  Sleep in your Normatec boots.

• 1:33:55Speaker 00

  It keeps the interstitial fluid, it just diminishes the amount of interstitial fluid you develop in your legs over the course of a day. Why does that matter? Interstitial fluid in your legs, i.e. you know, you can push your skin in and around your ankle and it's kind of mushy. If you eliminate that, when you lie flat at night, that interstitial fluid leaves your ankles and your legs and it goes into your bloodstream and your kidneys produce urine. So by wearing compression socks, then you mitigate the amount of fluid that you have leaking out of your blood vessels in your legs, and then you'll have less urine production at night. So, basic stuff, yeah. The timing of when you stop drinking fluids,

• 1:34:37Speaker 00

  eliminating caffeine from anything in the afternoon or evening, and then all day long, compression socks, except for like if you're going to the beach, you know, or something like that. That's what I would say. So, on weekends, if it's the summer and I'm biking a lot, I don't wear them, but otherwise I wear them.

• 1:34:53Rich Roll?

  What should men understand or know when it comes to erectile dysfunction?

• 1:34:57Speaker 00

  You know, you're not alone. So, a lot of guys think that they're the only guy around, and you shouldn't be embarrassed to bring it up with your primary or for sure your urologist, because there's great medications that can help augment it. About 2% of men annually over 50 develop erectile dysfunction, so-

• 1:35:18Speaker 00

  That's, you know, 20% of guys who are age 60 have it, at least, right? That's reported, so it's probably higher than that. So, you're not alone. There's great medications that you can use to, you know, augment whatever performance you have. And I always tell my patients, you know, urologists can get guys, you know, we can get you to wherever you want to be. But we start with simple medications, over the counter stuff.

• 1:35:44Rich Roll?

  In what case is it incident of erectile dysfunction, an alarm bell, or sort of a canary in the coal mine regarding a larger circulatory or cardiovascular issue? Because if somebody comes in with that and you're just, they give a pill and it's like problem goes away, you're dealing with symptom, you're not actually getting at the root cause of what's, that really needs for drugs.

• 1:36:08Speaker 00

  Yeah, that's definitely one of the concerns or considerations for these kind of online shops that offer it is are you really thinking about the whole patient? So erectile, the concordant, you know, meta issues that you can have medically that can be reflected in ED would be diabetes. So diabetes, high blood sugars can have an impact on direct nerve function. And that's often first manifest in erections because the nerve for the erections are so small and they're so sensitive. The other is high blood pressure. So the small nerves have small blood vessels that go supply them with their nutrients. And so, high blood pressure can cause erectile dysfunction and uncontrolled blood sugars, i.e. diabetes, can do the same.

• 1:36:53Speaker 00

  So, those are the two things that you want to think about when you have a patient who has new onset erectile dysfunction is are there other factors that can contribute to that that we need to address also to help that person, you know, overall medically?

• 1:37:07Rich Roll?

  Sure, I mean, your body's trying to tell you something is off, right? So if you just deal with that, take the Viagra or whatever, you're blind, you're gonna, you're gonna have a problem, a much bigger problem later.

• 1:37:18Speaker 00

  100%.

• 1:37:18Rich Roll?

  If somebody's gonna go into their urolog, they've listened to this, they're like, wow, I just learned a lot, I better go to my GP and then perhaps my urologist. What are some guidelines that you could share around the questions that somebody should ask? Like the smart questions to know whether they're with the right person and they're gonna get the right kind of care?

• 1:37:42Speaker 00

  Well, it's... You know, I don't, I view medicine, modern medicine should not be paternalistic. It should be a relationship that the individual patient has with their doctor. So I try to be empathetic and I try to be there for my patients. I understand that there's some percent that just, you know, they don't care for me. So you have to have a good, open relationship with your, with your patient. And I think the patient should view it the same way. They should be able to have an open relationship. And then I think, yeah, just having a frank conversation. Hey, I'm a 50-year-old guy. Should I be thinking about screening for prostate cancer? I quit smoking five years ago. Do I have to worry about bladder cancer? You know, my erections are good now. Is there something I need to do in the future? Just having an open discussion.

• 1:38:25Speaker 00

  But I think the main things that urologists want to see patients for early is their cancer screening. And then certainly part of our specialty is to enable men to live out a full, healthy life. And that for some people would include refinement in their urinary function. So they get up a lot at night. They have trouble urinating. We can fix that. And then also their sexual function.

• 1:38:48Rich Roll?

  What would be an alarm bell that maybe you're not with the right practitioner? Is there something common that would come up that could, could let the, let the patient know? Like, maybe this isn't the right person for me to be seeing about this?

• 1:39:03Speaker 00

  Yeah, I think just, you know, brushing off questions and shrugging off concerns or considerations.

• 1:39:10Rich Roll?

  Like, oh, you don't need to get a test or something like that.

• 1:39:13Speaker 00

  That's right.

• 1:39:13Rich Roll?

  Being cavalier.

• 1:39:14Speaker 00

  Yeah, if they say that, you have to say, well, why don't you think I need a test? And, and I sometimes tell people that, but that's because they're, you know, 97 years old and they don't need to get screened for a, a cancer that may be lethal for them in 15 or 20 years. So it's a little bit about context. And certainly I, I try to appease and really develop a good relationship with every patient. But there are some that you just can't because there's just a personality conflict. So I think, you know, making sure that they're kind of available and trying to find people who are as empathetic as possible is always helpful. And then there's lots of online reviews that you can, you know, go to on the web to figure out, okay, what's this doctor really about? And those are quite powerful. And we now at Northwestern really fully respect and understand that.

• 1:40:00Speaker 00

  You know, medicine is not transactional. It's really like a lifetime journey that we try to establish with our patients and really kind of be there for them throughout these different intervals of care. And so, thinking about it that way is something that we've been pretty progressive about, but frankly, our patients are our consumers and they're gonna be very, they're gonna shop around and be critical. They want the best. And I think, you know, individuals are pretty savvy these days about refining and finding out, you know, the best portfolio of doctors for them.

• 1:40:32Rich Roll?

  In terms of male contraception, what should men understand about vasectomies?

• 1:40:40Speaker 00

  Well, vasectomies are done to help prevent you from having subsequent children with vaginal intercourse, but they're not...

• 1:40:49Rich Roll?

  Thank you for that. Public service.

• 1:40:51Speaker 00

  But, but sometimes, I say it like that because some people confuse having a vasectomy as being an effective way to mitigate sexually transmitted diseases.

• 1:41:01Rich Roll?

  Hmm.

• 1:41:02Speaker 00

  And it's not that, right? So, yes, you can have a vasectomy. It's safe to do and it will really effectively eliminate your ability to impregnate an individual with intercourse, okay?

• 1:41:16Rich Roll?

  But not at all impede your ability to pass on an STD?

• 1:41:20Speaker 00

  Or acquire an STD. So, you know, I, you know, depending on the, you know, the preferences of the individual patient, we will have discussions about, you know, PrEP, which is a, you know, medication you can take to prevent acquisition of HIV if you're in a high-risk, you know, kind of population. So, try to be proactive about engaging our patients and saying, "Hey, how can we serve you? What things are on your mind?" And then trying to be safe for them as well.

• 1:41:50Rich Roll?

  And the procedure, from what I understand, is safe?

• 1:41:54Speaker 00

  Vasectomies totally safe, yeah. Yeah, and this is the era of the vasectomy. Everybody says on, during March Madness, every guy will get their vasectomy on Wednesday right before, you know, the, the opening weekend starts. So that's, it's like the highest rate of vasectomies.

• 1:42:08Rich Roll?

  Is that true?

• 1:42:09Speaker 00

  Yeah, yeah, yeah. But, in general, it's totally safe and, you know, most people usually get them on a Thursday or Friday, then they have the weekend and they go back to work and they have no issue. So, not, not, not anything to be concerned about. It's highly effective in terms of... A contraceptive approach, 100%.

• 1:42:27Rich Roll?

  Is there anything that we haven't covered that you feel you want men to understand about, not just the prostate, but reproductive health?

• 1:42:41Speaker 00

  I think men are afraid to talk to their doctors about their feelings on their health and how they're doing. And they should take a note from the playbook that women use. Women are very proactive, in my opinion, about engaging with their physicians and telling them how they feel and telling them what their concerns are. Think about all these spectacular breast cancer survivors. They're champions, right? And as you mentioned when we let off this piece, you said, "Men are so afraid to talk publicly about their prostate cancer." It's this very strange dichotomy where women are champions and men perceive themselves as failures if they talk about their vulnerabilities. And one of their

• 1:43:23Speaker 00

  vulnerabilities, they feel like, is their men's health function, their sexual function, their urinary function, and their history of potential cancer. So I would tell them to just try to be open with their physicians. And if we understand where they're coming from, that helps us just break down those barriers. And it's part of what we try to do. I have a team that I work with. I have a great nurse practitioner who is, she's a great icebreaker with our patients. And so in that way, just being out there as a provider is helpful. But the patients need to understand that they should also feel free to bring it up, too.

• 1:43:59Rich Roll?

  Yeah. Get tested. Get your PSA test, yeah?

• 1:44:03Speaker 00

  Yes.

• 1:44:03Rich Roll?

  I'm telling myself.

• 1:44:05Speaker 00

  Get your test and send it to me. I'll help you interpret it.

• 1:44:07Rich Roll?

  Yeah, thank you. Is there anything, I mean, we covered a lot. There's certainly more that we could cover. But as we wind this down, is there anything that I've left off the table that we haven't covered? Any misunderstandings, further misunderstandings, or tropes that you'd like to correct?

• 1:44:27Speaker 00

  I think we did a great job. I mean, thank you so much for having me come on the show. I'm honored to be able to be here and talk a little bit about what I do for a living.

• 1:44:36Rich Roll?

  Yeah, I mean, you perform an unbelievable public service. And you're also an exceptional communicator of what you do and the importance of it, which is an added talent on top of your surgical hands and your ability to operate the Da Vinci.

• 1:44:54Rich Roll?

  And I really, I appreciate it. Like, I really wanted to, you know, make this whole episode, you know, a public service announcement, basically, for men to also give them permission to do what you just said, which is talk about it and raise their hand. And, you know, I'm gonna, I'm gonna take your advice as well. So, thank you for that. If people want to learn more about you, where should they go? Where would you direct them?

• 1:45:16Speaker 00

  They can find me on the Northwest, I mean, I'm everywhere, but Northwestern Medicines webpage and/or Ted Schaeffer MD.com will direct you to Northwestern to contact me if you want to reach out and have a question.

• 1:45:29Rich Roll?

  And we can go to that YouTube page and watch your procedures?

• 1:45:31Speaker 00

  Yeah, our YouTube channel is NM for Northwestern Medicine underscore Urology. So NM underscore Urology, and there's tons of my videos. And then we have a whole portfolio of different educational, you know, urologically based videos that are put up there by our team of experts.

• 1:45:51Rich Roll?

  Excellent. Thank you. Appreciate it.

• 1:45:54Speaker 00

  Thanks for having me.

• 1:45:54Rich Roll?

  Next time, let's go on a ride.

• 1:45:56Speaker 00

  Let's do it.

• 1:45:56Rich Roll?

  All right, cool. Thank you, Ted.

• 1:45:58Speaker 00

  Thank you.

• 1:45:58Rich Roll?

  Peace. Good plans.

• 1:46:14Rich Roll?

  That's it for today. Thank you for listening. I truly hope you enjoyed the conversation. To learn more about today's guest, including links and resources related to everything discussed today, visit the episode page at richroll.com, where you can find the entire podcast archive, as well as podcast merch, my books, Finding Ultra, Voice of Change, and The Plant Power Way, as well as the Plant Power Meal Planner at meals.richroll.com. If you'd like to support the podcast, the easiest and most impactful thing you can do is to subscribe to the show on Apple Podcasts, on Spotify, and on YouTube, and leave a review and/or comment.

• 1:46:59Rich Roll?

  Supporting the sponsors who support the show is also important and appreciated. And sharing the show or your favorite episode with friends or on social media is of course awesome and very helpful. And finally, for podcast updates, special offers on books, the meal planner, and other subjects, please subscribe to our newsletter, which you can find on the footer of any page at richroll.com. Today's show was produced and engineered by Jason Camiolo with additional audio engineering by Cale Curtis. The video edition of the podcast was created by Blake Curtis with assistance by our creative director, Dan Drake. Portraits by Davy Greenberg. Graphic and social media assets courtesy of Daniel Salis.

• 1:47:42Rich Roll?

  Thank you Georgia Whaley for copywriting and website management. And of course, our theme music was created by Tyler Pyatt, Tractor Pyatt, and Harry Mathis. Appreciate the love, love the support. See you back here soon. Peace. Plants. Namaste. [music]