Armor Men's Health Show

EP 601: Dr. Trubek on PSMA: The Latest and Greatest Tool in Early & Metastatic Cancer Detection

September 28, 2022 Dr. Sandeep Mistry and Donna Lee
Armor Men's Health Show
EP 601: Dr. Trubek on PSMA: The Latest and Greatest Tool in Early & Metastatic Cancer Detection
Show Notes Transcript

In this episode, Dr. Mistry and Donna Lee are joined by Dr. Simon Trubek of Austin Radiological Association. As a radiologist specializing in nuclear medicine, Dr. Trubek injects radiopharmaceutical or radioactive substances into patients to help detect the presence and severity of cancer. Today, he is here to discuss PSMA, or Prostate Specific Membrane Antigen--a recently approved agent that significantly improves prostate cancer detection and treatment. In about an hour, Dr. Trubek's patients can come in and have an injection of PSMA that will help detect the presence and disease progression of slow-growing, metabolically inactive cancers like that of the prostate. Tune in to learn how PSMA is helping radiologists detect metastatic cancer by finding lymph nodes as small as 4mm in size! If you or someone  you love has had prostate cancer and is worried about a recurrence, please visit https://www.ausrad.com/pluvicto/ today to learn how PSMA could set your mind at ease!

Voted top Men's Health Podcast, Sex Therapy Podcast, and Prostate Cancer Podcast by FeedSpot

Dr. Mistry is a board-certified urologist and has been treating patients in the Austin and Greater Williamson County area since he started his private practice in 2007.

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Phone: (512) 238-0762

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Speaker 1:

Welcome to the Armor Men's Health Show with Dr. Mystery and Donna Lee.

Speaker 2:

Hello and welcome to the Armor Men's Health Show. This is Dr. Mystery. Your host joined always with my co-host, the beautiful, talented, Oh wait, just me. Oh, sorry. Just dawn again to me. You're

Speaker 3:

Gonna do that. Geez,

Speaker 2:

I'm so predictable.

Speaker 3:

You know what? I have a whole thong. Is that word Dawn? Following a 65 to 70 year old. Now

Speaker 2:

You do. You're, you

Speaker 3:

Think I'm cute?

Speaker 2:

Your attractiveness of the 75 year old. That's right. Age group is, uh, pretty amazing.

Speaker 3:

One of them made me jewelry, by

Speaker 2:

The way, you would've made your mother proud. Anyway, this is a men's health show. I'm a men's health expert, board certified urologist. Uh, this show is brought to you by Naau Urology Specialist, the practice that I started in 2007. Ooh,

Speaker 3:

You're

Speaker 2:

Old. I'm an old man.

Speaker 3:

15 years ago.

Speaker 2:

If you happen to be in the area that we live in, in here, in Austin, uh, or anywhere else really in the world, and you want to get a second opinion on your disease process or just some advice on what's going on with you, Ur logically we are happy to take it. Mm-hmm.<affirmative> from you, Donna. How do people get

Speaker 3:

Ahold of us? You can reach out to Dr. Sunny second opinion mystery at(512) 238-0762. You can call that number anytime during the week. Our website. What were we

Speaker 2:

Gonna say? It's like that joke. You know, where, where, where that guy goes to the doctor and he goes, Uh, sir, you have cancer. I goes, Well, I want a second opinion. Doctor goes, You're ugly too.<laugh>,

Speaker 3:

Stop. Oh, good Lord. Our website for these terrible jokes are armor men's health.com. We can check out our locations. We're in Round Rock, North Austin, South Austin, and, uh, very cute Dripping Springs, Texas.

Speaker 2:

They love dripping. Today. We have a guest, Jonna. We do. Yes, we sure do. Stop it. There is the one excellent thing about this guest is one thing.

Speaker 3:

Right? That he's cute.

Speaker 2:

That is not true. Do you know where he went to medical school?

Speaker 3:

Baylor.

Speaker 2:

Baylor College of Medicine.

Speaker 3:

<laugh>.

Speaker 2:

Which even though he's a radiologist, kind of almost makes up for the fact that he went to Baylor. You know what

Speaker 3:

I'm saying? Oh

Speaker 2:

Lord. What? The other way around. You're always going to Baylor makes up for the fact that he's a radiologist.

Speaker 3:

It's always a radiologist joke. An an anesthesiologist joke

Speaker 2:

Or anesthesiologist

Speaker 3:

Or nobi ginger joke.

Speaker 2:

It's, it's, it's like that joke. A radiologist, a pathologist and a dermatologist walk into a bar on a Friday mm-hmm.<affirmative> because it's three o'clock on a Friday<laugh>,

Speaker 3:

And I'm off. There's definitely no urologist at that little

Speaker 2:

Hangout Doc. Dr. Trube, thank you so much for joining us today.

Speaker 4:

Pleasure to be here. He's

Speaker 3:

Exhausted already.

Speaker 2:

He's exhausted already. Dr. Simon Trube. Now you are a radiologist at, uh, Austin Radiologist Associate was, is that their name? What's her name?

Speaker 4:

Austin Radiological Association. And we've shortened it for, you know, people like you, like you, um, Whoa. It's, uh, Or or we sometimes call ourselves Ara diagnostic.

Speaker 2:

Ara Diagnostic. Yeah. You went to medical school and then you did a residency. You did, you did one year of internship. And that's where you and I hung That's together. That's, Yep. And then you did four year residency, and then after that you did, No, you went in a different order. Right. You went and made your nuclear medicine residency first.

Speaker 4:

That's right. That's right. I'm surprised you remember. Cause it's been 20 years. Yeah, I think it's been longer than that. Yes.<laugh>. So, no, I, I started off in surgery and, and I did that for a year and a half. And then I did nuclear medicine for a year and a half, and then radiology for four years. So I'm really smart.

Speaker 2:

<laugh>

Speaker 3:

Wow. You'all have the same sense of humor.

Speaker 2:

He washed out of surgery and all of a sudden he's saying he's smart. Anyway, he gets his the Fridays off and I'm working every day and working. I guess he's the smart one. He's the smart one. But tell me, what is a nuclear medicine radiologist? What does that mean? What kind of test do you do and what kind of education do you have? Explain that

Speaker 4:

To me. As a radiologist, we do a variety of imaging, uh, ct X-rays, ultrasound, mri, and that's what a general radiologist does. And then I'm subspecialized in nuclear medicine, which is kind of the reverse of radiology. We actually inject radiopharmaceutical or radioactive substances into patients. And those are taken up by certain organ systems that we wanna study. And we actually study the function of the system that we're interested in. So we can study, uh, how the liver works or we can study how the kidneys work. Like when you, you know, trying to evaluate U P J obstruction or renal function, we could do the same thing for the brain, for the lungs, et cetera, et cetera. So,

Speaker 3:

Stuffy's injecting though, what is that? Does it flush out, like how

Speaker 4:

Does that work? Yeah. Well, it, there's two things. It just decays by itself. That's in nature of, of the product, of the radio, pharmaceutical, depending, depending on what, what we're trying to study, there's a variety of them. And then they also flush out, typically they just get excreted through urine or bowel activity or you exhale. Sometimes we give a radioactive gas to, to evaluate how the lungs, is there

Speaker 2:

A set price to get gamma radiation, because I would like to hulk it out.

Speaker 3:

Nobody knows what that means. Nobody knows. I

Speaker 2:

Don't even what you said the incredible Hulk,

Speaker 3:

He Oh, that's what he got. Oh, that's

Speaker 4:

A Bruce Big B, right? He

Speaker 3:

Got gamma.

Speaker 2:

Is it Banner?

Speaker 4:

Oh, okay. Bruce, Bill Bigsby, br. I don't

Speaker 2:

Know. All right. We're not gonna too horrible stuff today. So, um, so when it comes to prostate, so, so

Speaker 4:

We use new, not my superpower

Speaker 2:

Imaging quite a bit when it comes to, uh, assessing kidney function and things of that nature. But recently we've started getting better ability to diagnose prostate cancer that has left the prostate. And uh, I'd love to talk a little bit about psma prostate specific Prostate,

Speaker 4:

Yeah. Prostate specific membrane. Membrane

Speaker 2:

Antigen. Now I've been hearing about PSMA for many, many, many years, and most of our listeners know about psa, which is prostate specific. And so we know that the prostate makes psa, but then going another level, now we know that on the surface of the prostate cancer cells or or prostate cells in general, there's something that we can detect called psma. And why don't you just tell us what has happened recently, just in terms of imaging, what has been approved and, and what are we doing now that we weren't doing three years

Speaker 4:

Ago? So there's been recent approval for a PSMA imaging agent. And this agent, like you were saying, targets prostate cells, prostate, prostate cells, prostate cells. Right? Yeah. So we attach a certain type of radiopharmaceutical to that, and then we inject this agent into the patient. It's a painless injection, just like an IV injection of any sort. And, and it goes to the prostate cells and we put the patient in a pet CT machine. And after a couple of minutes, we can see if, if the patient has a recurrence and, and exactly where it is. And this, this agent is actually, uh, superimposed on a CAT scan image, like a CT image. So we can actually measure the intensity of uptake, which correlates with the disease process itself, and be able to measure the size of the lymph node or the bone lesion, or we can actually see it in the prostate gland itself.

Speaker 2:

It's an, it's an amazing, uh, evolution. And for those listeners out there that have some experience with cancer, you may have heard of a pets a PET scan mm-hmm.<affirmative>, because a lot of patients think that the PET scan is the way to identify cancer, that spread mm-hmm.<affirmative> as if the PET scan was one thing, when in fact it's a different thing for the disease process. And some cancers are easier to detect with PET scans than others. And so the ability to do this with the psma, uh, uh, label is something revolutionary for prostate cancer. Right.

Speaker 4:

Absolutely. And I'm glad you bring this up because a PET scan is just a machine. What we study in the machine is up to us. So certain cancers, like for instance, uh, renal cancer that you deal with on a regular basis, the standard PET scan is really the FDG PET scan. And that is a radio, radio labeled sugar that we inject. And, uh, renal cancers, they eat a lot of sugar. So we can see it, we can see their metabolic activity. Unlike, uh, prostate cancer, prostate cancer doesn't consume a lot of sugar. It's a very indent, slow growing tube.

Speaker 2:

It's not metabolically active, active. So a standard PET scan isn't gonna see it. So if you come see me as a patient and you saw me for the last 20 years and I didn't order a PET scan, that doesn't mean I don't love you or didn't care about you<laugh>, and that the PET scan wasn't the right way. Right. To test whether it's gone anywhere. And because we are looking for prostate cells, of course the prostate's gonna light up on your scan, but if you see any prostate cells anywhere else in the body, you know that's not supposed to be there. Right? Correct. So if you see it in the bone or anything, So, so recently it was approved. We've been able to get a lot of PET scans. These, um, these PSMA scans approved by Medicare. Correct. And, uh, some commercial insurances. And I actually have gotten very little pushback now. So I I it's changed my way of evaluating somebody that's high risk. If somebody has a high PSA and we find cancer now, instead of doing a bone scan and a CAT scan like I used to mm-hmm.<affirmative>, now I'm doing a lot more just PSMA scans. Correct. To tell me if the cancer's gone somewhere. That's correct. How long does the test take?

Speaker 4:

The imaging test is you're in and out in about an hour. You come in, you get the infusion, the injection of the PSMA imaging agent, and then you, if you've ever had a CT or an mri, it's very similar. You just put in a machine that looks very similar and you're done and you go home. Would

Speaker 2:

You say that the, uh, ability of this test to identify metastatic disease for like lymph nodes or bone disease is better than a standard CT scan and bone scan? Oh,

Speaker 4:

No question. It's superior to it

Speaker 2:

Because you can see very small areas of uptake. Right. About how small of a, of a metastasis do you think this PSMA scan will pick up?

Speaker 4:

So we routinely see lymph nodes, four millimeter lymph nodes,

Speaker 2:

Which, and CAT scan. It's gotta be almost two centimeters before you see you.

Speaker 4:

Correct. And by criteria it has to, to call it positive, you have to see a change by five millimeters from, from prior images.

Speaker 2:

So you have to have two CT scans to call something positive. That's correct. With the PSMA scan at the leave node lights up, you know that it's, that it's abnormal, uh, you know, uh, just it's a's a revolution and identifying cancer. We're gonna talk about how, um, we are using this technology at the next level to not just be able to see that you have cancer spread, but we're gonna use this technology to actually cure cancer. Absolutely. So Dr. Trube, thank you so much for joining us today, Donna. Uh, we're gonna be back to talk about therapeutics and PSMA scans in just a second. Why don't you tell people how to get ahold of us and send us an email. That's right.

Speaker 3:

If you have questions for Dr. Trube about this discussion or any other discussion we have for Dr. Mystery, you can email us at armor men's health.com. You can submit a questionnaire and we will answer it anonymously. And again, we're in Round Rock, North Austin, South Austin and Dripping Springs. If you're listening to us from the other side of the world, our website, again, armor men's health.com, our phone number(512) 238-0762. And we forgot to mention the podcast today. Listen to our podcast. It's magical. And you might get a free t-shirt if you reach out to me cuz I have like 5,000 of them.

Speaker 2:

And it's what allows me to be Dr. Worldwide. I gotta change things up because our podcast requirements and our radio requirements are a little different.

Speaker 3:

Yeah. Cuz people in China were like, Wow. In America they're hourly. They're

Speaker 2:

Hourly. Last 15 minutes long.<laugh> you think they were insulting us in China? Yes.

Speaker 3:

And

Speaker 2:

Russia. It's probably because they know you're half Thai. That's

Speaker 3:

Right. They're like, We don't like those Thai people.

Speaker 2:

I wish we were getting hacked by the Russians because we never get hacked. We're not important enough. We, we are one of the, one of the most brought it to us, the most listened podcast or, uh, most famous ones on the internet. Right? We won awards, didn't

Speaker 3:

We? We won a few awards. Pro Best Prostate Cancer podcast. Best Men's Health. Well, you know, we're second best, but I keep saying best. And then Best Men's Health and then Best Sexual Health Podcasts.

Speaker 2:

You know what, I haven't reminded our listeners sometime. We are the second largest urology group in town, which means that we have to work just a little bit harder.

Speaker 3:

We're cuter on the weekends. I keep saying on the push our boobs up a little higher on Fridays.

Speaker 2:

I don't think my boobs are gonna getting higher. Anyway, we're joined again with our guest long term friend of mine, someone that I did internship with back in the good old days when we were young young men in Houston at Baylor College of

Speaker 3:

Medicine. They're not gray in

Speaker 2:

The beers and not gray everywhere.<laugh> did I tell you the other day, a patient, I walked into a patient room and he said, I'm always so relieved when I'm with an older doctor. I took a double take and looked behind me for somebody else. Right.

Speaker 3:

I saw your ego go

Speaker 2:

Son a gun. I still think of myself as a young buck on the stage. And one of the reasons that I think of myself as so young is because of the cutting edge therapies that we do. Dr. Trube, thank you so much for joining us again.

Speaker 4:

Pleasure to be here. Thank you for having me.

Speaker 2:

So in the last segment we talked about a relatively new introduction of an agent called PS m A scan to help identify cancer that's gone outside of the prostate. And this helps us identify lesions that are much smaller than you would with the traditional CAT scan and bone scan. And when you get on these people early, you can really do something If you know that their T 12 is where the one tumor they have is, this is called small metastatic or oligo metastatic disease mm-hmm.<affirmative>. And we can do radiation right to it to earlier the better.

Speaker 4:

Right. Earlier intervention is, I mean, is very, I impactful the patient's survival and quality of life.

Speaker 2:

So getting on them early is really important. And now we can identify tumors that are outside the pro are much smaller now, wouldn't it be awesome if you could take this same PSMA and attach a little raygun to it and then put it into the body and the ray gun could kill the cancer pew.

Speaker 4:

He is a genius. Is that the noise of

Speaker 2:

It's a little ray gun, right? Yes. And it's a great analogy. Am I, am I the first one to think of

Speaker 4:

This? I think the second after drew bed. Oh,

Speaker 2:

<laugh>. So why don't you tell us, you know, that's all in joking. This is fascinating. Cutting edge stuff. It's exactly what we thought we should be at, which is that you can tell the tumor, you can tell the little ray gun mm-hmm.<affirmative> where to go and how to kill just the cancer. Which is amazing because regular radiation therapy and chemotherapy hurts everything. That's right. But to have targeted therapy now is like fair cutting edge. Why don't you tell us about PSMA ligand therapy? Just

Speaker 4:

Like we talked about earlier, if you have a positive PSMA scan, then we know we can treat the disease. So what we say in our business is that if you can see it, you can treat it. Once you've identified the small cells of metastatic disease, you come back and you get an injection of the same PSMA agent. But we switch out the ray gun from one that shoots light out that we can take pictures of Yes. To one that actually kills and destroys the cells. And it's cellular targeted therapy. Just like you were saying, you know, the cells get destroyed on a cellular level. You don't destroy everything, you don't lose hair, you don't have bowel problems, all, all the complications. You're

Speaker 2:

Not gonna feel tired of, you know, hormones or whatever else you're on. Correct.

Speaker 4:

Correct. You don't have to have systemic chemotherapy, which is, you know, toxic. So this is really innovative therapy for, for patients with, you know, biochemical recurrent prostate carcinoma and the beauty of the imaging and the therapies, like you were saying, you can identify the disease much earlier on so you can intervene earlier on. So you can have, uh, you know, significant results and just a much better quality of life.

Speaker 2:

You know, when people talk about prostate cancer and I diagnose somebody almost nine times outta 10, the patient comes in convinced that this prostate cancer's gonna be slow growing and not a problem. And they're right. But in a small group of patients, about 10% of patients, we are finding them at the metastatic level when we first diagnose them, their PSAs are very high. And then the prospect of having to do all of this crazy therapy, the systemic chemotherapy and getting sick and like losing your hair, like you said, and getting, getting ill. The idea that for some of these patients, we could offer them a therapy. That sounds almost too good to be true. Right? It is. It is a therapy that will not make their whole body sick and will be targeted against prostate. And this is cutting edge brand new stuff, right? We have it right here in Austin.

Speaker 4:

Absolutely. We've done three patients already. We're the first center in, uh, central Texas to be doing these therapies. We've been recognized as the center of excellence by the Society of Nuclear Medicine and Molecular Imaging.

Speaker 2:

We're getting patients from Johns Hopkins.

Speaker 4:

Here's correct patients to you. Yes. It's incredible. I

Speaker 2:

Mean, you know what I'm saying? Yes. I mean, you couldn't even be a surgeon you had to drop out.

Speaker 4:

I know, but you know, it's like being the second best. No way. You just have to

Speaker 2:

Work a little harder. No, no, no way. You come on my show and I don't make money of you for that Buddy.

Speaker 4:

<laugh>, I just couldn't take it. Couldn't take the pressure. You couldn't take the

Speaker 2:

Fridge. So you're getting patients from Johns Hopkins. We've done more cases here than MD Anderson already. Correct. Because we're the first here in Austin. And I say we, I mean you and an amazing team that you have there at a a, you know, you're gonna have a greater experience with this than almost anyone. You know, if you're a patient out there and you've been diagnosed with metastatic prostate cancer, what should they be? Uh, so it's not just metastatic prostate, let's just say that if you were diagnosed with prostate cancer and you were treated and now your PSA is rising again, this is the first step, right?

Speaker 4:

Correct. And that's what you guys call biochemical recurrence. You've had the, the prostatectomy or radiation therapy and then your, your PSA levels are slowly climbing and you know that it's somewhere, but we just can't find it with a bone scan or a regular CAT scan. This is where this imaging agent is really instrumental in identifying early recurrence and the earlier you intervened, the better the outcome is gonna be. So

Speaker 2:

For a lot of those patients out there that have already, maybe you were diagnosed with a PSA recurrence, maybe say five years ago before P PSMA was out there. If you're out there listening, talk to your urologist and make sure that you get this PSMA scan done. It's paid for by Medicare. A lot of commercial interns are paying for it that way you'll know because if they think that, that your lymph nodes were positive, but really there's a small lesion in your spine or in your femur, then you'd like to know that.

Speaker 4:

Absolutely. And like you were saying, that's oligo metastatic disease. You can treat it with focus therapy and have a tremendous result and not have, uh, you know, progression of disease potentially.

Speaker 2:

And it's available inside the office. The drug itself is given through an IV infusion. Correct?

Speaker 4:

Yeah. So let me tell you about our therapy center. We have three rooms. They're especially designed rooms for the administration of this radiopharmaceutical. We actually treat other tumors like they're called neuroendocrine tumors. Similar deal. Patients come in, they have wifi television, they have their own medic, they get the infusion and they're monitored the infusion's about 30 minutes, and then they're monitored for about an hour afterwards. And then you go home with, with some instructions and, uh, you go back to your urologist for monitoring and you come and see us every six weeks for the, the duration of, of the therapy

Speaker 2:

Course. Now it takes about 30 weeks to get fully treated and then you get imaged afterwards. Uh, you know, metastatic disease for prostate cancer can cause leg swelling and uh, and bone pain. It can cause lots of urinary and other kinds of discomfort depending on where the tumor goes. Mm-hmm.<affirmative>. And we would expect those symptoms to improve,

Speaker 4:

Correct? Oh, absolutely. And that's, that's the initial indication for the use of this therapy agent is actually to improve the quality of life and to extend survival. But this was initially studied for really sick patients with advanced disease. We're expecting the indications to be changed in short order because the results are, are, are really good. And I think, you know, um, there's a lot of good change to come. So it's something that you definitely need to talk to your urologist

Speaker 2:

About. What I've learned about medicine is that when you don't have a next step, a lot of times doctors delay the next to last step. So what I mean by that is I know patients that have been, had their prostate removed and then their PSA started going up, but we didn't think we had that many good options, so we just let it go up for a while. Right. And then you put him on hormone therapy and then they fail hormone therapy and you just let it rise for a while. Well, he's not symptomatic. Nothing's going on. I don't wanna put him on chemo yet. And so that's why all these people were so sick at the end. Correct. But now that we have this next level now, I feel like more patients and more doctors are gonna be willing to go through the algorithm quicker because we know that the smaller the disease, the more likely we are to, to help it and to kill it. And so people will go more rapidly through the process so that they are able to be qualified for this PSMA ligand therapy.

Speaker 4:

Absolutely. And I mean, this is gonna be really impactful. I mean, there's almost 250,000 new diagnosis of prostate carcinoma every year. And, and 34,000 patients die every year for prostate carcinoma. So, Oh my gosh. I mean, this is gonna be, this is gonna be a game changer for all those people that are suffering. It's, it's really significant.

Speaker 3:

We just have to get them to the doctor.

Speaker 2:

Right. This is, this is amazing. So if people, uh, have a urologist that's not as, um, knowledgeable about this, do you want them to come see me or come see you

Speaker 4:

Directly? No, you go see their urologist and the, the urologist understands the patient. They put the jigsaw puzzle together, They get the psma, uh, so they, they get the psa, um, blood work. Mm-hmm.<affirmative>, they get the appropriate imaging, they understand the patient, they understand the surgical and radiation intervention or chemotherapeutic interventions that have been done prior to that. And then they decide what's appropriate for the patient. And then you send them to, you know, a center of excellence like, like ours.

Speaker 2:

So if they wanted to reach out to you and learn more, uh, how did they contact you?

Speaker 4:

Um, you can look up, uh, ARA diagnostic or you can, uh, call 5 1 2 5 1 9 3 4 5 6 extension 2 3 5 1, or email us@theranosticsatarad.com. At theranostics is a Port Manto kind like brand Angelina. Okay. It's therapy and diagnostics.

Speaker 2:

The, and that'll be on our, uh, show notes. Mm-hmm.<affirmative>, it'll be, And then of course if you wanna just email us, we'll give you that information too. That's right. Dr. Trube, thank you so much for joining us. Say this is fascinating information. Donna, how do people get ahold of us?

Speaker 3:

You can reach out to us at armour men's health.com and call us at(512) 238-0762. I'll send you this information. If you ask for it, ask for Donna.

Speaker 1:

The Armor Men's Health show will be right back To submit a question for Dr. Mystery, visit armor men's health.com.