Armor Men's Health Show

EP 611: Complex Cancer? Don't Rush To the OR! Dr. Fleming of UT Dell Medical School Explains the Benefits of Pre-Op Prehabilitation Therapy

December 07, 2022 Dr. Sandeep Mistry and Donna Lee
Armor Men's Health Show
EP 611: Complex Cancer? Don't Rush To the OR! Dr. Fleming of UT Dell Medical School Explains the Benefits of Pre-Op Prehabilitation Therapy
Show Notes Transcript

In this segment, Dr. Mistry and Donna Lee are joined by surgical oncologist and UT Dell Medical School Associate Professor Dr. Declan Fleming. The strengths of academic-level healthcare include interdisciplinary collaboration across medical specialties and proximity to experimental and cutting-edge developments in oncology medicine. Together, these factors make medical schools the perfect arenas in which to fight complex cancer cases. Another weapon in Dr. Fleming's arsenal is prehabilitation therapy, or the practice of preparing patients for major surgeries by increasing their overall wellness. Listen in to learn why postponing surgery and allowing patients to complete a course of prehabilitation dramatically improves their recovery and ultimate outcomes, even in serious, metastatic cancer cases. To learn more or send Dr. Fleming a question, call or email NAU Urology Specialists today!

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.

We enjoy hearing from you! Email us at armormenshealth@gmail.com and we’ll answer your question in an upcoming episode.

Phone: (512) 238-0762

Email: Armormenshealth@gmail.com

Website: Armormenshealth.com

Our Locations:

Round Rock Office
970 Hester’s Crossing Road
 Suite 101
 Round Rock, TX 78681

South Austin Office
6501 South Congress
 Suite 1-103
 Austin, TX 78745

Lakeline Office
12505 Hymeadow Drive
 Suite 2C
 Austin, TX 78750

Dripping Springs Office
170 Benney Lane
 Suite 202
 Dripping Springs, TX 78620

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. Heres always by my co-host Donnel Lee.

Speaker 3:

That's right. Can I add producer to my

Speaker 2:

Title? You can, mm-hmm.<affirmative>, but then you actually have to get the stuff done properly. Oh,

Speaker 3:

Okay. Well, there's that<laugh>.

Speaker 2:

it. So I wouldn't, I wouldn't set the bar that high.<laugh>. As our partner, Dr. Lucas Jacked says, I put the bar really low and then step right over it.<laugh>, I'm a board certified urologist. This is a men's health show. This show is brought to you by AAU Urology Specialist, the Urology Specialty Clinic that I started in 2007. Mm-hmm.<affirmative>, we love taking care of you and all of your urologic needs. I think you're gonna find yourself getting a real special level of care with us. When you're diagnosed with prostate cancer, you're gonna see a physical therapist, you're going to see a nutritionist, you're going to see the sex therapist, a sex therapist if necessary. Just whatever you need for whether you have a cancer diagnosis or a sexual health diagnosis. I think that for those of you with sexual health problems that want a higher level of care, you really can't get a more comprehensive, uh, clinic than us when it comes to other urologic needs. I, I, I think I can say the same.

Speaker 3:

I, I agree. And don't forget people listening, our brand new listeners, especially that we have awards for Best Sexual Health podcast, best Men's Wellness Podcast, and best prostate Cancer podcast per feed spot.com.

Speaker 2:

And you'll have to choose which ones we did not give ourselves.<laugh>. How do people, how do people get ahold of us?

Speaker 3:

Donna, you can call us and ask about our awards that we made up at 5 1 2 2 3 8 0 7 6 2. And our website is armor men's health.com, where you can send your questions that will answer anonymously. And you can see our really cute faces smiling

Speaker 2:

Today. We are joined by one of my really great friends, Dr. Declan Fleming, an associate professor at UT Dell Medical School. In the department of what, general surgery or surgical oncology?

Speaker 4:

It's, well, the department's surgery and perioperative care, and the division is surgical oncology.

Speaker 2:

So busy. So, Dr. Fleming or Declan, I'm a surgeon.

Speaker 4:

Yes, you

Speaker 2:

Are. And there, and there are very few surgeons that make me, you know, not feel like I have as big balls<laugh> your

Speaker 3:

Inferiority complex.

Speaker 2:

Do you know what I'm saying? Yeah. Like, he's one of them.

Speaker 4:

Oh,

Speaker 2:

Man. Like, like when, when there's a case, if you're, if, if your mom out there is diagnosed with a bad disease and they go to their surgeon, they're like, well, this is this, this may not be something that we can operate on. Mm-hmm.<affirmative>, you pull out Dr. Fleming. That's exactly what he and I did. For your own mother, Donna, for your own mother. That's right. Your own mother had something that people thought was not gonna be really easy to operate. Mm-hmm.<affirmative>. I called up Declan and you know, he and I went in and took care of her problem and Right. Exactly. Right. And, and you are just such a badass.

Speaker 4:

Oh man.<laugh>

Speaker 3:

<laugh>. It's

Speaker 2:

Such a bad as, and, and many of you out there may not know what that means, but that is, you know, the body is so complicated and has just, in its normal state, it's complicated. Forget about sticking a huge 15 centimeter tumor right in the middle of it and making everything grow around it. And then all of a sudden you gotta take this out, out and save somebody's life. It takes a lot of courage on the doctor's part to be able to take the life of patient's hands in, into your own hands. You

Speaker 4:

Know, you know, it's funny how, how you just get used to the idea of doing that over the years. I I, if you think about the stuff that you do regularly right now, how fantastic was that when you first started? Absolutely. I mean, you, you literally could not imagine the things that now you and I do routinely, and

Speaker 2:

Everything we do is a big part of that, guy's, that that guy's month. Right. Like, he's been looking forward to that surgery. He's had to take time off work, and we're like, I hope somebody shows up on time today, because I gotta like, get to lunch at them. You know,

Speaker 5:

Because, because like,

Speaker 2:

Because it's such a routine part of our day, but such a big part of that patient's life Oh, yeah. Of what they're going through. Yeah, absolutely. And I'm doing prostate cancer and relatively easy, thankfully for most of my patients things. You're dealing with some really, really, really heavy things. And, uh, what I wanted to talk about was kind of what's the difference that patients should be seeking? Like what kinds of cancers, what kind of medical conditions really should they be seeking an ac academic level care like you're providing and just, you know, community based care, because although I hate to admit it, I mean, I guess there's some role for the academic centers

Speaker 4:

<laugh>. I think, I think there are a few. The really great thing about being in Austin is that the level of care that people are able to receive from the private practitioners here in town is just so high. It, it's, it's really extraordinary.

Speaker 2:

It's a very competitive market. It is. And if you're not good doctor in Austin, you're not gonna make it here.

Speaker 4:

Right. Uh, just to, just to get in town.<laugh>, when I first moved here, it's been 21 years ago now, I, uh, interviewed with a couple of the, um, chief medical officers for a couple of the, uh, hospitals. And one of them literally told me, oh, yeah, we, we really don't need you here.<laugh>, you know, I was coming from MD Anderson,

Speaker 5:

<laugh>, are you sure? Maybe look at my resume

Speaker 4:

Again. But, you know, his point was we've got people that are able to do things that are, that are really complex that, that take a great level of skill. And we've been doing them well for a while, but, but what we're seeing, I I think now this is shown in a number of different areas, is that if you can have your care delivered by somebody that is doing this frequently, that that, that, uh, is all he or she is thinking about, that all their concentrating on that they're doing the same complex bits of the operation over and over again, that you're gonna have a better outcome. I think that the thing that academic centers are doing well are, they're really good about organizing multidisciplinary review so that instead of being taken from one practitioner to the next, to the next, to, uh, sort of assemble your team ad hoc, uh, that there are people that are concentrating on

Speaker 2:

That first. So if you need an oncologist and a radiation oncologist, and a general surgeon, and a GI doctor, and an internal medicine doctor,

Speaker 4:

And an radiologist, endocrinologist, all those things, having those people all in a place where they're meeting every single week, the vast majority of the people that come in, just as a matter of practice, you're gonna get all those people reviewing this and giving their opinions. So it's not one person's brain or one person's habits that are driving the care process. It's, it's some level of scrutiny that's outside of just one individual, and people have to come to consensus. And that's been shown over and over again.

Speaker 2:

And we talk about that a lot on the show. It's this idea that if you only have one particular skill set, everyone's gonna look like that Right. Brown

Speaker 4:

Shoe

Speaker 2:

Store. Right. So, so if you're, if you're, if you're the brown shoe story Yeah.<laugh>, I mean, if you're a surgeon and then you don't think something's resectable, for example, and you just kind of throw your hands of it, the idea of a multidisciplinary team can say, well, listen, you may not be able to get rid of it all, but now I have this that can help rid of this. Right. And we can extend this person's life I this much. Right. And it does require, because there's so much medical knowledge out there, the idea that one person could somehow, you know, except for me,<laugh>, and by and Bob, all of it is just so, it's, it's, it's fantastical.

Speaker 4:

No one is going to be completely familiar with the latest of, uh, of every little aspect of treatment. Right. You know, because I spend a lot of time treating GI cancers. I'm really familiar with a lot of the, uh, a lot of the chemotherapy things. I, I know the doses of radiation therapy that people can and should receive and all the rest of that. But you're not doing it, but I'm not doing it. Right. Right, right. And, but even with that, uh, literally every single week we, we've got, uh, a group of medical oncologists that are in what's called new drug discovery. Right. So, so what they're doing is they are doing the clinical trials of the brand new medicines that have been used, you know, in the dish to, to kill can, certain types of cancer cells are on rats, and they understand the science behind it, but it's just now being, being used in humans. And they're trying to figure out what's the right dose, what's tolerable, what's not tolerable. And because they're in this network of people that do that, they're finding out about all the positive results from different early stage clinical trials, and, and they understand where the, uh, where the field is going, not just what's being done commonly now, and being able to bring that to bear and understanding, um, okay, well maybe we can't treat you with this now, but in six months there's gonna be this clinical trial that comes out. And so what we need to do is we need to find a way to, uh, to arrest or slow what's going on for the next six months, and we can get you enrolled in this trial. And then that's gonna be something that

Speaker 2:

We, that sounds all will and great. But my mother just got diagnosed with cancer Yeah. And they told her she's gonna die. So there's no time to waste Dr. Fleming. Oh, tell me about that. The urgency that comes with a new cancer diagnosis and the pressures and stress that come with a disease that's been developing for 10 years.

Speaker 4:

Well, that, that's the problem is, right. Your, your house is on fire, but it's been burning in the basement for five years before, uh, before you recognize that there's something going on. And the truth of the matter is, cancer doesn't speed up at the moment that it's diagnosed.

Speaker 2:

It's not, it's not like you found it and now it's like, well, I better start causing some trouble.

Speaker 4:

Right. And, and you know, we know that, uh, for instance, pancreas cancer is a cancer that I treat really frequently. And the, the treatment of pancreas cancer has really shifted dramatically over the last, last few years. Uh, our, our our initial way of dealing it with it was, well, as soon as you see someone with a cancer, if you can do an operation, do the dang operation, get that thing out of there because it makes a huge difference. But what we were finding is that people would go through this enormous surgery, and two and a half or three months later, they've got metastatic disease, they've got cancer that spread to other parts of the body. And a spot treatment, like a surgery does not deal with metastases, does not deal with cancer that is diffusely spread, that it will never successfully treat something that spread out. And so, in essence, we did this huge surgery trying to deal with a spot when it was already spread. There is no way that person did not already have spread of the cancer into other parts of the body when that surgery was done. It was just that it was not yet able to be identified with the tests that we have. We don't have things that are sensitive enough to pick it

Speaker 2:

Up. We're gonna be right back to talk a little bit more about, uh, pancreatic cancer. Uh, we're joined again by Dr. Declan Fleming, associate professor at UT Dell, uh, medical school, a really good friend of mine, a badass surgeon, and just, uh, someone who really, uh, is after my own heart when it comes to understanding emotional body, kind of physical aspects of new cancer diagnosis and what kind of makes things better. Yeah. In the last segment, we discussed some of the emotional timeliness that kind of gets impressed upon people when they get diagnosed with cancer. Oftentimes I'll diagnose with somebody with prostate cancer and say, well, listen, I'm not gonna operate on you for 12 weeks. We want things to calm down. And they're just, they're, they're awestruck. Like, don't you understand? I was just diagnosed with cancer. I'm like, yes. I told you, you know,<laugh>. And so that came from me, that, that, that was my words. Right.

Speaker 4:

Well, there's not a per, there's not a single person that doesn't want that problem dealt with yesterday, right? Mm-hmm.<affirmative>, because you, you feel like something's, something's already gone horribly wrong, and you've been wasting time, even if you, even if you just found out about it, even if you're told at Charlie's stage, it is so terrifying to have that diagnosis given to you. There's

Speaker 2:

Guilt, I think exactly what you're talking about. But when it comes to getting through treatment the best mm-hmm. Whether it be surgery or radiation or chemo, we're not all really healthy to start with. And so when you are going about to embark upon a treatment that's gonna take something away, I mean, no matter what we do, it's gonna take a toll on you. Yeah. You wanna get into that in the best way possible. Possible. So in prostate surgery, we do pelvic floor physical therapy, we do erectile rehabilitation therapy, and we do nutrition therapy, and we've seen a big benefit. And you have two before big major abdominal surgery. I'd like you to tell us more about that. Yeah,

Speaker 4:

Absolutely. So there's a concept, uh, known broadly as pre-habilitation, which is the things that you're doing in

Speaker 2:

Recent. So instead of rehabilitation after the injury, right, it's, it's before the injury.

Speaker 4:

Yeah. It is prehabilitation. And the idea is that to be normal and functional and healthy, you've gotta be, you've gotta be at a certain level. So just imagine sort of a horizontal line running down. If I've, I'm above the line, I'm at home, I'm functional, I'm doing the things that I would want to do, a hundred percent of the people that I treat similar to you, I hurt. Everybody gets an injury. And most of those people for a time are injured to a degree that they, they can't do all their

Speaker 2:

Normal, they go below their line.

Speaker 4:

Right. They go below their line. And the idea is that, well, don't take somebody who's at just barely at the line and, and subject them to a big injury. Do something to build that person's functional and self-sufficiency and resiliency level up beforehand. So back in the sort of early to mid two thousands, people started thinking about doing this. The problem was the people that were, uh, trumpeting the idea of doing this were all, all people that had this idea that, well, what we're gonna do is we're gonna get people in great cardiovascular shape. And so they were sitting in people on exercise bicycles and telling pedal as fast as you can for as long as you can,<laugh>, and we're gonna get you in great shape. Well, indeed, it, it improved people's cardiac function, but it didn't necessarily make them more resilient or more able to withstand the surgery. Our idea around prehabilitation has really evolved over the last several years, and we know that, yeah, cardiovascular fitness is really important, but, uh, also doing something to help your core, uh, to help your balance, uh, teaching people mindfulness, helping them to become more able to tolerate stress. Emphasizing nutrition, nutrition is an, an enormous, uh, aspect of this because as you can imagine, to heal from any sort of wound or heal from any treatment, your body has to be in a place where it is building protein. Right. And if you're in a protein

Speaker 2:

Completing way Yeah.

Speaker 4:

State Yeah. There's no way you

Speaker 2:

Can heal anabolic and catabolic. Yes.

Speaker 4:

Right. Exactly. So we did a, uh, we did a program at the University of Texas where we did a four week prehabilitation program for people where they, uh, this was home based. They, the first session they learned, uh, how to do the exercises we wanted'em to do. We gave them nutritional supplements, we gave'em a schedule to follow. And then they did all this at home with, uh, a video to help them re uh, remind them what to do. We actually did this really cool thing, uh, was working with exercise science people at, uh, in the department of Kinesiology. And there's this thing called blood flow restriction training, where you essentially, you put bands that are, that are like little blood pressure cuffs on the top of your, uh, at the top of your arms and the top of your legs, and then you do exercises. What's been shown is that, that if you can, you can have people do sub maximal effort, so not quite as, as physically straining

Speaker 2:

Exercise. And it still builds the muscle up,

Speaker 4:

And it builds it as if they were doing the absolute max sprints and the heaviest lifts and all the rest of that. And, and we did this for four weeks. The hardest part was convincing people that it was okay to wait for four weeks before, before they surgery

Speaker 2:

Because they just got diagnosed with cancer. Exactly. And you're trying to kill my mother. Right. Stop having her exercise. But,

Speaker 4:

But when you tell people this is gonna hurt you, it's gonna take quite some time to recover, the quicker you recover, the quicker you get onto either other treatment or back to normal life. Absolutely. To get to this point, this cancer's been in you and growing and changing for three to five years. Four weeks is a drop in the bucket. It's not gonna change. And we prove that the, the stage of the cancer didn't change during that time. Nobody lost out on being, being able to be treated. And these people, we, we had a group that got the treatment and we compared them to a group that didn't. And we found that their length of stay in the hospital dropped in half, went from 10 days to five days, and their incidents of major complications dropped from, uh, uh, from one person in every three down to one person in every

Speaker 2:

Eight. These are incredibly, huge differences. It's in outcome, it's outstanding. This idea that functional intervention just to make you healthier before surge you in the ho you know, if you're in the hospital five days less, what kind of difference that makes to your life.

Speaker 4:

Oh, right. So I was telling you just a little while ago, I, I recently had a procedure for atrial fibrillation, spent one night in the hospital after the procedure whole, the whole doctor's bill$195,000. Oh, oh, I know. I didn't, sorry, I didn't do that. I didn't know I was worth that much.

Speaker 2:

<laugh>, maybe half

Speaker 4:

That much. But if you think about it, all right. So, so now that included the procedure, so that, that was a big chunk of it. But one day in the hospital right now is around$30,000. Just, you know, check into the Hilton. That's, you know, that's what's, so if you, if you take that and we drop people, stay in the hospital, imagine how many billions of dollars we would save if we chose to say to people, you're not ready for this procedure yet. We're gonna do something to make you better, and you're gonna stay in the hospital for

Speaker 2:

A short period of time. And I think that it's, it's, some of our, our listeners may not recognize it, but if you need multiple steps in your procedure, if you're supposed to get chemo before surgery or surgery before chemo, and you're not healthy enough, you don't get the chemo Right. And then you die.

Speaker 4:

Right. Exactly.

Speaker 2:

You're not healthy enough. The

Speaker 4:

People with complex cancers that survive their cancers are the ones that get each of the individual components in

Speaker 2:

Sequence on time. Exactly. And with you as healthy as possible. Exactly. And I would just urge you, as you do your next levels to really think about sleep and stress, we, in our, in our clinic, have started initiating sleep bracelets with the whoop program. There are sleep mats that you can do that judge a person's sleep. And just, it's, you know, that, that Heisenberg principle, when you, when you measure it, you change it, right? Yes. And so, uh, just by having people focus on their stress levels, their pain after surgery, their recovery after surgery improves because, you know, a lot of times in the clinic, which person's gonna require the most pain? Me, the one that's real tense, right? Are you sure you're gonna have enough morphine for me? I'm worried about pain. Right. That guy's gonna be sitting in bed for three days,

Speaker 4:

Uh, that's, you know,

Speaker 2:

Hooked up to pain meds and he's gonna last in the hospital longer. Well,

Speaker 4:

You know, it's, it's really clear that the people that require more narcotic pain medicines have worse outcomes. The more we can do to keep people from ever having to need narcotics, whether that be, uh, doing acupuncture or, or hypnosis or, you know, we, we do, uh, anybody who has an abdominal operation, we're doing a nerve block of the nerves coming from the back around the abdominal muscles.

Speaker 2:

You taught me this amazing taps block.

Speaker 4:

Yeah. It's incredible. And, and, and those people, their, their, uh, narcotic consumption is dropped by about 90% compared to otherwise. And if you can do Tylenol, Motrin, uh, blocks, uh, some, uh, some stretching, some exercise, uh, things like that, and avoid the narcotics you're staying in the hospital is gonna be shorter. Your complication incidence is gonna be lower. Huge, huge differences from things that are, that have less to do with medicine and more to do with

Speaker 2:

Preparation. And so those listeners that have may just been joining us, let me assure you something, Dr. Declan Fleming and I are badass surgeons,<laugh>, we live and breathe operating. We've been doing it for decades. Yeah. We only dreamed in our lives that we would get to operate. And now we're talking about high fiber diets, nutrition and stress management

Speaker 3:

And meditation.

Speaker 2:

Like, like we were some kind of yogis on a mountain. And what do we know? It makes a big difference. It is. And it lets us operate more. It does.

Speaker 4:

It does Well, and, and again, you and I, we know a hundred percent of the people that we treat, we hurt. We're gonna injure everybody, but it's injury with

Speaker 2:

A purpose. That's

Speaker 4:

Right. And if, and we can minimize the injury, prepare people for it, get them ready so they bounce back quicker than everybody wins. And that's what we all go for.

Speaker 2:

Well, Dr. Fleming, I cannot thank you enough for joining us again. You're just an inspiration to me. I just, just love operating with you. And, and, and thank you so much for all that you do for the

Speaker 4:

Patience. You know, I, I gotta tell you, Sonny, that, uh, I am just so appreciative to have you as a colleague. It's just, it's just awesome to be able to have a friend that I can work with and that we know we're going for the same thing for people. That's

Speaker 2:

Awesome. Awesome. Well, Donna, how do people get ahold of us and get a message, Dr. Fleming? That's

Speaker 3:

Right. You can reach out to us at armor men's health.com, where you can submit an inquiry and you can check out our podcast wherever you listen to podcast. Um, 5 1 2 2 3 8 0 7 6 2. Thank you, Dr. Fleming.

Speaker 1:

It's my pleasure. The Armor Men's Health Hour is brought to you by Urology Specialist. For questions or to schedule an appointment, please call 5 1 2 2 3 8 0 7 6 2 or online at armor men's health.com.