EP 618: High PSA, Prostate Cancer, and HIFU: What You Need to Know About Prostate Testing and Treatment

In this episode, Dr. Mistry and Donna Lee discuss different approaches to diagnosing and treating elevated PSA, enlarged prostates, and prostate cancer. If you're not sure whether you should be screened for prostate cancer, or whether screening even works, listen in! Dr. Mistry explains how prostate exams like the 4kscore Test or prostate MRIs can help predict your prostate cancer risk. They also break down the reasons that HIFU treatment for prostate cancer is the best option for patients wanting to preserve function and maintain their lifestyle. This information is crucial for everyone with a prostate, so tune in and learn more about keeping your prostate healthy with help from NAU Urology Specialists. 

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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Transcript

Speaker 1: 0:07

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

Speaker 2: 0:13

Hello and welcome to the Armor Men's Health Show. This is Dr. Mystery, your host, board certified urologist all around. Great guy<laugh>.

Speaker 3: 0:21

I knew you were gonna say that. You've been saying that a

Speaker 2: 0:23

Lot here with my co-host, Donna Lee

Speaker 3: 0:26

<inaudible>. Great gal. That's

Speaker 2: 0:27

Me. That's Ru, Dr. Donna. Dr. Donna. This is a men's health show, uh, although we do talk about a number of topics that affect women as well. I'm a board certified urologist. We treat a variety of different urologic conditions that you might kind of imagine, like urinary incontinence, uh, enlarged prostate, prostate cancer, kidney stones, a variety of other malignancies of the genital urinary system in women. Our practice treat urinary incontinence and we're gonna treat all the other things that affect women and men, both, uh, similarly, bladder cancer, kidney stones, uh, blood in the urine, and a whole host of abnormal urinary issues like pain with urination or pelvic pain. That's what we do. Uh, our practice is n a u Urology Specialist. We are based out of Central Texas here in Austin. And Donna, how do people get ahold of us and where are our offices?

Speaker 3: 1:11

You can reach out to us at 5 1 2 2 3 8 0 7 6 2 and even ask for me, our office locations are Round Rock, north Austin, south Austin, and the very cute dripping Springs, Texas, and our website, armor mens health.com. You can submit your questions there and we will answer them anonymously. And I think we have a topic today that you wanted to chat about.

Speaker 2: 1:30

Absolutely. I think that when there was the pandemic, a lot of people did not go visit their primary care doctor. And so increasingly we are seeing men that are coming to us with the diagnosis of elevated psa. The PSA is a blood test that is done to measure your risk for having prostate cancer. Right. Even though, you know, in our world this is kind of common knowledge, I would say almost half the men that, that are referred to me for elevated PSA don't know that test

Speaker 3: 1:57

Exists because they're just focused on the fact that somebody might stick their finger in their booty<laugh>. Well, and they don't want that test.

Speaker 2: 2:04

Well, the PSA test is not predicated on putting your finger anywhere<laugh>. It's just a blood test. It's just a blood test that should be done as part of your routine work now. Right. There's controversy on whether or not screening men for prostate cancer really has any value. There's a controversy. What's

Speaker 3: 2:19

The controversy?

Speaker 2: 2:19

The controversy is that a lot of men who are found to have prostate cancer don't really need treatment because the cancer's too slow growing and that a lot of people that have high PSAs don't have cancer and may undergo unnecessary biopsies. And all of these kinds of conversations are legitimate. But what ends up happening is that if your primary care doctor does not believe that PSA testing is useful, they won't order it. And so instead of having a conversation with you, which is what they're supposed to do, have a reasoned conversation with you. Sometimes, especially those of us that may be parts of big health systems where the rules of PSA testing are kind of decided by somebody else

Speaker 3: 2:55

Who's not a doctor

Speaker 2: 2:56

<laugh>. Right. More, more like a panel of mm-hmm.<affirmative> of administrators. You may not be offered that test. So just this week alone, I was, I, I saw two patients in their late sixties with high PSAs that have never had tests done who go to the doctor regularly. So in some ways it felt like kind of a, a missed opportunity to have caught them a little earlier. And although the vast majority of patients won't really run in any trouble with a delayed diagnosis, there are some that do have a problem. Yeah. What are we here for? If not to find those few vulnerable patients that are, that could have been saved with early testing.

Speaker 3: 3:28

So why'd they end up with you or just because they finally caught the psa?

Speaker 2: 3:33

Sometimes, sometimes, sometimes they change doctors, doctors retire. Mm. Uh, they change insurance plans and then somebody decides to take a fresher look at them.

Speaker 3: 3:39

So there are PCP that then sends them two

Speaker 2: 3:41

Specials, then, then their primary care provider will send them to us. Okay. When it comes to your psa, the guidelines would state that really it's met in their fifties that need to be tested. And then that testing should stop, uh, over the age of 70. Those are our kind of our official guidelines in the preventative task force.

Speaker 3: 3:56

That's an annual test, right?

Speaker 2: 3:57

That's an annual test. Okay. In our clinic, we, we have a more aggressive strategy of checking for PSAs. Uh, virtually all patients over 40 who are on testosterone replacement will get their PSA checked. Uh, African American men over the age of 45 will start getting their, um, uh, PSAs checked because cancer tends to show up earlier. So it's not more aggressive in African American men mm-hmm.<affirmative>, but since it shows up earlier, it's diagnosed later in the process. Oh. So, so if, if you match, if you match ages, uh, it tends to be a little, a little bit more aggressive in African American men, although they seem to do just as well if you catch'em early. Hmm. Um, we also, um, will continue, we will use what's called an age adjusted PSA range. So if you're under the age of 55, I want to see your number closer to two. If you're under the age of 65, I wanna see your number closer to three or three and a half. And then the 4.0 cutoff that most people use for a psa. Really you should be over the age of 60. Now, I, I may have muddled some of those ages there, but that's because we don't like to use hard cutoffs. I want to see where your PSAs have been. Where are they going? Kind of what the trend is. Do you have a family history of prostate cancer? Do you have a big or small prostate? Because if you have a small prostate and a high psa, that's more worrisome than a, than a PSA that might be high in a really big prostate. Mm-hmm.<affirmative>. And so these are the kinds of, um, nuances that we'll want to use when we evaluate, uh, your psa. Uh, I had a patient this week, he was 65, he had a PSA of eight, and I told him that he has a 40% risk of having prostate cancer, and he know what his response was. Hmm. Oh, I don't have cancer.

Speaker 3: 5:37

<laugh><laugh>. Ah, I like that. I

Speaker 2: 5:41

Was, I was taken aback. He

Speaker 3: 5:42

Goes, yeah, what'd you say?

Speaker 2: 5:44

No, no, that doesn't affect people like me. And I was like, oh,

Speaker 3: 5:47

What was he white and affluent<laugh>? He was not. What

Speaker 2: 5:50

Does that mean? He was Asian. Oh. And affluent.

Speaker 3: 5:52

Oh, well, it's the money thing.

Speaker 2: 5:54

Crazy Rich Asians, I guess. Wow. So I thought it, it was a really interesting kind of way of being, uh, you know, uh, himself. He was like, well, I, I don't have cancer. I'm not going to check for it.

Speaker 3: 6:05

Oh, what did you do?

Speaker 2: 6:07

I negotiated with him

Speaker 3: 6:09

<laugh>. I bet.

Speaker 2: 6:11

So it's not my job to force you, you know, as a patient of mine to do something you don't want to do. I'm baffled. Um, and, and culturally, um, you know, it's, it's not that doctors have to be blind to race or to culture. We really have to understand how does race and culture affect your decision making? Where are you coming from? Culturally, and this was a fascinating kind of experience. This was a, you know, a a person who was a self-made, very wealthy immigrant who was extremely healthy and really prided himself on his health and the fact that his family was healthy. His father lived till 105. You know, cancer is not something that that affects their gene pool. And I, I respect that. But his PS a was I

Speaker 3: 6:56

<laugh>. He came from la la land

Speaker 2: 6:57

Apparently, and, uh,

Speaker 3: 6:58

Land of la

Speaker 2: 6:59

La and he was well-read. He knew why he was coming. I feel like maybe he just came to argue

Speaker 3: 7:04

<laugh>. Uh, yeah.

Speaker 2: 7:05

So how we negotiated with this particular patient was, uh, we have, uh, several adjunct tests that we can do. So if you have a high psa, but you don't want to have to have a prostate biopsy, uh, we can certainly, um, uh, you know, try to better refine whether or not you have a high risk for prostate cancer or not. So the two tests that we used in this particular patient, one is called the 4K O P K O score. And this uses some more like refined PSA testing, uh, metrics that can not only tell us what your PSA or your 4K score is, but can with a good degree of reliability, tell us what is the chance that we're gonna find a dangerous cancer if we, if we biopsy you. So those men that are particularly kind of, you know, hesitant to undergo a biopsy or more appropriately if you've already had a biopsy. So sometimes we'll meet guys who had a biopsy 10 years ago or five years ago, and don't really want to go through it mm-hmm.<affirmative>, but their PSA still keeps going up. So we'll do a 4K score and we'll do a prostate mri. Hmm. And, uh, Donna, you've seen us order lots of prostate MRIs. Oh,

Speaker 3: 8:13

Yeah. We've seen lots of 4K score results come through too.

Speaker 2: 8:16

And so it's not, uh, it's not that everybody gets it. Uh, and 10 years ago, insurances didn't pay for a lot of these things, but because these tests help us avoid biopsies in many cases, right. The insurances and certainly Medicare have come around to, uh, being a lot more open to us ordering these tests and kind of better stratifying patients that, um, uh, that might have disease. Mm-hmm.<affirmative>. Um, and so, uh, if, if you're, if you're out there and you've been diagnosed with a high PSA and you've been scared about getting a biopsy, or you wanna learn more about your options when that test comes through,

Speaker 3: 8:52

Just take that guy's, uh,

Speaker 2: 8:54

Attitude. I don't have cancer<laugh>. It doesn't happen to people. Does

Speaker 3: 8:57

It work the other way? Does DOESN like me, does I have a bazillion dollars? Does that work when I turn it

Speaker 2: 9:01

Around? Money does help. Yeah.

Speaker 3: 9:04

Well, I'm gonna pretend that I got a bazillion

Speaker 2: 9:05

Dollars. Money doesn't buy you happiness. It's gonna, but it can help you rent it for a while.

Speaker 3: 9:08

Just like that guy's. Not cancer. We got money.

Speaker 2: 9:11

Well, you know, the, the, the, the role that I have is not to just say, well, you're right. You know, um, uh, you are, you know, not, not, not gonna have a problem. Good luck with you<laugh>. Um, but instead we try to negotiate and say, okay, you know, you believe you have this belief that you're not going to get sick, and that's great. Mm-hmm.<affirmative> and, you know, attitude goes a long way.<laugh>. Yep. But let me order some additional tests, then we can kind of take this information and give you as give you enough kind of data to analyze. And if in the end I say that you have a 10% chance of having cancer and you say, that's too low to undergo a biopsy, then that's fine. But if I say, if you have a 40% chance of having cancer, that's dangerous. Yeah. How will that change kind of how you go about doing things? Wow. And, uh, and once again, we're here to kind of save people's lives. So we're gonna give them that information, right. Donna, how do people get their lives saved with us?

Speaker 3: 10:08

<laugh>, call us at(512) 238-0762, where we will save that life and our website, armor men's health.com, where you can submit your questions and we'll answer them anonymously. As always, you can listen to our podcast wherever you listen to free, wonderful podcasts like this, although ours is unique and exceptional. And thank you guys so much for listening and we love

Speaker 2: 10:28

You. Hello and welcome back to the Armor Men's Health Show. This is Dr. Mystery, your host, board certified urologist. This show is brought to you by N Na U Urology specialist, the practice I started in 2007, right here in central Texas. Uh, we treat all variety of urologic conditions and I'm joined as always by my co-host, the better loved member of this team. Better

Speaker 3: 10:49

Love, better, more admired,

Speaker 2: 10:51

Appreciated, more admired by whom? Professional comedian Donnelly. That's

Speaker 3: 10:54

Right. Welcome to my show,<laugh>. Welcome to my, I have a new following of men between the ages of 60 and 75

Speaker 2: 11:01

<laugh>. It's your target demographic,

Speaker 3: 11:02

Donna. Nope. They show up at the clinic looking for Donna. Ooh.

Speaker 2: 11:05

They have COR vets.

Speaker 3: 11:06

That's right.<laugh> from 1976.

Speaker 2: 11:08

1976. In our last segment, we talked about patients who are referred to us for elevated PSAs. Kind of what that means in terms of a potential prostate cancer diagnosis and different tests that we offer to help better stratify your risk for cancer. And, uh, now I thought we talk a little bit about haifu.

Speaker 3: 11:24

Hifu sounds like a karate chop. Ha

Speaker 2: 11:26

Fu ha fu haifu or high intensity focused ultrasound is a treatment for prostate cancer that's been around for maybe five to seven years. FDA approved in the United States, but has been around in Europe for, uh, much longer. Almost two decades. About 10 years ago or 15 years ago when I first started practice, patients would be taken to The Bahamas to get haifu. Really? Yeah. Like some, some of the doctors here would go to the Cancun or to The Bahamas. Wow. And they had one of these machines there. And the patients that were, were, you know, particularly well-read and well-healed because I think they charged'em$26,000 to go get it done. Now they would

Speaker 3: 11:59

Go that include the Bahama Breeze drinks

Speaker 2: 12:01

<laugh>. That's right. All the Bahama all you can drink<laugh>. Yeah. All inclusive, including your prostate getting zapped<laugh>. That, that's quite an all-inclusive Hmm. Good times. This high FU procedure, H I F U or high intensity focused ultrasound is offered, uh, probably in a handful of locations here in the United States. And the main reason is because the machine itself is fairly pricey. We're very fortunate here in Austin to have two machines, uh, in fact, uh, running around Austin. And that's because, uh, the company that makes the HIFU machine is headquartered right here in Austin.

Speaker 3: 12:32

That's right here in Austin and in

Speaker 2: 12:35

France. And in France. It's called E dap. It's a big jump. E D A P. They got into the business by making, uh, urologic equipment for shockwave lithotripsy. That means they use ultrasound to break stones. And so this really kind of, kind of speaks to all the medical utility that ultrasound or sound waves have. In urology. We use sound waves for breaking up stones. We use ultrasound for imaging. Mm-hmm.<affirmative>, the prostate, the abdomen, the kidneys. We use ultrasound to help rejuvenate and regenerate the nerves and arteries of the penile erectile bodies to help you get better erections. And in this case, we use sound waves or, uh, sonogram to heat up and kill prostate can. This is very appealing to a good number of patients because we can target it to reduce the likelihood of impotence and incontinence and we can target just where the cancer is. Right.

Speaker 3: 13:24

Instead of oblating the whole prostate,

Speaker 2: 13:26

Which is kind of like what radiation and surgical removal do, which is kind of obliterate the entire prostate. Which I do. I mean, if the appropriate patient presents, then removing their prostate or setting them for radiation are things that we definitely do. But I have patients that come all over the country to get

Speaker 3: 13:43

High. Mm-hmm.<affirmative>, you know why? Cuz you've done more than anybody in Texas.

Speaker 2: 13:46

We've sure. We've sure. Done so many of those high food procedures, but also because we insurance started covering the procedure, we accepted insurance and a lot of places in the country still don't accept insurance to cover haifu because they were so happy making$30,000 per procedure. Mm-hmm.<affirmative>. But today Medicare pays for haifu high intensity focused ultrasound to determine if you're a candidate, we will do a free second opinion, a telemedicine second opinion

Speaker 3: 14:12

For this particular second opinion

Speaker 2: 14:13

For this particular thing.

Speaker 3: 14:15

You're not just

Speaker 2: 14:16

For pro. Yeah. Yeah. If you're listening out there,

Speaker 3: 14:18

If your toe hurts, you're not getting a free second opinion

Speaker 2: 14:21

For your ed. You come in for a visit. That's right. Uh, but for prostate cancer, especially because so many of our patients do listen to the show and travel from out of state, we're actually not allowed to charge your insurance if you're outta state. Do you know that Donna? You can't. No. You have to be, you have to be licensed in the state, the patient's in,

Speaker 3: 14:38

So patients can't come

Speaker 2: 14:39

To you. So I can go to Hawaii and charge for visits by telemedicine if the patient's in Texas, but, uh Oh, gotcha. But, but if I'm in Texas, then the patient has to be in Texas. Oh God. So, um, what's

Speaker 3: 14:51

The cash pay price

Speaker 2: 14:52

For a what?

Speaker 3: 14:53

For the haifu now

Speaker 2: 14:55

For the Haifu is still$13,000, uh, about 13,500.

Speaker 3: 14:59

And in New York they're still charging

Speaker 2: 15:00

50,000.

Speaker 3: 15:01

Oh, it's 50 now. Yeah. Wow. Went up for like 35.

Speaker 2: 15:04

It's very expensive at those places. Wow. I think Duke is still charging that much money and Methodist in Houston is still charging that much money. Wow. And the main reason we don't charge that much is because it takes us two hours. Yeah. And we already own the machine, so it doesn't make any sense to like,

Speaker 3: 15:17

To rob the patient.

Speaker 2: 15:19

<laugh>. Yeah. Especially, and, and, and, and I will say over the years, probably 80% of patients who are interested but still had to pay cash, were still able to come up with that kind of money. Where I owned, I think 50,000 would've been a amount too hard. Too hard to climb. Yeah. But what benefits we've gotten is because our price has been affordable. I've had tremendous experience doing, you know, the most, many cases. Yeah. So I've seen what happens when it goes well, what happens when it doesn't go so well and what problems can arise because any surgical procedure can have potential complications or potential problems. Right. So the ideal patient is gonna be, uh, a patient who has cancer that's, uh, limited to one part of the prostate, even if it's not just one core out of the biopsy taken, but one part of the prostate. Mm-hmm.<affirmative>, if you have an MRI that was done that showed a lesion and uh, the cancer's localized that lesion, we can, we can use that information to target our H fu or high-intensity focused ultrasound energy. Mm-hmm.<affirmative> to help break it up. Um, generally speaking, um, most people, um, with what we would call kind of a, um, a, a borderline clinically significant disease, that means somebody with Gleason six Cancer, a lot of them are candidates for it. Even if the cancer's on both sides of the prostate. Uh, the procedure itself takes about an hour and a half to two hours. It's done as an outpatient. You do go to sleep. We do give you a, uh, full general anesthetic because we don't want you to move during the procedure. Uh, the ultrasound probe while you're sleeping is placed into the rectum. We<laugh> just met him.

Speaker 3: 16:56

Oh,<laugh>. I missed that. Sorry.

Speaker 2: 16:58

I can't believe

Speaker 3: 16:59

It. Rectum near killed him. There it is. There

Speaker 2: 17:01

You go. So, uh, it's inserted into your rectum and then we image your prostate gland. Um, and then we target which areas we're going to treat. We robotically program program that into the machine, and then the machine marches through your prostate and, uh, uses ultrasound energy or sound waves to heat up the tissue. If you use a high enough intensity, uh, of the sound wave, you can, you, you can break things apart, you can break stones apart. You can, you can, it's amazing. Use a weapon. Uh, and certainly you can use to be heat to heat up tissue. And uh, that's the kind of, uh, properties of the ultrasound that we use to kill cancer. Uh, surprisingly. Um, we do use ultrasound ultrasonic energy in, in other, other kinds of, uh, surgical fields as well. Mm-hmm.<affirmative>,<affirmative>, uh, when we're using, when we're doing laparoscopic surgery where we use little sticks to cut things open and, and dissect things. Mm-hmm.<affirmative>, one of the tools we use is called a harmonic scalpel harmonic because of sound waves

Speaker 3: 18:01

Does it? Harmonize.

Speaker 2: 18:02

Harmonize. And then that uses ultrasound also to cut tissue. Um, and in this case we use ultrasound to heat tissue. Uh, the success rate I usually tell patients is about 80% as effective as surgery. Um, uh, and I, and I usually quote radiation to be about 90% effective as surgery. So for those patients that are very concerned about their quality of life, they want to maintain their erection. They don't want any risk of incontinence and they do not want to have radiation therapy because of potential long-term side effects. These are people who are great candidates for haifu. And if you've been diagnosed with prostate cancer and you've not been told about haifu as an option, or if you had radiation for prostate cancer and your cancer's come back and nobody's talked about haifu, then those are great circumstances in which we would like to see you and talk to you about, uh, this procedure. It's covered by Medicare, it's covered by many insurances now. So payment is usually not an issue. It's really an issue if you're a candidate based upon the kind of cancer you have. Mm-hmm.

Speaker 3: 19:07

<affirmative>, my father-in-law, father-in-law had it done. He was on the show too.

Speaker 2: 19:11

Yes. He was on the show. He had a great

Speaker 3: 19:13

Experience. He thought it was great. He said, I just wore that catheter for a week after. But he didn't have any erectile dysfunction issues No. In incontinent issues afterwards. So he was super pleased.

Speaker 2: 19:22

Yes. I love seeing him at parties because he tells me how good the erections are.

Speaker 3: 19:25

<laugh> my mother-in-law's doing the earmuffs cuz you know, she's a little proper.

Speaker 2: 19:32

I give'em a high five and say, good job buddy.

Speaker 3: 19:34

<laugh>. That's awesome.

Speaker 2: 19:36

Well, Donna, uh, why don't you talk people through the process of how they get a second opinion when it comes to their prostate cancer.

Speaker 3: 19:42

You reach out to us and let the phone operator or the patient care coordinator know that you heard the show that, um, you heard Dr. Mystery talking about the free second opinion for Haifu high intensity focused ultrasound. That person will get you on Dr. Mystery's schedule and there will be no charge for you to talk to him about it to get that second opinion. Our number is 5 1 2 2 3 8 0 7 6 2. You can even send, um, if you're interested in that second opinion for ha fu, you can send an inquiry to armor men's health.com and I get those inquiries. So I'll get right back in touch with you and put you on the schedule. And you remember to check out our website again. Armor men's health.com. I was having a little brain fart there. Dr. Mis got so excited about these free second opinions that are coming

Speaker 2: 20:25

In and the more records you can have with you when we have that conversation. Oh yeah. Better. Yeah, please. So your pathology reports and any imaging tests that you've had really help move that process along.

Speaker 3: 20:34

That's right. We can do an electronic medical records request so we're not hurting anybody's feelings like your other doctor. But call us at(512) 238-0762.

Speaker 1: 20:42

The Armor Men's Health Show is brought to you by N A U 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.