The Peter Attia Drive - #343 – The evolving role of radiation： advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions

00:00:00.000 Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:16.540 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

00:00:21.520 into something accessible for everyone. Our goal is to provide the best content in health and

00:00:26.720 wellness, and we've established a great team of analysts to make this happen. It is extremely

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00:00:36.960 is made entirely possible by our members, and in return, we offer exclusive member-only content

00:00:42.700 and benefits above and beyond what is available for free. If you want to take your knowledge of

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00:00:53.200 of the subscription. If you want to learn more about the benefits of our premium membership,

00:00:58.000 head over to peteratiyahmd.com forward slash subscribe. My guest this week is Dr. Sanjay

00:01:06.180 Mehta. Sanjay is a radiation oncologist at St. Joseph's Medical Center in Houston, Texas,

00:01:10.840 where he's been in practice for more than 20 years. I wanted to have Sanjay on the podcast to

00:01:14.620 talk about all things pertaining to radiation oncology, but also the history and some of the

00:01:19.320 misconceptions around radiation exposure and radiophobia. We talk about some of the very

00:01:23.580 interesting applications that I only learned about recently that are very common outside of

00:01:28.840 the United States that involve low-dose radiation to treat inflammatory conditions and athletic

00:01:35.060 injuries. Now, of course, those of you who are interested may recall that because this podcast

00:01:39.740 is called The Drive, I do occasionally talk about cars, and given that Sanjay and I have a shared

00:01:45.620 passion for them, and in fact, that's how Sanjay and I met, we do end this discussion with a little

00:01:51.120 bit of a deep dive into cars. But of course, back to the main point of this discussion, we talk about

00:01:56.380 the evolution of breast cancer, including the shift from radical mastectomies to more conservative

00:02:00.480 approaches like lumpectomies and sentinel node biopsies. We talk more broadly about the role that

00:02:05.180 radiation plays in modern oncology, how doses have changed, and how advancements in targeting tumors

00:02:10.300 while minimizing damage to surrounding tissues have rendered side effects much more rare.

00:02:14.960 Certainly more rare than they were even 20 to 25 years ago. Sanjay talks about the role of low-dose

00:02:20.780 radiation for inflammatory conditions such as arthritis and tendonitis, and how this approach

00:02:25.360 is more widely used outside of the U.S., and why it's his hope and mine that it becomes more adopted

00:02:30.200 here in the U.S. We speak about the history and misconceptions of radiation exposure, including

00:02:35.180 radiophobia, nuclear accidents, and early uses of radiation. So, without further delay,

00:02:41.200 please enjoy my conversation with Dr. Sanjay Mehta.

00:02:44.960 Sanjay, welcome back to Austin.

00:02:51.680 Thank you, Peter. Pleasure to be here.

00:02:53.680 I think this is the first time we're together not driving, right?

00:02:56.760 I think so, yeah. That is true.

00:02:59.620 I don't know. Somehow we're going to resist the urge for most of this discussion to not talk about

00:03:03.800 cars. Don't want to bore your audience.

00:03:05.420 I know. It is called the drive.

00:03:07.420 This is true.

00:03:08.100 So, I feel like we will reserve the right to have some automotive discussions at the end. For listeners,

00:03:14.580 Sanjay might be one of the most knowledgeable human beings on cars. He's also a very dangerous friend to

00:03:21.700 have because he's always the bad one on the shoulder when you're contemplating a new set of wheels or a new

00:03:31.040 something for your cars. But in his other life, in addition to being the founder of MD Motorheads,

00:03:38.120 right?

00:03:38.420 That's right. Yeah.

00:03:39.180 Which is a Facebook group of doctors who are gearheads.

00:03:43.200 We're about to crack 3,000 members. It's exploded.

00:03:46.600 Yeah.

00:03:46.860 That's awesome. So, shout out to MD Motorheads. You're also a radiation oncologist,

00:03:50.840 which we also spend some time talking about.

00:03:52.700 Right.

00:03:53.240 I guess we thought it would be a really fun idea to do a podcast for a couple of reasons.

00:03:57.580 One is just the bread and butter of what you do as a radiation oncologist is a bit of a black box to

00:04:02.440 many people. Myself included, if I'm going to be completely truthful, even training in surgical

00:04:07.480 oncology, I feel like I had much more familiarity with the medical side of oncology than I did with

00:04:13.840 the radiation side of oncology. So, for myself, for the audience, I think it would be wonderful to

00:04:18.940 understand more as it's a field that has evolved a lot. I'm guessing the last 25 years has seen a

00:04:25.180 lot of change.

00:04:25.620 It's one of the youngest fields too in that respect. It's not steeped in some of the traditions that

00:04:30.460 surgery and medicine are. So, yeah, it's a new field, highly evolving very rapidly. And the

00:04:34.480 technology has changed so much just in really in the last decade or two. It's pretty incredible.

00:04:40.120 Just out of curiosity, when did it become its own discipline, its own set of boards and everything

00:04:44.420 like that?

00:04:45.060 As a kid growing up in Houston, some of my family friends were radiologists. And I remember it just

00:04:50.080 like probably an elementary school kid that some of them were talking about radiotherapy. And

00:04:54.140 these were diagnostic radiologists who at the time, CT scanning was pretty new in the 80s.

00:04:59.160 And prior to that in the 70s, and then prior to that, it was kind of just a fellowship.

00:05:02.800 Radiologists would have a Cobalt-60 machine that they would train on for a few weeks. And you do

00:05:06.600 a few easy calculations and you do some crude treatments. But it really started, it came into

00:05:11.320 its own starting in the 70s and then really more into the 80s. And that's when it became its own

00:05:15.700 discipline. And the ACR had a separate carve out. And so, our residency training is completely

00:05:20.400 independent of diagnostics now. So, we just do, it's an intern year followed by four years of

00:05:24.900 radiation oncology with a little bit of overlap, but not a lot of diagnostic training at all,

00:05:29.520 just because there's so much to do just on the therapeutic side.

00:05:33.240 Got it. I had no idea that it was that new. And in terms of medicine, that's obviously like

00:05:37.020 very new. The second thing that I wanted to talk about on the radiation front is this idea of using

00:05:42.800 very low-dose radiation to heal injuries. I think that while people will be incredibly interested

00:05:49.420 to understand the ins and outs of radiation oncology, again, given the ubiquity of it in

00:05:54.300 treating people, I think a lot of people are going to be very interested in this idea that

00:05:58.480 why aren't we using low-dose radiation more to heal some of these nagging orthopedic injuries that

00:06:04.600 people have? And of course, we'll go far down the rabbit hole on that. But I don't think we can have

00:06:08.660 this discussion without giving people some understanding of what radiation is. And I would like us to do it in

00:06:16.080 a way that's both rigorous enough that we can really get into some of the science of this,

00:06:21.520 but also get into it gently enough that people that maybe don't remember high school physics well

00:06:27.160 enough can come along for the ride and not get lost. But once we get into grays and millisieverts

00:06:32.540 and all that stuff, I want everyone to be fluent when we start talking about doses.

00:06:35.960 Right, right, right. Radiation itself, the term itself has got a bit of a negative connotation,

00:06:41.860 but basically it's part of the electromagnetic spectrum. So we have everything on the one in

00:06:47.120 the range of increasing energy of photons, which are just particles of light. On the one end,

00:06:52.060 you have radio waves and microwaves. On the other end, you've got infrared, excuse me, you've got

00:06:56.120 ultraviolet, and then you get into x-rays and radio waves. And in the middle of all that is the

00:07:00.220 visible spectrum. So when you see, I'm sure everyone's seen the graphs where you've got the

00:07:03.520 rainbow, red, green, blue that we can see. The human eye can only perceive a tiny little narrow spectrum.

00:07:08.720 These are wavelengths.

00:07:10.380 These are actually wavelengths and energies, which are the very low end energies. You have

00:07:14.200 things like radio waves. In that situation, both radio waves and microwaves are what they call

00:07:19.220 non-ionizing. And I know you've talked about this on some of your previous podcasts, and you had a

00:07:23.680 really good one with Atari Walla from Pronuvo. It was really nice in-depth discussion. But essentially,

00:07:28.800 the bottom line is that the low energy stuff that is non-ionizing cannot damage tissue. And that goes

00:07:34.740 all the way up to visible light. Then when you start going to the higher energy x-rays, that's

00:07:39.020 when you get both x-rays as well as ultraviolet light, and then the higher particle stuff. But

00:07:44.060 basically, the higher you go in the energy and the energetics of the particles, the more likely

00:07:48.160 exposure to these packets of energy are going to cause damage to your DNA.

00:07:53.460 Why is it that the shorter the wavelength, because that's what's changing as you go from radio waves to

00:07:58.400 microwaves to visible waves to ultraviolet? Why is it that as the wavelength gets shorter,

00:08:03.760 the energy gets bigger?

00:08:04.940 Yeah, I'm not sure what the reason is. They are inversely proportional to each other. I don't

00:08:08.640 know that, I guess I'm probably not enough of a physicist to answer that question precisely. But

00:08:12.720 having said that, that is the characteristic of this. And in doing so, that's one of the big reasons

00:08:17.580 why all the fallacies about your cell phone giving you brain cancer and all are just that. They're

00:08:22.860 fallacies because even having a cell phone on your ear for hours a day, it's non-ionizing radiation.

00:08:29.060 And standing too close to a microwave oven, again, non-ionizing radiation, so that cannot damage

00:08:33.860 your cells.

00:08:34.900 The radio wave is too long.

00:08:36.900 That's right.

00:08:37.520 The microwave is too long. It doesn't have the energy. You can stand on it all you want. It can

00:08:43.580 heat, but it can't damage.

00:08:45.260 Correct. It can excite the molecules, but it won't actually eject an electron, which is what would cause

00:08:49.480 an ion to form, which is why it's called ionizing. And that's where we deal with on the, I'm on the

00:08:54.380 therapeutic end. So diagnostic radiologists deal with lower energy x-rays than we do. The very high

00:09:00.600 energy x is what we use in our linear accelerators to treat cancer. So that's the big difference there

00:09:05.180 is kilovoltage versus megavoltage, but all of these are ionizing.

00:09:09.220 Okay. So let's talk about how these are measured. How do we quantify them? Because people on the podcast

00:09:15.640 have heard me talk about this, I suspect. We talk a lot about calcium scores and CT angiograms

00:09:21.440 and PET-CT. I think the frequent listener will have been somewhat familiar with how we talk about

00:09:26.920 how to dose those things.

00:09:28.840 So radiation dosage, there's a couple of different terms that we've talked about. The main one we talk

00:09:33.460 about when we're talking about patient treatment is the unit called the GRAE, and that's an SI unit

00:09:38.060 that essentially is joules of energy per kilogram of tissue. So that's what they call absorbed dose.

00:09:44.020 So that's in tissue. Whereas when you're talking about exposure in the general, in the air, and

00:09:48.660 in general exposure, it's in the air, we usually use the term sievert for that. And actually both

00:09:53.440 those terms for the most part are equivalent. It's just that the sievert itself will take into

00:09:58.280 account if you have different types of x-rays, different qualities of x-rays that have different

00:10:02.980 degrees of potential to be ionizing, that they have a quality factor you'll multiply it by.

00:10:07.940 But for the most part, we use the term GRAE when we're talking about, for example,

00:10:11.060 when I treat a prostate patient, they're going to get somewhere between 70 and 80 GRAE,

00:10:15.840 but it's fractionated into small daily doses as to be tolerable for the body.

00:10:20.420 And then when we talk about millisieverts like we're going to, that's really just

00:10:23.620 a measure of exposure, not absorbed dose in tissue per se.

00:10:27.760 What's the relationship between a GRAE and a millisievert? Is it a one-to-one relationship?

00:10:31.640 Yeah, so a GRAE and a sievert technically. If anyone's kind of old school, you listen to older

00:10:35.600 stuff, you'll hear the term RADs. A lot of people have heard of RADs.

00:10:38.060 So one RAD is equal to one centigrade. 100 RADs is a GRAE. It's just an SI unit versus the old

00:10:44.320 terminology. And a sievert is the equivalent, only it's in air, not in tissue.

00:10:49.800 But a sievert is a GRAE?

00:10:51.180 Correct. Correct.

00:10:52.280 So when you give 70 GRAE, you're giving 70 sieverts or 70,000 millisieverts over the course

00:10:58.840 of the treatment?

00:10:59.360 That's correct.

00:10:59.960 Okay. Just so people can kind of anchor this to things that are familiar, living at sea level

00:11:06.740 exposes us to one to two millisieverts of ionizing radiation a year?

00:11:12.840 That's exactly right. At altitude, it could be double that, actually.

00:11:15.840 That's right. If you live in Denver, it's easily double that or triple that, correct?

00:11:19.880 Just another thing for comparison, a pilot who spends a lot of time traversing the North Pole,

00:11:26.720 which is typically how they're going to fly. They're not going to go all the way around the

00:11:30.040 center of the earth. Might get another three or four millisieverts of radiation.

00:11:34.360 It's quite a bit. Quite a bit. That's right. Per trip, actually. So that can add up.

00:11:38.460 And I was actually talking to a pilot friend about this. They don't really have any limitation in terms

00:11:43.800 of total exposure that requires them to be taken out of the air. A lot of them, they're forced to

00:11:48.680 retire at 65, I think is the commercial requirement. But they don't really monitor the actual

00:11:53.600 exposure to that level. And I think the reason they don't really use that as a limiting factor

00:11:58.360 for the amount of work is really just that even though they get a higher dose, there's been no

00:12:02.900 proven increase in cancer in those types of populations, even in flight attendants or anything

00:12:07.600 like that. The same way that people in Denver and the people here in Texas don't have any higher

00:12:11.960 incidence of cancer. Now, the NRC recommends that a person not be exposed to more than 50,

00:12:21.880 I believe 50 millisieverts of radiation in a year. Correct.

00:12:25.780 Now, someone like me, that's easy unless I'm out there getting a lot of diagnostic radiology or,

00:12:32.000 of course, undergoing therapeutic radiation treatment. But for someone like you who has

00:12:38.640 to set patients up or one of your techs, are you guys approaching that level of exposure?

00:12:44.040 Not at all. And so it depends on what type of radiation we do. Now, typically for our external

00:12:48.420 beam machines, we're doing it all remotely from behind a shielded wall. So the vault in which

00:12:53.820 the machine is placed is custom built just to shield based on the angles that the machine can

00:12:58.700 move through. If there's like a direct angle where the machine is hitting a wall, that wall has to be

00:13:03.020 built 10 times thicker than the walls where the beam can't reach. So essentially our dose when treating

00:13:08.140 remotely is close to zero. So we keep film badges, but it's almost become kind of a joke that when

00:13:12.820 we're not doing brachytherapy, which is dealing with actual live radioactive sources, our exposure

00:13:17.480 is super low, almost negligible really. But back when I was in residency doing a lot of GYN implants

00:13:23.000 and things like that, where you're putting cesium or iridium actually into the body cavities and

00:13:28.020 you're actually up there putting it in up close. We had a ring badge on it. As a residence, we'd

00:13:31.880 rotate every month, but if we didn't rotate, some of the faculty actually got pretty high doses.

00:13:36.520 Any idea what the sequelae of that was?

00:13:38.580 I know of a couple of folks, the ones who did a lot of GYN therapy, especially in the older

00:13:42.180 days, we're talking about in the eighties and the seventies, where you could actually

00:13:44.600 see dermatitis on their hands from doing that, just from the hand exposure. One of my faculty

00:13:48.880 members actually had a giant cell tumor of the bone in her finger. And again, this is

00:13:53.060 after decades and decades of doing it. It was a benign growth, but that was a real thing.

00:13:57.320 There's a lot of data out there on, especially people who were dealing in x-ray for dentistry

00:14:02.600 and stuff like that back in the day when they didn't have shielding or anything like that,

00:14:05.640 that they would get dermatitis. The most common thing you'd see is skin irritation in that

00:14:09.220 sort of situation. Dermatitis and even some chronic flaking and things like that.

00:14:13.800 So let's talk about some types of x-rays that people are familiar with and give a sense of

00:14:19.380 radiation dose. And I'm also curious as to how much this depends on the size of the individual.

00:14:26.120 In other words, does a person that is larger receive more radiation for this same test,

00:14:32.220 like a chest x-ray?

00:14:33.200 They certainly do because you have to use more energy to get into a larger person. Having said that,

00:14:38.260 there's two different things here. Because what we normally deal with when I'm talking about dose

00:14:41.920 to a tumor is the dose actually at that spot versus a whole body dose, which is a very different

00:14:47.260 metric. And so for someone who I'm treating with, say, eight weeks of radiation for prostate cancer,

00:14:54.100 their prostate may get 80 gray in 1.8 to 2 gray fractions per day. But that's literally only

00:15:00.880 to a small volume, roughly the size of the prostate gland itself. And when you even get just a few

00:15:06.360 millimeters away from that, that dose gets cut in half. And then it's exponentially lower

00:15:10.660 because the intensity of the radiation varies with the square of the distance.

00:15:14.920 So as you get even a couple of feet away, that goes down significantly. But typically a patient who

00:15:20.720 is getting 80 grays, if 80 gray was a whole body dose, that would obviously be lethal. But the whole

00:15:25.780 body dose is more like a few milligray in that sort of situation. So we typically don't see full body

00:15:32.200 sequelae or anything from doing even the heavy duty diagnostic treatment. Now for the CT scan,

00:15:37.120 we almost consider that negligible in our area. Because again, I'm dealing with

00:15:40.460 mega voltage, high dose cancer killing radiation. And so when they get a CT scan, which is going to be

00:15:46.520 just a few millisieverts or milligray, that's almost considered rounding error versus what they're

00:15:51.460 getting to the tumor area.

00:15:52.660 But let's take something like a chest x-ray. So chest x-ray, people should anchor to this idea for

00:15:57.640 what it's worth. And we can come back to this. NRC says, hey, limit your annual radiation to 50

00:16:04.460 millisieverts. You've got 2% of that just being alive because you happen to go outside and be

00:16:10.480 exposed to the sun. So the other 98% might come through flying diagnostic. Let's say you fly a lot,

00:16:18.000 that might get you up another 10%. So let's talk about a chest x-ray. You got a cough, you go to

00:16:23.180 your doctor, they do a chest x-ray. That's how many millisieverts for a normal size person?

00:16:28.240 Normal size person, it's a fraction. It's probably less than one millisievert actually. So it's

00:16:32.080 significantly, it's something that where people who are concerned about things like diagnostic

00:16:36.300 mammograms and all every year, you're still talking about maybe one millisievert, even a

00:16:40.460 little bit less than that with some of the newer machines. You're in a zone where there's a principle

00:16:45.220 we talk about, it's called ALARA, A-L-A-R-A, which is as low as reasonably achievable. And that's been

00:16:51.540 the mantra for our radiation safety people, the Nuclear Regulatory Commission and whatnot,

00:16:56.320 that you want to keep things as low as possible. But having said that, when you're talking about

00:17:00.700 numbers of less than 50 millisieverts, that's kind of an arbitrary number. I should have maybe

00:17:05.420 gotten a chest x-ray when I had my cough last time, but I just don't want to do it. I don't

00:17:08.480 want the exposure. But it's so minimal in terms of biologic effect that we really don't even really

00:17:12.940 worry about those, even if it's getting one of them a month or so. And a big reason for that is

00:17:17.940 a lot of these numbers, especially the 50 millisievert number, is extrapolated from higher

00:17:23.260 exposure rates. There's something called the Linear No Threshold Model, or LNT, and that's

00:17:28.660 been written about extensively. And that's what we're all taught in radiobiology and residency.

00:17:33.340 One-fourth of my radiation training in residency was actually radiation biology, in addition to

00:17:38.400 clinical oncology and radiation physics. So the Linear No Threshold Model is what states that

00:17:43.420 we know based on all the data from nuclear fallout from Chernobyl, from Three Mile Island,

00:17:49.520 of course, from Hiroshima and Nagasaki, from the bombs, that at a certain dose exposure,

00:17:53.700 there's a certain risk of developing a cancer or any other endpoint, whether it be dermatitis

00:17:57.960 or bone marrow suppression. All of these numbers are well sorted. But when you try to extrapolate

00:18:02.460 lower, so you take maybe say a dose of one full sievert, the 1,000 millisievert, and you start

00:18:08.440 extrapolating that lower and lower to where you're looking at 100 or 50 millisieverts,

00:18:12.460 the Linear Model assumes that there's some level of damage even at those lower levels.

00:18:17.300 But in reality, there's actually a threshold. The LNT, which is Linear No Threshold, has actually

00:18:22.080 been proven to be actually erroneous. And so at very low doses, it's actually been shown that there's

00:18:27.560 almost no incidence of any sort of biological damage. And there's also, it's controversial,

00:18:33.320 but there's animal studies showing there may be a hormesis effect at low, low doses like that.

00:18:37.580 Tell people what that means, because that's obviously going to come back later in our discussion.

00:18:41.180 Regular listeners of your podcast know all about hormesis, and you talk about in the exercise

00:18:45.940 realm and cold plunges and saunas and whatnot. But the whole idea is doing some degree a small

00:18:51.720 amount of cellular damage. When the body repairs that, it actually comes back stronger than it was

00:18:56.440 without the exposure in the first place. And in animal studies, they've actually shown at very low

00:19:01.620 doses, we're talking about single-digit millisieverts here, that they've seen in mouse bones,

00:19:06.320 for example, decreased osteoclasts and increased osteoblastic activity. So the bones actually

00:19:10.500 heal quicker. Some of the soft tissue as well has been shown to actually recuperate much in the way

00:19:16.620 you see in the hormesis from other causes. And that's not something that we're claiming is widely

00:19:21.700 accepted, but there is a lot of data showing that that is certainly a possibility, which goes against

00:19:26.200 this classic LNT model. And the LNT model itself, the guy that won the Nobel Prize for it in the

00:19:31.960 1940s, did this all on fruit flies. And his work was disproven over the years after that. And so

00:19:37.500 a lot of this low-dose radiation safety stuff we have is certainly a noble goal to keep the dose as

00:19:43.040 low as possible. But when we get down into these millisievert ranges, I think that they're probably

00:19:46.700 a little bit overblown in terms of the actual negative effects on the human body.

00:19:51.940 When I think about where, for example, something like a CT angiogram used to be,

00:19:56.300 that would easily have exposed a person to 25 millisieverts to do a CT scan of the heart.

00:20:03.200 You're doing it, slowing the heart down, getting the contrast in there, et cetera.

00:20:07.340 Today, the really fast scanners, the best of the best scanners are somewhere between one and three

00:20:13.180 millisieverts for that same procedure. I certainly favor having patients getting a scan with that.

00:20:20.340 Acknowledging, though, that I don't have amazing data to point to, to say that the 25 millisievert

00:20:27.280 one versus, just to make the math easy, the 2.5 millisievert one, 10-fold difference,

00:20:33.200 poses any difference in risk.

00:20:34.700 Exactly.

00:20:35.540 How do you think about that? What would be your confidence in saying that 2.5 is not actually

00:20:41.320 better than 25 from a cancer risk standpoint?

00:20:44.680 So again, going back to that Alara principle, there's not a whole lot of data at these levels.

00:20:48.740 I certainly would strive to keep it as low as possible, which is what that mantra says,

00:20:53.280 but I would go with the machine that has the best resolution. And if 25 is,

00:20:57.220 if the radiologist tells me that that image is significantly better than a 2.5

00:21:01.180 millisievert exposure, some of the older machines are just less efficient. You may get a better image

00:21:06.620 with the lower dose. I think the dose is pretty negligible.

00:21:09.220 Got it. So in other words, you're saying, I don't really care if it's 25 or 2.5 is quality.

00:21:12.760 And the good news is these brand new scanners are faster, which is why they're giving you less

00:21:19.180 radiation.

00:21:20.300 They seem to have better resolution.

00:21:21.700 And the same thing applies. That's on the diagnostic side. On the therapeutic side,

00:21:24.780 where I am, our machines are called linear accelerators. And there's a similar progression

00:21:28.960 as we've been able to focus the beams more and more precisely. It's a modulation of the beam,

00:21:33.920 meaning you have a lot of photons being showered in the general vicinity of a patient,

00:21:38.160 but you're blocking out everything except for a small area to treat. And the same way,

00:21:41.840 the newer machines do definitely have a lower exposure to the, at least in the room in general.

00:21:47.000 So what should people be thinking about in terms of extraneous radiation? When should people be

00:21:54.320 saying to their doctors, hey, do I really need this? For example, when you go to the dentist every

00:21:59.620 year, they typically want to do a set of x-rays. Is that anything people should be worried about?

00:22:03.300 Not at all. Not in the least. I would certainly not skimp on dental x-rays, mammograms, if it's

00:22:09.360 someone that needs cardiac workups and things like that. The risk-benefit ratio is so heavily

00:22:14.040 in favor of doing these studies that I don't even think twice about them. I think part of this comes

00:22:19.240 from, you know, I've been doing this 25 years now. I have so many patients, by the time they come to me

00:22:23.380 as a cancer patient, they've been through so many CT scans. And nowadays we do PET scans. We follow up

00:22:28.300 with annual PET scans after the fact, which are not only the CT, but you've got a radioactive

00:22:32.080 isotope that's being injected into them. And we just really don't see. Now, there are certain

00:22:37.000 situations where you are giving a, for example, an intravenous therapeutic dose of radiation,

00:22:41.980 say for thyroid cancer or things like that. There's certain new theranostics that are out there.

00:22:47.220 In those situations, you have to be concerned because they can get into the multiple,

00:22:51.060 get into a sievert range. But when you're in these millisievert ranges, it's so important to do these

00:22:55.280 studies. The benefits of mammograms are so proven. Dental x-rays, I don't really think twice about them.

00:22:59.960 Okay. By the way, just on the PET scan, so if you do a PET CT, for example, which again,

00:23:05.460 these are not routinely done. These are typically done in oncology patients only. But just for my

00:23:10.380 own understanding, are we talking 50 to 100 millisieverts if you're doing a whole body PET

00:23:15.040 CT? I think it can be in that range. Yes. I think that's exactly right. So PET CTs are relatively new,

00:23:20.200 but up until maybe a decade ago, the PET scan was independent of the CT. They would do them separately,

00:23:25.340 but the data is so much better when you have the anatomical CT data overlay with the PET that

00:23:30.500 whatever that extra dosage is, I think it's well worth it in terms of the resolution of what we're

00:23:34.520 able to see and what we're able to gain from that information. Okay. So now let's pivot from the

00:23:41.200 diagnostic to the therapeutic. Is it safe to say that the majority or the most prevalent or common

00:23:50.900 type of radiation oncology treatment would be for breast cancer? Breast and prostate are the number

00:23:56.820 one and number two, depending on what patient population you're talking about. Prostate may even be a little

00:24:00.860 bit higher. And this goes back to the 80s when the trend from doing a Halsteadian type of radical

00:24:07.220 mastectomy was falling out of favor and the randomized data was obtained in the 80s showing that a lumpectomy,

00:24:13.240 breast conservation, which is lumpectomy followed by radiation, has the same outcomes in terms of

00:24:18.640 overall survival as a full mastectomy. That's when breast really took off in the 80s. And around

00:24:23.800 the same time is when prostate radiation started becoming a thing. But at the time, radical

00:24:28.720 prostatectomy was obviously still king. But now in the 2020s, I think prostate has taken off and it's

00:24:34.860 probably close to matching breast cancer now. Those are number one and number two, but we also do,

00:24:38.920 depending on where you are in the country and what your affiliation with the hospital is, tons of CNS,

00:24:43.820 lung, lymphoma, GI, not colon, but more rectal and anal distal GI cancers. Even in the pediatric

00:24:51.380 world, we try to avoid radiating children, but it's a very big part of that as well. So we use

00:24:56.320 it for almost all types of cancer now, actually, all solid tumors anyway. Well, let's talk a little

00:25:00.620 bit about breast cancer, given how common it is. I'll tell you something funny. Despite training at

00:25:06.260 Hopkins, I never once did a radical mastectomy. I mean, it was already long gone from clinical practice

00:25:12.600 25 years ago. And again, just for listeners to make sure they understand the difference between a radical

00:25:17.380 mastectomy and a mastectomy, or what's called now a modified radical mastectomy, the current version

00:25:24.200 of a mastectomy removes all the breast tissue along with the lymphatic tissue in the axilla. Certainly,

00:25:31.340 I did more than my fair share of those, but the radical mastectomy, the Halsteadian procedure,

00:25:36.360 removed also the entire musculature of the pec, pec major, pec minor, the whole thing. It basically

00:25:43.320 was a disfiguring operation that left the woman with nothing but ribs. Imagine what it's like to

00:25:51.680 not even have pec muscles. You sort of take for granted what you need to do to move your humerus.

00:25:57.880 And yeah, to think that it's only been 40 or 50 years that someone had the courage. I think it was

00:26:03.500 probably Fisher. Right. Fisher's big study in the 80s, which now we have 40-year data from that.

00:26:09.020 And it's interesting how now even the modified radicals are relatively rare. We still have some

00:26:13.580 advanced cases that they have to go that route. But we see tons and tons of patients now who are

00:26:18.420 so much happier, their quality of life is much better. By just having a simple lumpectomy,

00:26:22.720 a central node biopsy, and if it's all negative, especially if they've had their mammograms,

00:26:26.340 you get a small T1 or T2 tumor. We give radiation to the whole breast following that.

00:26:31.160 And the radiation is, again, fractionated into small daily bits. They'll get somewhere in the

00:26:35.880 neighborhood of, these days, it's actually only about three weeks of treatment, maybe about,

00:26:40.180 I say, 40 gray in roughly 15 fractions. We used to give, even when I was in a couple decades ago,

00:26:46.440 we were giving 50 to 60 gray. It was quite a bit higher dose. But the 40 gray in 15 fractions to the

00:26:51.940 full breast, and with the modern technology, we can cover the breast tissue without a significant

00:26:56.980 heart or lung dose. We can even use tangential beams, even if it's a left-sided tumor,

00:27:00.920 to stay away from the heart, which is things that we couldn't do very well in the past.

00:27:05.400 The overall and disease-free survivals are pretty much comparable to someone who had a modified

00:27:09.620 radical. Yeah. For folks who want to know more about that, Sid Mukherjee in, I think it was in

00:27:15.180 The Emperor of All Maladies. Yes. Has a chapter on this. Fantastic book and one of your best podcasts.

00:27:20.200 Love that guy. Yeah, he's a legend. So let's talk about that. So a woman has a stage one or a stage

00:27:25.820 two breast cancer. Typically these days, I think they're moving mostly to neoadjuvant chemo before

00:27:32.420 resection. Yes, in a more advanced case. But if it's a typical T1 or even a small T2 that we see,

00:27:38.520 they may not need any neoadjuvant therapy. They just will have their lump. If it's, like I say,

00:27:42.700 a one and a half centimeter mass that's easily resectable, they'll remove that just without any

00:27:47.240 neoadjuvant treatment. And we'll do adjuvant radiation and then potentially, depending on the

00:27:51.600 receptor status, adjuvant hormone therapy, which is the domain of the medical oncologist. But we

00:27:56.100 still work with them. So just surgery followed by three to four weeks of radiation. How long after

00:28:00.800 surgery can you begin radiation? Wound healing, we give them a little bit of time. We generally

00:28:04.880 do our CT-based simulation and three-dimensional planning maybe two to three weeks after their

00:28:10.120 surgery. And then by the time, it takes about a week to do all of our computer programming. And then

00:28:13.880 we'll start the treatment within three to four weeks post-op. So tell me a little bit about that.

00:28:17.880 I was completely unaware of that. So I'm a woman, I've had a lumpectomy. Sentinel node was negative.

00:28:24.140 So I've got an incision about this long for the listener, five centimeter, six centimeter incision.

00:28:29.680 They've probably closed it with beautiful internal sutures. I've got some steristrips. They're off in

00:28:33.780 a week and I've got a nice little scar a week later. I come and see you how many weeks after that?

00:28:38.360 I usually will see patients for consultation. A lot of times the breast surgeon will send them prior to

00:28:42.160 anything being done. So I'll see them for their initial consultation ahead of time. But then we plan on

00:28:46.280 doing what's called a planning procedure or a simulation where we're going to put the patient on the

00:28:50.460 table and essentially do a dry run for their treatment, usually a couple of weeks after treatment.

00:28:55.520 And that involves essentially positioning the patients. Typically for a breast patient, they'll be prone

00:28:59.420 with their arm behind their head. We call it the movie star pose to get the arm out of the way of the

00:29:03.440 axilla essentially. So by putting them in this position and then putting them on a wing board that'll

00:29:07.420 slightly elevate their torso. And there's a lot of different geometry here that we can use.

00:29:12.000 Back in the old days, they had all kinds of ways of doing plaster casts and things like that. But

00:29:16.380 we essentially do now, we'll use what we call a vac lock, essentially a bean bag with a vacuum

00:29:21.160 port. And the patient sinks into the bag, we suck all the air out of and lock it, becomes a rigid

00:29:25.380 cast of their body. And that way they fit into the groove that we've made for them. We'll actually

00:29:29.500 form it and mold it around their elbow so they're comfortable. Many times with patients who've had an

00:29:34.260 axillary dissection, they may have a little bit of scarring, a little decreased range of motion to be

00:29:38.220 able to get their elbow back there. So we'll work with them the best we can. Whatever position we get

00:29:41.860 them in, we do a CT in that position. And that's the position we have to reproduce for the daily

00:29:47.020 treatment. And the key there is that when they have their arm out of the way, we have to have room so

00:29:51.900 that the machine can move around from different angles. The actual radiation machine has a gantry

00:29:56.160 that can move really 360 degrees, can treat from any angle you want. But we have to be able to model

00:30:01.080 tangential beams. We don't want direct anterior field that's going to radiate the breast, but the

00:30:05.780 photons are going to go right into the chest. By using an angle, we can cut across the surface and

00:30:10.900 actually shape the beam to match the curvature of the chest wall. So we cover the entire thickness

00:30:15.720 of the breast tissue, or even in the case of an advanced, maybe a T4 patient, something like that.

00:30:21.160 We may even do this post-mastectomy, so you're treating the full chest wall. And we go a little

00:30:25.200 deeper below, into the ribs, into maybe the first inch of lung tissue below that. But by using these

00:30:30.120 tangential beams, that really minimizes the treatment, the photons damaging the lung tissue.

00:30:34.900 So all of that is planned ahead of time. We do a CT scan.

00:30:37.580 Just to be sure, planned pre-resection, because you're seeing the tumor itself?

00:30:42.740 What I meant was pre-treatment.

00:30:44.520 Got it. So post-resection.

00:30:45.720 Post-resection, you'll see a tumor bed. The lumpectomy cavity is obviously

00:30:48.600 clearly visible. It's a fluid pocket on CT. So I'll scan the whole chest. Takes about a week. I

00:30:53.920 have a whole team. I have a wonderful staff, a radiation dosimetrist that helps do the computer

00:30:57.960 planning, and then a radiation physicist that actually calibrates the machine prior to actually

00:31:02.620 starting the patient. So we do the scan. Of course, the CT scan is two-dimensional slices,

00:31:06.820 but we have three-dimensional modeling software. So I'll have a full 3D model of the patient I can

00:31:11.260 look at. The slices are how thin?

00:31:13.120 It varies. This is not a diagnostic scanner thing. So usually something like two millimeters,

00:31:17.760 three millimeters. We don't have to go super high resolution. And so that way, once it's

00:31:21.940 reconstructed, then I can have a nice idea of what angles to bring the beams in at, because every

00:31:27.040 person has a slightly different curvature to the chest wall. You're going to have to customize the

00:31:30.560 anatomy, different breast sizes. We have all kinds of different techniques, so I won't go

00:31:34.440 too much into the details. But if someone is very large-breasted, we could even treat them prone,

00:31:38.440 have a special pillow to allow the breast to hang down.

00:31:40.520 And it's also, I'm guessing, where the tumor was in the breast. So if you have large breast

00:31:44.380 and a superficial tumor, definitely prone would be amazing. The tumor bed is so far from the patient,

00:31:51.520 right?

00:31:51.620 That's true. But technically, what we call the clinical target volume, the area that we're trying

00:31:56.300 to radiate would actually include the entirety of the breast tissue, even all the way down to the

00:32:00.920 chest wall. So there's two different ways. There's full breast radiation, which is what most people

00:32:04.640 get. But what you're describing actually is partial breast. We would just target the lumpectomy

00:32:08.660 cavity. And that can also be done. We save that for usually for older women who have a very small

00:32:14.600 tumor. And when I say older women, it's more because of the fact that the remainder of the

00:32:19.380 breast remains untreated. So a local recurrence is a little bit more likely in someone that has not

00:32:24.100 had full breast radiation. But in a selected subpopulation of small breast cancers, in some

00:32:29.320 with a very large breast, you can do partial breast where you're only targeting the lumpectomy

00:32:33.400 cavity. But for most of our patients, we actually do treat the whole breast as standard of care,

00:32:38.260 plus or minus the axilla. That's where the pathology comes in. Because if they did have a

00:32:42.340 positive lymph node, then we have to go after the axilla and sometimes the supraclavicular and even

00:32:46.920 intramammary nodes in some cases.

00:32:49.360 Okay. Yeah. So this is infinitely more involved than I thought, which means I'm not the only

00:32:54.040 one that probably was ignorant of what is involved. How long does each session take?

00:33:00.400 When they're actually on treatment, it's about 15 minutes, sometimes even a little bit less than

00:33:04.020 that. Some of the newer machines can deliver the beam even faster. But when I say 15 minutes,

00:33:08.480 I'm talking about, I have four patients an hour typically. So in and out of the room in 15. So

00:33:12.860 that includes getting them on the table. The key thing for accuracy and reproducibility is

00:33:17.720 positioning. So the reason we made that mold and we've not only did we get them in position,

00:33:21.900 but I've also got a couple of dots on their skin to use as reference marks to make sure that the

00:33:26.440 patient is in the correct position. That whole process probably takes five minutes every day

00:33:30.800 when the patient gets in the room and then maybe another five to 10 minutes for the actual beam

00:33:35.040 to be on. And my favorite thing is to come in the room after the patient's first treatment. And then

00:33:40.060 the most common question I get is, hey doc, when do we start? And I'm like, no ma'am, that was,

00:33:45.700 they're like, really? That was it? Because the patient feels nothing. So the machine will go through

00:33:49.120 its various angles. It's pre-programmed. The entire process is about 15 minutes a day and

00:33:54.300 they can leave feeling the same as when they got there, just like getting any x-ray. They jump in

00:33:58.080 their car and go right back to work or to the gym or the golf course. When did this become so automated

00:34:02.660 with the robotic arm and stuff? Did you do this in your residency or were you the ones manually

00:34:07.080 doing that in residency? So I was in residency in the late nineties, early 2000. So it was a very

00:34:12.280 interesting time because we were at the cusp. My first year of residency and I was at UTMB in Galveston.

00:34:17.480 And it was a combined rotation with MD Anderson. So we were at a time, this is 1998 we're talking

00:34:22.120 about, where at the end of the old era, we didn't even use CT planning. We just had a couple of

00:34:26.560 orthogonal films and we were literally drawing our tumor volumes out with a grease pencil on a

00:34:31.140 physical x-ray and using that cutout to go trace a styrofoam negative and make a metal or a lead alloy

00:34:38.860 block, which you would slide this, basically this aperture in the path of the beam. That's the way it was

00:34:43.040 done for decades. And so we were still doing that when I started residency. But by the end of

00:34:47.920 residency, we had full-on CT planning, where now we're doing a full CT scan, doing everything

00:34:51.940 virtually. And of course, it's far more precise and you can model multiple different iterations.

00:34:57.480 Okay, do I want a beam coming in from this angle? Do I want to bring in an orthogonal beam from here?

00:35:01.880 Do I want to block out a little bit more of the chest wall to get the heart dose down? I can see all

00:35:07.400 that stuff now. So by the time I finished residency, we were basically doing what we do now,

00:35:11.220 albeit with much slower computers and just being in the infancy of that, it was probably more like

00:35:15.660 20 to 30 minutes per patient. But the last 15 years, roughly, to answer your question,

00:35:20.380 things have been much more automated. And instead of having lead blocks that you're sliding into the

00:35:25.040 path of the beam, now everything is shaped in the head of the beam by our computer. So you hit a button

00:35:29.280 and when I've already programmed the treatment planning values, the machine knows how to shape the beam to

00:35:35.260 match the aperture of whatever you're trying to do. So that's all fully automatic now. So the therapist

00:35:40.340 job, we have a radiation therapist who actually positions the patient in the room. They get them

00:35:44.640 in position, they take a picture x-ray first, either a cone beam CT, which is a low dose CT,

00:35:49.940 or just a PA in a lateral film. And we actually overlay that with our planning imaging to make

00:35:55.540 sure that the original reference from the planning day matches today's image. The machines will

00:35:59.760 actually superimpose the daily image with the reference image. So everything is automatic.

00:36:04.520 I can say, okay, are we directly on? If everything lines up correctly, then we literally have two

00:36:09.100 images that look identical. I just see one image, which if it's slightly off, if there's even a few

00:36:13.260 millimeters this way or that way, we account for that by moving the table. The table is motorized.

00:36:17.920 So the patient will be laying there and they'll feel it move just a few millimeters this way or that

00:36:21.300 way until we have perfect concordance between the daily setup and the original. That's really,

00:36:26.880 really improved our accuracy. And the regional miss, the geographic miss, which was a problem in the old

00:36:32.440 days when we didn't have digital imaging and all this stuff is essentially gone now.

00:36:36.840 The actual radiation beam is generated by what? The ion is generated by?

00:36:41.240 So that's another thing that has changed. Now, essentially, when I say now, the last basically

00:36:45.560 30 years, most machines in the US are linear accelerators. So these are artificially generated

00:36:50.840 x-rays. It's essentially accelerating electrons through a long vacuum tube, an essential electron gun.

00:36:56.940 And at the very end of the tube, you've got a tungsten target. And so the electrons hammer that

00:37:02.760 target and then they shower photons out. So you're generating the x-rays that way. And this has been

00:37:07.240 done actually, I think your alma mater, Stanford, had the very first one in the US, the medical linear

00:37:12.380 accelerator. But prior to that, they were using these for atom smashers and they have the gigantic

00:37:16.260 machines that were used for physics. But it started in London, I think in 53. And then I think in the

00:37:21.220 late 50s, Henry Kaplan at Stanford had the first one. So we're essentially still doing that even

00:37:26.020 today, what, 70 years later. But the key difference is how we're able to shape those photons once they

00:37:31.280 come out of the machine now. And so when the actual photons are coming out, they're completely

00:37:35.880 unfiltered. It comes out in a cone shape and it diverges just as any light source would. You know

00:37:40.340 how when you hold a flashlight to a wall, you get a nice precise circle. As you pull the flashlight

00:37:44.660 away, it diverges. So we have filters and we have what's called the multi-leaf collimator that can

00:37:49.420 actually shape the beam, as I mentioned earlier, that can actually match the anatomy of the patient.

00:37:53.920 But now that's all done automatically. We program it ahead of time as opposed to the old days when we

00:37:58.280 had to use lead blocks that were actually physically blocking the beam. But basically, the LINAC has

00:38:03.260 been the standard. Prior to that, we were using a cobalt-60 machine, which is essentially, it's not

00:38:07.700 even a machine. It's basically just exposing a patient to a radioactive isotope and then shutting

00:38:11.940 the jaws again. And actually, those are still in use in most of the world. There's a few left in the

00:38:16.060 U.S., but they've mostly been decommissioned now because the LINACs have taken over.

00:38:20.440 When you say that a typical treatment might be 15 gray over the course of the three weeks,

00:38:26.900 fractionated over 15 treatments?

00:38:28.820 So it's actually about 40 gray.

00:38:30.320 40 gray, I'm sorry.

00:38:30.900 So roughly 2.5, 2.6 gray per day. And you're right, times 15 treatments. So you're getting roughly

00:38:36.500 40 gray to the breast. And then we usually actually do a boost. So we'll give what we call a tumor bed

00:38:42.260 boost. We give a little extra dose to just the lump itself, the lumpectomy cavity itself. And

00:38:47.220 there was a couple of French trials that showed that adding an extra 10 gray over an extra five

00:38:52.040 days, so two gray times five, just to the lumpectomy cavity itself improves local control over just

00:38:57.500 the whole breast radiation.

00:38:58.340 Okay. That's actually what I was going to ask. I was going to ask, if the 40 gray

00:39:01.200 is distributed completely uniformly across the breast, the answer is no. It is, but then you have that

00:39:07.740 an extra boost. It's a customization based on the patient's pathology. I'll occasionally have a

00:39:12.480 patient that the breast surgeon will call me and say, hey, Sanjay, we did our best, but we had a

00:39:16.940 persistent positive margin. I went back and did a re-resection and there's still a positive margin,

00:39:21.380 or maybe the positive margin is at the chest wall. They can only go so far. In that case,

00:39:25.300 instead of giving a 10 gray boost, I might give a 16 gray boost or something to account for,

00:39:29.640 instead of just treating microscopic disease, potentially macroscopic residual in that sort of

00:39:34.120 situation. So every patient's a little different. And then the axillary nodes themselves are

00:39:38.640 normally not treated in an early stage patient, but depending on the risk factors, if it's a very

00:39:43.020 large tumor or if there was a positive central node, maybe an incomplete axillary dissection,

00:39:48.060 in many cases, we end up treating the full axilla. And in some cases, when it's advanced disease,

00:39:52.680 we end up treating level two and level three. So you end up getting the super clav as well.

00:39:56.980 If we go back in time to 25 years ago, 30 years ago versus today,

00:40:00.900 what are the typical side effects that a woman experiences from this treatment? And by the way,

00:40:06.280 was she typically getting 40 gray 25 years ago, or was that a little more? I think you said,

00:40:11.380 and now they've come down a bit, it was sort of 50, 60 gray.

00:40:14.080 This brings up a point I need to kind of emphasize. It's not so much the total dose,

00:40:17.580 it's the dose per fraction. So how quickly are you getting it? So the standard of care was actually

00:40:22.120 50 gray rather than today's 40-ish gray, but it would usually be given in two gray per fraction

00:40:27.840 daily doses rather than the 2.6, 2.7 that we're using now. So the effective dose,

00:40:32.820 when you take into account, there's a whole radiobiology lecture that we're not going to

00:40:36.220 bore people with, but taking into account the dose per fraction and the total dose,

00:40:40.800 the biologically equivalent dose with the BED is roughly the same now at 39.9 gray given in 15

00:40:47.740 treatments versus the old 50.4 gray that was given in say 25 to 28 treatments. So it was a longer

00:40:53.880 process, you're right. And we still do that in some cases. And this comes back to another question

00:40:58.560 you asked about, about the homogeneity of the dose. And so our goal, of course, is to have 100%

00:41:04.200 coverage of the whole breast. But the reality is the way that photons are going to be interacting

00:41:08.900 from different beam angles and whatnot, you're always left with hot spots and cold spots.

00:41:13.780 And so the biggest difference between what we're doing now versus the old days wasn't so much the

00:41:17.780 total dose, it was the actual homogeneity that you touched on. So the heterogeneous old way of doing

00:41:23.120 things with a cobalt machine or with a low energy x-ray, unfortunately meant that there were hot

00:41:27.560 spots and cold spots in the breast. And that of course could either be manifested as scar tissue

00:41:32.060 if it's a hot spot or heaven forbid, a geographic recurrence if there was a area that was underdosed.

00:41:38.040 So with the modern computer planning, we were much more homogeneous. So even though you may say,

00:41:43.440 I got 50 gray back in 1995 and now I'm getting 40 gray, you're now getting 40 gray in two and a half

00:41:49.660 gray fractions, which is equivalent to the old 50. Plus we don't have 150% hot spot and a 60% cold

00:41:56.660 spot. We have a nice 100% match all the way across. It's like a CAD CAM type of thing. I'm about as close

00:42:02.520 to an engineer as an MD can be. And so we do actually simulate the dose distribution of the

00:42:07.980 radiation in the tissue. In the modern days, we get a nice homogeneous dose. And therefore that goes to

00:42:14.040 your next question, which was what is the patient experience? Maybe not so much 20 years ago,

00:42:18.280 but more like 30, 40 years ago with the older cobalt machines, they would get a terrible dermatitis.

00:42:23.100 Many times it was moist desquamation confluently over the whole chest wall. Axillary desquamation

00:42:29.160 is always bad because of the friction of the arm. But with the modern treatment now with, first of

00:42:33.800 not using cobalt, using linear accelerators, the energy of the photons is higher, which means the skin

00:42:40.100 dose is slightly lower. So you're getting maybe a hundred percent on the skin rather than 150% like you

00:42:46.100 once did. So we don't see anywhere near the skin reaction that we used to. It's more of a, maybe a

00:42:51.880 grade one or a grade two erythema. So mild redness, or maybe sometimes a little bit of sunburn, but nothing

00:42:57.480 as severe as we used to. So these days, patients do still get a sunburn. We give them a little free samples

00:43:03.000 of Aquaphor. They can use an aloe vera plant if they have it, just your normal type of skincare stuff,

00:43:08.260 as opposed to the old days when we were actually treating essentially burn victims with

00:43:11.760 silver sulfadiazine and heavy duty narcotics and things like that. The modern era, it's so much

00:43:17.300 better than a lot of the patients, especially if it's someone that doesn't have a very large breast.

00:43:21.560 There's less energy being put into a smaller size person. They don't get anywhere near the skin

00:43:26.000 reaction. And that's why if you did have a very large patient, we actually still use the old 50 gray

00:43:31.320 in 25 because you're giving less dose per day. And you do have a very large breast where you're going

00:43:36.860 to have areas that are going to have hot and cold spots. Sometimes that's still needed. So we have

00:43:41.700 to tailor it to the individual is, I guess, my bottom line there.

00:43:44.980 Did anybody ever look at when you had the very disparate hot and cold spots and follow women

00:43:50.460 for recurrence?

00:43:51.620 Yes.

00:43:51.980 Was there any association between the cold spots and recurrences?

00:43:54.460 There certainly is. And so the problem was, is that in the old days, you didn't have computer

00:43:58.240 modeling. And actually the old school physicists got to give your hats off to those guys that had

00:44:01.740 slide rules and probably abacuses or whatever the heck they had back then. You couldn't really tell

00:44:06.080 exactly where the hot and cold spots were by actually having a computer show you. You had to go based

00:44:11.100 on the fact you choose a photon energy and you know what the dose distribution at various depths

00:44:16.320 is. And so you would try to minimize that by again, having beams coming in from different angles.

00:44:21.060 And then by using multiple angles and multiple fields, you could paint in the dose as best as

00:44:26.240 you could. But yes, certainly there were issues where as you get deeper into the tissue, the dose

00:44:31.560 would be lower. And then this is again, before my time, but there certainly were studies showing

00:44:36.440 that there were geographic misses. That was obviously not good, which sometimes would lead

00:44:40.220 to like a salvage mastectomy or something like that. But in the modern era, not so much.

00:44:45.520 What is the impact of breast implants in this type of treatment, either saline implants or

00:44:50.960 the older, well, actually they're not older now, they're back in vogue, right?

00:44:54.040 They're back in vogue, right?

00:44:54.660 Yeah, of course.

00:44:55.540 Either way, the x-rays we use, they are not at all affected by that because it's essentially

00:44:59.560 tissue equivalent.

00:45:00.480 Pardon my ignorance. I completely forget. Are those implants typically under the peck or between

00:45:05.120 the peck and the breast?

00:45:06.140 So we see both.

00:45:07.360 What's the current standard?

00:45:08.640 I think most of them we see are actually under the muscle.

00:45:10.700 Silicone under the peck?

00:45:11.980 Mm-hmm. But I've seen them both. Even now, the plastic surgeons have different criteria

00:45:16.040 for that. But regardless of what it is, if it's under the peck, then of course, it's really

00:45:19.980 a little farther away.

00:45:20.980 It's irrelevant, yeah.

00:45:21.120 It's not a huge issue, but the radiation will still affect that area. But typically these

00:45:25.320 implants are pretty tolerant of that. The only issue down the road is they may have

00:45:28.800 a capsular contracture or something from fibrosis. The bigger challenge we run into

00:45:33.220 is for our post-mastectomy patients who are going to be reconstructed and they have expanders

00:45:37.920 put in. And that's where the relationship between the radiation oncologist, the surgeon,

00:45:42.100 and the plastic surgeon is key.

00:45:44.240 Explain to folks what expanders are, how that works surgically.

00:45:47.680 So essentially what's happening is when you have a full mastectomy, if a patient wants

00:45:51.140 to have their breast reconstructed later on, the breast surgeon will remove the breast,

00:45:55.300 but then the plastic surgeon will come in and place some sort of a placeholder to allow

00:46:00.080 the soft tissue and all the connective tissue and the skin to stretch to allow for future

00:46:04.600 implant placement. And so those tissue expanders, they can actually inject saline into them with

00:46:10.220 a port and gradually stretch them with time. That's normally what they would do if there

00:46:14.800 was no radiation involved. Again, most mastectomy patients really don't need radiation because

00:46:19.440 this gets away from what we mentioned earlier, where breast conservation is lumpectomy only.

00:46:24.120 But there are some patients with a full mastectomy who are going to get reconstructed.

00:46:27.820 So they come to me when I do their CT scan, they have this expander in place from the breast

00:46:32.300 surgeon. So we have to, again, modulate the beams and we treat the entire chest while we

00:46:37.300 make sure we're covering everything. But simultaneously, we have to make sure that we

00:46:40.960 don't have those hot spots in the area of the expander where potentially you could cause

00:46:45.540 scarring and fibrosis and cause the expander to have to be removed, have the plastic surgeon

00:46:49.980 have to revise it. That becomes a whole nother hill of beans there that we don't like to mess

00:46:53.860 with. But we have techniques now to be able to keep the dose off of them. And again, as

00:46:58.380 you mentioned earlier, whether it's silicone or saline, it's roughly the same density. But

00:47:02.520 some of these tissue expanders have bits of metal in them. They may have other artifacts.

00:47:06.460 And so when I'm treating with photons, with x-rays, depending on what you're hitting, the

00:47:11.700 effect is based on the density, the atomic number of that tissue. So metal behaves very differently.

00:47:16.840 Bone behaves differently from air. But when you're in the spectrum of saline, tissue, water,

00:47:21.540 it's all basically the same. We can model all that very much like, I'm getting ahead of myself,

00:47:26.260 but very much like when we have a prostate patient with a prosthetic hip, a piece of metal right next

00:47:30.620 door, we're able to compensate for that with the modern computer treatment planning systems.

00:47:35.720 Do women experience any systemic symptoms from radiation like nausea or vomiting, or is that

00:47:41.580 pretty much? Not at all. The only time we see radiation patients who have nausea or vomiting,

00:47:45.880 it's a lot of times for other sites, they may get concurrent chemo radiation where the chemo

00:47:49.820 could be responsible. But for breasts, we don't do concurrence, usually sequential. The only time I

00:47:54.440 really see radiation-induced nausea is if I'm treating an esophagus or a pancreas or something

00:47:58.440 that's treating in the abdomen or somewhere along the GI tract where nausea is more of an issue,

00:48:02.920 typically not for breasts. Okay. Let's talk about prostate, which is obviously also the bread and

00:48:08.520 butter of the field. So first off, which patients are typically being radiated?

00:48:13.520 The answer to that has been evolving. There was a time as recently as probably 20 years ago where

00:48:18.560 we only treated patients who were probably medically inoperable that the urologist would

00:48:23.200 say, hey, you know, this is a high-risk anesthesia patient. Let's send them to Dr. Mehta for radiation.

00:48:28.080 And that's a big reason why a lot of the older data was not as good for radiation because of the

00:48:32.940 patient selection criteria. But in the modern era, as we've gotten more and more precise and our

00:48:37.880 side effects have gone down and our cure rates have gone up, now it's pretty much wide open where

00:48:42.180 pretty much anybody who's eligible for surgery would also be eligible for radiation. So there's not that

00:48:46.640 big of a divergence as there once was. You've gotten to know Ted Schaefer, who's not only good

00:48:52.900 on the podcast, but is equally, let's just say, interested in cars. He sure is. So you, me, and

00:48:58.300 Ted have a lovely little text thread about cars. He and I may have another text thread in case our

00:49:03.940 teams meet in the playoffs as well. He's a big Ravens fan. So, and I'm from Houston. So I'm hoping we

00:49:08.660 get there. Let's talk about a patient that comes in to see Ted for a biopsy. They've got a Gleason

00:49:14.940 three plus four, and then another patient who's a Gleason four plus four or four plus five or

00:49:20.580 something like that. How does that patient navigate their way through the system as to whether or not

00:49:26.340 they need radiation or should they undergo surgery? And does androgen deprivation therapy necessarily

00:49:31.940 come with radiation? Or is there a scenario where you undergo radiation, but you don't require

00:49:37.780 androgen deprivation? So to answer your last question first, androgen deprivation for high

00:49:42.300 risk disease is certainly standard of care. Gleason eight or higher for sure. The Gleason

00:49:47.940 sevens are always a gray zone. And so a four plus three with high volume disease typically also do get

00:49:53.720 concurrent and adjuvant androgen suppression along with radiation. But one of the things that's really

00:49:59.160 changing now is I know Ted talked a lot about with the decipher score where they can look at the

00:50:03.380 chromosomes of the actual cancer cells and have a much more granular view of exactly are they truly

00:50:09.800 high risk? Or can you say that this one three plus four is more like a three plus three? So for a lot

00:50:14.540 of the three plus fours now with the decipher test, and there's also an AI test. I know you had a really

00:50:18.680 interesting discussion with your AI expert, and that wasn't too long ago, called Artera. And we're using

00:50:24.200 that. That's actually in the NCCN guidelines now. So that Artera test can help us differentiate between a

00:50:29.220 unfavorable and a favorable intermediate risk patient. I treated my own father not too long

00:50:34.540 ago. He was the first person I did this on. The Artera test is essentially they just use the actual

00:50:39.640 images of the H&E slides that were already done for the pathologist. And it's interpreted by a

00:50:44.640 machine learning computer that has been trained on hundreds of thousands of prostate images from the

00:50:50.060 old RTOG studies, the 94s, all the stuff that was done back in the 90s. And it can now come back and

00:50:55.280 say, okay, very much like decipher. It can say that this is a three plus four, but it's a favorable or

00:50:59.580 an unfavorable person in that subgroup. And so because of that, we can stratify better and actually

00:51:04.920 tailor it to where maybe a three plus four doesn't need androgen ablation at all. And maybe even some

00:51:09.760 four plus threes, if they come back low enough on the scale, you always have to talk about the side

00:51:13.960 effects and whatnot. But the standard of care was always to give concurrent androgen ablation for

00:51:18.360 intermediate risk. But now we're able to really take some of those people out of the equation with these

00:51:22.300 new studies. And is the main selling point, because most patients just want things taken out. I have

00:51:29.380 cancer, take it out. Is the reason that a person might select radiation therapy, especially if it

00:51:36.060 comes with androgen deprivation therapy, because of the sexual function and urinary function? Like

00:51:41.900 what's the main advantage? Those are number one and number two. Yeah. Lack of incontinence and lack

00:51:46.720 of impotence. But of course, when you have androgen ablation, that clouds things a little bit.

00:51:50.560 But typically, the number one thing we see is patients who don't want to deal with diapers.

00:51:55.840 And for the most part, although incontinence is still described to some degree in the literature,

00:52:00.860 in my personal experience, I don't think I've seen a single patient who came in

00:52:03.860 continent who left with anything less than that. There's no pads, there's no nothing.

00:52:09.220 And then of course, as I talked about with breast cancer, we can also focus very precisely on the

00:52:13.520 prostate itself. So the dose to the penile bulb, the dose to the rectum, the dose to the bladder

00:52:18.540 are so low now that the side effect profile is essentially zero from a radiation standpoint.

00:52:24.820 Now, they may be having hot flashes from the androgen deprivation and decreased libido and

00:52:28.940 fatigue, as you know. But on the radiation side, because we have all these tricks now,

00:52:33.020 very much like with breast, the way we can avoid the heart and the lungs, in the case of the prostate,

00:52:37.120 we can almost completely avoid the bladder and the rectum and even the penile bulb now.

00:52:41.320 So the quality of life, those are the reasons why people tend to choose radiation.

00:52:46.340 And I know we've talked about this before, you're just not seeing the proctititis.

00:52:50.320 Yes, almost none. In fact, I think Ted had mentioned in his last talk, there's a gel spacer that is

00:52:55.640 often inserted. It's an injection that's done transperineally, and it separates the rectum from

00:53:00.540 the bladder. But in my years of doing this, when you're very diligent about how you do this,

00:53:05.000 very much like a surgeon pays attention to the details, so do we.

00:53:07.840 I can actually trim the dose off of the posterior prostate and just make sure the dose fall off

00:53:13.240 between the posterior prostate and the anterior rectal wall is so rapid that the anterior rectal

00:53:18.800 wall is always going to get some dose, but usually it's not clinically significant.

00:53:22.920 And what we do to manifest, to make sure that that is a daily thing, because we're talking about

00:53:26.700 treating patients for multiple weeks, we actually coach the patient to come in with a full bladder

00:53:30.840 and an empty bowel. And by being diligent about that and imaging daily to double-check that,

00:53:35.860 in fact, the bowel is empty and the bladder is full, that allows those two organs to separate

00:53:39.840 from the prostate. And even a few millimeters of separation is all we need to take advantage of

00:53:44.920 our modern focused radiation beams.

00:53:47.840 And does the patient need to be coached to time their breath or anything as the beam is at that

00:53:54.820 most delicate edge of the rectum?

00:53:56.940 Not so much for pelvic patients, but we do that for breast cancer, especially left-sided

00:54:01.820 breasts. So just to go back to that, you actually have a deep breath hold, which will get the chest

00:54:06.180 wall away from the heart. So we do that in the case of thoracic tumors, but in the pelvis,

00:54:10.240 the diaphragmatic position doesn't really make any difference. It's more about bladder and rectal

00:54:14.200 filling and emptying, respectively. That's much more important.

00:54:17.440 Everybody I've talked to who's had LASIK eye surgery always says they're so worried that they're

00:54:21.560 going to do something, they're going to flinch. And do patients feel the same way when they're

00:54:25.440 undergoing radiation? Like, what if I just flinch my pelvis or do something like that? It's going

00:54:29.840 to get too close.

00:54:30.760 I get that question all the time. And from a LASIK standpoint, I think I would be worried

00:54:33.740 about it. That's probably why I'm still wearing these Coke bottles, unfortunately. But in the

00:54:37.680 case of prostate cancer, first of all, the dose is given over the course of several minutes.

00:54:42.040 And then each of those fractions is, again, talking about one fraction out of multiple weeks. So

00:54:46.000 even if someone absolutely had a coughing fit or something like that, first of all,

00:54:50.280 we're watching them. We can stop the beam. We can stop it at any given moment.

00:54:53.720 But slight variations day to day, the biggest variations are going to be based on bladder

00:54:58.020 and rectal filling. We take that into account when we're doing the treatment planning. So

00:55:01.820 there should really be no adverse outcome. Because what I actually do is I'll map out

00:55:05.720 where the volume of the prostate is, and we will actually purposely expand that volume and

00:55:10.500 treat the full dose of radiation, even a few millimeters outside of the prostate to make

00:55:15.340 sure that there is any internal organ motion or anything like that, that we take that into

00:55:19.020 account. But typically, if someone's coughing or something like that, we'll just hit the

00:55:22.200 pause button and get them reset. And ultimately, it's not an issue.

00:55:25.760 What about patients that are inoperable? First of all, what leads to a patient being inoperable?

00:55:30.960 And how do they show up?

00:55:32.580 Typically, the urologists have already screened the patient. Everyone's first exposure is going

00:55:36.700 to be to what the urologist tells them. And luckily, in this day and age, I'm lucky we have

00:55:40.780 people much like Ted who are very open and who are very open to not just doing surgery, but who

00:55:45.600 actually look at the other options and present everything to the patient. But typically, a patient who maybe

00:55:50.140 was medically inoperable will certainly come to me. But even somebody who maybe is on the borderline

00:55:54.360 who wants to see both sides of the token, a general urologist will send them to a surgical

00:55:58.280 specialist and to me, and we'll go through all the pros and cons of everything. And really, what it

00:56:02.980 comes down to, to not belabor the point, it comes down to two things. You want to be cured.

00:56:07.280 Cure rate is key. But quality of life is equally important, if not more important, for most people.

00:56:12.400 And so now that cure rates with our modern focused radiation allow us to get such a high dose

00:56:16.880 into the prostate, we can say that they're essentially equivalent to surgery. So we don't

00:56:21.080 have that deficit like we did 20 years ago when our fields weren't as precise. It was sort of the

00:56:25.380 shotgun approach versus our sniper approach. Now, because the cure rates are better, then it really

00:56:30.320 comes down to the quality of life changes. And that's where there's a spectrum of things.

00:56:34.840 Now, is this an apples to apples comparison? Because the patient who undergoes the robotic

00:56:41.880 prostatectomy today does not go on androgen deprivation therapy. They get to walk around.

00:56:47.660 In fact, you've probably heard Ted on the podcast, he says, we'll give those patients TRT if they're

00:56:51.920 hypogonadal. Why does the patient after radiation therapy still need to be androgen deprived if,

00:56:59.640 in theory, the radiation is as effective as the surgery?

00:57:03.780 That comes to a key point where it's trading one thing for another. You don't have the incontinence.

00:57:07.980 You don't have the, at least the short-term risk of impotence like there is from surgery. You don't

00:57:12.260 have the penile shortening or whatever other sort of things that they have to deal with. But you have

00:57:16.540 to deal with hot flashes and decreased libido and whatnot. But again, most of the patients who are

00:57:22.280 intermediate or high intermediate risk are going to, if they end up not having a negative margin or

00:57:27.320 seminal vesicle invasion after prostatectomy, they're still going to come to me for radiation

00:57:31.280 anyway. And they're still going to need to be on androgen ablation. So there's a significant

00:57:35.840 number. Now, these days we'd certainly treat a lot less Gleason 6 than we used to. We observe

00:57:40.260 most of them. But there's a lot of Gleason 6 folks that even in this day and age will choose to have

00:57:45.160 radiation just because it's maybe a little bit more aggressive form of watchful waiting. And in that

00:57:49.580 case, there is no androgen ablation and they just glide through the whole process.

00:57:53.180 Has there been a trial of Gleason 3 plus 3 watchful waiting versus XRT no ablation?

00:58:00.340 No, unfortunately there's no actual trial. There's just observational studies.

00:58:03.580 That's kind of what we're dealing with there.

00:58:05.260 Oh gosh. And obviously you can't figure out what the biases are, but what do those observational

00:58:09.860 studies show?

00:58:10.880 People don't die from Gleason 6 disease, as we all know, because quality of life they do so

00:58:14.880 well with the radiation, there is just less of a chance of it progressing to a 7. And when they

00:58:19.620 come to me, it's interesting the different patient populations. I also get people, this is not

00:58:23.420 mainstream, but I get a lot of transplant candidates who need a renal transplant and they cannot get

00:58:28.040 their transplant unless they're cancer-free. Even if it's one core of a Gleason 6, they're

00:58:32.420 ineligible for their transplant. So those guys I will certainly treat, but I've been following them

00:58:36.920 now for 20 plus years that we've been doing it. Quality of life, they do so well. And this way,

00:58:41.400 they don't have to worry about androgen ablation when they do become a Gleason 7.

00:58:44.620 So it's really interesting. There would be a very interesting and elegant study taking,

00:58:51.040 let's call it medium to high risk 3 plus 3s. So people based on family history or some other

00:58:57.500 phenomenon, genetic or otherwise, you randomize them to watchful waiting versus radiate them

00:59:05.860 without androgen deprivation. I mean, you'd have to do this as a very long-term study. So the question

00:59:11.180 is, outcome number one could be conversion to 3 plus 7 requiring surgery and or androgen deprivation

00:59:19.020 therapy. And then of course, outcome two, the very long-term outcome would be overall survival.

00:59:23.160 That's the key. That's why these haven't been done. You wouldn't need decades to do a trial.

00:59:26.420 Yeah, it's a 20-year study.

00:59:27.660 But it certainly would be interesting to see what it would show. But the real world

00:59:30.820 observational studies show that all the Gleason 6 guys, I would say until maybe a decade ago,

00:59:35.760 we did a lot of Gleason 6 patients. They mostly were sent for radiation.

00:59:40.140 Why were they sent?

00:59:41.260 I guess it's a combination of different things. People have different levels of tolerance for

00:59:44.800 watchful waiting. In the pre-MRI days, everyone had to have an annual biopsy. And that alone is more

00:59:50.980 anxiety invoking than really the radiation is. Not to mention, we'd see a fair number of folks with

00:59:55.560 urosepsis and complications from that. So now in the MRI era, we don't really see that anymore,

01:00:00.760 but that was done very routinely. And because the patients had so little proctitis and cystitis,

01:00:06.160 especially in a Gleason 6 where not only am I not worried about pelvic lymph nodes, I'm not even

01:00:10.900 really worried about the seminal vesicles. So my field is very small, which really minimizes the

01:00:16.240 side effects because the bladder, a full bladder, when it's actually full, it'll move superiorly and

01:00:20.900 anteriorly where the dose is close to zero. So most of these patients, they just kind of laugh

01:00:25.200 and say, I'm coming in for my daily treatment and I'm right back to my normal life again.

01:00:29.340 In the absence of androgen deprivation, radiation has become very simple for prostate patients now.

01:00:34.480 And again, what fraction of Gleason 7s can do radiation without requiring androgen deprivation

01:00:42.640 therapy?

01:00:43.380 That answer would have been zero probably five years ago, even as recently. But now with Artera and

01:00:48.320 Decipher, it's probably, I'd say a quarter of them don't need it. If it's a 3-4 with a low

01:00:53.420 Decipher, low Artera score. And again, this is still an evolving area where I don't think anyone

01:00:58.540 has the exact answer, but that's what most people are doing nowadays. And even some 4 plus 3s that

01:01:03.680 have low Deciphers are potentially candidates to avoid that. And the biggest change in this has now

01:01:08.960 been our ability to do PSMA PET scans to follow up. Because otherwise, I think that the extra

01:01:14.300 androgen deprivation was more of a Band-Aid for not being able to see what's going on afterwards.

01:01:19.120 Now, if someone has a recurrence and you do a PSMA PET, I've got a guy that had treatment 20 years

01:01:23.980 ago with radiation. Now he's rising PSA. Otherwise, he'd just be stuck with ADT for years. Now I see a

01:01:29.840 positive periaortic lymph node on a PSMA PET. I can just treat that area and very successfully.

01:01:35.560 There's no long-term data yet, but it seems to be working really well. Similarly to how we would

01:01:39.660 use a FDG PET to target a lung tumor in the past. What about these patients that show up

01:01:45.020 with two spine mets? How effective is radiation there, given that that's a favorite spot for

01:01:50.560 a prostate too? You're talking about initial presentation with oligometastatic disease?

01:01:54.920 No, let's say, okay, we could talk about that or we could talk about post-treatment three years later.

01:01:59.360 So post-treatment three years later, palliative radiation does work very, very well. It would be

01:02:03.400 probably five treatments. You can even do what they call SBRT, which is stereotactic body radiation,

01:02:08.480 maybe in a single fraction. And it definitely is very good. We kind of joke about it and just

01:02:13.020 kind of spot weld that spot where it's not going to prevent something else from popping up elsewhere,

01:02:16.940 but that's extremely well tolerated. And usually it'll stop the progression at that site.

01:02:21.300 So there are people who had high risk disease. And to get back to what I mentioned earlier,

01:02:24.920 if they had a couple of spots like that at the time of initial diagnosis, now it's been shown that

01:02:29.600 you can treat the oligometastatic disease if it's in the bone only at the same time as the primary

01:02:34.360 lesion. And the outcomes are actually not significantly worse if it's just limited disease.

01:02:39.420 And what is a more favorable presentation, oligometastatic to bone or oligometastatic to

01:02:45.800 para-aortic?

01:02:46.900 Bone, for sure. Actually, I had a guy walk into my office with a PSA of 1900. He looked just as good

01:02:52.920 as you or me. I actually took him on a TV show I did many years ago. It was kind of an interesting

01:02:57.300 story. 1938, 65-year-old guy, Mr. Macho, had never been to a doctor in his life, widower who decided

01:03:04.580 that he was dating a younger woman now. And she's like, if you want to be with me, you got to go get

01:03:08.000 checked out. Colonoscopy clear, blood work all clear. Oh, by the way, your PSA is 1900.

01:03:12.900 Which means the lab made a mistake. I mean, that's what you would think.

01:03:15.540 Yes, that's what you would think, except for his bone scan looked like a Christmas tree. And this was

01:03:18.580 in the pre-pet era. I mean, he had disease in every bone in his body with zero symptoms. So this is an

01:03:24.340 outlier situation. But in that situation, you need lifelong androgen deprivation and chemotherapy.

01:03:30.060 Back then, it was mostly taxol-based therapy. We didn't have all the second-generation

01:03:33.280 androgen ablation drugs that we do now, like enzalutamide. But at that time, when we saw that,

01:03:38.880 you know, he went and got chemo and got androgen ablation. When he came back to see me,

01:03:41.980 fully functional guy, perfect shape. His PSA was down to 1.5 with just the systemic therapy.

01:03:48.080 And at that time, the tumor board, we presented him, the decision was made to go ahead and treat his

01:03:52.600 prostate as though he was a de novo presentation because all the bone disease had resolved. He did

01:03:58.600 great. So you treated his prostate. And how long did he live? He's still alive. This has been,

01:04:04.940 I got an email from just about a year ago. So I think he, at least as of a year ago, he was 12 years

01:04:08.660 out, still doing great with zero side effects. He's on androgen ablation for life. So he's certainly

01:04:14.140 going to have issues from that. But overall, still very functional. How is this possible?

01:04:18.060 Well, what's the biology of that tumor that allows him to still be alive?

01:04:22.540 I don't think it's even necessarily just prostate. I've even seen it in breast cancer patients in the

01:04:27.140 small subset where it's bone only disease with no visceral metastases. Some folks can live for a

01:04:32.500 very long time with bone only disease. And I'm not sure what the answer to that is.

01:04:36.980 And has he suffered any debilitating fractures?

01:04:40.980 You would expect that at this point, but no, not even one.

01:04:43.700 This guy's in his late 70s now.

01:04:45.540 Now he's in his, yeah, late 70s and has not fractured a thing and is still active. The guy

01:04:49.560 plays golf.

01:04:50.580 I hope he still has that young girlfriend.

01:04:52.340 I'm not sure about that. But other than that, other than the hormonal aspects of it, yeah,

01:04:58.000 it's amazing. I've seen many, many people with four-digit PSAs that we get them down,

01:05:01.980 at least NED for some window of time, even if it's not that long.

01:05:06.780 Four-digit PSAs?

01:05:08.380 Yeah. I think the highest I've seen is 7,500. That was a person that ended up passing away. But

01:05:12.780 the guy who was 1900, I think a lot of it is a function of, just like any other type of tumor,

01:05:17.260 he had all the other risk factors that were lined up. He was young, healthy, no other comorbidities,

01:05:22.540 active.

01:05:23.660 Ted has told me about some of the most terrifying cases are the exact opposite. These guys that show

01:05:29.300 up-

01:05:29.700 With a low PSA.

01:05:30.620 With a very low PSA. A PSA of 1.9-

01:05:33.920 Those are worse.

01:05:34.940 Rampant metastatic disease.

01:05:36.520 Right, right, right. And that's the thing. You get some of these really poorly differentiated

01:05:40.100 cancers that no longer resemble their prostate progenitor cells. They're very hard to monitor,

01:05:44.580 and a lot of them even don't even show up on a PSMA PET scan.

01:05:48.580 Anything else you want to talk about on the oncology side of this, as far as what should

01:05:54.160 people know as they're engaging with a radiation oncologist? What questions should they be asking?

01:06:01.260 It sounds like it's no different than surgery, where there's clearly a difference between good

01:06:08.220 surgeons and not so great surgeons. There presumably are people that take the kind of care you take

01:06:13.580 and agonize over the details. How can somebody find out if their radiation oncologist is practicing

01:06:22.120 in your philosophy?

01:06:23.040 It's difficult in terms of actual metrics. Even for the surgeons, like, you know, Ted is excellent

01:06:29.080 outcomes, but it's not like it's a published series.

01:06:31.720 And not only that, the best surgeons often are treating the hardest cases.

01:06:35.260 True. So it's a handicap right there.

01:06:36.840 It's a handicap right there.

01:06:37.720 100%. It really comes down to finding someone who's got the experience. And in my case, because

01:06:42.100 we do so much prostate, I think I've done something close to, in the modern era, 7,000 cases,

01:06:47.880 probably 10,000 when you include the pre-image guided radiation days.

01:06:51.700 Someone who specializes in the area that the cancer is located in. So someone like me, I may

01:06:56.740 be extremely experienced in breast and prostate, but maybe for a pediatric malignancy, you're not

01:07:01.260 going to come to me. You're going to go somewhere or a CNS or something that's unusual. You have to

01:07:05.020 find the right tool for the job, but you have to just interview your doctor. I don't think there's

01:07:09.200 anything specific to radiation.

01:07:11.120 And asking about complications.

01:07:12.980 I think being very open with them and saying, yeah, exactly. And so ideally, maybe you come to

01:07:17.820 someone who knows something. Like I get a lot of patients who aren't familiar with the field,

01:07:20.840 but they'll have a patient, they'll have a family member that's a nurse or a dentist or a veterinarian

01:07:25.180 or whatever it is. Someone that has some medical background, they can say, okay, let me ask them

01:07:28.760 more specific questions. And these days with the internet, you can do all kinds of research in

01:07:32.800 terms of when I'm talking about matching my volume of the dose distribution to exactly conform to the

01:07:39.640 tumor volume. That's something that's very easy to talk about. But I mean, for an educated patient,

01:07:44.660 they can ask to see the actual computer simulations. A lot of my engineering patients-

01:07:48.520 I was about to say, engineers probably have an easier time than-

01:07:50.940 They do. And my engineering patients are really the only ones who do this. I usually pull out all

01:07:54.760 the graphs. I show them dose volume histograms with area under the curve for each organ. And you

01:07:59.740 can see, okay, the prostate dose area under the curve is huge. The dose of the bladder and the

01:08:03.460 rectum is super low. You can actually quantify that. But for a lay patient, it's hard. It's not

01:08:07.880 that easy to do that. I think a lot of it, you have to go with your gut too, in terms of this guy's had a

01:08:11.500 lot of experience. And the initial consultation is where it all comes down. I'll spend an hour with

01:08:15.500 a patient and go through every little nuance of what could and couldn't happen. And my main MO is

01:08:20.900 to sort of over-prepare them and have them be pleasantly surprised maybe when the side effects

01:08:25.260 aren't as bad rather than the other way around. It's hard to find the right person, but there's

01:08:28.900 a lot of good doctors out there. Let's spend a minute just on the brain, because I guess that's

01:08:33.900 sort of a unique case. I know it's not where you are-

01:08:36.380 Still do a lot of it.

01:08:37.340 Oh, you do?

01:08:37.940 Mm-hmm.

01:08:38.280 Okay.

01:08:38.480 Not as much as prostate and breast, but yeah, both primary and metastatic.

01:08:41.940 Yeah. So again, because the brain is such a sink for mets, A, it's a source of a lot

01:08:47.960 of primaries, but it's also where a lot of cancer spreads. It's often a place where you

01:08:52.600 can't operate, either because the tumor, the met or the primary is too close to say the

01:08:58.500 brainstem or something too vital. So radiation is a pretty common tool there. So talk about

01:09:03.900 the history of radiation in the brain and the spectrum of everything from whole brain radiation

01:09:08.700 to gamma knife and stereotactic and all sorts of things in between.

01:09:12.560 Sure thing. The main differentiating factor for brain patients is whether it's primary

01:09:16.260 or metastatic disease. And although primary brain tumors are relatively common, they are

01:09:20.860 dwarfed by metastatic disease. So the vast majority of what most radiation oncologists see when

01:09:25.760 you're treating CNS is going to be usually lung, especially small cell-based brain metastatic

01:09:31.440 disease. And so in those situations, the trend used to be where everyone would get whole

01:09:35.840 brain radiation. But now with the advent of stereotactic radiosurgery, which is more focused,

01:09:41.080 precise radiation, the newer data shows that you can actually just treat the area of metastatic

01:09:45.520 disease as a delineated on an MRI scan and not necessarily radiate the whole brain like

01:09:50.580 we used to. But for decades, everyone got whole brain radiation. And for the most part,

01:09:54.400 they did all right. But the problem was you're looking at a patient population that maybe doesn't

01:09:57.780 have that much of a life expectancy. Now that systemic therapy, immunotherapy, everything has

01:10:02.360 gotten better, especially in the case of lung patients. They're living longer. We have evolved

01:10:06.400 where we've been finding people that were previously radiated to the brain were having

01:10:09.920 cognitive issues years down the road. Not for the short term, they would tolerate it well,

01:10:14.200 but maybe they'd start to have more forgetfulness, an inability to remember numbers and names and

01:10:19.280 whatnot. And this was from whole brain radiation?

01:10:21.540 Whole brain radiation.

01:10:22.100 And give me some doses.

01:10:23.340 So we're talking about 30 gray to the whole brain given in 10 fractions of three gray each.

01:10:29.260 Three gray times 10 was a sort of a standard thing.

01:10:32.540 This is a staggering amount of radiation.

01:10:34.420 And that's to the brain. So it's a different story.

01:10:36.280 And just to be clear, do you need to use way more radiation because that's what you're

01:10:42.380 delivering to the brain? Is this an example of where the sieverts and the gray are very different

01:10:46.760 because you have to get through the skull?

01:10:48.940 No. So the only difference between sieverts and gray in any patient is going to be whether

01:10:52.100 we're talking about dose in tissue or coming out of the machine. Basically the dose in air versus

01:10:56.820 dose in the patient. The biggest thing with brain tumors, yes, the bone certainly is going to

01:11:02.020 attenuate more dose. But what I'm talking about is actually 30 gray into the brain itself,

01:11:06.580 the actual brain tissue.

01:11:08.360 Doesn't that mean you need much more than 30 gray coming out of the machine?

01:11:11.200 A little bit more.

01:11:12.020 The bone doesn't do that much?

01:11:12.840 It's not like they're wearing a football helmet or something. Yeah. Photons can still pretty much

01:11:16.460 go through everything. It's not metal. So it'll still go through. The dose is a little higher

01:11:20.340 and it gets to be like, for example, in a lung patient, it's more of an issue when you have

01:11:24.120 multiple different areas. You got bone, soft tissue, and air. In that situation, you have to

01:11:29.240 modulate the dose more. But in the case of a whole brain, it's been found, of course, that the

01:11:33.100 hippocampal dose is very much related to their cognitive deficits down the road. So now that we

01:11:39.200 have IMRT, which is a term I hadn't mentioned before, but that's basically intensity modulated

01:11:44.660 radiation therapy, which is also the magic behind allowing us to treat a prostate without burning the

01:11:49.180 bladder and the rectum. And the newest form of IMRT is called image-guided radiation therapy.

01:11:54.300 So you hear IGRT. Basically, those two terms go together. But by using IMRT, it's kind of like an

01:12:00.460 HDTV versus this 1960s black and white blurry set where we can treat with multiple small pixels and

01:12:07.180 high definition, so to speak. So now when we do a whole brain, if I have to do a whole brain for

01:12:11.720 multiple metastases, by using IMRT, I can literally carve the dose out. I can map out the hippocampus and

01:12:17.680 carve the dose out of there. So you see these two cold spots on the hippocampi and really have a

01:12:22.200 very low dose there while still treating the remainder of the brain parenchyma.

01:12:24.900 Are there other parts of the brain that you carve out and protect?

01:12:27.560 That's the main one. Of course, we are going to not necessarily completely carve out because when

01:12:31.380 you have multiple metastases, really the whole intracranial space is at risk. You have to cover

01:12:34.900 everything. So believe it or not, 30 gray sounds high to you, which it is. But for a glioblastoma,

01:12:39.940 we use 60 gray. Granted, that's not to the whole brain. That'll be to the, either if it's an

01:12:44.100 unresectable patient, it'll be the primary mass. And then we will give maybe 46 gray to

01:12:48.600 the peritumoral edema. But then the rest of the brain is getting much less, hopefully zero in many

01:12:53.540 cases. Do we know what the survival difference is for an unresectable glioblastoma with and without

01:13:01.640 radiation? It's certainly worse. There's, again, multiple confounding factors there because someone

01:13:06.900 who's unresectable probably has other negative issues as well. They have poor overall performance

01:13:11.360 status. They have neurologic deficits. Whatever the reason the surgeon can't operate, that makes

01:13:15.260 it worse. But yes, even then in that situation, you get probably, again, you're measuring survival

01:13:19.820 in weeks to months, but it's probably double with radiation than without. A lot of our GBMs though are

01:13:25.580 resected, hopefully fully resected in terms of at least radiographic, a post-op MRI not showing any

01:13:31.380 enhancement. If you have someone that's got a fully resected primary who's a younger patient with

01:13:35.880 not a lot of neurological deficit, they can live a couple of years actually.

01:13:39.660 Why is this cancer unsurvivable?

01:13:42.280 That's the key question. I know you and I are both Rush fans. Neil Peart was lost to

01:13:46.320 GBM as well. And yeah, it's so many people that's taken away. But I think it just has

01:13:51.080 to do with the invasiveness of the fingers of the tissue in terms of even when you think

01:13:55.540 you've gotten the whole thing, there's microscopic fingers that are always on the periphery and

01:13:59.720 you can't just radiate it indiscriminating like you can other parts of the body because

01:14:03.040 you've got the brain there. There's always a fine line you're walking between causing,

01:14:07.320 say for example, necrosis of the brain versus letting the tumor recur. And so that's really

01:14:12.500 the number one issue. We do have a new tool now as far as radiation oncologists in terms

01:14:17.300 of treating CNS tumors, which is called proton therapy that you've probably heard about.

01:14:21.520 There's several centers in the country now. MD Anderson where I am in Houston has a huge

01:14:24.980 one. But with protons, you potentially can have the dose go into the brain to a certain depth

01:14:31.000 and not exit out the other way, like an x-ray would. X-rays are like light. It goes right

01:14:35.420 through you. You may have a decreasing dose, but it's kind of like a bullet. You got an exit wound

01:14:38.920 going out. With proton therapy, this is one of the areas where protons shine because you can

01:14:43.080 actually modulate what's called the Bragg peak of the physics of the protons to where it'll go at

01:14:47.840 certain depth and not go out the other way. So down the road, hopefully we'll start to see

01:14:52.240 improved survival. So far, it really hasn't shown to be a huge improvement, but there's less

01:14:56.120 integral dose to the rest of the brain. And it's especially important in pediatric patients where

01:15:00.400 you've got children with growing skull bones. And if you can avoid radiating the growing bone to cause

01:15:05.600 a deformity later on, that's huge. So proton therapy is one tool we have, but I wish I had an answer for

01:15:11.560 GBMs. That's going to be a game changer whenever that does happen. I find GBMs to be just such a

01:15:17.240 frightening type of cancer. And I do wonder if it's going to require some sort of injectable

01:15:22.240 immunotherapy or something. I think so. I just, you have to basically figure out a way to treat

01:15:27.660 the brain systemically. You have to mechanically overcome the blood brain barrier and come up with

01:15:33.380 some sort of systemic treatment for it. Okay. So today, how many patients are undergoing whole brain

01:15:39.880 radiation? Whole brain radiation is probably, to give you a number, I don't know what the absolute

01:15:45.400 number is, but it's probably 10% of what it was 20, 30 years ago. The original studies out of

01:15:51.300 Kentucky that Patchell had done in neurosurgery, everyone used to get whole brain radiation following

01:15:56.440 resection of the metastasis, or even if it was unresectable. And there was some good data back

01:16:00.700 then supporting that. But nowadays, rather than whole brain, you're usually going to do a focus

01:16:04.640 treatment just to a smaller area. And this is kind of a universal trend to less radiation dose

01:16:10.300 to a smaller volume. Same thing in lymphoma, you want to treat just the enlarged lymph node and not the

01:16:15.600 entire lymphatic axis. So it's the same idea where you're trying to minimize side effects.

01:16:20.180 So whole brain, we still use it in specific cases, like for example, small cell lung cancer.

01:16:25.260 Part of their regimen is going to be once the primary has been treated, if they have a complete

01:16:29.960 response in the thorax, prophylactic cranial radiation. Only for small cell. PCI, 20 gray,

01:16:35.880 five fractions, been done forever, shows an advantage to have lower disease.

01:16:40.180 How much of a reduction in CNS meds?

01:16:42.020 It's a lot. I think it's probably 70, 80% reduction in CNS failures, because they all

01:16:48.440 fail there otherwise. Small cell, they just all do that. And at 20 gray, they really don't have

01:16:52.440 too many side effects. But again, of course, the caveat is always extensive stage small cell lung

01:16:56.880 patient isn't going to have a long-term survival, but at least they won't fail in the brain. It's a

01:17:00.980 quality of life issue.

01:17:02.040 I'm sorry, this is done with every small cell patient, no matter how early it's caught?

01:17:06.800 If they have a complete response to primary treatment, yes. Basically,

01:17:10.620 maybe there's some nuances, but for the most part.

01:17:13.320 Okay, so what's a gamma knife?

01:17:15.240 So gamma knife is, instead of using a linear accelerator, it's actually using cobalt-60,

01:17:19.960 like I described earlier. But you have multiple small sources that can actually be used,

01:17:24.420 very high-resolution cobalt, essentially. So you're doing the same thing,

01:17:27.880 but instead of using a linear accelerator-based treatment, it's using cobalt.

01:17:30.960 So is that used anymore?

01:17:32.280 There still are centers that use it. It still works very well for what it is,

01:17:34.880 but the focus is very narrow. There's a lot of children's hospitals and all that. I think

01:17:38.280 we're still using it. But the linear accelerator, which is abbreviated LINAC, the LINAC-based

01:17:42.720 stereotactic radiosurgery for the most part has taken over from that because it can do all the

01:17:47.340 same things and also have more flexibility to do more than just CNS. St. Jude's Hospital has a

01:17:53.320 fantastic PD-CNS program and they still have, well, it's been a while now, but they did have a

01:17:57.520 gamma knife last time I checked. Okay. So we've talked a lot about radiation. We've touched a

01:18:02.620 little bit on the idea of radiophobia, but maybe let's use that as a bridge to talking about using

01:18:07.940 radiation to enhance tissue as opposed to eradicate a subset of tissue. Does it stem from nuclear

01:18:16.860 accidents? Is that largely where radiophobia comes from?

01:18:20.500 I've done a deep dive into this this year, which goes along with all these benign cases that I'm

01:18:25.680 treating now. They're essentially arthritis tendonitis, which we'll talk about. And what's

01:18:29.660 really interesting is that this radiophobia is largely a US-based phenomenon because the first

01:18:36.220 cases, first of all, x-rays were discovered in 1895 by Rankin. In 1898, there was the first case

01:18:43.960 described of actually radiating both arthritis type things or ankylosing spondylitis or other

01:18:49.420 arthritis and also tumors. Even back then, we had no idea how it worked, but there were cases

01:18:54.000 pre-1900 that were already being used for that. And then in the subsequent now 120 plus years,

01:19:00.220 we have this divergence where Germany and the UK, all of Europe really, are using radiation routinely

01:19:05.620 for arthritis and tendinitis. But in the US, it seems to be a basic nuclear phobia, the Cold War,

01:19:10.940 like you mentioned. But another thing that's been talked about, there's a guy named Jason Bechta that

01:19:14.920 has a really good podcast on the subject. He's out of Vermont. Standard Oil, the Rockefellers and all

01:19:20.580 actually had a massive lobby group that were actually actively promoting oil over nuclear

01:19:26.720 power plants. The amount of spread went from just the energy industry into just the general zeitgeist

01:19:31.660 of the entire country. And so at that time, the radiophobia just caught on. And it was, of course,

01:19:37.380 bolstered by World War II and seeing what happened in Hiroshima and Nagasaki.

01:19:41.060 And then on top of that, you've probably heard about the radium dial workers. There was a movie,

01:19:45.520 it's actually called The Radium Girls. These are essentially women in the 1920s that were using

01:19:50.760 radioluminescent phosphorous paint to paint the watches.

01:19:54.080 Watch dials, yeah.

01:19:55.020 Being a watch guy, you'll probably appreciate that. But that was the only source of illumination

01:19:58.220 they had. So in order to keep the brushes very fine, they were literally dipping it in the radium

01:20:02.720 paint. And then after each brush, they were licking the brush to keep the tip real fine. And so they

01:20:07.400 were ingesting bits of radium. So there were a number of cases where they ended up, the radium

01:20:12.040 is metabolized like calcium. So it was actually incorporating into the mandible and they were

01:20:16.820 getting osteoradionecrosis of the jaw and things like that. So all of these different phenomena

01:20:21.680 added together became a big deal because prior to that, people were using radiation for all kinds

01:20:26.260 of crazy things. It was in suntan lotions and waters. And there was something called vigoridine

01:20:32.220 that they were using for ED, topical salves that had radiation in them. It was literally

01:20:37.020 no end to it. And then when all this sequela started to come out that, hey, maybe this isn't

01:20:40.680 such a good idea, that's when things took off. But now that we look back, the reality of it is,

01:20:45.580 is that a lot of that was really overblown, even so much so that those radium dial painters,

01:20:50.020 which we hear about this from day one in our residency training, there was only a small percentage,

01:20:54.360 like I think 50 out of 1500 roughly, that actually had toxic sequela. So most of them didn't.

01:21:00.120 Is there a way to quantify how much exposure they had to radiation?

01:21:03.160 And that's the thing, you know, they've licked different ways, but there have been some basic

01:21:06.300 ideas. It was, again, we're talking about at that era, it was probably a couple of

01:21:10.120 millisieverts to that particular area, but it was daily for decades. And so part of the reason why,

01:21:16.100 if you actually look at the numbers, it was probably a super high exposure, but when you

01:21:19.140 spread that out over such a long period of time, that's sort of the general trend. Like I mentioned

01:21:22.760 earlier, it's not just the dose, it's the dose over time. The denominator matters a lot. And so

01:21:27.720 that's why most of them actually did very well. They even used to use radium internal nasal

01:21:32.100 applications in the 19, I guess, 1920s to 1940s, essentially a radiation equivalent of a tonsillectomy

01:21:38.780 or adenoidectomy. And it was done in something like a half million to 2 million children in the

01:21:44.360 U.S. and even in the armed forces. It was done routinely back then. And there's been very few

01:21:49.020 adverse sequela that were reported. I don't even know what the dose was, but it was high.

01:21:52.060 Right. So there's a lot of cases where the exposure based on our 50 millisievert rule we

01:21:56.640 talked about would just make people fall out of their chair. The actual reality of it is,

01:22:00.940 is that many times the actual end results aren't as bad as we had expected.

01:22:05.400 Again, hearing you say this, Sanjay, the listeners are going to be thinking,

01:22:08.640 what?

01:22:09.820 Yes.

01:22:10.440 Because we're all so brainwashed into believing that radiation is horrible.

01:22:16.780 Right.

01:22:17.940 Right. I can tell you so many stories. I got patients who I've had to treat. I had actually

01:22:21.640 had a guy who was involved in nuclear testing at Los Alamos in the 1940s. He's passed away now,

01:22:27.280 but I saw him in his 80s. So this was in the early 2000s. This was 60 years after that. They had very

01:22:33.320 little monitoring back then, but he was close enough to feel the heat from a thermonuclear bomb.

01:22:38.780 And by the time I saw him, he had had thyroid cancer, as you would expect. He'd had one or two

01:22:43.260 lymphomas. I think I ended up treating his prostate. So he'd had at least four or five

01:22:46.820 different malignancies, but the guy was as functional as most 80-year-olds are. The guy

01:22:50.400 was still walking and talking and doing just fine. And it actually seems that when you look at the

01:22:54.960 population studies that were done outside the blast at Hiroshima and Nagasaki, when, of course,

01:22:59.460 the initial concentration, everyone dies from the thermonuclear energy. But as you get several miles

01:23:04.060 out, not only are the cancer rates actually roughly the same as the background, you actually see,

01:23:09.760 evidence of hormesis where you have some patients in whom, or maybe not hormesis, but some sort of

01:23:14.140 radio protection where you actually have lower rates of leukemia and thyroid cancer when you get

01:23:18.260 a few miles farther out than you did in the general population. So it's all very much dose-dependent,

01:23:23.340 time-dependent. But I think the human body, we're evolved really to handle this to a larger degree

01:23:28.900 than we realize because, again, mammalian DNA, we came from the background of the animal kingdom where

01:23:34.040 there was tons of exposure from natural cosmic rays and whatnot. And then our predecessors had

01:23:39.640 to be able to survive. Our DNA had to be somewhat resilient in order to get to this point. I think

01:23:44.140 it's more resilient than a lot of people give it credit for.

01:23:47.220 So this first came up maybe a year or two ago when I was lamenting, it must've been two years ago,

01:23:53.080 I guess, because I was kind of lamenting my Achilles tendon, which I wouldn't say it was injured.

01:23:58.420 I just had a little bit of tendonitis. It was just bugging me a little bit.

01:24:03.000 You and me both, brother.

01:24:04.200 And so it was through that discussion that we got into what we're talking about now,

01:24:07.860 which seemed crazy. I just decided I didn't feel like driving to Houston all the time to undergo

01:24:12.320 therapy and my Achilles is fine now. I just did sort of standard therapy. But I've sent a few

01:24:17.240 patients to you who have had similar injuries, both high hamstring tendinopathies, Achilles

01:24:23.560 tendinopathies. So talk a little bit about this idea. How prevalent is this type of treatment in

01:24:28.580 Europe? How prevalent is it here?

01:24:30.860 So prior to probably 1970 or maybe 1980, it was very prevalent even in the US. It was very widely done.

01:24:37.200 Everyone, I talk to them about it now, it sounds like I'm doing something experimental and radical.

01:24:41.860 But if you go over to Germany, again, going back to ankylosing spondylitis papers in 1898,

01:24:47.620 they do something like I hear between 20 and 50,000 patients a year in Germany. It's mostly

01:24:53.340 observational studies. There's very few randomized trials, but low dose radiation for tendonitis,

01:24:59.580 osteoarthritis, plantar fasciitis, all the itities you can think of, bursitis.

01:25:04.400 A low dose of radiation has a similar anti-inflammatory effect to what you would

01:25:08.540 get from a cortisone injection.

01:25:09.060 And let's define the dose.

01:25:10.580 So now we're talking about very low dose, meaning 50 centigray or 50 rads given six times over two

01:25:18.160 weeks. So three gray, 0.5 times six is three gray to the affected joint using a very low energy

01:25:25.320 machine. So this is especially in the case of someone who's got a hand, you're talking about

01:25:28.900 electron beam radiation.

01:25:30.060 Sorry, let me just make sure I got that straight. You were giving 40 gray total to a breast.

01:25:38.200 And now for the Achilles, you're giving how much?

01:25:41.520 Three gray, six fractions of half a gray each. So all six fractions combined is about the dose of

01:25:49.000 one fraction for a typical cancer. That'll give you the idea. And giving it in a superficial fashion

01:25:55.040 where especially if it's a hand, you only have a couple of centimeters of thickness. So we use what's

01:25:58.600 called electron beam therapy. The same linear accelerator when the electrons go and hit the

01:26:03.660 tungsten target and make photons, if you remove the tungsten target, you just get direct electrons.

01:26:08.480 And electron energy can be modulated to where you can treat a superficial skin cancer. You can treat

01:26:12.780 a knuckle. I can treat a temple squamous cell and not go into the brain. In the old days, before they

01:26:18.260 had linear accelerators, I told you this goes back to the turn of the previous century, they had

01:26:22.000 orthovoltage machines. And these basically created kilovoltage x-rays, not the megavoltage

01:26:27.160 x-rays we use now. And all they could do was superficial stuff back then. And that's where

01:26:31.820 it works very well. The dosage has changed tremendously, but these days, the biggest data

01:26:36.140 comes out of Germany, half a gray, three times a week, Monday, Wednesday, Friday for two weeks,

01:26:40.840 just to the affected joint. And it has an anti-inflammatory effect very similar to either

01:26:46.100 a cortisone shot or an NSAID.

01:26:47.940 And how many weeks is the course?

01:26:49.440 Two weeks. Monday, Wednesday, Friday, six treatments. And the protocol is what we typically

01:26:54.140 follow. The German protocol is to wait 12 weeks. And you usually see, depending on the

01:26:58.900 joint, somewhere between a 60 and 80% success rate where the pain is, if not zero, at least

01:27:04.740 markedly decreased. And then after 12 weeks, the German protocol allows for a retreatment.

01:27:09.360 And at that point, you get up to 90 plus percent success in terms of reducing pain.

01:27:13.400 And this is for joint arthritis?

01:27:14.880 Arthritis, tendinitis, bursitis, plantar fasciitis is a really big one now that we're doing a

01:27:21.080 bunch of. I've done probably close to 70 cases across the board just this last year.

01:27:24.620 Which is kind of remarkable because anybody who's had it, you know, I had it once back

01:27:28.200 in med school, exactly 25 years ago.

01:27:30.280 Did you get it treated or was it just, did it just resolve?

01:27:32.940 I mean, I just went to PT and rolled on golf balls and did the usual thing, but it took

01:27:37.020 months to get better.

01:27:38.800 It's such a big deal.

01:27:39.840 So you're saying of the patients that are coming to see you with plantar fasciitis, how

01:27:44.400 many of these patients, how long have they been hurting, first of all?

01:27:47.600 Many times for years. And in fact, my biggest cohort recently, which is still relatively

01:27:51.780 new, I haven't done thousands of patients. Like I can speak from decades of experience

01:27:55.720 with cancer. We're talking about dozens to hundreds. A couple of surgeons that were having

01:27:59.380 trouble standing and operating. They literally couldn't perform their normal duties. Six treatments

01:28:04.780 to the fascia and they're walking like nothing ever happened.

01:28:08.100 How long after the last treatment did it take?

01:28:10.520 In the case of plantar fasciitis, it was almost immediate. Within a week. I have other cases,

01:28:15.880 especially when we do like knee arthritis, if there's a lot more pathology going on in

01:28:20.080 a knee. I treated my own Achilles, which I can tell you about. It took two months or so.

01:28:24.620 I was almost wondering if it was going to work or not. I was my own first patient. Before

01:28:27.460 I offered to anybody, I treated my own Achilles.

01:28:29.120 Like a true doctor.

01:28:29.640 Physician, heal thyself, right? And so I literally jumped on the table because a colleague of mine

01:28:34.340 had posted about it that he did his, he's a radiation oncologist in Florida. He tried

01:28:37.880 it out. And so I was like, you know, I have the machine. I know this should work in theory.

01:28:41.740 We were just never taught about it in residency. And I look at all the German data. There's tons

01:28:45.040 of it. It's like, why do we not do more of this? And sure enough, I'm actually my own

01:28:48.660 personal case control study because I did steroids and PRP in my left Achilles. And then later on

01:28:53.660 this past year, did the right side with only radiation and no steroids. And now I'm walking

01:28:58.260 without a limp.

01:28:59.280 You obviously did the other side.

01:29:00.540 No, no, actually I didn't. The PRP actually finally did. So I had two cortisone shots and PRP in

01:29:05.140 the left. And then a year later, radiated the right. Both of them are holding up pretty well

01:29:10.080 so far.

01:29:10.720 Got it. The other area that is of huge interest for me at least is the very, very high hamstring

01:29:17.060 tendinopathies. So that ischial tuberosity pain, very, very common for runners. Seems to be

01:29:24.920 anecdotally much more common in women than men based on pelvic anatomy.

01:29:28.300 I've only treated women for some reason with that. And they've all had tremendous results.

01:29:32.320 It's still the same protocol. It's the three gray over six treatments over two weeks.

01:29:36.600 Exactly. For any type of an arthritis, you're essentially lysing all the macrophages and

01:29:41.500 you're eliminating that cytokine storm that would have normally resulted. It's very similar

01:29:45.420 to what cortisone does, but the difference is it seems to be based on the studies we've

01:29:48.700 seen is much longer lasting than a cortisone shot. Not to mention the fact that you're not

01:29:52.260 necessarily violating the capsule. And in the case of an Achilles tendon, you run the risk

01:29:56.440 of rupturing it with multiple injections. So totally non-invasive. You just get up on the

01:30:00.560 table. Most of my patients, they go right back to whatever they were doing. And many

01:30:03.240 of them are actually quite athletic and they don't take any breaks during treatment. They

01:30:07.020 just do what they do. They're still working out.

01:30:09.460 Is there any literature looking at this for spine injuries? By injuries, let me be clear

01:30:15.500 what I mean. So when you think of all the times that people are getting spinal epidurals

01:30:20.720 for irritation of spinal nerves, herniated discs, things of that nature, is there any reason

01:30:26.580 to believe this could have any efficacy there if indeed there's some efficacy, which there

01:30:30.680 clearly is due to spinal injections or epidural injections?

01:30:34.180 There is some data for spinal osteoarthritis specifically. It's less robust than all the

01:30:39.740 extremities. I've actually done a few cases and it's actually worked quite well. Medicare

01:30:43.820 actually does reimburse for these things. The issue with the spine is it's such a multifactorial

01:30:48.880 area where if you've got a nerve root compression or a disc issue, I can't fix that part of it.

01:30:54.260 But there is limited data that I've seen out of Europe that did show some degree of relief,

01:30:58.800 but it's not the 80 to 90 percent that we quote for the extremities. It's probably half

01:31:02.560 that.

01:31:03.340 Interesting. And do you think it's because of patient selection? Like if you knew you were

01:31:07.660 dealing with a facet arthropathy, that should in theory respond well.

01:31:12.260 It should. And it does. I've done a few of those. SI joints seem to respond quite well,

01:31:16.300 and that's in the literature. That's included. So hips, SI joint, lumbar spine, those sorts

01:31:21.220 of things. They are described. They're just not as routinely treated. There's not as the level of

01:31:25.880 experience that we do have with everything else. But your ability to center the beam

01:31:31.040 is remarkable. You're using the same high fidelity equipment you're using for Radonc.

01:31:35.820 A hundred percent.

01:31:36.480 So you can hit a P inside if you want to.

01:31:38.720 Well, you could, but that's exactly what you don't want to do because you're basically trying

01:31:41.900 to eliminate all the macrophages in the region. So you're actually better off treating larger fields.

01:31:46.380 So it's the exact opposite of what we do with cancer therapy. And because the dose is so low,

01:31:51.420 you're not really gaining anything by being too cute with the small fields. You actually want to

01:31:55.320 treat the region. It's like almost like an abscopal effect for the whole area.

01:31:58.840 So if you're treating somebody that comes to you and they've got an Achilles tendinopathy,

01:32:03.340 usually there's a point of maximum tenderness, but it usually hurts up and down the whole Achilles.

01:32:08.580 How do you position the beam? And are you literally hitting from mid calf down to heel?

01:32:14.320 From the insertion in the gap. In my case, part of the gap, the inferior gastroc was painful too.

01:32:19.780 So I treated that entire region. The field was probably about that long,

01:32:23.020 all the way down to the calcaneal insertion and even onto a little bit of the plantar surface of

01:32:27.500 the heel. Because again, when you're talking about these super low doses of radiation,

01:32:32.100 if it was a sarcoma of that area, I'd be treating a tiny little area. But over here,

01:32:35.720 we want to treat the whole region. Most radiation oncologists, we talk to their experience

01:32:39.640 treating an extremity. It's usually for a sarcoma. So that's a whole different ballgame where

01:32:43.700 you're giving 60 grade to someone who's had a sarcoma in their leg or something. And you have

01:32:48.180 to worry about things like edema. You can have lymphedema of the distal extremity if you've

01:32:53.180 radiated the whole circumference of a leg or something like that. But with these low doses,

01:32:57.300 it doesn't affect any of that. So you do treat large fields. So it'll be from the insertion of

01:33:01.740 the Achilles all the way down. If it's a plantar fascia, the entire plantar surface of the foot.

01:33:06.580 Another thing that we see a lot, which is not arthritis, is diputerins, contracture,

01:33:10.580 and also the foot equivalent, which is leader hose disease. I had to look that one up. That was a

01:33:15.300 trivia question. But it's essentially palmar or plantar fibrosis. And so radiation works well

01:33:21.400 there as well. Very well documented. And that requires a higher dose though. You're talking about

01:33:26.280 three gray per fraction, five fractions, and then you do it again after a few weeks.

01:33:31.000 So 15-15.

01:33:32.060 15-15.

01:33:32.560 It's almost cancer.

01:33:33.600 Yeah. Almost palliative cancer, not a high dose. But again, that's for fibrosis.

01:33:38.040 And keloids, it works very well to get teenagers with big old golf balls hanging off their ear

01:33:43.120 after getting their ear pierced and things like that. And so again, you're treating the fibroblast.

01:33:46.980 In that case, you use four gray times three treatments of 12 gray, relatively large dose

01:33:52.080 per fraction.

01:33:52.760 And you can totally protect the brain?

01:33:54.400 Totally. 100%.

01:33:55.580 I've seen, obviously, patients with debilitating keloids. What does it look like after the treatment?

01:34:01.600 So the treatment has to be adjuvant after a surgical resection. If you just radiate an

01:34:05.920 intact keloid, it's not going anywhere. Because you don't have the DNA mechanisms of a weak

01:34:10.840 cancer cell that can be wiped out. So it's kind of like doing a lumpectomy.

01:34:14.200 But obviously, if the surgeon just did the resection, the keloid's coming right back.

01:34:17.900 The fibroblasts go crazy and they roar right back. So in order to do it right, a lot of

01:34:22.300 people do it and they have multiply recurrent keloids even after treatment. You have to do

01:34:26.000 the first treatment the same day as surgery. So you're just not letting those fibroblasts get

01:34:29.900 a chance to have any sort of a foothold. So I would literally arrange it with the dermatologist

01:34:33.580 to do the resection, send them straight to me. So we get the first dose in that day.

01:34:37.560 And ultimately, the cosmetic outcome is as good as if they didn't have radiation.

01:34:41.060 You'll see the scar wherever it is. We get sometimes kids that have had acne scars all

01:34:45.200 over their chest that have these bumps everywhere and they were all resected flat. And you radiate

01:34:49.080 them, they just stay flat. You don't see any sort of dermatitis from radiation.

01:34:52.700 I think what's amazing to me is I just think there's too many people that don't know this.

01:34:56.180 I think there's too many people that are walking around suffering either from something

01:35:00.600 that's cosmetically upsetting, like a huge keloid, especially on a visible part of their

01:35:05.060 body. Obviously, everybody listening can relate to some nagging injury, tennis elbow, golfer's

01:35:10.400 elbow, Achilles tendinopathy, hamstring tendinopathy. These things nag for years at times.

01:35:18.260 The data was showing some like one in seven people in the country are afflicted and the

01:35:22.200 socioeconomic costs are massive. And there's also, you know, going to your whole quality of life

01:35:27.600 and longevity bias. I mean, we're talking about something that can really affect someone's ability

01:35:31.260 to exercise at all, and it can lead to exacerbation of other medical problems.

01:35:35.920 You know, I was very encouraged to hear you say a second ago that Medicare is covering some

01:35:39.580 of these things.

01:35:40.340 And private insurance too, yes. For the most part. Now, a lot of times, because it's relatively

01:35:43.560 new, I'll have to get on there and do a peer-to-peer with the company, but I've had no rejections

01:35:47.400 at all. Even for the spinal ones, which are a little bit, there's less robust data,

01:35:51.360 but I've gotten everybody covered.

01:35:52.560 So, I think the question is, do we need more radiation oncologists? Because how are you

01:35:59.220 making room in your practice to treat these patients when your cancer patients are probably

01:36:04.860 ringing you off the hook as well?

01:36:06.180 That's a big reason why it hasn't caught on. I think there's a component of just,

01:36:09.920 you've got eight hours or 12 hours a day that the linear accelerator can run. We're busy with that.

01:36:14.540 But one of the things is that because, unless it's a deep hip or something, for most of the

01:36:18.780 superficial, for all the other joints, you can use one of those old-style orthovoltage machines

01:36:23.120 that I mentioned earlier, like what they use in Europe. They still sell those here. There's a

01:36:26.780 company called Extrol that still makes them, and they're perfectly acceptable for all the joint

01:36:31.540 stuff, except for the very deep ones, like maybe a SI or a hip joint. But you could have a small

01:36:36.740 center set up, and those types of machines don't even require the shielding because the energy of

01:36:40.680 the photons is very, very low. It's highly underutilized at this point, and the Europeans have shown us

01:36:46.300 the way. It clearly works, and America just has to catch up.

01:36:50.240 Yeah, this is definitely an area where we are way far behind.

01:36:53.500 But it's truly exciting. I mean, I love treating cancer patients. It's really personally very

01:36:57.340 rewarding to tell someone that they're NED, there's no evidence of cancer in their body anymore,

01:37:01.640 their PSA is low, their mammograms look good. That's what's kept me going this long. But the

01:37:06.120 amount of immediate relief we're seeing from all these inflammatory conditions, right away,

01:37:11.080 it's a night and day. Patients come in one day, they can't grip a doorknob or lift a gallon of milk

01:37:15.700 out of their fridge. And after six treatments, they can, and they're just, they think you hung

01:37:19.380 the moon. It's an amazing thing. I'm hopeful that people listening to this,

01:37:24.400 so if there's a million people listening to us have this discussion, and one in seven of them,

01:37:29.920 let's just say one in 10 of them, at some point in the next couple of years are going to experience

01:37:34.540 the type of injury that would benefit from this. How can they go about finding, you know,

01:37:39.320 they can't all come to Houston to see you. I'm trying to get you to move to Austin. But regardless

01:37:42.860 of where you end up, they can't all come and see you.

01:37:45.960 You already said the answer. I'm just going to move to Austin. We're just going to do this full

01:37:48.100 time and drive cars on the weekends. No, but seriously, there's an uphill battle because

01:37:53.120 as I've been going out and trying to get the medical community in Houston aware of it,

01:37:56.880 you have a lot of pushback because number one, you've got orthopedic surgeons, podiatrists,

01:38:01.840 hand surgeons who are looking at this like, number one, what are you doing? What are you talking?

01:38:05.180 They look at me like I'm crazy. And number two is like, even if this actually works,

01:38:08.720 the concern is when someone's got maybe a knee arthritis, it's been nagging them and maybe

01:38:12.800 they're going to need a total knee at some point. Their concern is, wait a minute, is this taking

01:38:16.320 surgery off the table? Which it's not by the way, because it's such a low dose. There's been plenty

01:38:20.920 of cases of surgery after the radiation. It's not an issue. Or you're taking away from like when you

01:38:26.040 had your plantar fasciitis, I'm sure the podiatrist build something for when they do those extra

01:38:30.060 corporeal shock treatments and steroids and whatever it is. It's a different paradigm that would

01:38:35.660 potentially be taking away. A lot of doctors are very negative about it. Most of them at this point

01:38:40.100 are very negative, but I think that tide is going to turn just like anything else. It's just going

01:38:44.300 to take a lot of education, a lot of time, a lot of talks like this. Well, I think at the end of the

01:38:48.060 day, look, I don't think patients will have any patience for turf wars. Yes, that's true.

01:38:53.100 And so if I'm a patient, every doctor needs to be a fiduciary. They need to put my interest ahead of

01:38:59.880 their interest. And what's interesting is that I think you can have your cake and eat it too.

01:39:03.800 The reason I say that is many times this is an adjuvant for other things. So if you've got a

01:39:08.080 podiatrist that's doing all these PRPs and the other things, I'm actually looking at starting a

01:39:11.840 protocol. I just treated a nurse in Houston who's a NP who does stem cells off label, but she does

01:39:16.860 them routinely, has quite a big practice. We're going to look at maybe you can do radiation with

01:39:21.180 adjuvant stem cell treatment because it's such a low dose. This may be the sort of combined modality

01:39:25.780 thing down the road that we haven't really approached where there may be options to do other things

01:39:29.700 still. But again, I mean, for Medicare to improve something is a huge bar. How are you getting

01:39:35.300 Medicare to improve this? Are they basically acknowledging that, well, hey, if Europe's

01:39:39.320 been doing this for a hundred years and it's working, like what's their bar?

01:39:41.860 That's what it looks like. You know, I've got the C61, which is the ICD code for prostate cancer,

01:39:46.340 which is in most of my patients. We've got the osteoarthritis codes. Now they just go right

01:39:49.740 through typically without any sort of a problem. Some of the private insurances, you have to get on a

01:39:54.520 peer-to-peer call, but all I literally will do is quote them a couple of the German studies.

01:39:58.940 Unfortunately, we got a little bit of a setback because there's only two randomized clinical

01:40:03.080 trials that are both heavily underpowered, poorly run studies, just not well done. So that's been a

01:40:07.960 little bit of a setback. And the randomized data may never come just because of the nature of this

01:40:11.900 sort of thing. But having said that, that's not the obstacle anymore. It's really just public

01:40:16.660 awareness. And like you said, just like a guy that doesn't want a radical prostatectomy and wants

01:40:20.700 radiation therapy for his prostate, he's got to be his own advocate. And the data is out

01:40:24.460 there. The information is out there. There's a couple of big Facebook groups and one is only

01:40:28.220 Diputrins patients. And they literally will post up there, I've got this big nodule. What do I do?

01:40:32.440 My surgeon wants to cut on me. And so there's actually a whole network now. So there's a lot

01:40:36.180 more of that education going on. They've got big PDF files of doctors all over the US that will do

01:40:41.260 Diputrins radiation. So Diputrins is a little bit more commonly accepted, but as I'm slowly talking to

01:40:46.320 these folks, they're going to migrate into their arthritis space as well. So I think it'll come

01:40:50.820 and the general public has nothing but great positive outcomes from this.

01:40:55.240 Do we have a sense of the durability of this? So for example, I have a little bit of osteoarthritis

01:41:00.300 at my AC joint on the right. It barely bothers me, but every once in a while, if I'm doing something

01:41:06.460 really violent overhead, reaching for something, or I play a ton of football with my son, it'll bug me

01:41:12.080 for like three weeks. I'll take a little bit of Advil. It's fine. If I did a treatment there,

01:41:17.120 would it be done or am I doing this treatment annually? How would it work?

01:41:20.820 There's a lot of variability there, depending on what the actual anatomy that's causing it. If

01:41:25.060 it's literally just a straight up osteoarthritis case with no physical structural issue, I've seen

01:41:30.220 cases. Now again, I've only been doing this about a year, so I don't have the 25 years of experience

01:41:34.280 I do with cancer, but I've talked to, there's a couple of doctors who do this routinely. They've

01:41:38.360 been doing it for 20 years in LA. One of them treated his own neck, shoulder, and spine. I think

01:41:42.600 he's at 15 years out, anecdotal obviously, but never had to retreat himself. Typically the German

01:41:48.220 studies allow for two treatment, two retreatments. Because the dose is so low radiobiologically,

01:41:53.640 I don't see any reason why you couldn't do it. I don't know about annually, but maybe every few

01:41:57.860 years or something like that. But there seems to be a fair bit of data that a lot of patients who

01:42:02.220 don't have other struck, like a knee that's bone on bone, it might only last a month or may not even

01:42:06.700 work. But for the other ones, like the hands and all, it seems like it's certainly longer lasting

01:42:10.880 than any sort of cortisone shot. But I think months are very reasonable and probably years for most

01:42:16.280 people. Now, what about non-osteoarthritis, like rheumatoid arthritis and things like that? Is there

01:42:21.280 any reason to believe that this could help with the debilitating injuries that those patients

01:42:25.240 experience? So I've done three cases of rheumatoid arthritis and one guy that had a Gaudi arthritis as

01:42:31.020 well. Because again, it's a systemic disease. I'm not going to pretend to be able to cure that with a

01:42:34.560 local treatment. But to a single knuckle that's driving them nuts, it's still an inflammatory

01:42:38.660 process. And yes, it works great for that. So if a patient has rheumatoid arthritis, where they're

01:42:44.360 really experiencing a lot of deformation in the hands, you think you can help that patient with the

01:42:50.280 local part of it? Yes. It won't reduce the deformation necessarily because a lot of that is

01:42:54.360 longstanding. But if they were treated early enough in the course of the disease? Yes. I think

01:42:58.100 there's no strong data to support that, but I don't see why it wouldn't work personally. And it

01:43:02.500 definitely, from a purely palliative standpoint, just to reduce pain, it does work. You have to manage

01:43:07.780 their expectations. What are some other examples of where this could be used, at least in your

01:43:13.220 experience so far, in terms of reducing reliance on NSAIDs or opioids or other things like that?

01:43:18.560 Tennis elbows become a big one, doing several of those. How far down the arm do you irradiate?

01:43:23.580 I base it on where the patient, if they palpate, and if they're getting pain down into the brachial

01:43:27.320 radialis, and if it's radiating further down, I'll treat a larger field. Because again, there's no

01:43:31.200 reason not to. Bigger fields are better. No need to be. And again, it's just six. Three gray.

01:43:35.260 Three gray. Three gray. And again, that's three gray locally. It's to an area where there's no

01:43:39.920 vital organs nearby. The total body dose is negligible. It's like getting a CAT scan initially

01:43:44.080 for the rest of the body. So I would treat definitely the joint capsule and a little bit

01:43:48.460 of the distal humerus and the proximal radius and whatever else. But if it's hurting larger,

01:43:53.060 I'll just treat a larger field. In that case, we use opposed lateral beam. So the patient will just

01:43:57.540 lay there. The beam will come in from one side and rotate around from the other side, and we treat them

01:44:01.220 both. Because that way, we get the same type of homogenous dose we do with our cancer

01:44:04.860 patients. I've actually done several piano players that have dequeur veins, tenosynovitis in their

01:44:10.140 wrist. Because when you're stretching to play those notes, I'm a musician as well. All my musician

01:44:14.240 friends are coming to me, the wrist pain is going away very quickly. My biggest patient cohorts so

01:44:19.580 far are former patients because they don't have radiophobia. They're like, I've been through 80

01:44:23.520 grade in my prostate. This is a joke. I'm bringing my wife with me. And half the times the wives sit

01:44:28.280 there for their daily treatment anyway, and they start chatting in the lobby. So we do the wife's hand

01:44:32.320 the same time we're doing the husband's prostate. And for the most part, the hands, the wrist, the

01:44:36.080 elbows, it's very rapid. In the case of the tendinitis, like my Achilles, it was a couple

01:44:40.360 of months, but that's not outside of the window of what we've been conditioned to expect from all

01:44:44.780 the German studies. So it can be not as immediate of a relief as a steroid shot, but it does seem to

01:44:50.140 be more durable. Yeah. We failed to mention at the outset that you're also a remarkable musician.

01:44:55.800 How much do you still play the drums? I got a couple of, actually a couple of doctor buddies. We get

01:44:59.960 together and jam every week or two. And one of them is actually a guy now who's actually got his

01:45:03.980 own YouTube channel and Spotify. And he was actually a professional musician before becoming a

01:45:07.900 cardiologist. So we may actually start touring again. But back in the day, we had a full doctor

01:45:12.000 band, a full seventies rock cover band called Ultrasound. Those are the good old days. We used to

01:45:17.800 play, you know, Journey and Rush and Led Zeppelin all day long. Yeah. I was commenting recently on a

01:45:22.640 podcast how much I regret not seeing Rush during their last tour. Again, because of a GBM, tie it back into

01:45:29.780 what we're doing here. Neil was a genius. So greatest drummer of all time. Are you going with

01:45:34.100 Neil? Are you going with Bonham? Neither, because I went to college here at UT and that opened my

01:45:39.520 entire eyes up to the world of jazz. So the jazz drummers can all drum circles around those guys in

01:45:45.380 terms of pure technical ability. But yeah, feel, rhythm, not necessarily being able to wow people the

01:45:51.700 way the jazz guys can, but yeah, Neil and Bonham are both right up there on the rock side of things.

01:45:55.880 Would you put them at the top of the rock list?

01:45:57.980 I would put Neil first. I'm just partial to Rush. And a lot of that has to do with their music,

01:46:02.540 not necessarily. Now, Neil was obviously an innovator, but as a 16 year old, I'm sitting

01:46:06.200 there trying to imitate every single note on his drum solos, everything like that. Neil,

01:46:10.520 number one, but Bonham and the new generation rock guys are incredible. The guys that grew up with

01:46:15.020 Neil as an inspiration, you've got 12 year olds who can do this stuff in their sleep. And then all

01:46:19.880 these math metal bands, you got dream theater and things like animals as leaders. Some of

01:46:25.860 these guys are doing things. I pride myself as a drummer on being able to analyze the music really

01:46:29.980 well. It's getting to the point where it's almost more math than music. Like it's so intricate,

01:46:34.720 the modulation of the time signatures and things like that. It's actually getting beyond where

01:46:38.560 even I'm having trouble understanding it now. But these guys-

01:46:40.900 And can you appreciate it from an auditory perspective? Does it get too technical where

01:46:45.560 it's hard to appreciate and distinguish?

01:46:47.640 That's a fine line because when you think about it, music is just math with emotion added in.

01:46:52.480 And it gets to a point where some of it is not appreciable anymore, at least not to me. Some

01:46:56.000 of these guys love it. But that's where the jazz side comes in, where it's all about feel. But even

01:47:00.420 the jazz guys will be extremely talented in terms of their ability to feel the beat and have it be

01:47:06.560 pleasurable to the ear, but they're doing such intricate things. And when you can balance those two

01:47:11.160 things out, that's heaven as far as I'm concerned. When you can have the emotional side and also

01:47:14.740 be technically challenging and not just playing a straightforward- The straightforward stuff is

01:47:18.880 great too, but it gets a little bit tedious sometimes.

01:47:21.860 So we met actually driving.

01:47:24.420 AMG Drift Academy, I think it was.

01:47:26.240 Yeah, yeah, yeah. Which by the way, not to crap all over it, I ended up doing it because at the last

01:47:31.120 second I got a phone call from my driving coach and he was like, hey, I'm doing this AMG driving

01:47:35.660 school and they got an extra spot in the advanced drift school. Do you want to come? But I'd already been

01:47:40.380 to the Drift Academy with my friend, Josh Robinson. I was like, yeah, sure, I'll go.

01:47:44.120 And I was like, boy, this is the last time I ever do one of these schools.

01:47:47.240 Josh's school is a hundred times better.

01:47:48.880 It doesn't compare.

01:47:49.560 It's not even close.

01:47:50.120 If you want to learn how to drift.

01:47:51.940 Yeah. If you want to learn how to drift, you go to the Texas Drift Academy.

01:47:55.040 I want to go to Minnesota with him and do that ice class.

01:47:57.440 Are you going on this run?

01:47:58.640 I don't know if I'll be able to make it or not. I'm trying to.

01:48:00.400 Okay. Yeah.

01:48:00.580 Yeah.

01:48:01.060 Anyway, we met, but it was totally random.

01:48:02.920 Well, I knew who you were because I've been a member. I've been a follower for years. I was like,

01:48:06.040 that's Peter T over there. So luckily we got paired up in the same group and that's kind of where it

01:48:10.120 started. It was totally random. I was actually just, it was a last minute thing. That was actually

01:48:13.300 a level two. So I was like, you hadn't done the level one.

01:48:15.700 Right, right, right.

01:48:15.980 So I was like, man, how did this guy get in here without even doing the level one?

01:48:19.280 So having done that, I agree, especially those cars with the automatic transmissions and the

01:48:23.400 turbo lag, not the greatest for drifting.

01:48:25.540 Yeah. Yeah. You've been kind of a car nerd your whole life. What is it about cars that has you

01:48:30.420 as excited as you are?

01:48:31.920 You know, I think whenever anybody asks me that, I kind of think about it in terms of

01:48:35.980 every three or four year old boy is enamored by cars, but normal people just grow out of it.

01:48:40.420 And some of us never do. My dad certainly liked cars. He taught me how to change my oil and whatnot,

01:48:44.520 but he wasn't a fanatic like I am. So it just kind of started there. And then it got to the point

01:48:48.740 where like, my parents will tell you the story. I was that four year old who could tell you

01:48:52.060 at a car driving by, if it was an Oldsmobile that had Cadillac hubcaps on it, like, how the hell

01:48:56.340 does this kid know this thing? Yeah. I don't know where it just kind of clicked over the years. It was

01:48:59.880 always just a nice release. I guess being a mechanically oriented type person, I think if I didn't do

01:49:04.140 medicine, I would have done engineering, which is why it's so impressive. What did you study in

01:49:06.540 college? I was actually biology. I did a BA with art. So I did a lot of jazz studies at UT. So I was a

01:49:11.720 music guy. Engineering just seemed fascinating to me. You know, I was always interested in medicine

01:49:16.840 from day one, but I think that really the mechanical side of things, like knowing that every car's five

01:49:21.600 gear ratios and what their torque converter lockup is and what their horsepower and torque is,

01:49:26.400 it's just- And what posters of cars did you have on your wall?

01:49:29.380 The same as everybody. Actually, no, because everyone had a Countach, right? I never had a Countach.

01:49:33.360 See, I had a Countach. What did you have? I mean, they're cool. I would have like a

01:49:36.540 Callaway Corvette, Miami Vice Testarossa, 928, which I'm almost done with my old 928,

01:49:43.160 getting it back on the road. More of the domestic stuff and the stuff that's more attainable,

01:49:46.980 Fox Body Mustangs, the five liter Mustangs of that era are really cool. C4 Corvettes back in that

01:49:52.700 era when they were state of the art. I mean, I loved watching Knight Rider. So I thought Pontiac Firebirds

01:49:56.840 were super cool. It's funny. I just bought my youngest, his first Lamborghini

01:50:03.200 poster. He's mostly got sports posters on his walls, which is great. But I was like,

01:50:08.000 you got to have like a Lamborghini poster. So let's go pick one out. So we scrolled Etsy

01:50:13.100 for hours because I wanted to figure out what his taste was. Did he want to go retro? Did

01:50:18.200 he want like a Countach? But in the end, I think we went with, I can't even remember now. Actually,

01:50:23.820 we just ordered it. I think we went with an Urucan.

01:50:25.760 Urucan and a modern car. Great car.

01:50:27.620 Oh yeah. It was going to be an Aventador or an Urucan. But get the color right and get

01:50:31.580 the angle right.

01:50:32.720 Have you driven a Countach yet?

01:50:34.280 I've never driven a Countach. Have you?

01:50:36.040 I have. It's one of those don't meet your heroes kind of things. It's cool,

01:50:39.800 but it's kind of a POS too. The bar has moved a long way since then. It's for the experience.

01:50:44.960 I mean, you clearly don't expect it to perform like a modern car, but even if you

01:50:48.660 judge it for what it was in the eighties, is it still not enjoyable?

01:50:53.740 It's enjoyable because of the eighties campiness in retrospect, but even compared to its contemporaries,

01:50:59.660 you look at an eighties 928 Porsche or even a Testarossa, those cars are beautifully driving,

01:51:04.780 you know, long distance cruisers, super comfortable, compliant suspensions. You got good ergonomics

01:51:09.340 and the Countach is so awesome because it has none of that. It's awesomely bad.

01:51:13.060 Yeah. Yeah. I've driven a Testarossa. Have you ever driven an F40?

01:51:16.400 I have not. I would love to have ridden in one, but I haven't driven one. It's a race car.

01:51:20.580 You're basically just sitting on the ground with a carbon tub around you.

01:51:23.720 So if you could have three road cars, but you can't sell them, you're not making the decision

01:51:31.020 based on economics. What are the three you want? Three road cars, not daily drivers.

01:51:36.400 Are we talking about just three cars that's all you can have in your garage? No, no, no, no.

01:51:39.440 These are your three grail cars. Okay. I would probably say, man, there's too many to choose from,

01:51:45.160 but to go with, it's going to sound like a cliche, but McLaren F1. I mean, how do you

01:51:49.040 not pick that? If I could only have one, that's the one I want.

01:51:53.560 It's got to be there. I sent you the picture of me sitting in that one.

01:51:55.900 Yeah. I was jealous. I was jealous. Oh my God.

01:51:57.980 That would have to be number one, but then there's at least 10 that I could pick from Be Happy,

01:52:01.760 but I would probably say, and one of them is one that I have a lot of experience with,

01:52:05.640 which is the Ford GT. I just think that's one. Gen 1.

01:52:07.620 Gen 1, one of the all-time greats. I would probably pick stuff that's manual and somewhat analog.

01:52:13.040 I'd probably have to say Carrera GT, Porsche Carrera GT with an NA V10. They're unobtainium

01:52:18.600 now, but they were reasonable of just a few years ago and they're just, there's plenty of faster

01:52:22.960 cars. A Carrera GT today is going for about 1.7, 1.8. 10 years ago, it was half that.

01:52:29.600 Yep. And what's an F40 going for today? It's got to be three.

01:52:32.760 I think at least. Yeah. I mean, six, seven years ago, it was half that.

01:52:36.920 Yeah, it was half that.

01:52:37.980 Do you think this is a bubble or do you think these things are not coming down in value?

01:52:42.020 They're never making any more of those. Limited supply demand is never going to wane for those

01:52:46.300 at least. I think when you look at other collector cars, like some of the pre-war stuff, it's going

01:52:51.100 down because the target market is all unfortunately dying off. Those people aren't around and you

01:52:55.120 appreciate that. And that may happen at some point, I suppose, there's going to be a point

01:52:58.360 where nobody cares about this. We'll probably be long gone by then.

01:53:00.860 But the McLaren F1 is unattainable.

01:53:03.680 And there's so few of them. That's in a completely different league than the other cars, but even

01:53:07.080 like something that Ford GT, they made 4,000 of them. It's not that rare.

01:53:10.400 Well, a few of them are gone.

01:53:12.060 A lot of them are gone thanks to, yeah, lack of traction control. But still, I don't think

01:53:16.580 they'll ever go down just because that era, I think the Gen 2, the current Ford GT, which is a

01:53:21.340 twin-turbo automatic car, will ultimately be eclipsed in value by the old one, even though right now

01:53:25.640 there's still more. They're almost double or triple, but I think it's going to go the other way.

01:53:29.240 So where would you put the 959 on this list?

01:53:32.280 We talked about that a little bit. It's right up there. The only downside to the 959

01:53:36.320 is that it was so ahead of its time. That essentially is what a modern Porsche is now.

01:53:42.740 So yeah, it's super cool. You've got the 80s campiness, the looks, but it's basically like

01:53:47.140 driving a 993 turbo for the most part. It doesn't have that NA V8 or V10 sound. It's a turbocharged

01:53:53.540 flat six, like everything was after it. At that time, there was nothing like it.

01:53:57.220 Did they have four-wheel steering as well?

01:53:59.040 You know what? I think they did.

01:54:00.380 It was so modern.

01:54:02.440 So modern. Sequential turbos and even water-cooled heads. Those were all air-cooled Porsches back

01:54:08.520 then. They managed to water-cool the heads. And now Canepa does a really cool version,

01:54:12.920 a Restomod version, but those never came to the US. I think you know about that, right? It was

01:54:16.160 the Bill Gates rule. Did you hear about that?

01:54:18.180 I did know about this. Say more.

01:54:19.760 I don't know all the details. I should have read it, but essentially he was able to get the

01:54:23.880 gray market to passage for these cars for some loophole. I don't know the details of it. And only after

01:54:29.200 that, were they able to import them into the US? Of course, now that they're older, you can get

01:54:33.260 anything under a 25-year-old. I like the oddball stuff like that. That's just unavailable. The

01:54:38.260 959, I would still put a click below the Carrera GT just because of that naturally aspirated F1

01:54:43.340 drive V10 that just sings and the 959's motor doesn't have that level of character.

01:54:48.900 I'll tell you what's interesting about the Carrera GT, which by the way, would be on my list of three

01:54:52.900 as well. Most people listening to us now, if they're not car nerds, wouldn't spot a Carrera

01:54:59.720 GT if it ran over their toes.

01:55:01.940 Yeah. That's like a bigger Boxster, right? It's just like-

01:55:04.420 They're like, what is, is that a Porsche? What is that car? Like that doesn't even look,

01:55:07.600 like it doesn't stand out at all. Whereas if you saw a McLaren F1, you don't need to know

01:55:12.620 anything about a car to know you saw something special.

01:55:15.680 For sure. For sure.

01:55:17.040 And I think the same is too with the GT. The GT is absolute head turner no matter what.

01:55:22.260 And the interesting thing there is it's really based on a 60s design. It was a tribute,

01:55:26.200 but Camillo Pardo, who was the designer for Ford, who basically reinterpreted it for the 21st century,

01:55:32.800 kept that original character, but made it aero-friendly and was able to use all these

01:55:37.140 hard points from the old car, but make it modern and basically upsized the car. It's like 110%

01:55:42.640 size of the original that you could actually fit two people in because the original GT40s were tiny.

01:55:47.380 And they apparently generated tremendous front-end lift in Le Mans. And the modern one,

01:55:52.700 I've actually run at the Texas Mile on an airstrip over 200 miles an hour. It's dead straight.

01:55:57.280 They did everything right without resorting to the modern cars with all the big wings and all

01:56:01.100 the big downforce. It's just well-balanced.

01:56:03.000 It is a beautiful, beautiful car.

01:56:05.820 Okay. Now of the modern cars, anything that you really, really fancy, let's define that first

01:56:13.460 wave of hypercars in the 2015. So when the LaFerrari, the P1, and the 918 came out, which is

01:56:21.400 2014, 2015. So 10 years ago.

01:56:23.200 They call it the Holy Trinity for some reason.

01:56:25.080 Yeah. Golly. That was staggering, right?

01:56:27.700 It was.

01:56:27.880 So from that era forward, what do you fancy the most?

01:56:32.940 Those cars, again, at that time, I liked them more than I do now, just because, again,

01:56:37.280 the hybrid technology is leaving those kind of, they're a little outdated now. I think out of

01:56:41.200 those three, I was personally, maybe I'm sounding like a Porsche fanboy, but the 918 was just stunning.

01:56:47.020 Part of it was just the design, forget about the performance. And it had an, again, NA V8,

01:56:50.660 high revving, bespoke to that car, not in any other platform. And the electric component was just the

01:56:56.520 gee whiz thing of the moment, which of course made it ungodly fast. But that NA V8 and the way the

01:57:02.140 exhaust sticks out of the back.

01:57:03.260 Well, that's why, by the way, I've got a friend who has all in silver, 959 Carrera GT 918.

01:57:11.540 That's the Trinity right there.

01:57:12.540 Like that's a Trinity.

01:57:14.240 That's like having, you know, F40, F50, Enzo, LaFerrari, same sort of thing. I mean, all of those

01:57:20.320 cars were amazing, but since then, the interesting thing about that era a decade ago was that was

01:57:24.600 probably the inflection point after which performance doesn't matter anymore. Who cares?

01:57:28.580 We've saturated performance.

01:57:30.100 Who cares?

01:57:30.320 You're traction limited at this point.

01:57:32.020 Right. And not only that, you can buy a used EV. You can buy a Tesla Plaid that'll do 60 in

01:57:36.760 two seconds flat, 50 grand that'll smoke everything.

01:57:39.060 Tell everybody about the time you took your Tesla Plaid to Koda. How long did it take you to smoke

01:57:44.360 the brakes on that?

01:57:45.520 So when it was stock, one stop.

01:57:49.460 Incredible.

01:57:49.960 One stop.

01:57:50.660 Make sure people understand this because they don't know. So that means you came out of

01:57:54.600 pit lane, right? So you're going up to turn one.

01:57:56.800 I did an outlap. So I did an outlap. But the first, coming down.

01:58:00.200 So the first hard break.

01:58:01.040 First hard break.

01:58:02.060 Is going into turn one.

01:58:03.540 Going to turn one. And my buddy was in an SF90, which is a thousand horsepower Ferrari hybrid,

01:58:08.580 which is basically the fastest Ferrari you could ever buy. I was catching up with him in 20 and

01:58:13.720 coming down the front straight, I caught an SF90 in my daily driver, but I nearly rear-ended him

01:58:19.540 because the car was able to stop just barely for turn one, but the brake fluid boiled at

01:58:24.780 that point. The car was not designed to do that, unfortunately. And what's interesting

01:58:29.280 thing is you would say, okay, it's an electric car. It's heavy, blah, blah, blah. Other electric

01:58:32.560 cars don't do that. The Lucid, the Taycan, they actually have really good brakes. But at the time,

01:58:37.940 I didn't realize this because they had been advertised as being track ready or at least

01:58:41.240 able to run a, like we're talking about how it ran so good at the Nürburgring. But the factory

01:58:44.700 brake fluid is DOT3. I find out after the fact, which is low boiling point, just boiled it.

01:58:49.480 The car is designed for efficiency, low drag. By the way, I didn't even use DOT3 in my simulator.

01:58:54.860 Right. I was running DOT4 in the simulator.

01:58:56.560 Probably boiler simulator. Yeah, yeah, yeah.

01:58:58.280 So a 5,000 pound machine stopping from a hundred and I probably did 160 on the front straight.

01:59:04.220 I bet more.

01:59:04.900 Yeah. Well, that's about, I think it was limited actually that time. I didn't have a track.

01:59:08.060 The amount of BTUs that you're trying to shed off of those brakes, just forget about it. So

01:59:12.040 thankfully it had regen braking.

01:59:13.600 The brakes are fine if you put better fluid in?

01:59:15.300 Well, they're better. They're less terrible.

01:59:17.760 But if you want to track a plaid, you're going to need new brakes.

01:59:20.300 Did I tell you what I did? No.

01:59:21.420 I ended up having a full Willwood setup put on the car. So all new rotors, custom ducting,

01:59:26.240 Mike Dussault, Dussault Designs. Actually, he bought a plaid for himself. He's the guy that built

01:59:30.120 the Z06 I'm driving now. But he ducted into the front brakes, basically custom brake ducts. That car

01:59:35.740 is sealed. The whole front end is sealed. It's not meant for that. It's meant to just be low drag.

01:59:39.580 So you weren't getting any air on them?

01:59:40.960 Nothing. Nothing at all. So he actually made custom ducting. And after that,

01:59:44.900 the car was unbelievable because you could actually late brake and do really well.

01:59:48.880 So what lap time can you do in a tripped plaid now?

01:59:51.580 Here's the problem. You can only get one solid lap before it starts pulling power due to heat

01:59:55.760 to the battery. But my best was a 224. And so that's at a 5,000 pound car. That's no weight

02:00:01.040 taken out. Just a stock car. Didn't do any mods to it other than just the brakes. But you do one lap,

02:00:05.820 just to re-answer your previous question. I don't know how much time we have,

02:00:08.500 but I'll just keep it brief. That one stop turn one, brake's gone. Thank God I have regen. So I

02:00:14.500 just literally nursed it. But I couldn't turn off. So I go through the S's and I'm just 30 miles an

02:00:19.520 hour, whatever I got down through. The regen is enough to keep the car from completely just going

02:00:23.200 off the tracks. 30, 40, 50. So coming through 9, 10, coming into 11. Again, I'm not on the throttle

02:00:27.920 at all. I'm just maybe going 40 miles an hour. But the regen is coming down the hill towards 11.

02:00:33.000 11. The regen has kept me from gaining any more speed. My right foot is on the floor. The fluid

02:00:38.160 is boiled. So I had to go wide in 11 into the gravel, completely around. And then, you know,

02:00:43.300 that's when I found out about all that. And the McLaren Senna both taught me where all those orange

02:00:47.520 squares are spray painted on the arm coat where you can have the emergency offs. So I literally went

02:00:51.780 through the gravel, came within inches of the arm coat 11, and then just hobbled in. But then after

02:00:57.200 that, the next time out, we put Castrol brake fluid in it and changed the pads. Then it was

02:01:03.600 good for maybe a lap. So then ultimately, that still wasn't good enough. So we did the big brakes.

02:01:07.920 Now, I see guys out there with Teslas. They're clearly not pushing as hard as you.

02:01:11.540 Or they're mostly Model 3s. The Model 3 is 800 pounds lighter. It's not as fast,

02:01:16.340 but it's a way better track car. So I've got dozens of laps in Model 3s. They do fine because

02:01:20.360 they're not making 1,000 horsepower and they don't weigh 5,000 pounds. They still will boil their brakes.

02:01:25.020 But if you just do pads and fluid, that's actually a very desirable, especially if it's a little bit

02:01:29.620 damp outside, not much can keep up with you in a Model 3. And autocrosses, they've won national

02:01:33.980 championships with just coilovers in a 4,000 pound sedan. That's where EVs have gotten.

02:01:38.760 But just to answer the previous question, we did the brakes on the Model S. And then once that was

02:01:43.240 done, the only thing that eliminated the brakes as the weak link, but the battery, the cooling is still

02:01:48.100 not there. So you've got guys spending tons of money. I actually was looking at doing a really

02:01:51.860 heavily modified aero Tesla Model 3, like Randy Pope's drives. It'll only do a lap at Coda.

02:01:57.700 It's such a high speed and high braking, but you can hot pit and go right back out and you can keep

02:02:02.100 hot pitting, but you'll never get a full lap time, but it'll do just fine if you do that.

02:02:06.460 But the next gen cars, the Porsche Taycan, even the Lucid Sapphire now, those cars, they're just as

02:02:11.600 heavy, just as powerful, and they can do it. Have you taken the Taycan Turbo S out?

02:02:16.800 I did when it first came out in 2020.

02:02:18.740 And what'll that lap at?

02:02:20.040 At the time I was on stock tires and everything, probably a 230-ish, right around there.

02:02:25.720 I think I probably sent you that video. At John Hennessey's track, I had the Taycan,

02:02:29.760 the Lucid, and the Plaid all lined up on the drag strip. I'm in a 750 horsepower Porsche that can run

02:02:35.340 tens in the quarter mile, and the Plaid and the Lucid walked away from me like I was on foot.

02:02:39.760 You just didn't have the traction control?

02:02:41.060 No, it didn't have the power.

02:02:43.000 750 horsepower versus 1,100.

02:02:46.400 How much does the Lucid have?

02:02:47.380 This was the old Lucid. Now, the new Sapphire Lucid has more, has 1,200, but this was 1,100,

02:02:52.600 and it's still a tenth or two behind the 1,000 horsepower Tesla.

02:02:55.780 Because they all have great traction.

02:02:57.300 And they're all all-wheel drive. The traction is a non-issue.

02:02:59.940 All the same tire.

02:03:00.560 It's literally just power to weight at that point.

02:03:02.260 Power to weight, and they would just take off.

02:03:03.080 So I didn't realize that. So the Taycan Turbo S was only 750.

02:03:06.980 When you stand on a Turbo S, if there's a Plaid next to you, he will leave you like you're not moving.

02:03:11.160 That's like the Audi. It's a super fast car in the real world, but that's why horsepower doesn't matter

02:03:15.060 anymore. But that was more horsepower limited. The Taycan would happily do... And actually,

02:03:19.120 I had a Turbo before the Turbo S, which had steel brakes. Turbo S had ceramics. And even the Turbo

02:03:23.760 would do it on all-season tires. The very first Taycan that came out. This was in the early days

02:03:28.300 when Porsche was... VW was having to respond to Dieselgate. You remember Dieselgate, that whole

02:03:32.820 deal. So they had to build these electric cars, and they had to go to states that were CARB,

02:03:38.280 basically the California Air Research Board, emissions compliant because of all the diesel

02:03:42.060 penalties they had. So the first cars didn't come to Texas. They only went to New York.

02:03:45.620 So I got a non-Turbo S, a regular Taycan, one all-season tires out of New York. And on steel

02:03:51.300 brakes, Porsche's Porsche. I mean, it was squealing in the corners of an all-season tire, but it lapped

02:03:56.180 20 minutes. No problem. Brakes were solid. There's just something about the German engineering

02:04:01.240 there. But having said that, the Lucid is now equally good, if not better, despite being a

02:04:06.620 brand new non-legacy company who is, again, not trying to build a track car. But the Lucid Sapphire

02:04:11.580 is faster than a Plaid now. It runs eights in the quarter mile, but it can actually track. And even

02:04:16.200 my old Lucid, which I was expecting to... It can run eights in the quarter mile?

02:04:20.020 Eight nineties. Yeah, it can crack in sub nine now. It's several car lengths ahead of a Plaid,

02:04:24.400 which is beyond bonkers. You have to warn passengers. These cars now, you can't just accelerate

02:04:29.840 and you have to say, hang on, just put your head against the headrest before I concuss you.

02:04:35.960 By the way, we failed. You very, very briefly mentioned it, but my favorite car post the

02:04:41.640 holy trinity of 2014 and 2015 is, of course, the McLaren Senna.

02:04:45.020 The Senna. Yep.

02:04:46.280 How does the Senna stack up for you? And what was your fastest lap time in a Senna?

02:04:49.740 So my best, again, the biggest limitation of the...

02:04:52.200 The tires are limiting that.

02:04:53.060 The non-GT... The Senna GTR can probably... I've seen guys run like, I think, two flats in those

02:04:57.780 things. I know a coach of mine had run a 208, just barely even trying. But the Street Senna

02:05:02.740 on the Trofeo R, just it understeers. It's really just not meant for that, but it'll still... And

02:05:07.340 it got tons of downforce, tons of braking, but it just doesn't have the grip. So I think the best

02:05:10.980 I did was a 215. And again, when you're driving a car, that value...

02:05:14.360 But that's insane for a street car with street tires.

02:05:16.960 That is insane.

02:05:18.080 But at the same time, I'm sure a pro could do better. I was still thinking, you know,

02:05:21.480 that arm code gets really close to a car of this value. It could be a really bad day.

02:05:25.180 Breaking into turn 12.

02:05:27.520 150, even on Trofeo R's. McLaren doesn't want you to put slicks on it. And so I violated all

02:05:32.600 the rules. I ended up putting a set of Pirelli tires off the Ferrari Challenge cars on it.

02:05:36.600 When I first put it, again, slicks need camber. You can't get much camber out of a Street Senna,

02:05:41.640 which to me was the most disappointing thing. Whereas the GTR, you got four degrees.

02:05:45.200 Even without camber, when I first stopped on that backstreet, completely stocked Senna with

02:05:49.280 just slicks on it, at the 150 mark, I almost parked it in the corner. It was incredible.

02:05:54.000 Even with the Trofeo R to stop at 150 in a tire that drove me to Houston and back,

02:05:59.320 the bandwidth of today's tires, that's a whole nother topic. It's incredible what even an

02:06:03.740 all-season Michelin can generate a 1G. 1G is nothing anymore. All my old car and drivers,

02:06:09.300 I have a library of thousands of magazines. 0.8, 0.9 was a huge deal 30 years ago. Now you got

02:06:14.920 minivans that do that. And even all-season shod sports cars that are heavy can do that on a

02:06:20.420 regular tire. The chemistry of these tires these days is unbelievable.

02:06:24.580 Yeah. And the Pro Mazda, we're 2.3.

02:06:28.640 Yeah.

02:06:29.100 Yeah.

02:06:29.500 Right. I mean, that's just-

02:06:30.700 And that's not even on a Pirelli. I'm a cheap guy, so I run-

02:06:33.780 Yeah. Well, same-

02:06:34.620 I run hard.

02:06:35.360 AMG GT3, I was running Hankooks, which would at least last me two weekends. And even then,

02:06:39.920 that car was running 2.11s on Hankooks with just me driving it. So the pros are running faster than

02:06:44.760 that. Yeah. I think Senna GTR, not a street car, of course, but just-

02:06:48.880 The problem with the Senna street car is it's too track for the street and it's too street for the

02:06:52.720 track. A 720S, which is mechanically identical without all the downforce, is a beautiful GT car.

02:06:58.600 Drive it cross-country. You can store stuff in it. Super comfortable. And on Hoosiers, not on

02:07:03.560 slicks, but on Hoosiers, and I changed that to steel brakes, that's a 2.16, 2.17 car. It's not that

02:07:09.580 much slower. So faster than your old GT4.

02:07:13.420 Yes. The McLaren GT4, that one, I'm sure, I think Randy Popes could probably run close to that.

02:07:18.780 But driver to driver.

02:07:19.620 Driver to driver, three seconds probably. And that's all in the straights because the GT4 car

02:07:23.720 has half, well, not half the power, but it has, and actually my GT4, I cheated. I tuned it. The

02:07:28.660 570S GT4 was already detuned from the street car, but you can tune the street cars as well. So when I

02:07:34.220 pushed an extra 150 wheel just by tuning it because stock turbos can handle that. So that would go

02:07:39.360 175 on the back straight, whereas a regular GT4 can do 20 miles an hour less than that.

02:07:44.280 But even then, the 720S, actually the 720S and Senna are identical on the back straight.

02:07:49.260 The Senna can stop later though.

02:07:50.620 Stop later.

02:07:51.220 Yeah. The Senna, you can wait till 100.

02:07:53.780 Yeah. In the 720 with the aftermarket steel brakes, pads, and a Hoosier, which is still a

02:07:59.420 DOT tire, you can still brake it a little bit after 200. It's not bad at all for a car that you can

02:08:04.560 go shopping at the outlet malls in because it's got a massive frunk. And the ride compliance,

02:08:09.020 that's the biggest thing about McLaren. So the Senna is more tied down, but they all

02:08:12.960 have that active suspension that doesn't use sway bars or springs. It's all hydraulic. It's

02:08:17.440 all fully active. There's hydraulic lines that diagonally connect the front right to

02:08:21.440 the left rear wheel. So the pressure in those lines combats body roll. So you can have it

02:08:25.360 be a plush highway ride, or you can have it be a stiff track car. The bandwidth is almost

02:08:30.520 unobtainable in any other car.

02:08:32.820 Do you think McLaren is somehow underperforming relative to what they should be doing given both

02:08:37.360 their quality as an automotive brand and as a racing brand?

02:08:41.720 Underperforming in terms of sales, is that what you're talking about primarily?

02:08:44.840 They are. Yeah, they truly are. And a big problem is, I think, is the perceived,

02:08:48.740 I mean, actually, it's not just perceived, the actual lack of reliability. I love the cars,

02:08:53.460 but they're always, it's all the jokes about British electronics, they all come to bear.

02:08:57.000 Even the Senna would go into limp mode on between nine and 10. If you floored it,

02:09:00.520 it wasn't just mine. We had Senna Fest going on with 20, I think we had 20 on track at one

02:09:05.180 time. Some guys were just kind of tooling around, so they were fine. But if you were

02:09:08.420 hauling ass between nine and 10, when you get a little bit of suspension droop,

02:09:11.500 you'd go into limp mode. If you're accelerating through that, I would literally-

02:09:14.260 Even a GTR?

02:09:15.320 No, no. I'm sure the GTR is fine. I haven't tracked one of those, unfortunately.

02:09:19.220 Is that a mode issue?

02:09:21.220 No.

02:09:21.740 Like if you were in track mode?

02:09:23.040 That was in track mode. I think it happened to me even one time,

02:09:25.720 I forgot to put it in track mode. I think it still did it. It's a G-Force related to

02:09:30.220 suspension droop issue. They just freaked out the computer. And they had McLaren guys on site who

02:09:34.500 were actually working on patches.

02:09:36.220 And they could patch it?

02:09:37.220 They did. I think it made it less frequent, but I think it still happened after the patch.

02:09:40.980 I have to ask the McLaren guys about that.

02:09:43.260 Well, I think it's safe to say nobody's listening to us anymore now anyway, but

02:09:47.100 in case anybody still is, this has been an awesome discussion.

02:09:51.220 I really appreciate the offer to come out. This is a true privilege. Peter,

02:09:54.980 what you have done in this community is unparalleled in terms of, I think I told you when I first met

02:09:59.720 you, I was like, dude, how do I get CME for this stuff? Your lectures are better than almost all,

02:10:03.380 not lectures, but your podcasts are better than almost all the CMEs because you get the right

02:10:08.140 quality people on here, much better than me by far. And the way you phrase the questions and the way

02:10:12.920 you parse everything, it's so understandable for a wide bandwidth. I got my non-medical friends and

02:10:18.440 family all the way to the colleagues. Everybody gets something out of them and that's hard to do.

02:10:23.140 Well, hopefully today we delivered a lot of insight, both to people who are obviously interested in

02:10:27.980 radiation therapy for cancer, which unfortunately is going to be a lot of people.

02:10:31.180 And then of course, this other application around the treatment of inflammatory conditions,

02:10:36.060 which again, inflammation lies at the root of so many other things. And just in case anybody cares

02:10:41.220 about a little drumming in cars, hopefully they got something too.

02:10:44.240 I think we have a whole indication for a whole separate series here that truly is the drive.

02:10:49.020 If you ever want to do that, we can do that.

02:10:50.800 All right. Well, thank you, man.

02:10:51.660 Awesome. Thank you, Peter.

02:10:52.560 Thank you for listening to this week's episode of The Drive. Head over to peteratiamd.com forward slash

02:11:00.580 show notes. If you want to dig deeper into this episode, you can also find me on YouTube, Instagram,

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02:11:44.680 medical condition they have, and they should seek the assistance of their healthcare professionals

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02:12:01.960 about where I keep an up-to-date and active list of all disclosures.

The Peter Attia Drive - April 07, 2025

#343 – The evolving role of radiation： advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions ｜ Sanjay Mehta, M.D.

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