Chapters Transcript Video Prostate Cancer Perspectives Aside from non melanoma, skin cancers, prostate cancer is the most common cancer diagnosed for men in the United States and the second leading cause of cancer death. For them, its varying degrees of aggressiveness along with high incidence to mortality ratio provides significant challenges for both patients and the medical community. However, the treatment landscape of prostate cancer and its metastatic form is rapidly evolving. Most recently trials with parp inhibitors as a monotherapy or as in combination with androgen receptor pathway inhibitors has a great promise in improving their outcomes. Welcome to the Baptist Health Doc Doc podcast, a conversation for physicians by physicians providing insight on the latest in medical practice, research, technology and innovation in health care on the Doc doc podcast. Hello, I'm Doctor Rohan Gar, a medical oncologist and Chief of Gender Medical oncology. I specialize in the treatment of prostate kidney, bladder testicular and penile cancers at Miami Cancer Institute, part of Baptist Health, South Florida. And joining me is today, Doctor Adil Kaiser, a board certified Radiation oncologist, specializing in the treatment of genetic urinary and gastrointestinal cancers at Miami Cancer Institute, part of Baptist at South. Thank you for the kind introduction and for having me here, um I thought it would be interesting to start off this discussion by some of the uh by a discussion of some of the more recent advances in terms of screening guidelines. Yes. All right. You know, uh screening for prostate cancer has always been uh a challenge in the sense, you know, the various guidelines either from American Cancer Society, A U A, you know, SMO and also, you know, United States Task force and also PCF. So there are several measures, several organizations, but the goal is, you know, informed discussion in the shared decision making, a physician and a patient sit together and talk about what are the risks, what is the family risk, what are the symptoms and then collectively make a decision whether screening for prostate cancer is an option for them and how it is done and what are the risks and benefits associated with it. But I think the key for practicing clinicians is to make sure identify their high risk patients, especially patients with family history of prostate cancer, uh patients from African American origin because it has been shown that people with high risk uh of uh with family history are with based on their uh ethnicity. You know, there is a high risk of them to have not only prostate cancer, but they present with higher risk disease, which can have implications on their life expectancy. So, uh according to various guidelines for men with average risk, which is at age 50 we would recommend them to have prostate cancer screening in the form of psa check and optional rectal exam. Now, having said that for African American men, a lot of data has now come up saying that it is better to start early if possible. So some of the screening guidelines are actually talking about starting screening at age 45. Now, in addition, if men have family history, especially with a mutation called BRCA mutation, it's very important to screen them very early even at age 40 that helps identify men at an earlier stage so that we can identify cancer earlier and take care of it at a localized farm. Um And then the next big important aspect is disparities, you know, as you know, patients who have access to care, there is always an option, but the big level of awareness is to bring up how to identify people who don't have access, you know, disparities due to various reasons, not just their access to medical care, financial situation, economic situation. Um And then uh based on various other aspects of their current health situation, I think it's important for us as a community to raise awareness about prostate cancer screening. And uh the goal would be to identify people who are at high risk for cancer, be identified and screened with this process. So, um no, I think that was a great summary of some of the more recent screening recommendations and it just raises and highlights the importance of doing a good solid family history, you know, at the time of the initial consultation, because again, if you have a family history of breast cancer and then you discover yes, you know that breast cancer was associated with the BRC A one or two mutation, then obviously, those are patients that you want to flag and start screening at an earlier time point. So, very important for urologists and PC PS to keep that data in mind. All right. So moving forward actually, so uh we now uh you know, beyond screening, we are also looking at new imaging tools and techniques. You know, Doctor Kaiser can talk about uh the role of MRI in prostate cancer as well as the new PS MA imaging, which we widely use now, right? So MRI has been a tremendous tool and I would say, you know, very important advance in terms of diagnosing cancers and particularly in diagnosing higher grade tumors. So a lot of data, especially out of NIH and Dr Pinto's group showed initially that if patients had a biopsy um and a standard, let's say 12 core biopsy for a elevated PS A and they were discovered to have prostate cancer that if you took that took those patients did an MRI up to one third of those patients based on the data could be upgraded on confirmatory biopsy. In other words, a biopsy that's done after the initial biopsy, but targeted to high grade high pyra score lesions that are seen on the diagnostic study. So that became a real game changer in the last several years in terms of how we diagnose prostate cancers to the point that now a lot of uh guidelines suggest that you should actually do the MRI even before you do the biopsy. So that the initial biopsy itself is MR guided and therefore that you do the standard 12 cores. And if you see any high grade lesions within the prostate, that those should be sampled in addition to the 12 cores. So as a consequence of that, I think we have much better uh patient stratification, you know, we again are very good on the MRI of identifying these higher grade lesions. MRI is not so good for lower grade lesions. Um It's really separating the high grade tumors and of course, that's important to us because we really are slowly as a field dividing the patients more into kind of low grade tumors that are indolent that can be watched, let's say with active surveillance versus the more higher grade tumors that we need to be more aggressive with. So I think MRI has been a great tool to help with that decision making. And then in terms of the PS MA testing, this has been also another game changer. I think in particular, I wanted to highlight the recurrent setting before the advent of PS MA testing. We had other modalities too that we explored like oxy et cetera. But none of those actually gave really high specificity and sensitivity in terms of identifying recurrent tumors. Ps MA of course, has been a real game changer at Baptist Health South Florida, particularly at Miami Cancer Institute. We've instituted PS MA PE CT testing for patients who qualify. In other words, recurrent disease or high grade disease de novo. And with that, we've noticed that we can much better identify uh recurrent lesions that we previously would not. So we see many cases where standard CT imaging just shows, let's say a small lymph node subcentimeter. But when you layer on the PS ma pet component, we see that it's positive and, and uh initially, we were doing a lot of biopsies to confirm this and we found that there was such a high rate of concordance that they were real um when they were PS MA avid. And in addition, the data also suggested that the specificity was so high that now we've kind of moved away from biopsying all of the PS ma avid lesions. We almost assume that they're all negative. I'm sorry that they're all positive. However, there are notable false positives in some cases, particularly in osseous areas like the ribs. And I know we've shared some cases like those perhaps you can comment on that point, you know, yeah, you know, PSM imaging as you said has been game changer I think anyone with biochemical relapse, you know, relapse setting, I think it has really impacted their treatment outcomes. And as you rightly pointed out, you know, uh based on our general assessment of these scenarios, most common expectation is the recurrence happens mostly in the tumor bed or in the pelvic region. And then, uh but we have to be very mindful of some false positive reasons as we rightly discuss, you know, which is our common discussion point in our tumor board, you know, specifically distant findings in the setting of low psa, we do see false positive changes in the ribs, which has been quite a challenge. And there is a lot of data, you know, for patients who have only isolated rib findings, you know, we have to be very cognizant about benign bone lesions because you know, sometimes occasionally fractures, you know, fibrous tissue or bony islands can look PS ma positive, they may not be metastatic disease. So it's very important if you have an old scan to compare, go with the history. And also, you know, the PS is very low, be very be very careful in coining some terms as metastatic because this may really change the treatment approach. And in very exceptional scenarios, I think when the clinical picture doesn't match with what you think the scan is showing, try to get a biopsy if it's feasible. And I would like to share an example we had a patient with diffusely positive lumbar spine lesion actually. And this didn't match the clinical picture. So we went ahead and did a biopsy and it actually in fact turned out to be a hemangioma. And there is no literature which shows that hemangioma do sometimes have ps ma positivity. And additionally, uh some other cancers, you know, for example, again, this is not common but you know, kidney cancer or myeloma can also be randomly ps ma posture. So I think this is a valuable tool, psm aging. It has definitely changed the treatment approach. But when the radiological findings don't match your clinical expectation where things are out of proportion to what you would expect. I think it's very important to do biopsies or definitely have a multidisciplinary conversation. That way we make sure we do the best care for our patients. So Dr Gargi just to kind of expand on that point a little bit. Do you in your practice now for, let's say a de novo high risk patient, do you go straight to the PS ma pet CT for staging or do you still do the classical bone scan plus contrast CT first. And it's again, it's a variable uh approach. So if it is clear a high risk disease, uh you know where the glisten score is high and the PS A is more than 20. Now, I have been using PS MA P as my standard base line scan because it's one scan which covers everything and helps avoid, you know, additional scans. Now, I think the practice is variable. The guidelines are also a little bit broad here. Some prefer to do both because uh the biggest challenge is follow up scans because most of the data right now for follow up is based on CT scan and bone scans PS MA scan as a follow up scan for reassessment, the the the the utility is still being questioned or we still don't have data. So it creates a lot of um you know, ambiguous zones for us how to interpret the data. Um you know, when we are very, when I start with PS MP and if it gives me all the information, I need, we just stick with that. But in select patients, we do obtain bone scan and CT scans. Exactly. And I, and I've kind of been doing the same thing. You know, if I see a patient with very high risk features, we go straight to the pet CTPS ma pet CT to be specific and um occasionally though insurance will deny it and in that case, they want to see AC T scan first. So, so we're kind of obligated to do the standard staging and then move to PS MA pet if needed and indicated. Um But definitely it's kind of become more and more the default. And in the recurrent scenario, I think it's important as you said to understand that there's obviously a correlation with the, the amount of PS A that you're seeing and the probability that you'll actually see something on the PS MA pe T scan. So at least at Miami Cancer Institute we've agreed in general as a default to have a cut off of 0.2 nanograms per miller in terms of the minimum PS A before you would pull the trigger and order a PS MA pe T scan in the recurrent setting. I mean, I'm assuming 0.24 patients who had surgery and recurrence, maybe for patients who had radiation and we are looking at recurrence, maybe we could have a higher threshold of PS A for updating the PS MP. So the radiation failure guidelines still are utilizing the Phoenix definition, which is the NATER plus two. So again, because it's a gray area because the guidelines are not really set yet. Uh What we've been doing is if we see a highly um a high velocity in terms of the PS A growth and yet it's not quite reached the 2.0 landmark, I might still pull the trigger and order a PS ma pet ct in that patient. Uh But typically, if it's very slow velocity, again, looking at all these other clinical factors, then we may not, plus you also have to rule out benign causes of PS A increases, you know, prostatitis, et cetera because the prostate is still present post radiation. So definitely not a unfortunately clear cut guidelines. But I think in the post op cases, we have a little bit more understanding, you know, 0.2 is the generally considered the acceptable uh PS A cut off for surgical failure, at least biochemical surgical failure. And so we thought that was also reasonable to, to do the ps ma pet scan at that level. And yeah, I agree. And, and I think it's important for uh you know, physicians are focused on prostate cancer care to really, you know, understand these fine nuances about when to obtain these scans. And what are the different indications? What are the potential false positives to make sure we are all aware about these changes? And that way we can give our patients the best care they can before we move away from this topic, I had one other question for you. Um you know, specifically in the recurrent setting, one of the challenges uh with many of the PS ma pet scans is that there's quite a bit of uptake in the renal system because that's the way the molecule is cleared. So you actually have quite a bit of uptake in the bladder. And unfortunately, this can obscure recurrences at the anastomotic location. Um So what are your thoughts on this? You know, obviously there's different vendors that have come up with potential alternative ligands that can be used instead of PS instead of the classic one that's employed. I think you have a very important question because when we are looking at biochemical relapse. The biggest concern is it's at the, you know, prostate bed, including around the bladder neck area. And all these dyes, we have three different or four different agents uh which we use for our PS ma pet scan. They are all Xed through urinary system. I think the biggest challenge here is uh timing the imaging so that timing to the point where the activity in the bladder with the agent is less so that we do that or there are some protocols where they use diuretics before they image the patients so that the patients you know, avoid and they do it. And then there are some newer imaging uh uh technologies, you know, one of the commercial vendor called Paloma imaging technique that has reportedly less bladder activity. So, you know, you know, a fractional benefit over other scans where it can have a better ability to identify bladder neck recurrences with limited noise from the expression of the dye in the bladder. So I think it's again, you know, this again as you rightly brought out, you know, it's very important for us to uh be very much involved with our uh radiation team. Uh I mean, um the nuclear medicine colleagues where we communicate with them that we are very focused on bladder neck or tumor bed recurrence and you know, tune the imaging so that so that you know, we can focus on bladder neck more appropriately. Otherwise if it doesn't give us the information, then it becomes challenging for us to plan a treatment based on radiation or anything else. Yeah, I mean, the one thing I would add to that is, you know, as Dr Gargi has pointed out there's nuances to this and this is still being worked out. So, at least in our practice for patients with post op biochemical relapse, we have in addition to the PS ma pet gotten MRI S and I can tell you just literally yesterday, I had a patient where the PS ma pe T scan was fine. It didn't really show anything at the anastomotic bed. But when we did an MRI, it actually showed a two centimeter area of recurrence, highly correlative and consistent with local recurrence. And based on that patient's PS A level, that was not surprising. So I think it's important to, you know, not just do a pet scan in a post op patient. And you should also do some pelvic imaging, particularly MRI, I think is the one that we favor. That's interesting. I think it's, I think it's a good point to segue into, you know, radiation therapy approach is what we have at Miami Cancer Institute. You know, uh Doctor Kaiser, can you talk about MRI neck options, proton versus photon therapy? Which is a common question we get though as a medical oncologist, I cannot answer, but every patient has that question for me. So maybe can you share your thoughts on different tools and techniques use in radiation therapy. Sure, sure, I'd be happy to do that. Since we were just talking about post-operative cases, I thought I would start with that. So, you know, again, it's very important to identify if a patient has nodal recurrence or gross recurrence at the anastomotic bed because that affects our radiation dose. So having that proper staging is key just to make sure that you're adequately treating the patient. So typically, if you look at the post operative trials, they're treating mostly to a dose of around 66 gray to the post operative bed. But if you have gross recurrence, we are typically dose escalating those cases just to the an tema bed to a dose anywhere between 70 to 74 gray. Uh you don't really, of course, need to do that. If there's no evidence on imaging of a gross tumor recurrence, there was actually a paper that examined 64.8 gray versus 70 gray and found that there was no added benefit going to 70 gray even if there was a clinically positive margin. And so, so all you're doing if you treat to 70 gray is really enhancing the toxicity profile. So our practice in general has been to treat, you know, somewhere in that 66 and in rare cases, if we're very suspicious, maybe to the 70 gray dose. Now, in terms of the nodal disease, it's the same issue um, since before the advent of PS a pet scans, we weren't really picking up a lot of these smaller nodal recurrences. Uh, most of those were just treated to a dose of, you know, anywhere of 45 to 50 gray on most of the clinical studies. And that's why, you know, when a patient sees me for recurrence after surgery, the general number we quote in terms of success based on the get studies is in the range of about uh two thirds. So if you do a combination of hormonal therapy and radiation, you have a two thirds success rate. But what I tell these patients is now with PS MA testing, we are more confident that we are probably ruling out distant recurrences and, and we're dose escalating the nodal recurrences and we anticipate a better success rate. So that's the post op setting. Now, for de novo setting, you pointed out, you know, for intact prostate, uh you know, if they select radiation of course surgery and there's other options available to them too. But if they select radiation, uh they also have the additional uh uh issue of selecting which radiation modality would be best. And of course, as you highlighted, there's several, you know, we have MRI guided radiation therapy at our facility. We're blessed also to have proton therapy, uh more specifically pencil beam scanning proton therapy. So intensity modulated. In addition, we also have uh standard true beam technology which we also use for SP RT. So all of these platforms are here. And what we try to do is of course, um pick and choose and personalize the care to what would be best for the patient. Now, in terms of just protons versus photons, again, we don't have a phase three trial completed just yet to say that protons are superior or or maybe the results are equivalent. But based on just do symmetric data, we know that if you do proton therapy, because again, you know, with protons, you have actual mass to the radiation beam, we can control where it stops. It doesn't just go through the patient like a standard photon beam would and because there's no exit dose, uh we are able to minimize dose to structures like the bladder, the rectum. Um the people who are would be naysayers to proton therapy would say, well, that's true. But really what you're doing is you're reducing the low dose area of radiation therapy in the pelvis. But the high dose area of radiation to the rectum and the bladder, meaning the part of the rectum and bladder that is adjacent to the prostate are still going to be similar. And that is actually a fair criticism. Um So, you know, you could argue, you know, until we have phase three data available that most of the serious complications are in the high dose areas, which would not be that different. However, we do have data already available based on IM RT that the amount of the volume of the bladder, for example, that gets irradiated, highly correlates with future toxicity in terms of especially simple things like urinary frequency. And that makes sense because the more radiation exposure there is to the bladder, the more chance of fibrosis. And so we generally favor doing proton therapy as a result to minimize these risks in the majority of I think are intact patients. And that's done with standard fractionation, which is usually uh in, in our group 39 sessions at two gray per day or with hypo fractionation using the Cleveland Clinic based model. Um But when you go down to Mr Linac, the last topic that I wanted to highlight or SP RT, we've typically used the standard doses. Uh So that's a dose of 36 to 40 degrees to the prostate. We've had great results. There was a lot of excitement on Mr Linac after the publication of the Mirage trial out of UCL A. Uh Their group basically showed that with MRI guided SP RT. So same doses um in a, in a prospective trial, they found less acute toxicities uh with, with um Mr guided radiation, presumably because you're using a smaller margin because you can actually account for the prostate motion during treatment on the Mr guided machine as opposed to a standard photon unit. So that created a lot of buzz. But at the end of the day I think what's going to push the needle and really make Mrl Act, uh you know, the MRL Act believers to really say that this is a superior mode of treatment would be if the late toxicities are improved. So I think that just requires longer follow up on the Mirage trial and other trials that are ongoing. That's amazing. I mean, I think there's so many opportunities and options. I think it's very, as you rightly pointed out, it's patient centric, you know, you find the right treatment that fits best for your patients needs. And that I think is very important aspect of the care delivery that is being provided for patients at Miami Cancer Institute. So maybe moving forward now in the advanced cancer setting, you know, beyond localized cancer, beyond biochemical relapse, you know, unfortunately, there are a percentage of patients who eventually develop metastatic disease which becomes resistant, you know, uh you know, we have uh several new treatment strategies now and there is this rapidly evolving field called Theranos sticks, which I guess again, talks volumes about multidisciplinary approach. You know, how well we can coordinate to give our patients the best care. You know, maybe you can start about what, what is your opinion about Theranos and maybe we can dive into our clinical trials with that, right. So classically, in terms of, you know, the role of radiation and prostate cancer, it's been limited primarily to patients with curative curative cases. So low risk, intermediate risk, high risk patients that do not have metastases. And the field was really biased towards external beam radiation because of that. Um And as you pointed out, the game changer has now been the introduction of radio pharmaceuticals targeted radio pharmaceuticals to be more specific. And the real trial that pushed the needle on, this was the vision study that was completed in Europe, which basically showed that for those patients who were at end of line therapy, meaning they've exhausted all the anti androgen therapy, hormonal therapy. Um all the targeted agents and chemotherapy. Then those patients were examined in a clinical trial where they were given standard of care or standard of care plus Pluto, which is a luteum +177 based treatment. And what they found was that those patients who received plato actually had a better survival. And in addition to that improved quality of life. Um but I always tell people this is not a cure. It's just another systemic therapy in addition to the systemic therapies that they've already been receiving with their medical oncologist. Um but it's nice to now finally have an option available for these patients who are um you know, advancing in terms of their cancer after even chemotherapy. You're right, you know, uh I mean, this is a valuable option, especially compared to chemotherapy. It's well tolerated. That is very key for these patients because who are generally elderly with widespread disease and a treatment which can be well handled. So, uh again, you know, as you know, doing a deep dive into this topic, you know, you know, we want to improvise on as you rightly pointed out, you know, it helps but not long term, the durability is not there. So we are glad to have, you know, opportunity to open clinical trials. And in fact, you know, there is a trial which we have at Miami Cancer Institutes called Lunar, which is actually looking at the synergy between lum 177 with a P inhibitor called NRA rib. You know, it is exciting because both drugs have a potential synergistic mechanism. Uh both affect the DNA of the cancer. One damages the DNA and the other one prevents the repair. So we are very glad to be one of the only institutions actually in the US to have the combination of a Park inhibitor and luteum in advanced setting. I think this has the potential to move the needle to see if we can help more patients and also help them achieve a durable response with the terrans therapy. Obviously, it's a first in human study. So we are very careful, we want to make sure it's safe, doesn't cause any side effects for our patients. But I think in the realm, I think the next decade, we will see thetic to be spoken about more and more and not only about L 177 I think there's a high probability to get other radio pharmaceuticals as you pointed out, you know, potentially actinium 225 thorium and maybe iodine base and some other copper based Theranos, which we could uh provide for patients which are reasonably well tolerated and adds to their options and moving forward. I also actually want to, you know, in the introduction, we spoke about the combination of part inhibitors and androgen receptor path inhibitors. So beyond targeting the cancer expressing PS M, we can also target the cancer genomic profile. You know, patients with prostate cancer are known to have mismatch repair deficiency or DNA repair deficiency. And now there are about up to 25% of patients who have BRCA 12 ATM rat, 51. These are all different genes which help repair and there are drugs which can block them and we have at least four different drug combinations which work for them. So there is an Ira olaparib, uh there's Stalla Zoerb and you know, so the Andrea, these are the options which we can use for patients. So this adds to their uh uh treatment Armamentarium. And if they have something called M SS I high, we have the option to use embro. Now moving forward, uh you know, there's another trial which I actually wanted to briefly touch upon. Uh we uh as a part of uh NRG, we have a trial called NRGGU 009. Can you talk about that trial? And how it is helping our patients. Right. So we're excited to um at Miami Cancer Institute, be a voting member of NRGNRG Oncology is a national organization, NIH funded uh promoting research and larger clinical studies across the United States. And basically, we are collaborating with them on one of their bigger studies, which is G 09, that's a study specific for high risk prostate patients. And what it's really trying to do is personalized care. And the way it's doing that is looking at the genomic analysis of the tumors. So in addition to the classical features that we use to risk high risk patients, right Gleason score, ps A clinical stage, we are now leveraging the decipher test and we basically are using this test to look at gene expression. It's a validated test that's already being used. But specifically in this trial, we're looking to distinguish high risk from very high risk. So those patients who are just high risk, the question is, can we de escalate therapy in particular systemic hormonal therapy? And so those patients are randomized if they have a low decipher score to one year of AD T versus the standard 18 months, if however, they have a high decipher score, then we're looking at potentially dose escalation because we're concerned this is an tumor. So those patients are getting standard of care versus standard of care plus an additional drug pub. So I think, you know, it's an exciting study I'm very excited that we are able to offer it to our patients at Miami Cancer Institute. And it just highlights again how we're trying to personalize care and just piggybacking. Also on the point you made earlier about doublet therapy and combination therapies. I think this is very important, you know, combination therapies are routinely used in a lot of cancers, you know, folfox and gastrointestinal cancer, you know, a BBD and lymphomas, et et cetera. Um And this combination could be very, very synergistic. So I think we are very excited to have the Lunar Study at Miami Cancer Institute. And in addition to that, we also are exploring possibilities of layering on focal therapy to our systemic agents. So there was a lot of movement in the last few years uh in terms of adding on SP RT, which is focused high dose radiation treatment uh to metastatic lesions after the publication of the Saber Comet study. Um And in addition to that for prostate, specifically, the oral study which was out of Hopkins, basically showed that you can target PS ma avid and and uh osteo lesions and actually increase the time interval that you could stay on a systemic agent or without a systemic agent. That's I mean, I think it's exciting time right now because we have so many options. And the most key aspect for a patient is, and now we have a multidisciplinary care. It's a patient centric where we are focused on the patient but different modalities, you know, it's medical oncology, radiation oncology, and our urology oncology colleagues. We all work together so that we give our patients at Miami Cancer Institute the best care they can receive. And at the same time, you know, they get to see all the providers so that they can understand different options and then be it genetic driven, imaging driven or disciplinary driven, we are able to provide them the best care they deserve. So moving forward, um you know, one other important aspect, you know, maybe a brief aspect I would like to touch upon is genetic testing. You know, people currently, we are not treating patients just based on the name of prostate cancer. We are trying to do a deep dive into their genetic makeup. You know, any patient who has metastatic prostate cancer is critical for us to obtain their genetic makeup. You know, to understand what kind of mutations are driving and we are tailoring therapy based on genomic testing and other critical point I would like to add is germline genetic testing, not only testing the tumor, but we are actually testing the patients to see if they're born with those abnormal BRCA, one BRCA two mutations because you will be surprised. It's quite a common mutation in about 2 to 5% of patients with prostate cancer. We do find that and in the last 4 to 5 years, all the guidelines have been revised especially from, you know, as ONCCN. And now it's a routine practice for people who whoever presents with high risk prostate cancer, metastatic prostate cancer. They, they need to be checked for germline mutations to see if they are born with. So that this helps their family, the first generation, uh the first generation uh of, you know, family members to see if they have, they are the carriers of those mutations. So again, to talk about the multidisciplinary approach, we do have our medical genetics who are a part of our team who help us with this testing. So again, it was really, you know, uh you know, nice chatting with you with all the things which we have from screening to imaging, to novel treatments, to clinical trials we have for prostate cancer patients. And more importantly, focusing on multidisciplinary approach so that the patients get their best care. Thank you, Doctor Kaiser for taking your time and uh discussing about, you know, what we have to offer for patients with prostate cancer at Miami Cancer Institute. Uh It's a great learning uh opportunity for me as well to learn different tools and techniques, what patients can get from radiation oncology team. Yeah, and thank you again, Doctor Garcia. I agree. I think it was a great discussion. We learned a lot. Hopefully the audience will have a lot of points to, to think about um and to help their patients to find out more about the topics covered. On the doc to doc podcast. Please visit physician resources dot Baptist health.net. Created by
