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December 22, 2019

Treating Cancer with the Latest in Radiation Therapy with Dr. Sheinbein

Speaker 1: 0:09
Welcome back to the Armor Men’s Health Hour with Dr. Mistry and Donna Lee.

Dr. Mistry: 0:16
Welcome back to the Armor Men’s Health Hour. This is Dr. Mistry, your host always joined by my cohost, and board-certified cohost Donna Lee.

Donna Lee: 0:24
Thank you for remembering that part. And you’re a board certified…urologist.

Dr. Mistry: 0:26
Urologist. Yes. And a self-proclaimed men’s health expert.

Donna Lee: 0:29
It made you a superstar.

Dr. Mistry: 0:31
That’s right. And so, Michael’s your your husband. And is he excited about Christmas?

Donna Lee: 0:36
Yeah. He’s so excited that I bought him the present he wanted. It has to do with a Porsche, always. I got him a Porsche Lego set. How about that? It cost me 150 bucks.

Dr. Mistry: 0:44
Really?

Donna Lee: 0:45
Yes. It’s legit.

Dr. Mistry: 0:46
Good job, Michael. I don’t know if I would trust him to sit in a room and put that thing together.

Donna Lee: 0:52
That’s all he wanted, and I’m done. Merry Christmas.

Dr. Mistry: 0:54
Well, Merry Christmas. Merry Christmas. Today I’m joined by a wonderful friend of our practice, someone that we trust with a lot of our patients and even some of our own family members. This is Dr. Courtney Sheinbein from Texas Oncology. Welcome Courtney.

Dr. Sheinbein: 1:08
Thank you so much for having me today.

Dr. Mistry: 1:09
So, you know, Courtney, you and I joined this town like about the same time. Both of us over near the Seton Williamson campus, and both of our practices have grown incredibly. So I really appreciate you, you know, coming and talking to me today.

Dr. Sheinbein: 1:22
My pleasure. Very happy to be here today.

Dr. Mistry: 1:24
When we talk about cancers, it’s not usually something that’s, it’s something that’s confusing to a lot of patients. It’s something that’s frightening to a lot of patients and it’s certainly a topic that we talk about a lot on this show because in urology we deal with multiple different types of cancers: prostate cancer, bladder cancer, kidney cancer, testicular cancer. But as a radiation oncologist, you deal with almost all the cancers, right?

Dr. Sheinbein: 1:45
Yes, that’s correct. Pretty much all adult cancers.

Dr. Mistry: 1:47
You know, when we, when I have patients that come in and they’re being faced with potentially going through radiation, I get a mixture of kind of responses from patients. What are some of the kind of common, I guess I would say myths or perspectives that patients come to you with when they’re told they may need radiation.

Dr. Sheinbein: 2:06
I think a fair amount of people had patients or family members treated in decades past and they’ll have different stories about the toxicities of the treatment and the technology is much, much more refined than it was 10, 20, 30 years ago. So that’s one of the things that we’ll see. We’ll also have a lot of concern that if you get radiation exposure, is that going to create a cancer? And yes, that’s the case, but the risk is also quite, quite low.

Dr. Mistry: 2:27
Well I think you brought up an important point. You know even in prostate cancer 20 years ago it was an incredibly potentially destructive kind of treatment with lots and lots of side effects. And today we don’t necessarily see quite that degree of side effect.

Dr. Sheinbein: 2:41
Yeah, absolutely. So if you went back in time to our older technology, you’d see about a 25% rate of rectal bleeding after radiation for prostate cancer–25%. And now it’s down to maybe half of a percent, probably less than that. So it’s almost never seen.

Dr. Mistry: 2:55
I think that because the diagnosis of cancer is such a frightening kind of sudden kind of thing that people have to contend with, we draw upon the experience of others to help us understand what we’re going to go through. So if your father or your mother or your uncle had radiation or some kind of treatment for cancer years ago, you may think that nothing has really progressed. But technology has really played a big role in radiation treatment.

Dr. Sheinbein: 3:19
Oh, absolutely. The technology, since I started residency in the early 2000’s compared to now is just so much different. So, so different–in a good way.

Dr. Mistry: 3:29
You know, you mentioned it–you were a resident at a little known medical school of this state…what was it called again?

Dr. Sheinbein: 3:35
That was called Baylor College of Medicine. Have you heard of it?

Dr. Mistry: 3:36
Oh man. I’ve heard that they make some of the most amazing physicians on earth.

Donna Lee: 3:43
You must not have gone there.

Dr. Mistry: 3:44
You went to medical school somewhere at University of Texas Southwestern though. Is that fully accredited?

Dr. Sheinbein: 3:51
No comment.

Dr. Mistry: 3:51
Okay, well, not everybody can get into Baylor for medical school, but it’s great that you got in there for your fellowship, so that’s great. But you know, back in Houston, there’s a well known medical oncology place called MD Anderson. Have you heard of it?

Dr. Sheinbein: 4:04
I have not heard of that, no.

Dr. Mistry: 4:06
And so, what they have is an incredible marketing budget. I mean, they treat patients well and I’m not being facetious about that, but one of the things that they really advertise quite a bit for cancer is the use of proton therapy. And I will tell you there is not a patient that comes through that I don’t recommend radiation for prostate cancer. And they immediately bring up should they go do proton therapy? You know what I tell them and I want to hear your insight into it, I want to hear what do you think the difference between proton quote unquote therapy is and traditional whatever we do here in town is. Really, I’m taken by the fact that machine that they have there is old. I mean, it was there when I was a resident there 12 years ago. I mean it’s pretty, it’s got green neon lights, it’s, I mean, and it makes for great marketing. But what are you really getting when you decide to do something like proton therapy and moving to Houston for nine weeks and yada yada yada?

Dr. Sheinbein: 4:54
Sure. Yeah. And so we actually even have a proton machine part of our organization in Dallas, Texas. And when we need to do it, I definitely send patients that direction. What it does different is the low dose fall-off…this gets a little technical, but the low dose radiation exposure is less. But the area that you’re focusing on, which is the prostate gland itself and then the things right next to it are getting the same exposure. So really what you’re saying is less low dose exposure to the organs that such as like the hip, which really isn’t an area we really see the side effects, but the same exposure on the prostate gland, the same exposure on the adjacent rectum, and the same exposure on the adjacent bladder, which means the side effects you get at the treatment are essentially the same. There’s really not a big differential. The cure is going to be the same.

Dr. Mistry: 5:34
So when you’re getting radiation today, it’s not really like a ray gun just shooting you from one direction, right? I mean the radiation is coming from multiple directions and everything is being guided by real-time imaging.

Dr. Sheinbein: 5:44
Yes, that’s correct. So every day when the patient comes in for treatment, the machine does a rotation around them and generates what we call a cone beam cat scan. So it shows us the prostate gland in 3D. We can lock on within a few millimeters and then deliver the treatment. When we’re delivering the treatment, the machine’s going to rotate around to multiple angles and open and close little doors that kind of gate the radiation. So it just exposes over the gland and keeps it concentrated there and blocks it off from everywhere else as best it can.

Dr. Mistry: 6:09
How long can people expect a treatment for prostate cancer to last and how long is each treatment?

Dr. Sheinbein: 6:15
So probably in and out of the office within a half hour. The actual beam time is probably about five minutes. So it’s fairly quick.

Dr. Mistry: 6:21
It’s pretty quick.

Dr. Sheinbein: 6:21
Yeah, most of the time is set up, getting you in the exact right position.

Dr. Mistry: 6:24
A number of our patients that are going to get radiation therapy are asked to do hormone ablation therapy. And so in our clinic, as our listeners know, we do a lot of testosterone replacement therapy. We try to do it in a monitored and safe and careful way and try to treat the whole patient. That’s kind of what our philosophy is. Now we’re talking about an alternative treatment. We’re talking about like, prior to radiation, we want to take all your testosterone away. We see is associated with decreased muscle mass, bone mineral density loss, loss of libido, erectile dysfunction, a number of things that just kind of make you feel icky. I’d like you to tell us what patients are usually recommended to undergo that, and what are some of the things that you might tell somebody who’s on the fence about doing that?

Dr. Sheinbein: 7:07
Yeah, I mean, I agree with you completely. It’s definitely a quality of life concern when you’re talking about that. For what we call intermediate risk prostate cancer patients, so your Gleason score is 7, perhaps. Your PSA, maybe between 10 and 20. There’s some slight benefit to doing it with delaying the chance of recurrence and the time to recurrence, if you do the hormone therapy with all the costs that you were just mentioning. If you get into someone who’s a high risk aggressive prostate cancer, something where we think the cancer is going to come back, no matter what we do within 3 years to 5 years, we really want to consider that treatment option to help extend and improve their chance of survival.

Dr. Mistry: 7:40
I think that’s important. You know, a one-size-fits-all kind of philosophy is something that I’m not a big fan of.

Dr. Sheinbein: 7:45
Oh, it doesn’t work.

Dr. Mistry: 7:46
And, I think that what it ends up doing is making people feel like their specific factors are not being taken to consideration. So if they’re, if the patient’s younger, sexually active, real physically active, and they’re in their 50s or early 60s, these are patients that sometimes I may advise to forego the hormone ablation treatment and just go for radiation.

Dr. Sheinbein: 8:07
And frequently what I’ll do is if I am going to go down that road, we do depo injections and I usually like to recommend the shortest possible depo injection at the front, at the beginning, just in case they have an adverse reaction, because it does have a huge impact of quality of life. It’s not a benign medicine. So if they have an adverse reaction, it wears off as quick as possible and then we can decide if we want to continue or not.

Dr. Mistry: 8:26
What do you think the next stage of radiation therapy is going to include? Is it going to include higher dose, shorter treatments? Is it going to just have increased improvement in imaging? Or are we going to come up with a new, you know, particle that we start shooting at people?

Dr. Sheinbein: 8:45
There’s definitely investigation into new particles. I think the cost of that at this point, it’s probably putting that, you know, way out into the future, but I think what she said is exactly correct. Shortening the course of treatment is things that we’re looking at right now. There’s data for moderate shortening of the treatment–we call that hypofractionation. And then there’s studies also ongoing at looking at kind of really condensing it down to 5 fractions or less. But these things are still semi-investigational. And so I’m kind of staying right now with the standard 7-8 week course. But as more data comes out, we certainly have the technology to shorten the course as needed.

Dr. Mistry: 9:17
You know, I think that’s a great point. You know, when we’re dealing with people’s lives and something as dangerous as cancer can be, it’s hard to sometimes be on the bleeding edge of a new technology and having people that kind of follow the standards and the protocols I think is comforting to a lot of people. So, Courtney, we’re out of time on this segment, but we’ll be right back to talk about an interesting topic on metastatic disease. Donna Lee, why don’t you tell people how to get ahold of us.

Donna Lee: 9:45
I will. During the week, you can call us at (512) 238-0762. You can also send us an email during the week or anytime to us or Dr. Sheinbein: armormenshealth@gmail.com. That’s armormenshealth@gmail.com. We’ll ask your questions on air anonymously. We have four locations in the Austin area: Round Rock, North Austin, South Austin, and Dripping Springs. And our website is armormenshealth.com, where you can see Dr. Mistry’s shining face and mine, too.

Dr. Mistry: 10:11
And catch that podcast.

Donna Lee: 10:11
That’s right. Catch the podcast anywhere you catch podcasts, and we will be right back after these messages.

Speaker 1: 10:16
Dr. Mistry wants to hear from you. Email questions to armormenshealth@gmail.com. We’ll be right with the Armor Men’s Health Hour…Welcome back to the Armor Men’s Health Hour with Dr. Mistry and Donna Lee.

Dr. Mistry: 10:50
Welcome back to the Armor Men’s Health Hour. This is Dr. Mistry, your host, here as always with my cohost, Donna Lee.

Donna Lee: 10:56
Hello, happy Sunday everybody. We’re moving, you know? The show’s moving.

Dr. Mistry: 11:00
Yes. I’m excited about it being on a Saturday. They think that we’re going to need to tone it down.

Donna Lee: 11:04
No, we’re not moving for that.

Dr. Mistry: 11:06
Fewer penis jokes.

Donna Lee: 11:06
Dang it. Little kids in the car.

Dr. Mistry: 11:08
Oh man. Boring.

Donna Lee: 11:11
Boring.

Dr. Mistry: 11:12
Well, we do have the disclaimer at the beginning, so I feel like we can say things. And I am a board certified urologist. I feel like…

Donna Lee: 11:18
You can talk about things.

Dr. Mistry: 11:18
You however, I’m not sure. You need to turn it down, lady.

Donna Lee: 11:24
I can talk about penises if I want to.

Dr. Mistry: 11:24
Well, there you go.

Donna Lee: 11:25
Anyway.

Dr. Mistry: 11:25
So we’re joined again by our guest, Dr. Courtney Sheinbein with Texas Oncology. Thanks a lot for sticking with us, Courtney.

Donna Lee: 11:32
Welcome back.

Dr. Sheinbein: 11:32
My pleasure. I wouldn’t be anywhere else right now.

Dr. Mistry: 11:35
So, Texas Oncology is a pretty big group. They have medical oncologists, radiation oncologists. In some places, they even have urologists. Maybe you could tell me what are some of the benefits of, as a patient and as a physician, of a large oncology group like Texas Oncology?

Dr. Sheinbein: 11:51
Quite a bit of benefit actually for us. We have access to the latest technology. So in our center we have some of the best technology just here in Austin. We also have access to proton machines in Dallas. When I meet a patient, if we need access to a medical oncologist to add additional treatment options, they’re right down the hall. I can walk down the hall and talk to them. Whenever I need help from Dr. Mistry, he’s just a phone call away. So…

Dr. Mistry: 12:11
That’s right.

Donna Lee: 12:14
Bat signal.

Dr. Mistry: 12:15
That’s right. It does help. I recently sent my own godfather to you, and luckily he doesn’t listen to the show, so he’s not gonna know that I’m calling him out. But you know what’s interesting about him is he was treated for a kidney cancer over a decade ago. He then developed a mass in his lung that you treated with radiation therapy. This was a long time after his initial diagnosis. And it gets me to really thinking about the traditional wisdom when it comes to cancer that spread out of the local organ, or metastatic cancer, what we would call it…it just seems like a death sentence, an immediate death sentence in a way. That’s not the case. Maybe we could talk a little bit about oligometastatic disease.

Dr. Sheinbein: 12:57
Sure. That’d be a great topic to talk about.

Dr. Mistry: 12:59
So, when we talk about that term oligometastatic, what do we really mean?

Dr. Sheinbein: 13:02
What we mean is that there’s limited evidence of spread of the cancer beyond it’s site of origin. So perhaps 1, 2, 3, maybe even 4 additional locations beyond the original site where it began.

Dr. Mistry: 13:12
What cancers are the most likely to benefit from, not just treating the main cancer where it is, but also kind of where we can see it pop up?

Dr. Sheinbein: 13:21
So we’re actually seeing that more and more. Around a decade ago, I don’t think we did a lot of these kind of treatments, but I think we see more and more with lung cancer, with prostate cancer, with kidney cancer, pretty much you name it. I think more and more when we hit those couple sites that we see on the imaging with a higher dose of radiation, and coupled with some of the newer chemotherapeutic agents and immunotherapy agents, we’re seeing extended control of the cancer.

Dr. Mistry: 13:45
It’s really amazing. And I think that the improvement in imaging technology really says something. So even small little tumors that maybe we couldn’t have seen one or two decades ago, we’re now able to see and then you can target it. And so what we’re really talking about is treating the primary cancer and then going after wherever it is and shooting with radiation. Right?

Dr. Sheinbein: 14:04
That’s exactly right. Yes.

Dr. Mistry: 14:05
And I think that the type of cancer that was the most kind of dramatic for me, was I have a patient now that’s been a patient of mine for 10 or 12 years. And when he first came to see me, I diagnosed him with a liver metastasis from a colon cancer, and he’s still with us. They treated the liver mass, and then they treated the colon cancer, and he’s still there doing well…and that’s really amazing.

Dr. Sheinbein: 14:28
Yeah. With colon cancer, I’ve treated several patients where it’s gone into the liver, it’s gone into the lung. And just as you’re describing, you can see an extended outcome, which is just wonderful for our patients.

Dr. Mistry: 14:38
I think that, you know, with other oncologists that we’ve had on the show, we talk a little bit more about this notion of managing cancer as a more chronic disease process and less like a death sentence.

Dr. Sheinbein: 14:49
No, that’s absolutely true.

Dr. Mistry: 14:50
You mentioned in passing kind of the newest therapies. I mean using the your own body’s immune system to attack the cancer, using less toxic drugs to kind of defeat the cancer, looking at the cancer’s internal workings kind of mechanically and then using a drug to impact how the cell is dividing…these are very different kind of therapies than traditional chemotherapy.

Dr. Sheinbein: 15:14
Oh, completely different. And in the time since we both graduated from residency, I mean the number of new medications that have come out is just incredible. Absolutely incredible.

Dr. Mistry: 15:23
And so we expect a different type of side effect. And then to be able to couple that with radiation therapy to help tumors get smaller in size and grow slower is an incredible advance, I think.

Dr. Sheinbein: 15:34
No, absolutely. Like I said, we have seen some people where we traditionally would have thought that their survival time was less than 6 months and they’re still following up with me 5, 6, 7 years later.

Dr. Mistry: 15:43
In prostate cancer where I specifically see this kind of benefit are patients that have cancer that spread outside of the prostate, and maybe to like a bony structure, right? Like the hip or the spine.

Dr. Sheinbein: 15:56
Yeah. That’s the most common for it to go into the bone.

Dr. Mistry: 15:58
And those patients, those metastases do tend to respond to radiation therapy.

Dr. Sheinbein: 16:04
Yeah, absolutely. We can use a technology called SBRT where we can focus on that tumor with a really, really, focused beam of radiation. It’s a very high dose delivered over 3 to 5 fractions and you can basically obliterate that spot.

Dr. Mistry: 16:17
That’s really amazing. You think that patients in the past who might’ve complained about fatigue during their radiation or, I guess more specifically, well, why don’t you go through what are some common side effects that all radiation patients can maybe expect and then specifically those that are going to get radiation for a prostate.

Dr. Sheinbein: 16:35
So, going back into just the prostate location itself, what you typically would expect as you go through the course of the treatment is maybe some fatigue. You can end up with some bladder irritability, frequency of urination, burning on urination. You can get a little bit of rectal irritation like gas, loose stools. But in general, people feel pretty well through the whole course of treatment. If we’re talking about treating one of the spots that’s involving the bone, those really don’t have a lot of side effect. There’s a couple of risks associated with damage to the bone over the longterm, but in general, people actually fare pretty well.

Dr. Mistry: 17:07
So, you and I both treat prostate cancer. And we both treat local prostate cancer. I treat it with high intensity focused ultrasound, radical prostatectomy. You treat it with radiation therapy. And those are going to be the mainstays of therapy really, for localized prostate cancer disease. We, you know, on this show are always recommending people get second opinions when it comes to their cancer diagnosis. If somebody wants a second opinion or if they’ve been referred for surgery and want to talk about radiation, how do they get ahold of you?

Dr. Sheinbein: 17:40
Basically just give us a call and, we’ll, we’ll usually get people in within a day, usually. We’re really quick about that.

Dr. Mistry: 17:47
And you’re at the Seton Williamson location?

Dr. Sheinbein: 17:50
Yes, that’s correct. Yep.

Dr. Mistry: 17:51
What’s the phone number there for you?

Dr. Sheinbein: 17:52
Our number is (512) 687-2300.

Dr. Mistry: 17:56
And we’re going to have that on the Facebook posting. And then on the show show notes.

Donna Lee: 18:02
I’ll put your face there. We’re going to promote Texas Oncology.

Dr. Mistry: 18:02
Once we kindly figure out how to do show notes for a podcast. If any of you listeners out there know how to do a podcast correctly…

Donna Lee: 18:12
Can we hire you?

Dr. Mistry: 18:12
Yeah, definitely.

Donna Lee: 18:14
We have some people working on it…ish.

Dr. Mistry: 18:18
Who would have thought with a busy practice, a big family, that it would be hard to somehow do another job.

Donna Lee: 18:22
Maybe one of your 6 kids could work on this.

Dr. Mistry: 18:23
Man, I don’t know.

Donna Lee: 18:25
One of them is 22. She could do it. She’s a nurse though.

Dr. Mistry: 18:28
I hope she’s listening.

Donna Lee: 18:30
She’s busy being a nurse.

Dr. Mistry: 18:31
That’s right. And so, Courtney, thanks a lot for joining us here today. As I mentioned in our earlier segment, being diagnosed with cancer is frightening. Sometimes you don’t even know what advice to take you. You know, my advice to patients is always try to take it a little slow, find doctors that you trust. And I want to thank you for being one of those doctors that we really trust.

Dr. Sheinbein: 18:56
My pleasure, thank you so much for having me today.

Dr. Mistry: 18:59
So Donna Lee, we’re gonna need to tell people how to get ahold of us and a little bit about our practice.

Donna Lee: 19:05
If you haven’t memorized it by now, after being avid listeners every week, you can call us during the week at (512) 238-0762. We have four lovely locations. Dr. Mistry opened the first one 12 years ago. Was it like yesterday?

Dr. Mistry: 19:20
It does feel like yesterday.

Donna Lee: 19:21
You and Liz and one other person, maybe?

Dr. Mistry: 19:24
I was a young man back then.

Donna Lee: 19:27
You’re still a young man. You just don’t feel like a young man, because those 35 patients a day are wearing you down. You can reach us at again (512) 238-0762. Our locations are Round Rock, North Austin by the DPS office, by Lakeline Mall, South Austin on South Congress SoCo, and where all the homeless people are. And also in Dripping Springs, where there are no homeless people.

Dr. Mistry: 19:50
Have some compassion.

Donna Lee: 19:52
They’re busy bothering my front door over there.

Dr. Mistry: 19:54
That’s right.

Donna Lee: 19:55
And our armormenshealth@gmail is our website. I’m sorry, our email address, armormenshealth@gmail.com. Our main website is armormenshealth.com. You can see our shining faces. Anything else Dr. Mistry before we go back to commercial?

Dr. Mistry: 20:09
Well, I just want to encourage those of you that are interested to listen to our podcas, the Armor Men’s Health Hour is available on Spotify. It’s available on your Alexa. It’s available on Apple podcasts.

Donna Lee: 20:19
But you won’t listen to it. So you should like…

Dr. Mistry: 20:23
I like hearing my voice in real time. I just want to assume that it sounds really good on the podcast.

Donna Lee: 20:28
It does. I listen to it in the car and it’s amazing. And our little faces pop up, if you have the car that has the little radio thing.

Dr. Mistry: 20:35
As a professional comedienne, I think you’d like to go over your material to make sure…

Donna Lee: 20:39
I do, I critique the crap out of it. And then I tell me how awful I was, all night long. It’s horrible.

Dr. Mistry: 20:44
Well, we need to find a great psychologist for you.

Donna Lee: 20:46
I have a therapist. She’s a busy lady.

Dr. Mistry: 20:51
All right, we’ll be right back.

Donna Lee: 20:52
Alright, bye.

: 20:52
Dr. Mistry wants to hear from you. Email questions to armormenshealth@gmail.com. We’ll be right back with the Armor Men’s Health Hour.

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