In this episode of TMU we have the pleasure of being joined by two urology experts, Dr. Ravi Rajan, Urologist, and Dr. William Ding, Radiation Oncologist, as they discuss topics ranging from genetic testing in prostate cancer for personalized treatment plans to the importance of collaboration between urologists and radiation oncologists. Our guests highlight the significance of effective communication and seamless integration within the treatment team. They also shed light on the consequences of lack of collaboration and how it can impacts patient care and satisfaction. Listen along as they share valuable insights and practical tips for improving communication and collaboration between these specialties.
In this episode of TMU we have the pleasure of being joined by two urology experts, Dr. Ravi Rajan, Urologist, and Dr. William Ding, Radiation Oncologist, as they discuss topics ranging from genetic testing in prostate cancer for personalized treatment plans to the importance of collaboration between urologists and radiation oncologists. Our guests highlight the significance of effective communication and seamless integration within the treatment team. They also shed light on the consequences of lack of collaboration and how it can impacts patient care and satisfaction. Listen along as they share valuable insights and practical tips for improving communication and collaboration between these specialties.
0:00:00.0 Mark Edney: Hello, and welcome back to the newest edition of the Modern Urologist Podcast. I'm your host, Dr. Mark Edney. I'm a private practice urologist in Salisbury, Maryland. I'm part of a large independent group, and I'm sort of the new facilitator of this podcast and my goal has been to bring to you the listener, topics that are top of mind for the average practicing urologist in the United States, topics that are applicable, whether you're in an academic center, large independent integrated groups, or if you're a small independent private practitioner. We wanna talk about topics that are germane to the practice of urology. We're not gonna get into specific papers
and sets of data necessarily, but all of the things that are germane to allowing you to deliver the highest quality care possible, whether that's policy, the business of urology, relationships with other practitioners, which is what we're gonna get into tonight. All of the things that surround your practice and allow you to provide the highest quality care to your patients. I'm very fortunate to be joined this evening by two fantastic physicians, Dr. Ravi Rajan, who is a urologist, and Dr. William Ding, who is a radiation oncologist.
0:01:11.6 ME: Dr. Rajan has been practicing urology in Bucks County in Pennsylvania since 2000. He's highly regarded in minimally invasive procedures for prostate and bladder disorders. He has won numerous awards during his career, including Top Doctor in Philadelphia Magazine for 2018, 2019 and 2020. And also with us tonight is Dr. William Ding. Dr. Ding is a radiation oncologist. He graduated from Drexel University College of Medicine in 2007. He completed his residency training in radiation oncology at the California Pacific Medical Center in San Francisco in 2012. Dr.
Ding began his current position as medical director of the Summit Health Lawrenceville Cancer Center in 2016, where he subspecializes and developed his expertise in prostate and bladder cancers using cutting edge radiation therapy. Dr. Ding also is active as a principal investigator on multiple prostate cancer related studies in which he collaborates with St. Joseph University as a mentor in the mathematics department where he teaches data sciences to students on clinical data, and analysis and trial design. Dr. Rajan and Dr. Ding, welcome to the program.
0:02:13.1 Ravi Rajan: Well, thank you, Mark.
0:02:14.2 William Ding: It's a pleasure to be here.
0:02:16.1 ME: Very good. So what I wanna do this evening with a worldclass
urologist and radiation oncologist who work very tightly together is to unpack this very interesting professional dynamic in prostate cancer, and that is the relationship between urologists and radiation oncologists with respect to the treatment of early stage prostate cancer. In the best case, it's a collaboration and a multidisciplinary approach to prostate cancer care. And sometimes in the worst case, there's an
absence of collaboration or even two doctors working at odds to each other in the care of a mutual patient. So we wanna unpack some of those dynamics. And some of the things that we can consider doing if we find ourselves in that scenario where we feel like we're on two different islands, caring for the same patient, but not communicating and not seeing eye to eye with each other.
0:03:02.7 ME: We wanna talk about sort of some tips and tricks to help get yourself out of that situation and act in a more collaborative way, which is ultimately really what needs to be happening for our patients, 'cause we all care about the highest quality, best, most data driven, efficient and effective care for our prostate cancer patients. So to start off, I'll open it up to Dr. Rajan. Please let the audience know sort of a little bit about your practice and your collaboration with Dr. Ding. How
do you, in your practice, handle after there's a new diagnosis of prostate cancer? What's the pathway look like for your patients?
0:03:39.9 RR: Alright. Certainly, Mark. So first of all, it's very easy for me because I have a great radiation oncologist in Dr. Ding. So it makes my life much easier and makes things better for my patients. So, typically diagnose a patient with prostate cancer, which feels clinically localized. I discuss treatment options, mainly surgery, radiation, and active surveillance. If they're interested in radiation, then even if they're not strongly in favor, but if they have some interest or not sure, I'll have them see Dr. Ding. And the way I do it, we're on the same EHR. We have Epic I'll send a request into a center, and then the front desk really facilitates the appointment. And
of course, Billy can see all my notes on the chart, so there's not much lost in translation there. We have multiple academic centers near our practices. And we don't have the same rapport. Billy's... I'll text him whenever I have a question and he almost always gets back to me right away. Sometimes, I'll call him with the patient in the room when they're really nervous or confused. So it's really that two way communication that separates, I think, the great teams of physicians, and that's why we excel.
0:04:58.9 ME: That's fantastic. And that sounds like... Well, certainly one of the very common pathways is we diagnose prostate cancer, we have that conversation with our patients, "Here is your Gleason grade, your stage, your genetic results. Here are your options as I see them based on the literature, including for many, radiation therapy." And if you think someone is a radiation candidate and/or they're interested in it, it sounds like you move them along to radiation. There are other models whereby every patient who's diagnosed by the urologist has the radiation oncology consult and then they decide. So it's an interesting difference. I guess one of the questions is, should every
newly diagnosed low stage localized prostate cancer patient interview with both the urologist and the radiation oncologist? So I guess my next question is to Dr. Ding, what is your sense sitting from the radiation oncology perspective, do you sense... And I'm not talking specifically about Dr. Rajan's referrals, but in your world as a radiation oncologist, do you think you're seeing... What's your opinion of the number of consults you see for early stage prostate cancer? 'Cause I'm sure it's a portion of those newly diagnosed. Do you feel like it should be larger? Do you feel like most of the consults are appropriate? Are there consults you wish you were seeing, that you don't feel you're
getting?
0:06:20.7 WD: I don't see all of the consults that initially go to the urologist, but my sense is I see at least about 50% to 60% of the patients that get referred to me. And I think it really depends on the urologist. I say some urologists would send over almost all of their newly diagnosed prostate cancers over, regardless of their stage, Gleason score. And there are gonna be other urologists who only send over a handful. But as a radiation oncologist, you try to work with everyone, right? Especially in a big practice, you have to kind of gauge what their practice styles are and really work with them so that the patient get the best outcome. But I would say that as an estimate, at least 50%, I see the newly diagnosed prostate cancers.
0:07:19.5 ME: Very good. And this is a question for both of you, and I'll start with Dr. Rajan. There's been some literature, and this... It's older literature, but I bet it still holds true today. There have actually been studies done showing that if you consult with a urologist and a urologist alone, you're more likely to end up getting surgery. And if you consult with a radiation oncologist, perhaps without having seen... Although it would be rare to not have seen a urologist, but if you consult with a radiation oncologist, you're more likely to have a strong suggestion for getting radiation therapy. So that gets to our own personal professional biases with respect to the care that we provide. And I don't think the results of those data are sinister, necessarily, in any way.
0:08:09.2 ME: And certainly, there are fringes of each of our professions that unfortunately operate in a profit motive driven way. But I think the vast majority of us are trying to assess the patient, their data and what their interests are. We've been teaching for 20 or 30 years, this patient centered care, shared decision making, which is really bringing that... Getting away from that paternalistic approach and trying to get to what the patient's values are. And so I have my own sort of spiel that I try to make as middle of the road as possible, and try to match that with the patient's values. And I
try to get that out of them. You know, what do you want out of this? What are you willing to put up with in terms of side effects? What are you willing to go through?
0:08:50.5 ME: And I try to be very middle of the road, but I think a lot of this is that we are most comfortable with the type of care that we provide. And that's not a bad thing, and that can't be changed. I'm most comfortable as a surgeon talking about surgery, talking about complications of surgery, talking about the experience of surgery 'cause it's what I do. And I can talk generally speaking about radiation and generalizations about radiation, but the radiation oncologists are much better at getting into the details of the experience of going through prostate radiation. So let's talk a little bit about the potential for personal professional bias in our presentations and what you both do
to try to neutralize that so that we're delivering care that again is most specific and effective and appropriate for the particular patient in front of us. Dr. Rajan?
0:09:39.8 RR: Sure. Well, I'll say I used to have bias when I would do the radical prostatectomy. I finished training in 2000, so that was just when laparoscopic and robotic was getting started. So I don't do robotic prostatectomies now, so I don't do any prostatectomy. So I'm sort of a neutral party here in that I don't do either treatment. I don't do the surgery or the radiation. And so I don't think I have the same bias as I used to. Before, I loved operating and maybe my enthusiasm showed to the patients. So now, I'll have a discussion with them. Sometimes, I'll guide them one way or another.
Oftentimes, as you know, patients will say, "Doc, what would you do if you were in my shoes or family member?" I try to answer it as accurately as possible. So if a patient has strong aspirations to have surgery, I don't see any reason for them to see a radiation oncologist. If they are really afraid of surgery or know people who had bad outcomes or high risk for surgery, then I don't send them to my partners who do the robotic prostatectomy. So it is patient centered.
It's what the patient wants, but sometimes, I may have to guide them one way or another.
0:10:55.5 WD: That is probably one of the hardest things that I have to do when I'm doing a consultation. And that is how to present the information to the patient without sounding biased or presenting one option over the other. So what I normally do is, "Listen, I'm not a surgeon, so first of all, I'm not gonna talk about surgery. That's what Dr. Rajan does and that's why I will have you go back to Dr. Rajan to talk about surgery if you have any questions about how the procedure is done or the side effects. What I'm gonna concentrate on is radiation therapy." And despite giving them the information as objectively as you can, at the end of the day, they're still looking at you and saying, "Hey, doc, what's your recommendation? You've spent all this time with me, giving me all this data. You still haven't told me what I should do."
0:11:53.9 WD: And ultimately, you know what? I would just say that, if I would tell you what my personal opinion is, it is going to be biased, because I'm a radiation oncologist. Like you were saying, you are most comfortable with what you do. So I tell them about my biases, but at the same time, I tell them that this is really a personal choice. You really have to look at the different side effects. And because there's really... There's no free lunch in medicine. No matter what treatment you get, there's always gonna be a set of side effect profiles. And your job as the patient in this scenario is really to choose the set of side effects that you'd rather trade. That's how I present it.
0:12:38.1 ME: Very good. And I completely agree. We can try to consciously sort of moderate our presentations as much as possible, but ultimately, we know what we know and we have the experience that we have that creates some, I think ultimately, some degree of bias that we can't eliminate. But it's certainly important that we try to be as middle of the road as possible. But to your point, Dr. Ding, I completely agree. I still have... Particularly where I practice, which is more rural, a little on average, less educated, there's still that old, "You tell me what to do, doc. I don't know."
And sometimes in more urban areas with more highly educated populations who have done a tremendous amount of research on their own, they've been on Google for weeks before they come and see you. They've got very strong ideas about which way they may wanna go.
0:13:24.9 ME: And so, you're more curating information that they've gleaned rather than sort of being the provider of information, for folks who may be a little less sophisticated and are just looking to you as the doctor to make a decision for them. Again, that older, more paternalistic style. So it still exists, I completely agree with you. But it's a hard balance to walk, and I think it's really ultimately trying to get a sense of the patient in front of you. What do they need from you? What do they want from you? And what can you provide them? What are they asking for? And then to really
tailor that discussion to them. Next question I have is, sometimes as we work in these collaborative environments, and that's why the multidisciplinary approach, I think, is so important, 'cause you can sit around the table and talk about different viewpoints on the same patient, same disease from different specialty perspectives, because we've got completely different, sometimes, sets of literature that we respond to. And there's a very broad and rich radiation oncology literature with respect to prostate cancer. There's a broad urology literature, and there's a lot of overlap there.
0:14:30.1 ME: There are a lot of studies that involve, obviously, both surgery and radiation. But sometimes, we as urologists do the best we can to keep up with the urology literature. We certainly can't be experts in the radiation oncology literature. And sometimes, there are suggestions that go one way or another where the radiation oncologist will say, "Well, we've got some studies suggesting... Whether it's duration of LHRH therapy or the use of radiation in certain types or certain stages of prostate cancer we may be a little less familiar with." It could create some back and
forth in some discussions. How do you handle sort of differences in suggested pathway forward in a databased way, based on the literature in your specialty when it comes into conflict? How do you handle those conflicts? I'll start with Dr. Ding.
0:15:12.4 WD: Now, are you asking in the setting of a multidisciplinary meeting or as we talk to the patients?
0:15:22.1 ME: Well, I guess both. I want you to imagine a scenario... Yes, in the multidisciplinary meeting. But also imagine a scenario where there's a urologist in a community that isn't part of a multidisciplinary approach who maybe has sent a patient for radiation oncology consult to a radiation oncologist she or he may not even know, who are getting a letter back saying, "I would modify your approach in this way or that way." How do you handle it with someone you don't know, a consultant you don't know, versus how it's handled around the table in a multidisciplinary way?
0:15:54.9 WD: Boy, that's tough. If you're talking to someone who you don't have a working relationship with, you gotta be very gentle in how you approach the subject, especially if you disagree with the person. So, you try to build a rapport. At the end of the day, you just wanna be respectful. You wanna listen to where they're coming from, what their treatment recommendations are and how they arrived at those treatment recommendations. And then, you try to present your side as much as you can and use the most current data. Ultimately, if you approach this from a respectful way, you will reach a consensus, whether this is someone that you've worked with for a
long time, or someone that you just met on the phone. And again, ultimately, you really want to have the best care for the patient. And if you come from that standpoint, the other person is gonna respect that too.
0:16:50.2 ME: Great. Dr. Rajan, how do you handle sort of conflicts in treatment planning with the radiation oncologist?
0:16:57.4 RR: Best way is just to have a two way discussion, where some of the conflicts could be length of time for LHRH agents or whether they even needed the role of space. Or sometimes, there can be even turf wars where some of the radiation oncologists will do the space, or if they're, say, employed by a health system, will want their urologist to put in the marker. So sometimes, that can be in the way. But typically, if it's radiation, I will defer to the radiation oncologist how many treatments... The type of treatment that the patient receives. And with LHRH agents, the... Well, we can have a discussion on the length of time. Of course, sometimes, that changes based on the patient's symptoms or side effects from testosterone suppression. But if it's radiation involved, I'll leave it entirely up to the radiation physician, how and what type. And then, the other things, it's a discussion regarding the, like I said, space war and also the length of time for testosterone suppression.
0:18:08.3 WD: Just going back to what Ravi was saying before, I think one of the biggest
advantages of our working relationship is that, if there's ever a question, we just call each other on the cell phone. When we're seeing a patient, right then and there, if there is any kind of misunderstanding or confusion, just call the other person up. And if there's any disagreement on the therapy, we'll talk about it. And then sometimes, we even ask the patient for his input as to what his values are. So sometimes, that really helps us and guide us to which way we should proceed.
0:18:50.1 RR: Sure. Now, I'll give you an example, Mark, of a patient. Just in the last month, he was a person who wanted to have radiation. He was high risk, he was a rising PSA while under Dutasteride, and he had... I think he was grade group four. And I started him under Billy's direction. We said radiation, and I was going to put him on... I put him on LHRH agonist injection, and his PSA didn't go down. First guy I ever saw whose De novo PSA didn't go down. So that we rechecked it, it still went up some more. And then that's when Billy and I had to have a conversation figured out. And then we started him on ____ and now his PSA is going down. He still hasn't received his radiation. So we're always available for each other. And sometimes, the most effective time is when the patient is in the room. If Billy is available, it's great when we can have a
three way conversation with the patient.
0:19:46.4 WD: Ravi, that is the perfect example. I was going to talk about that example, but you beat me to it. That patient is just baseline, very nervous, and I think with him seeing that we were working with each other so closely, so efficiently, and we can pivot on even something that doesn't happen that often, I think really impressed him.
0:20:10.6 ME: And Dr. Ding, I think you make a fantastic point there at the end with respect to, when patients notice that their treatment team is working closely and efficiently and communicating with each other, it's a huge source of comfort to them. Because in our fractionated electronic medical records, between the same group, you share the EMR. But everybody knows if you're trying to communicate with people outside of your electronic universe, it's a nightmare. And you don't get records on time, and you don't get the correct records. And the communication in a lot of
cases is awful and the patients feel that fragmentation. And they feel like they're not cared for, and they feel like there's no team looking after them. And so the ideal, as you just described, is to have their prostate cancer treatment team in real time, communicating with each other.
0:20:54.1 ME: 'Cause I've had that experience where I've said, "Let me step out of the room," and I come back in, I said, "I just talked to Dr. Soandso, the radiation oncologist, we agree that X is the best way to go," and the smile just comes across their face. There's no better feeling than feeling like your team is talking to each other, they've got your back, and they're creating together the best plan for you. So absolutely, that's the ideal. And I think we... In a lot of areas, we fall short of that, but the more we can sort of integrate and communicate, and even if we're not in these collaborative systems, if we can make that phone call to the radiation oncologist that you referred the patient to,
you may not know the person, but if there's any... Ring them up and say, "Hey, listen, we've got this common patient, can we talk about the treatment plan?"
0:21:34.6 ME: There's no better feeling for the patient, of feeling like their team is actually collaborating, looking out for them. I want to sort of move towards the use of genetic testing, genomic testing in prostate cancer with respect to both early diagnosis and picking candidates for active surveillance. But when we talk about cell cycle progression scores, for example, the Prolaris test, not only have I found it helpful in my practice, and I want you both to talk about whether or not you use it and how you use it. I found it very helpful in my practice to help support a decision for active surveillance if their genetics are favorable. But a couple years ago, there was a second cut
point that was developed after a lot of research, looking at a single versus multimodality threshold for Prolaris. And in the radiation world, that gets to whether or not there's a need to add the LHRH prior to and concurrent with and after radiation. And the data actually sort of changes, or at least challenges some of the historical paradigms of how long we need to use LHRH particularly in favorable intermediate risk disease and unfavorable intermediate risk disease. And so I'm interested for both of you, do you use cell cycle progression scores? How do you use them? And particularly for Dr. Ding, do you use it early on, do you use it with respect to sort of the active surveillance
discussion, and what do you think about it with respect to that multimodality
threshold?
0:23:18.1 ME: And oftentimes, I'll send patients to radiation oncologists and I'll put in my note, "They may have unfavorable intermediate risk disease, but their cell cycle progression score is down in the single modality threshold." And I may still talk to them about a short course of LHRH, but in my practice, these are the guys that come back into the clinic and they're just miserable from the hormone shots. The hot flashes are awful. If I've got a cell cycle progression score, a Prolaris score that shows single modality, I feel much better about taking them off of their hormones because the data would suggest that they may not actually be getting a good benefit. So that's
what... I'd like you both to touch on the use of cell cycle progression or any other genomic testing, genetic testing that you might use with respect to decision making along those lines. Let me start with Dr. Ding. Do you use genetic testing, and if so, how do you use it?
0:24:10.7 WD: I do. So normally, I find it most useful to use it for patients who's got an
intermediate risk disease. And especially for patients with a low volume, unfavorable intermediate risk, 4 plus 3 disease, where they have other comorbidities such as diabetes, cardiovascular comorbidities, where I'm trying to give myself a reason not to offer hormone therapy. So I think that is the most valuable thing in terms of using Prolaris or any other of those genetic testing.
0:24:46.5 ME: Dr. Rajan, what do you think?
0:24:47.7 RR: I get Prolaris just on about anybody I diagnose with prostate cancer, either if it's active surveillance, it can maybe shift us away from active surveillance or make the patient feel comfortable that they're choosing the right option. And it's very helpful if I have somebody who's high risk, and I think they're gonna need multimodal treatment, whether it's surgery with radiation or radiation with hormones. There's the paper I can show the patient and they sort of say, "Yes, I'm probably going to need more than one treatment," so they're more accepting of having LHRH agents and/or it won't be a shock after surgery that they have positive margins and will need
radiation. So I really find it helpful in just about every man with prostate cancer. The more data we can get without risk, I'm happy. You know, the one size fits all
we used to do is slowly gonna go away.
0:25:44.4 RR: That's a very good point. One thing that I wanted to add on tailoring treatment is the addition of the PSMA PET scan, for me, I think has really changed my practice. So maybe not for your practice as much, because you don't really need to know where exactly the positive lymph node is, right? If there's a positive lymph node, you go a certain way. But for me, with the addition
of the PSMA data set, I am now able to dose escalate these previously unseen sub centimeter pelvic lymph nodes where I could get them a better local control or even talking about cure for patients who's got a lymph node... A pelvic lymph node metastasis, where... Whereas 10, 15 years ago, we weren't talking about that. So I really find that that has been really beneficial for me.
0:26:42.4 ME: That's a great point, Dr. Ding. It was actually gonna be one of my other questions, is, how is your cut point moving with respect to who's a candidate for primary radiation therapy to the prostate and pelvic nodes based on this PSMA data, which is new for all of us? We're seeing the uptake in these areas that never would've been caught on a bone scan, and most of the times, a CT scan would not have caught. So you get a small amount of uptake, for example, and maybe you've got a pelvic node, but maybe you've got a small, single retroperitoneal node higher up in the abdomen. Is that patient still a candidate for primary radiation therapy? And maybe you hit that
abdominal node, how do you make... Where's your cut point? How do you make that decision?
0:27:20.3 WD: Boy, that's a tough one. If it isn't the true pelvis and that I could get to it without overdosing a small bowel constraint, then I will go for it. The higher up you go, the more likely you're going to have a situation where the lymph node is too close to the small bowel, and that by delivering a tumoricidal dose to that lymph node, may increase your risk of having long-term small bowel toxicity. So it really depends on the location of the lymph node and how far it is to other critical structures, but it definitely has helped me really kinda hone in to these sub centimeter lymph modes that we would've never seen on MRIs or any CT scans prior to the PSMA.
0:28:14.2 ME: Very good.
0:28:14.3 RR: PSMA will change prostate cancer treatment. I'll give you a couple of scenarios. Honestly, we shouldn't... Instead of getting the 3T prostate MRI, give me a PSMA scan. I have more faith in that. Of course, we're not getting it early in this gentleman, and we're not getting it on anybody who hasn't been diagnosed with prostate cancer. But ultimately, I think it'll be more accurate. And stepping away from the radiation, but Focal therapy with PSMA scan will be the new frontier.
0:28:41.8 WD: Absolutely.
0:28:43.8 ME: I completely agree. And before we finish up here, I wanna circle back to the use of genetic testing. And Dr. Rajan, I think my practice is similar to yours. I get a reflexive Prolaris on all of the prostate biopsies that I do, because I think the information is useful whether or not they end up with lowgrade
disease or whether with high grade, more locally advanced disease. 'Cause I
think it's extremely helpful. Traditionally, it's been, in my practice, mostly used for decisions around active surveillance. But even in the higher grade diseases, certainly that single modality, multimodality cutpoint data, I think is really important. It's important, I think, for the viewers to understand also that Myriad has a standalone BRCA test, and so anybody who presents with Denovo metastatic disease, highrisk
or metastatic disease, most insurances are covering a BRCA test. And the interesting thing about the BRCA is, you can send a BRCA and if it's negative, it can reflex
to a MyRisk panel, which we were talking about earlier, which is the larger suite of genes that all peripherally relate to prostate cancer in one way or another.
0:29:54.6 ME: It's a nice way to get that MyRisk information for patients without dealing with the family history thing. I think that's been the main barrier to ordering MyRisk, is that you need these really complicated family history algorithms and gleaning family history is time consuming, and patients are often times... Don't have the specifics about their family history. So it's been a challenge, but if you order a BRCA on the appropriate patient, again, high risk, metastatic disease, Denovo metastatic disease, order the BRCA, it can reflex to a MyRisk, which is really, really helpful information. So I just wanted to put that out there as a nice way to be able to glean that information without really digging into the family history tree.
0:30:29.5 RR: And Mark, are you getting the blood or are you getting saliva?
0:30:34.7 ME: We find blood the easiest. We've got a lab draw center right in our office, right in our ESC, so we have nurses that draw blood all the time, so we have the blood draw kits. You can do it either way. So the practice...
0:30:46.8 RR: We don't have... [0:30:48.8] ____ practice. We don't have somebody on site drawing blood.
0:30:51.0 ME: Yeah, they have saliva kits, which are very easy. So it's very easy to collect saliva, if you don't have blood drawing.
0:30:56.1 WD: That's what we do, the saliva.
0:30:58.5 ME: Yeah, so fantastic. Well, gentlemen, this has been a fantastic, wideranging discussion. I think it's been very valuable. I think we've provided some really interesting perspective for the listeners. Before we wrap up, any sort of last minute thoughts, any points you wanted to make that you didn't get a chance to, any closing thoughts from either of you?
0:31:17.6 RR: I guess when we go back to, say, Prolaris, or we go to genetic testing, what do we think is more accurate to characterize a tumor? Is it the visual of the histology, which is what we've depended on since microscopes were used in medicine, or is it really what we can't see, the genetics? And I think more and more, we're gonna see it's the tumor biology and the genetics that will drive it. And we'll stop using Gleason and we'll just put the data in the computer, the computer will spit out a number regarding the prostate cancer, and that's how we'll be talking about prostate cancer or other cancers in the future.
0:31:53.0 WD: I agree as well. I think that's definitely where we're going. I think at this point, I'm still a little uncomfortable to disregard Gleason altogether, but I agree with you. I think in the future, that's exactly where we're going, and as we get more data set, I think one of the biggest challenges to how to use these complex data sets like genetics, the radiographic information from the PET scan. And I think I am very privileged to have such a great group of urologists to work with, so that we're in touch with each other all the time, so that we can talk about these complex data sets to make the best decision for our patients. Because ultimately, with all this information, you need to have a way to distill that information and talk with your colleagues to come up with a
plan. And it's really that communication that brings it all together.
0:32:53.6 ME: I completely agree. And I was just gonna say, to Dr. Rajan's point, I think genetics and genomics are slowly... Well, probably more than slowly revolutionizing both the diagnosis and treatment of cancers of all kinds, including prostate cancer. And Gleason is what we've had for the last, well, probably now 50, 60 years. And it served us fairly well before we had this genetic information. There's something to Gleason, there's something about these patterns. But I liken it to... When I describe the difference to patients, it's, you can look at a race car and from the external appearance, try to decide how fast it's gonna go. You can look at the shape and the build and the size and make some reasonable estimates. But to really understand it, you need to pop the hood and look at the engine. And that's what the genetics is giving us, is the ability to look at the engine. And so I think it's gonna be far more reliable and consistent in the long run. And I also tell patients, no single test is 100%. We kind of lose sight of that. We tend to, in medicine, I think, jump on the new thing and say, "This is it. This is the critical piece of information. I'm gonna hang my hat on this, and this is the way forward." We've gotta pull back from that a little bit. I think the genetics are far superior to Gleason, no doubt about it. But the genetics, again, some of these tests also have their weaknesses. And there are sometimes reports that aren't reflecting true reality.
0:34:10.8 ME: I think they're far fewer with the genetics, but it occurs. And so we think we... I don't see us getting to a point where we're completely throwing out Gleason. I think it's gonna slowly become of lesser and lesser import to the total decision making. But when I describe... When I'm talking to active surveillance patients, I say, "Listen, we are collecting data from all different sources and the decisions we make are based on an accumulation of the data." Now, some of those data points are stronger than others, but it's your biopsy, it's your surveillance biopsy, it's what your PSA is doing, it's what your genetic score is telling us. All of these things, it's important that we pay attention to all of those signals because no single signal is infallible. I agree, the genetics seem to be
far more reliable than some of the others, but they're not foolproof either. So I think it's incumbent on us to continue to continue... Collect as much information as we have available to our fingertips, appropriately weighted, depending on the data that supports it, but continue to watch all of the different signals that we're getting on our patients, and counsel them appropriately.
0:35:13.5 RR: Yeah. Very well said, Mark.
0:35:15.3 ME: Yeah. Gentlemen, thank you so much for joining us tonight. I'm gonna bring this to a close. Really appreciate your time and efforts, and hopefully look forward to having you back on a future episode.