SHOW INTRO (00:01.038)
Thanks for tuning into Tier One Health and Wellness podcast, the podcast that’s all about bringing you cutting edge evidence based insights on all things related to hormones and how hormones can and do impact your overall health and well -being. And now here’s your host, Dr. Keith Nichols.
DR. KEITH NICHOLS, MD (00:22)
I’m excited as one can be to welcome Dr. Joseph Bush today to the Tier One Health and Wellness podcast. Dr. Bush, it’s very rare that I get to interviews with someone or be with someone that I so highly respect and who is so much an expert in their field. Dr. Bush is an oncological radiologist at the Bush Center in Alpharetta, Georgia. I personally utilize Dr. Bush for my care as I’ve made it very clear and it’s okay Dr. Bush today to to divulge any information, my medical information, it’s free for everyone.
to hear an open book about my experience that I’ve had with my elevated PSA since I was a young man. So it’s something that I actually follow. I’ve had multiple MRIs all around the country. There’s not a better facility in my opinion in the country to get an MRI or have your prostate evaluated than at the Bush Center by Dr. Joseph Bush. We’re going to talk a lot about that today on this podcast. So Joe, if you don’t mind, please introduce yourself and tell us what you bring to this field.
Well, Keith, that’s a very generous introduction and I appreciate that. As you know, I’ve been in this prostate imaging world for 15 years. I’m one of the first doctors in America to actually do consistent imaging of the prostate gland with MRI. I first saw this technology in 2009 in Munich, Germany.
And when I tried to learn the technology, I ended up having to go to Europe to learn all the different techniques because Europeans obviously were way ahead of us. And I’ll explain more about that a little bit later. It’s very interesting. I’ve been interested in oncology because in 1998, my wife and I, Kathy, we were the first private positron emission
DR. KEITH NICHOLS, MD. (02:22.51)
and we really took a lot of abuse. Nobody really knew what PET scanning was, but as we all know today, it’s a very key imaging technology in all forms of cancer. And in the prostate cancer world where I work, PSMA, PET -CT, prostate specific membrane antigen imaging has now been approved in America.
at least two years ago. However, Kathy and I used to take people to Europe for at least 13 years to get this important test, which we now are drinking like water here in America. It is an important test for metastatic disease. It is an important test for staging advanced prostate cancer or high risk prostate cancer.
It’s not a very good test for initial diagnosis. There’s some research being done on that, but in my opinion, with the new MRI technology that we’re using, we have the ability to see and diagnose three millimeter, four millimeter early serious cancers. Going back on that, yes, I’ve been in radiology.
since 1973. So I’m really old at this. I’ll be 79 here directly. So I love my practice because after being in medicine over 54 years, I don’t really, I don’t have to notch my gun. I can relax and take my time with patients. Every private clinic is Keith, as you pointed out, as you know, there’s not a lot of people in here every day. We don’t try.
We’re not trying to knock down numbers. We’re not an insurance model. We are a concierge of boutique type practice. I fully expect to spend an hour with my patients after the imaging. In my personal opinion, if a family comes in here, a husband and a wife, and they’re greeted with the diagnosis of cancer, you know, you can’t get a 10 minute.
DR. KEITH NICHOLS, MD. (04:44.366)
interview and kick you out and say go read about it. You really need to inform your patient of cancer. And you and I are talking about prostate cancer since you’re in the testosterone world. And prostate cancer, the majority of prostate cancer is not dangerous. As I can show you on a slide here, you know, when a PSA is elevated,
Most of the time it’s secondary to prostatitis. And you can imagine the problems I had during COVID. COVID definitely raises the PSA and you don’t need a biopsy. You need an MRI, a good MRI. Now we’re going to talk about that because currently in America, the standard of care is the PSA.
And when the PSA is four, you’re gonna get sent to a urologist and they’re gonna want to biopsy you. A good urologist will get a good MR first. The finger waves, as you know, the finger can only feel the bright side of the moon. It cannot evaluate 60 % of the rest of the prostate. And now the blind random trust biopsy where they just put needles in your prostate.
They recommend the biopsy without an MRI. Well, at the American Urology Association International meeting two weeks ago in Texas, they stated that it’s up to 50 % error rate. Why would you let yourself undergo all this with all these error rates? I mean, it is not an accurate way to make a diagnosis. The most accurate way to make a diagnosis is going to be MRI of the prostate.
The problem with that is, how are you going to get a good MRI? Well, we’ll come back to that. But what does MRI do? Why is MRI so good? Why does it work? It works because the reality is you’re trying to evaluate tissue density. And what the MRI can accurately measure is the movement of water molecules in the tissue.
DR. KEITH NICHOLS, MD. (07:09.518)
And the prostate gland makes water. That’s what it does. It makes the ejaculate because the vagina will kill the sperm. So the water will change the acid -base balance and allow those things to swim. Those sperm can then swim nicely and she can get pregnant. So as you get older, what’s important to you is not trying to have children. You still want to maintain an erection and you want to be able to penetrate.
and you want to have the feeling of a good climax. It has nothing to do with the water. What the MRI does though is measure the movement of water and tissue. Now why is that important? Because if you look at the different kinds of cancer in the prostate under the microscope, in other words, look, this is low grade cancer here, three plus three. This is intermediate grade cancer, which is the sevens.
and then the high -grade cancers are the eights, nines, and tens. And this scheme of looking under the microscope is that the first number represents the dominant field that the pathologist sees when he looks under the microscope. For instance, in this corner here, you can see that here’s the threes and here’s all the fours, these clumpies, these groupies. So this is a four plus three.
And then this, God forbid, is a five. And you can see that water molecules are gonna move real easy here, and they’re not gonna move well here. Well, what Dr. Barron in the Netherlands figured out, and he won one of the highest awards in MR medicine for this, is that the cancers, the different kinds of cancers have different water velocities, and they can be quantitated.
And I was extremely blessed by the good Lord to be in the Netherlands when they did all this research. He did these thousands of patients where he showed that the speed in the normal prostate is here, the Gleason sixes are here, the sevens are here and the eights are here. So if you do a good MRI, you can calculate the velocities, the diffusion coefficients.
DR. KEITH NICHOLS, MD. (09:34.286)
And you know before you ever stick a needle in a patient that I’m going to be dealing with a six or a seven. Now it’s very accurate. I’ve been using this chart for 15 years. And it’s, in other words, I can look at your MRI and I can tell you you’re going to have a low grade Gleason 6 and I’m not going to bop you because Gleason 6 is no longer considered cancer. Dr. Lonnie Klotz.
Put this slide out there in 2010, Gleason 3 does not act like cancer, but 4 Gleason 4 does. So I am looking for Gleason 4s. Well, you can imagine this created quite a controversy in urology. So what they did is two very important doctors in the field, urologists, Dr. Edinger and Dr. Ross went back and looked at 26 ,000 men.
that had radical surgery on their prostates for Gleason 6. And none of those people had metastatic disease. And the ones that did get metastatic disease did not have Gleason 6. So therefore, most people believe that Gleason 6 is not going to kill you. The problem with Gleason 6, if you have it, is do you have any of this little microscopic four in the background
And is it gonna grow up and give you a problem in the future? Well, the way you follow that is you get an MRI. You don’t stick a blind needle in your prostate. And what you have to do is you have to come in every year, like the women, they get their mammogram, you have to get your manogram. And usually, if you have a significant cancer in there, in the last 15 years, it’s been my experience.
that it’s going to pop out within three to seven years. I used to just think it was three to five, but after this COVID business, I had two patients this year that after their COVID shots, the vaccines they converted to a higher grade tumor. I don’t know that the shots did that, but it sure does make you suspicious. Why did they all of a sudden change? The MRI.
DR. KEITH NICHOLS, MD. (11:57.71)
can see these cellular changes. And the public has a misconception that it has to be a T3 or a three -testler magnet. It’s not true. The diagnosis of these water molecules moving is actually made with a gradient image. So the electrical gradients become very, very important.
So you have to investigate what type of machinery do they have, how strong are their electrical gradients? And some of them, even though they’re 3T, are pretty bad. So you have to think about that. So anyway, the MRI is very, very accurate because if you try to do the blind needle biopsy, you end up sampling like 1 % or 2 % of the gland.
You ask your doctor, well, doctor, what’s in the red? You know, there’s your 12 needle biopsy, but what did you miss? And then the other thing is, and this has been my experience. For instance, we used to say that blind biopsies have a 40 % error rate. I actually have one patient that went 162 needles over a 10 year period.
and they missed his anterior Gleason 9. I had another patient that actually took 12 needles every year, which is the standard of care, 12 blind needles. And he did that for 10 years. That’s 120 needles. They missed his cancer. And when he came in for his MRI, not only did I see his cancer, which was a Gleason 9, he already had metastatic disease to the bone, which I could see.
is a very upset patient, but like I told him, the doctor in 2019 was following the standard of care. MRI was not recommended. You have to remember that 15 years ago, the way I was laughed at with PET scanning, I had a lot of people laughing at me about MRIs. But that – Well, Joe? Yes. Joe, not to interrupt you, but our listeners are going to question, well, why is that? I mean, how in the world can this be?
DR. KEITH NICHOLS, MD. (14:22.318)
If it’s going to miss 40 % or more of cancers, why is that the standard of care? And I think it’s real important that we understand a couple of things that you’re pointing out is that number one, the prostate is literally the only area of the body that we now continue to blind biopsy. If it’s anywhere else in the body, it’s not a blind biopsy. Well, why would that be? Why is that? Well, it has been published and written, and I’ve said this before, that if you took away
biopsies and radical prostatectomies, literally 50 % of all urology practices will go out of business. So there is a, there are politics and economics involved with regard to these tests. I didn’t get into that, but the Europeans, they’ve already got two published studies showing that if you get a good MRI, 40 % of the biopsies would go away in America. You’re talking about millions of dollars. I mean,
When I practiced in New York, I mean, a biopsy up there could cost $23 ,000 by the time you throw everything at it. I mean, it’s not that it was a bad biopsy. It was a very interesting fusion targeted biopsy with anesthesia. But when you throw all that together, if you had a good MRI, for instance, when I also practiced in Florida doing MRIs of the prostate, I actually had an episode where I went down there and told the doctor,
and told them you’re going to do 12 patients tomorrow that you’ve been told have cancer and none of them have significant cancer. Well, two weeks later, they called me back and they wanted to hire me because I was right, they didn’t have cancer. But one of the biggest problems in America, since I actually teach this stuff, I would say that 80 % of the MRIs that
come to me from all over America are poorly done and poorly interpreted. And you can talk about that, how that pans out clinically from my patients that see you in a little while when we finish the presentation. But yes, we’re going to, I would love to talk about that a little more detail with the very specific examples of my own patients.
DR. KEITH NICHOLS, MD. (16:38.254)
But there’s a reason when it comes to these blind biopsies that is referred to as a poke and hope approach, right? Yeah, that’s exactly right. I mean, and of course you’re running the risk too. When you put 12 blind needles in your prostate, the bleeding goes up, urinary retention goes up, your bladder can lock down. You can also get sepsis of four to five percent a min. So that means out of every 100 you do this to,
You’re going to get sepsis. Well, I can tell you right now I’ve done thousands of these matter of fact since I’ve been in Atlanta I’ve only had one sepsis in five years and I do this every week as You know on a targeted biopsy like you’re looking at on the screen right there We pick out the target where the green area is and we put the needle guide right on the target And then we take a picture that the needle hit the target
that’s not done in general practice. They do not do that. And there’s all this new stuff about doing transperineal biopsies where the public needs to understand that when you do a transperineal biopsy, you’re gonna end up putting four or five needles through the base of your penis. Now, I think we’re gonna end up with problems with this, with Peyronie’s disease, erectile dysfunction. I’ve already had that experience.
with patients. I do not think that’s necessary. I think a good targeted biopsy is necessary. Now, fusion biopsies can be very good with a good MRI and a good fusion technique, but it then relies on your radiologist to draw a good target. And in my opinion, since cancers are chocolate and vanilla,
They’re made up of Gleason 3s and Gleason 4s. You’ve got to put the needle on the four. So you need a target within a target, if you follow me. In other words, this prostate business is really, really complicated. It’s not just, you got an elevated PSA, you need 12 needles, and you got cancer, and let’s cut it out, or let’s irradiate it. It’s not that simple. I mean, the majority of patients really don’t need therapy.
DR. KEITH NICHOLS, MD. (19:04.878)
They just need good surveillance, but you’re right, Keith. I did the first trust line biopsies. They’re not, they’re not actually blind. You can see the prostate gland. You just can’t see the cancer in Chattanooga, Tennessee in 1986, taught my urologist how to do it. And I never saw a prostate for 20 years. So, you know, but that’s not unusual in radiology.
I used to do 15 OB ultrasounds a day. And of course now those are all done in the doctor’s office with the gynecologist. So times change. Well, what I’m doing now is of course I do these in -board targeted biopsies. I mean, and I’ve proven this to some of my own urology friends that they went ahead and put an additional 20 needles in the patient and they were all negative. I mean, why?
I don’t understand why we have to stick negative tissue. If you do not see any kind of target on the other side, why are you sticking it? I mean, now if you have a, if it’s controversial and you’re not sure, I can understand putting two needles on that target. Yeah, I think there’s some recent literature out as you know that adding any additional biopsies to a target biopsy really didn’t pan out to any increased finding. There were two studies
finished in Europe where they put an additional 12 needles in the patient over and above the target. And of those 1 ,200 needles, they found one cancer that they thought was significant. Well, good. Well, before we go any further with the presentation, I just want to make sure we touch base on some of the things you’ve already mentioned. Number one, yes.
I personally get an MRI with Dr. Bush every year now. I’ve done that for probably the past five years. And when he talks about what he does after your MRI, I’ve never seen that occur anywhere else in the country. He literally sits down with his patients for an hour or more going over that MRI image by image. In fact, sometimes it’s so much time that I start feeling guilty about
DR. KEITH NICHOLS, MD. (21:32.654)
taking up his time for doing it. And like, I’m sure you’ve got more patients to go to see. So this is not just talk. This is something that Dr. Bush does that I’ve not seen happen anywhere else in the country. It has not been reported to me by any other patient when they go somewhere else because they can’t necessarily travel down there to get an MRI in certain instances. So I have patients come in to see Dr. Bush from all over the country and they all will talk about just
the time that he literally spends with you. Now you have no questions when you leave there. I’ve had patients, prior to Dr. Bush, get MRIs in other areas of the country, out west, and they literally don’t get their MRI report back for weeks at a time. They don’t know what the radiologist saw. And that can happen as well. So when he, he’s, he’s not only talking to tall, but he literally walks the wall. And
I’ve also on two occasions had a targeted biopsy by Dr. Bush and what patients can do as what I did, they can literally go get their MRI and they will set it up to where you can literally have your MRI and your targeted biopsy to follow if needed. So the majority of time I haven’t needed a biopsy and admittedly the two times that I have had biopsies, Dr. Bush was the first one to say Keith.
This is something you could probably just follow. It’s, you know, it’s going to be a low grade if anything at all. You probably just could just leave it alone. But with my first, I was like, no, I’m here. Let’s go see what it is. So I went under through the targeted biopsy, no anesthesia, nothing. It was just, it was not a bad experience at all. It was not an unpleasant experience. the worst I can explain it was like a little electric jolt. Whenever you do the biopsy that last
less than a second maybe that was it and I was able to drive there get my MRI get my targeted biopsy go home immediately after and then the next day my biopsy report is back I just don’t see that level of service anywhere else it’s just unusual for it to be that way and when he talks about the quality of the MRI that does matter that matters in all aspects of medicine as y ‘all
DR. KEITH NICHOLS, MD. (23:53.23)
You know, most of my pages though, I was one of the physicians for the pro sports teams in Nashville, the Nashville Predators for 10 years, the Tennessee Titans for two. I did all the MMA fights and in Nashville for those pro athletes, there was only two radiologists basically that read all the MRIs. Why? Because they were literally heads above all the others. All right, Joe, before we continue on with the presentation, I would like our listeners to understand that what you’ve been talking about
You don’t only talk the talk, but you walk the walk. I’ve literally had at least five MRIs with Dr. Bush at the Bush center. I’ve been to other places in the country before he started the Bush center down there in Atlanta, Georgia. And whenever you go to the Bush center and get your MRI, he literally takes an hour or more after that MRI to explain every single image to you. In fact, there’s been instances there where I felt guilty.
for taking up so much of his time. And I just don’t get that level of service. I haven’t had any of my patients get that level of service anywhere else in the country. I’ve had patients that couldn’t travel to Atlanta that got an MRI somewhere else, and they literally had to wait on their results for weeks at a time. Not understanding that they didn’t know if they had cancer, didn’t have cancer. And so that’s just not the level of care you get from the Bush Center. It is exceptional. When he talks about the quality of the MRI.
that does matter. It’s the quality of the radiologist and the quality of the MRI. In fact, there are studies done with prostate MRI that identified that the experience of the radiologist made a huge difference in diagnosing cancer on these MRIs. But the quality of the MRI and the quality of the radiologist was also important in my field in spinal and sports medicine. And I was dealing with the athletes in Nashville. The Nashville Predators are one of their team positions for over 10 years. I worked with the Titans.
of the Nashville Football League for over two, there were only a couple of radiologists that read those MRIs because they were literally heads and shoulders above others that were just exceptional in their field. And that’s what Dr. Bush is. He’s exceptional in this field and people need to understand that all MRIs are not equal, all radiologists are not equal. All right. In my opinion, Dr. Bush is the rock star in this field. He’s at the head of the pack. Now, on a personal note,
DR. KEITH NICHOLS, MD. (26:16.782)
I’ve had biopsies on two occasions by Dr. Bush at the Bush Center. And what’s so great about the Bush Center is myself as well as my patients can literally drive in or fly in, have their MRI done, and have a targeted biopsy to follow if we see anything suspicious. And I’ve done that on two occasions and immediately Dr. Bush told me on both those occasions, Pete, it’s going to be level -graded or nothing. I really probably wouldn’t worry about it. We should just follow it along. But being the way I am, like,
Well, I’m here. Let’s just, let’s just see what it shows. Let’s just make sure. And so we did. And let me tell you, it was not a bad experience. It was, it was, I did not have any sedation or any anesthesia. And the worst I could say it was, was literally a second or less of just an electric type shock that you feel when they take the biopsy. And that was it. I was able to go there, have my MRI, have it explained to me in detail, have a biopsy to follow.
And then I was able to go home and I got my biopsy results the following day. And you just can’t get that level of care in very many places in the country, in any medical field. And lastly, when it comes to the quality of the MRI, I was going to kind of save this to the last, but I’ll save it for now because we’ll talk about your treatments for prostate cancer. I’m sure. But I’ve literally had men that couldn’t get their MRI there.
but where they were able to send their MRI report to Dr. Bush and he will over read another facility’s MRI. And what has happened on several occasions are two things. Number one, they were told they didn’t have prostate cancer. Dr. Bush reviewed the MRI, but in fact, that radiologist missed prostate cancer. They were subsequently cleaned by Dr. Bush, had the targeted biopsy, and he was correct. It was clinically significant prostate cancer.
I know of at least two other occasions that patients were told they had prostate cancer. And of course they were recommended that they undergo a radical prostatectomy. The patients literally called me in a panic and I said, look, let’s have Dr. Bush over read that MRI. He did, and it was not prostate cancer. And those patients, two patients, two men at least, were able to avoid a radical prostatectomy for cancer they didn’t have.
DR. KEITH NICHOLS, MD. (28:38.894)
So that is my clinical experience with Dr. Bush, my personal experience with Dr. Bush. I cannot highly recommend him enough. So I hated to interrupt the lecture here, but I just had to get that in there because I have just so much respect for this man and what he does. Very generous of you, Keith. One of the things that we did here, I have to admit, this was the first clinic of its sort, a man’s clinic.
in America, we’re very focused. I mean, we image the prostate, we biopsy the prostate, and we treat the prostate with only one modality. And if you fit, it works. If you don’t fit, we can’t treat you. But by being a cash model, instead of the insurance industry is horrible. They won’t pay for anything. They want pre -certifications.
I used to love to get the letters when I was in a group practice and it would say, we approve for you to do this MRI, but this is no guarantee that we will pay you. It’s just, they’re horrible. And we know for a fact now when they’re going to deny automatically many things that you order, they’re going to deny and hope that you go away. It’s just tragic.
And one of the reasons I have to give kudos to my colleague, Dr. Richard Hessler, the pathologist at the University of Tennessee in Chattanooga at Erlanger Hospital. He’s been reading my prostate biopsies for 15 years. Richard has a keen interest in prostate. He’s been backed up by the Dr. Epstein clinic at Johns Hopkins. Those are the only two people I use.
and they usually always say the same thing. But Richard loves reading my biopsies because 99 % or 98 % are gonna be positive. So like he says, he comes in every morning with a cup of coffee. They got Dr. Bush’s slides are up first. He says, I don’t have to wade through all these negative biopsies. I know that you’re gonna be, he says, as a matter of fact, if you’re,
DR. KEITH NICHOLS, MD. (31:01.646)
If your biopsy is negative, and he’s right about this, he usually calls me or what he does is additional slices through the tissue because he can’t believe it’s negative. And so he enjoys reading my stuff the next, the day after the biopsy because he knows I don’t like to biopsy a patient unless I think they’re going to have a significant cancer.
And to Keith’s point, I recently had a patient that I told the patient, his wife, that I really don’t want to bopsy. I think he’s going to be all right. But the gentleman also has BPH symptoms, which we can treat at the same time that we treat prostate cancer. But I literally begged him not to have it. And he says, no, Dr. Bush, I’ve flown all the way from California. I want you to put, as you said, Keith,
anything that’s suspicious. I said, all right, I’ll give you three biopsies. And all three of them came back negative. I mean, but I understand how patients feel, understand what they’ve been told. The big C word, as you know, Keith, really cares patients. And you have to understand that in the prostate world, the majority of cancers are not going to be dangerous.
Europe, as well as myself, we watch a lot of patients with three plus four. I personally believe that the future of prostate cancer is going to be genetics. And I don’t mean family genetics. We’re already learning. And thanks to Dr. Hessler, the pathologist, he’s the one that got me on this in 2012, long time ago.
We started pulling gene profiles on our patients that had aglisan three and aglisan four. In other words, is this a good four or a bad four? We’re learning that people actually have fours that act like threes. So do you really need to give them therapy? Do they really need to be treated? So my philosophy, Keith, is stay as natural as you can.
DR. KEITH NICHOLS, MD. (33:26.414)
for as long as you can. I mean, it’s kind of like what you do. It’s the testosterone thing. you got cancer. You can’t take testosterone. Well, you and I, we’re following so many patients with Gleason 3 that are taking testosterone. I think I’ve lost count and nothing’s happened to these people. I mean, their quote unquote lesions don’t grow because Gleason 3 cells take 400 and…
over 400 days before they duplicate themselves. And by patients taking testosterone, it does not accelerate that growth rate. If anything, it inhibits prostate cancer cell proliferation. So it’s the lower levels, the men that don’t get testosterone, they’re probably going to progress according to the medical studies, not the men on testosterone. That’s exactly right. And of course, in all honesty, that’s a reason that Keith and I do some biopsies.
Because we honestly want to know, yes, this is abnormal, but what are we definitely following? Does it have any four components? Is it all three components? And that’s why the precision biopsy is so important. You don’t just put a bunch of needles in and say, come back next year because we didn’t find anything. And just because you’re on testosterone therapy, I think you should be watched.
But, but once you know what you’ve got, then, then we’re, we’re, we’re operating in a safety mode. In other words, we know what you’ve got. We’re following both your T and your MRI. And if it does change, we’re going to say it, we will see it. And, and those numbers that I was telling you about those diffusion numbers, when a, when a cancer D differentiates the ADC numbers go down. I have seen that.
I got one famous case that got Dr. Epstein and Johns Hopkins involved. The poor guy had a four millimeter lesion that I followed for almost five years. And what happened was, all of a sudden it got a little bit bigger and those numbers plummeted. They plummeted from 800 to 900 all the way down to three or four.
DR. KEITH NICHOLS, MD. (35:53.326)
203 on it said man we got a bobsy this this is four millimeters we got three millimeters you can’t try that was a Gleason nine So so he undo and of course he had a giant glance so we underwent Of course they wanted to think about that. They wanted to take out his land for a four millimeter leaf. I mean that that’s just I That’s like taking a shotgun to blow away a fly. I mean it’s just not
And the Europeans believe that once you have a Gleason eight, nine or 10, they don’t care what you do. You’re probably going to get metastatic disease. So why not keep the guy’s sexual life? Why not keep him out of diapers? For instance, I’ve now treated Keith. I’m now at 342 men treated with Tulsa technology.
I’ve got zero diapers and zero pads. Well, we need to talk about that in much more detail about the treatment options for these men, but for our listeners to kind of consolidate what we’ve been talking about is the reason that we recommend these yearly MRIs is because you can see any subtle changes. You’re able to compare year to year to year. So we’re able to follow these MRIs along. That’s an important…
aspect of getting a yearly MRI if you’re at high risk. But also people who are as you will, MRIs aren’t perfect, they miss things. Well, I got to boost propel you. You see the bad ones. You will see the bad ones in an MRI. Yeah, good MRI does not miss a bad cancer. Does not miss a bad one. And so yes, it’s important that we get these follow up MRIs so that we can follow them along and look for any subtle changes. And once again, that MRI will see the bad ones.
Touching on some of what Dr. Bush has said, I wish that I could turn back the hands of time for some of the men that I’ve seen that I have on testosterone now that had radical prostatectomies for Gleason grade six, as well as for three plus four, and then a smaller area of the prostate. Those men, unfortunately now, as Dr. Bush said, they’re incontinent and they’re impotent, unfortunately. And they could have avoided that treatment, but so many men will tell me,
DR. KEITH NICHOLS, MD. (38:15.278)
I just didn’t know, I wasn’t told. So my patients always know, I’m always repeating this over and over again, an informed patient is the best patient. We wanna provide them with much information as they can, so they can make an informed decision. So now we’ve talked about the importance of an MRI, a quality MRI, a quality experience radiologist reading the MRI. We know that Gleason grade six is not considered cancer. We know the importance of following MRIs along.
But Dr. Bush, once somebody is diagnosed with a clinically significant cancer, out there many men are only told you’re going to undergo antigen deprivation therapy and you need a radical prostatectomy. That’s the standard of care. These men were not told about their other options. So please tell us about the options offered at the Bush Center, which I’m just going to go ahead and say right up front. When I’m diagnosed with my prostate cancer, I’m at high risk, I’m going to have Dr. Bush treated with a Tulsa.
So Dr. Bush, let’s hear how we, once a man comes into the clinic, he’s diagnosed with prostate cancer. What’s the next step? Remember the standard of care is the blind biopsy. The standard of care is if your PSA is four, you get a biopsy. Well, that’s, you know, that’s changing in other countries. It’s already changed in Europe. It’s changing in America too, as well. I thought it was really interesting that the international conference
the AUA conference in Texas recently that the Urology Association is finally mentioning that, you know, you don’t need the blind box. You should get an MR first. Okay. And all the error rates with that. Well, what’s going to happen is same way with this Tulsa. Now Tulsa stands for transurethral ultrasound ablation.
of the prostate Tulsa pro and what it is it’s high intensity ultrasound waves which are shot out of the urethra into the prostate gland. So it’s inside out therapy. Okay. Now why am I involved in all this? Well, I was taking people to Europe to get focal laser ablation.
DR. KEITH NICHOLS, MD. (40:39.502)
for very focal disease. And Dr. Jurgen Futterer in the Netherlands where I’d learned all this stuff from Dr. Futterer and Dr. Battens at Rebound University there. I mean, I must’ve been over there at least eight weeks over a period of time. But at the same time, I got to see, my wife actually saw
a Tulsa procedure while she was over there with one of our patients. And she said, Joe, you got to come see this. This is interesting. They can shoot the whole gland. In other words, just like radiation, just like surgery, but it’s very unique in that you carve out the sex nerves or the neurovascular bundles. You carve out the external sphincter and the pelvic floor musculature. As a matter of fact, I now have three different
They’re not publications, but three different presentations. One of them has been published in Europe, but where my latest one is that I have treated men on their external Sphincter wearing pads and diapers. And you got to remember that urologists feel that if you just wear one pad a day, that’s okay. You don’t want to wear any pads. You want, you want zero pads and you want zero diapers. Well, the Sphincter.
which is at the bottom of your prostate and surrounded by four muscles. When I’m doing a Tulsa Pro procedure, I can see that sphincter in three planes. In other words, almost like it’s three dimensional. So Tulsa Pro has the ability to just carve out a little piece of that sphincter where the cancer is touching and five to 10 millimeters on each side of the cancer.
so that we save over 50 % of the sphincter and we save all four pelvic muscles. Therefore, all these guys are dry, but we still kill the cancer. I’ve got my latest paper is gonna be 65 patients treated, only three recurrences and all three of those are Gleason 9s on the sphincter, but they’re all dry. And you gotta remember that Tulsa Pro is,
DR. KEITH NICHOLS, MD. (43:04.942)
Keith was talking about impotence and incontinence. You don’t burn a bridge with Tulsa. If you fail, and out of 342, I’ve got 31 failures in that I’ve had, which is really, really good compared to other technologies. And my main failures have been the Gleason 9s, which fail no matter what you do.
I’ve also had out of almost 30 Gleason 8s, which we’re not supposed to treat. I’ve only had two recurrences. I mean, it is a good technology. I mean, granted, I’ve only got three years of data, but on my data, I’ve got an 88 to 90 % retention of sexual function, zero incontinence. I’ve only got six strictures.
All treatments have urethral strictures. That’s where your urethra goes from a four lane highway to a one lane highway, secondary to damage from either surgery. For instance, one of my colleagues in Chattanooga has had three stricture operations since their prostatectomy. I mean, everything we do to the prostate can cause problems.
Radiation causes strictures, all the ablation therapies cause strictures. However, Tulsa has the lowest stricture rate in the industry. And it’s my understanding to right now, we have no documented cases in all the history of Tulsa that the colon has been injured. And what I heard recently is that our poor secretary of defense, who everybody knows,
has had all kinds of problems since his surgery for radical prostatectomy has now got a colostomy. I did not confirm that, but I was told that by the people that were involved in Washington. And as everybody knows, he had all kinds of complications afterwards and have to kept going in. Well, that’s just not the case with Tulsa. With Tulsa, you go home, what I…
DR. KEITH NICHOLS, MD. (45:30.83)
What I didn’t like when I first saw it in Europe is that number one, you had to spend a night in the hospital because they were using general anesthesia. Number two, they were using guide wires and catheters to insert the device. And so number three, it just seemed to me at night when I was sitting in the hospital with my patients, why can’t we do this on an outpatient basis?
Well, I’m here to tell you we have now done 342 patients with inserting that device with no guide wire and no catheter beforehand. And number two, we use pro -patho. And it is like general anesthesia. We do have a respirator in the room that will breathe for the patient if they don’t breathe with an LMA tube. But we usually don’t have to fool with that.
It’s allowed us to do patients with sleep apnea. It just gives us a bigger safety margin. So you have any images here in your presentation of the Tulsa procedure itself? For instance, everybody wants to think of Tulsa as it’s just being a focal procedure. Well, it can be a focal procedure, Keith, but the older I get, the more I see that, for instance, I’ve now got 13 patients where I’ve
begged them to let me do the whole gland. They wouldn’t let me do the whole gland. And now they’ve got another cancer where we didn’t treat them. Okay. That was going to be a question of mine and cause other people, you know, our listeners may ask that we know everybody knows the prostate’s got two sides. And so a lot of clinics will just treat one of the sides of, you know, localized therapy there. The problem is there’s such a high risk of it developing on the other side. So that’s what we’re about to hear from you now is about.
the importance of maybe whole -gland ablation for some of these cancers. My colleagues in Europe are working on how can we make sure, what is the better way to look at a good MR and say, ooh, this is not going to be a good focal case. For instance, this case here, you can see this gentleman has a little abnormality right there. But if you look at him on the rest, he’s pristine on the rest of his prostate. There’s absolutely no other abnormalities.
DR. KEITH NICHOLS, MD. (47:56.174)
big beautiful white peripheral zone, but this is abnormal. So I stuck a needle with a targeted biopsy and God bless him. It comes back four plus three. Well, I stuck that because I knew he had bad numbers, he had bad diffusion coefficient, and I knew that was going to be a seven. It even came back up a big four. Well, Tulsa can treat that very nicely by just easily
burning that focal lesion out. Well, this guy was 50 years old. The rest of his gland was pristine. I don’t mind that. One of the beauties of Tulsa procedure is that you can do whole gland therapy. In other words, you’re equivocal to radical prostatectomy. You’re equivocal to whole gland radiation therapy. And one of the things I love about it is I’m not a fan of ADT.
As Keith mentioned earlier, over my 15 years of interviewing patients that have had ADT therapy for years, they all say, hey, Dr. Bush, I’m not doing that again. I mean, I understand that it’s necessary when you have polymetastatic disease and metastatic disease that’s scattered over lots of your body. I get that.
But the Europeans now, if you have less than five lesions, they tend to just shoot them with the radiation and don’t give you ADT. In other words, you can kill the cancer without ADT. Well, Tulsa kills the cancer. It’s not, and what we’re trying to prove here at the Bush Center is that we can kill Gleason eights, nines, and tens as easily as we can kill the Gleason sixes and sevens.
although I prefer not to treat a Gleason 6. But so as you see in these pictures, the beauty of what we’re doing when we ablate the entire gland is we do not ablate the external sphincter and we do not ablate the sex nerves which are sitting in the blue. In other words, they are exposed to heat.
DR. KEITH NICHOLS, MD. (50:20.462)
So there can be a delay in the erectile function of the patient over a period of time. But we’ve actually had patients improve their sex life over a period of 24 months. And even in the international trial, this trial, the TACT trial, which people can look up in online, the TACT trial, T -A -C -T.
This is what made Tulsa approved by the FDA. Because if you look at their record, it was far superior to surgery, radiation, or HIFU, which is the same thing I’m doing, only you shoot the energy over the rectum and into the prostate. So they have a much higher rate of urethral stricture, and they have a higher rate of
You can see my numbers and I keep up with my numbers. I’m at zero. I’ve got six men out of 342. I got zero. I’m about 88 % of maintenance of rectile function and I’ve only got 31 recurrences, infield recurrences. I do have 13 men.
that have occurred outside of the treatment, even though I insisted on whole gland therapy. But I try to honor the patient if I can. I’ve also got one man who has had, who banked his sperm before we treated his cancer, and he’s had two daughters after he saved his sperm since his treatment of cancer with no recurrence of cancer.
I think it’s important for men that see this, understand what they’re getting themselves into with any type of treatment. And so we want to preserve urinary function and sexual function, but when we talk about sexual function, these men, yes, they can get an erection and they can have an orgasm, but they want to ejaculate and they need to understand there’s a difference between an orgasm and ejaculation. You’re not going to ejaculate any fluid. And so people need to understand that that’s part of it to save your life. So you can see, I was the
DR. KEITH NICHOLS, MD. (52:46.606)
I was the second one in America to do Tulsa. It’s one of the reasons I’ve done more than anybody else. It’s because Kathy and I were taking people to Europe to get the Tulsa procedure. So we knew about it and we watched it and we took care of these patients before it hit America. And then once it was FDA approved, we immediately went after it.
And of course, what we have done is we’ve done the whole whole gland therapy. I’ve done partial gland, even though I am very selective about that. Now, one of the things I’m most excited about is we can treat people who’ve had radiotherapy and that that and right now I’ve retreated seven men. I’ll have an eighth man scheduled now. The eighth guy is very interesting.
He had radiation seeds. Well, the recurrence happened between the seeds. So we have a clear shot at killing his recurrence without hurting this guy. In other words, we’ll put him to sleep with propethol. We’ll put the applicator down inside his prostate. All that takes just a few minutes. Then we’ll plan the treatment. Then we’ll shoot the treatment. And of course, I’ve also now done almost 30 men with just big old glands.
I’m very proud of the fact that I’ve gotten six guys off of catheters. I had one physician in here from Las Vegas this week who, God bless him, was catheterizing himself for seven years. And he told me this week, Dr. Bush, you have changed my life. He says, I’ve now gone for six months back to normal urination after his Tulsa procedure.
And I’ve got a large majority of patients that we treat the big, if I’m going to treat your cancer and you got a big land, I’m also going to cut down the size of your big land to try to improve your urinary function. What happened in Europe is in Finland and the Finns are number three in the world. I’m number two, they’re number three. They’ve done over 200 patients now. They’re the ones that they’re the first ones.
DR. KEITH NICHOLS, MD. (55:08.142)
to treat people with no cancer. They noticed that their patients were peeing better and sleeping all night after they did their cancer treatment. So they said, why don’t we try this treatment for overgrowth of the gland? And they continue to publish that data and it’s been very effective data. And I agree with that. All of my patients that were treated for BPH have done much better with peeing. So it’s another…
I think it’s going to be a good treatment of choice for extremely large glands. For instance, a normal gland is 30 to 40 cc’s. I’ve treated multiple men over 200. I’ve treated a guy that even has 275 cc’s successfully. And I just got a poster accepted this past December at the urology meeting in Chicago where I presented.
all the men I’ve treated over 90 ccs successfully. So it’s an interesting technology. It’s growing now. Now it’s been adopted by UCLA, Stanford, John Hopkins, Mayo Clinic. I heard last week that now MD Anderson’s gonna start doing it. People are getting on the bandwagon. The problem is, in my opinion,
Once again, it takes excellent imaging and you have to understand and know what are you treating in three dimensions and how do you protect those sex nerves and how do you protect that sphincter so they don’t leak. And you can see why we use propethol because what you have to do is insert this applicator into the prostate, which using MRI guidance takes about one minute.
and then you have to properly place this rectal device. And I have a lot of respect for this device because that’s why you don’t have rectal injuries. Both these devices are like automobile radiators. The water’s running in and it’s running out constantly. So it’s active cooling of the urethra and it’s active cooling of the rectum, okay?
DR. KEITH NICHOLS, MD. (57:33.454)
And you can see on this picture why we have to put you to sleep because of course we’re putting this thing down your penis into your bladder and this thing goes into your rectum. But the number one complaint on all my patients with Tulsa is that they have to wear the catheter for 10 to 12 days. If your gland is 200 cc’s, I’m going to make you wear the catheter for 14 days.
They get tired of the catheter. Some men, it doesn’t bother. If you go on our website, you’ll see I had two interesting events in the last few weeks. One guy is a big fisherman. He comes in the next morning and he says, Dr. Bush, I feel so good. I’m going fishing today. Now keep in mind, I took out his whole prostate the day before. And so he shoots us a picture standing in the boat with about a
fast, that’s two feet long. And then an old friend of mine who’s a vascular surgeon who I treated, he comes in the next day and he says, he says, Joe, I can’t believe this. I mean, you took out my whole gland yesterday and I’m telling you, I could go to the operating room right now and operate. And I said, that’s what my, we’ve not used one narcotic, Keith.
out of 342 patients post -operatively after the treatment. Wonderful. I’ve heard nothing but wonderful. Yeah, you’re just ablating the tissue. You’re not, and the other thing, I’m training a number of urologists now to do this. And it’s really interesting. They look at the guy’s urine and they say, wow, there’s no blood in his urine. That’s right. We’re not cutting.
Which by the way, a lot of people believe that when you undergo a prostatectomy, you’re spreading cancer cells around when you’re actually removed. You’ve got to cut the prostate out. There’s going to be bleeding. I always ask my patients, did the surgeon tell you, are you going to get your blood? Are you going to get COVID blood? What kind of blood do you want transfused back into you? I mean, there’s so many factors today since COVID has come up.
DR. KEITH NICHOLS, MD. (59:58.99)
but I’m gonna keep doing this, we’re gonna keep doing, we’re gonna keep records, and I’m gonna keep my statistics. I think one thing that I don’t like in the industry, I think doctors need to be honest with their patients. How many failures do I have? How many diapers, they never tell you how many of their patients are on diapers, they just tell you the national average. Well, to me, that’s not good enough. I mean, I…
If you’ve done 2000 patients and you’ve only got 10 people on diapers, patients need to know that you’re doing a good job. I mean, I think that the sphincter, when the cancer is next to the external sphincter, which by the way, folks is right down here at the bottom of the prostate. I think that’s where Tulsa is going to really shine because the surgeon’s got to take all that out.
He’s got, he’s got to come across all the muscles and the sphincter to get it out. Wow. Well, Joe, a few quick questions here. I’m sure the listeners are going to know. Do you find any insurances now covering MRI or Tulsa? Yeah, the, the, well, MRIs net, most all insurances now will cover. We tried, we don’t file your insurance, but we have your, your case pre -certed.
so that if you do file, it should be paid for. The problem is, is how much is everybody gonna pay? We found that the Christian insurances, that there’s about three of them out there, pay for not only the MRI, they’ll pay for the whole Tulsa procedure. Some of the insurance companies have paid for half of the procedure. It is an expensive procedure. It’s $35 ,000, it’s very expensive.
And that’s why you got to do it well, because you don’t want to sell somebody a used car that’s broken in a couple of months. That’s correct. Well, it’s important that men understand that prostate cancer, the second leading cause of cancer, men behind, I guess, skin cancer, one in six men are going to get it. And the key that we’re trying to teach for this present patient is number one, catch it early. Catch it real early if you can.
DR. KEITH NICHOLS, MD. (01:02:18.414)
And the best way to catch it early, if your PSA is rising, it’s going to be that MRI scan. It’s the least invasive way, the best way. And then there are treatment options that you can avoid where you end up once again, limp and leaking. Dr. Bush likes to put it limp and leaking. So incontinent or impotent, there are options for men out there with prostate cancer besides a radical prostatectomy. And so please look at all your options. I think the Tulsa.
For me personally, it’s going to be the best option out there. And I look forward to it. It’s the best thing to keep you high and dry. The number one thing that messes up Tulsa is if you have a large chunk of calcification. We have developed new techniques here at the Bush Center to shoot around the calcification. Also the third generation robot.
which holds the device in the patient is going to be moving in three directions, which means we’re going to have a new angle to shoot around calcifications. So the technology continues to develop. It doesn’t look anything like what I first got involved with in 2018. I mean, it is so far advanced now. It’s pretty neat with the software and now they’re going to be adding artificial intelligence to speed up the process.
It’s, it’s, it, it is a unique, disruptive, technology that will change people’s lives. There’s no question about that. I’ve seen it. It’s, it’s pretty impressive. Well, for listeners out there that aren’t my patients, if they want it to get an MRI at the Bush center, which I strongly encourage they do, if they’re going to get an MRI of their prostate, or they want you to potentially over read an MRI that they over that they already have.
How can they go about doing that Dr. Bush? Yeah, the best way to do that is, and I don’t have, I don’t have a, I can’t flash it up on the screen. It’s just to call the center. You can go on our website, which is, you know, Bushcenter .com and then, or you can call 770 -424 -627 -0. That’s 770 -424 –
DR. KEITH NICHOLS, MD. (01:04:43.15)
6 -2 -7 -0. And it is the Bushcenter .com and I’ve had many pages that would literally fly in to Atlanta, get an Uber to Alpharetta, have their MRI and able to go home that day. Yeah, or also get a biopsy in the afternoon and then go home. And then go home and then go home. There’s nowhere else in the country that you can get this done. And when I say it. Same way with Tulsa. They come in the day before.
We sit down in this office, we do all the qualifications, free Tulsa imaging, which nobody else does. I mean, we’re talking about one millimeter contiguous imaging, as well as calcium imaging in three dimensions. And we go over all that the day before in this office. And then we treat you the next day. Then the next morning you come in, we review everything with you, including your catheter care.
What we did, we show you the videos and then you fly home that day. So basically you spend two nights. If you’re coming from another state, it’s two nights at a hotel. Right. Well, I literally cannot speak highly enough for Dr. Bush and the Bush center. he’s literally one of my favorite people in the world. I think he’s changed the world of what he does. And, and so if you’re interested in, in more information, please go to the Bush center, online there. And if you.
or contact my office, I’ll be glad to give a ravian review because I am an actual patient of the Bush Center. Now I have the Tulsa yet, but I’ve certainly had multiple MRIs and I’ve had biopsies and I will personally attest to the care that you get there is the best you’re ever going to get. It’s not like anything you’ve ever seen. You go in, it’s not a cattle call whatsoever. It’s your appointment, you’re the only one there. You go to your appointment and you spend an hour or two there.
all the information you could ever ask for. So I just can’t speak highly enough. It’s just one of my favorite people in the world. So I can’t thank you enough for once again coming on and speaking with us today and educating us on prostate MRI and of course the total procedure. I’ve got a great team, including my wife, my technologist has been with me for 15 years. Our daughter, Jessica, the nurse, she’s outstanding on call 24 hours a day.
DR. KEITH NICHOLS, MD. (01:07:06.766)
seven days a week. We are known by the way for our post -operative care. I mean, that’s what we, one of the strong points of our team. I mean, this is serious business. And medicine today in the 54 years and Keith, you know this, you can’t practice anymore in the insurance industry. It’s just, it’s a zoo.
My patients go to my urology friend’s office and say, Dr. Bush, can’t we just stay over at your place? I mean, it just, you know, poor people, they have to crank out numbers. Right. In order to get truly personalized care, which equals to time spent with patient, quality time, you can’t work in an insurance -based system hardly anymore. You just cannot. It’s impossible. It’s literally impossible. And the doctors, we’ve lost control.
We have no control. That’s right. That’s correct. The only way you can control it is you have to be in a private boutique practice. And then my concierge doctors like yourself, they give you all the time you need. You call them, they pick up the phone. You get really good help right away. That’s right. Well, we can’t thank you enough for doing what you do. I can’t thank you, Keith. I mean, we’ve had some excellent patients together.
We have. And these men are on testosterone. Everyone listen out there. Dr. Bush and I have treatment that are on active surveillance. They are on testosterone. They have had treatment for their prostate cancer. They’re on testosterone and there’s no worsening of the disease. If anything, there’s going to be less recurrence and it’s protective against prostate cancer. So I’ve done a recent video on TNG. I think the only case that we’ve gotten in, that we’ve run in the difficulties with was a Gleason 9.
And the Gleason 9s and 10s, I don’t care what you say or what you do, it’s been my experience in 15 years, they’re going to come back on you no matter what you do. Well, and then that, and you know, listen, when you get a diagnosis of the Gleason grade 9, as Dr. Bush is talking about, and this particular patient who is the one of the greatest human beings you’re ever going to meet, it’s a generally nice man. He knew with that Gleason grade 9 that
DR. KEITH NICHOLS, MD. (01:09:31.854)
It was going to come back. He was informed by yourself, by myself that look, it’s going to come back. But nonetheless, he had great sexual function. And this is not a young man. This man’s up there in age. And yet he has an active sexual life despite being, you know, almost 80, I believe. He has, you know, no urinary incontinence. And, you know, unfortunately, it has to come back and he’s getting treatment. But he chose, some men decide to choose
quality of life. They don’t want to disrupt their quality of life. So he did not want to undergo a radical prostatectomy because it would, as he said, it’s going to take away my manhood, Dr. Nichols. And I want to go out on my feet, not on my knees. I want to maintain my manhood. And he has, and he has, and he’s still very pleased with all the fear that he’s got. And then he remains on testosterone to this day. That’s right. And I think that that’s unfortunately too many physicians believe you have to stop
testosterone therapy. I just don’t, I’ve, we, we watch it. If the cancer is going nuts or comes back, we’re going to know that. And then we reevaluate that. We don’t just blanketly say you can’t take it. That’s right. That’s wrong. I mean, that’s just absolutely wrong. But that’s been standard of care for almost all my career. You can’t take tea if you got prostate cancer. That’s right.
That’s right. And that’s just not true. Well, I can’t thank you enough. I can’t thank the world for men like you and men that do what you do. The world is a better place. Men like you and the Abraham, Morgan, and the Neal Rizziers of the world. I’m happy to be able to associate with men like you. So thank you once again, Dr. Bush, for even taking the time to educate all our listeners out there on what you do to make our lives better.
So thank you very much. All right. I appreciate that. And God bless all your patients out there. I mean, it’s, it’s always a battle in the journey. All right. Well, I’ll see you in the next month or two. It’s that time. It’s that time of year. So I’ll be, I’ll be down there myself and Alfredo George. All right. I think you’re all right. Thank you, Joe.
SHOW OUTRO
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