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Scot: Troy, are you ready to talk about colonoscopies?

Troy: I'm ready.

Scot: All right. Who's had one, by the way? Have you had one, Troy?

Troy: I have.

Scot: Oh, you have? I didn't think you had yet.

Troy: Yeah, I have had a colonoscopy. I went to my primary care provider last March and he said, "The recommendations have changed. You are due for a colonoscopy." And I said, "That's not the news I wanted to hear." I signed up for it and did it. I got in the first opening they had. They had a cancellation. I got in for it two weeks after that appointment. I'm like, "I'm just getting this thing done." And I did it.

Scot: Getting it out of the way. Mitch, you haven't had yours yet. You're not old enough for it, right?

Mitch: No, I'm still under 40. Is 40 the new 50? Is that the slogan?

Troy: Forty-five is the new 50.

Mitch: Forty-five is the new 50. Yeah, I got a decade.

Scot: All right. Well . . .

Troy: You're good.

Scot: Colonoscopies are one of those things that men just kind of don't want to get and don't want to talk about. We just want to ignore it, pretend it doesn't exist. But as I was thinking about this topic . . . And I have had my colonoscopy. I guess in my mind, it's two choices, right? It's possibly get the second most deadly cancer men get and have your life disrupted for who knows how long, or get a colonoscopy every 10 years, right? I don't know.

So today, we're going to talk about the reasons men don't get colonoscopies. Troy and I are going to talk about our experiences to find out if maybe some of the perceptions out there that people have about them are true or not.

Welcome to a Men's Health Essentials episode of "Who Cares About Men's Health," offering information, inspiration, and a different interpretation of men's health. My name is Scot Singpiel. I bring the BS.

And the part of the colonoscopy I didn't like was the prep. I don't know about you, Troy. Troy is the MD to my BS. What didn't you like about your colonoscopy?

Troy: I agree. The prep. And that's what I'd heard, too, going into it. The prep is the bad part. The colonoscopy is easy. That was basically my experience.

Scot: Yeah. Mitch Sears is on the show, and he's a ways away from his colonoscopy, but I guess you can't wait, right? You're pretty excited about it apparently.

Mitch: I wouldn't say excited. We're back to that area. I don't love these episodes, but it's something I want to be prepared for. So I'm ready to learn.

Scot: And I don't know his colonoscopy status, because we just met. We've got Nathaniel Ferre on the podcast. He's a community health educator at Huntsman Cancer Institute, and he works with the public to help them understand the importance of cancer screenings, including colonoscopies. Welcome to the show, Nathaniel. Have you had yours?

Nathaniel: Thanks, Scot. Great to be here. I, like Mitch, have not gotten mine yet. I'm not of the age quite. So we'll get there eventually, but . . .

Scot: All right. So, on the podcast, I guess we have Team Scoped, which is Troy and me.

Troy: Team Scoped. We've been there, done that. Speaking from experience.

Scot: And we have Team Unscoped, Mitch and Nathaniel.

So I want to start with actually both of you guys. Like Team Unscoped, what is your perception of what a colonoscopy is like? Mitch, what do you think?

Mitch: Oh, I've heard . . . No one talks about what actually happens, but it's like, "Here's this miserable prep step," and then the process itself sounds pretty uncomfortable. None of it sounds good. None of it sounds positive, but it's something you've got to do if you're not going to die from cancer. That's my perspective.

Scot: Nathaniel, you have a different perspective, obviously, since you help people understand the value of colonoscopies, and probably deal with a lot of these barriers that we're going to talk about today. What would you like to say about your perception or the perception of colonoscopies in general?

Nathaniel: Yeah, absolutely. Well, even though I haven't had it yet, I have heard it's a nice nap, right? You get a nice, solid sleep there in the middle of the day. And so that is an advantage, I guess, if you're looking for a good rest, but . . .

Scot: That's so funny because I had a friend that got it that said the same thing, that when they came out of the whatever it is that they put them under, it was like, "Can you please put me back under? I was having a great dream."

Mitch: Wow.

Nathaniel: "This is a great break right here."

Troy: That's so funny. My first thought when I woke up was, "I need to give patients more propofol," because that's the medication they gave. I was like, "That was so nice. I slept so well. I had no idea what was going on." That was my first thought when I woke up. So it was a nice nap.

Nathaniel: Yeah. Other than that though, obviously I think we've all heard about the prep. Like Troy said, it is a rough part maybe of it. But again, I think you think about the pros and the cons, and you think about what you're getting accomplished there. That few days of hard prep can really pay off with a great nap. And then, of course, the cancer screening to go on top of it.

Scot: That's right. And colon cancer, tell me . . . When we talk about cancers a lot of time, we talk about survival rates, right? We talk about dying. That's obviously the worst thing that can happen. But cancer can also cause really a lot of disruption in your life.

First of all, I did say it's the second deadliest cancer for men. How important is finding it early? How important is the colonoscopy in this step to survival or minimizing the impact on your life?

Nathaniel: Well, for colorectal cancer, extremely important. As we look at the five-year survival rates, which we normally do for cancer, if we find it early, we have over a 90% chance of five-year survival. It's really treatable. We've gone a long way to be able to treat this disease.

Where it really gets tricky and why that mortality rate is so high is the late stage. If we don't get screened, if we find it late, that mortality rate just skyrockets and the survival rate dips all the way down to 14%, which is really sad and very disruptive.

And so that just stresses the importance of screening and finding this early in order to be able to treat it much better.

Scot: And I understand about less than half of colon cancers are discovered at an early enough stage to make a difference.

Nathaniel: Yeah. Luckily, we're getting better with that as we continue to make strides in screening, but as we see some of these trends going on where people are maybe getting it younger or not paying attention to some of the prevention things that we can do, it is difficult to find it. But if we do get screened, then we can find it. It's just a matter of taking that action.

Troy: That kind of speaks to the age change too. Like I said, I went to my primary care provider. I think the recommendation just recently had changed. I was surprised to hear it had changed to 45 from 50.

I will say I had not looked forward to the colonoscopy, but I thought, "I'm good until 50, and maybe by then there will be another screening technique." And there wasn't, so I had the colonoscopy. But why has that recommendation changed, and why are we now getting it at 45?

Nathaniel: Yeah, that's a great question, and it really speaks to some of the trends that we're seeing as we see younger and younger people get affected by this disease.

Actually, certain groups, too, historically have been affected worse. The screening recommendation has been 45 for a long time for African-American males and females, as it's really affected this group much more hard than other groups in comparison.

And so lowering that to 45 is really an indication of we're seeing it younger. We're seeing increased risk due to diabetes, due to some other gastrointestinal diseases. And so, in order to reduce that, we see there's not a huge risk with a colonoscopy. We're looking at what's the pro, the con, the risk versus the reward, and the risk is quite low for a very high reward of finding those cancers early and really being able to address them.

Scot: I think most men and most people know that colonoscopy is something that is beneficial for them. But I mean, let's face it, there are a lot of reasons to put that thing off, right? It's like one of those things that's really easy to postpone time and time and time again because there's kind of a lot of stuff involved that it's easy to postpone.

Troy, was there anything that made you want to put it off? I mean, you jumped right on it, but what might make you . . .

Troy: I jumped on it.

Scot: Yeah. What might make you put it off? Well, first of all, why did you jump right on it? I'm curious about . . .

Troy: I'll tell you. That's exactly why I jumped on it, because I knew of every reason I wanted to put it off. And I knew the longer I put it off, I was just going to dread it.

Here I am, a healthcare professional, trying to talk myself out of doing it. I was literally just talking to myself saying, "I don't really need this. I'm low-risk. I don't have a family history. I don't see why the age dropped to 45. Why can't I just wait a few years?" All of these things. And so that's when I finally said, "I'm getting in as soon as I possibly can," because the next appointment wasn't until August. And so I got this done in early April.

And so, yeah, the big reasons I didn't want to do it were just the embarrassment of having to go in there and having a whole lot of people around me and having a probe inserted in my rectum and going up there and looking for polyps. Just that piece of it. It's just the fact that you have to be exposed like that. So I wasn't thrilled about that.

The prep, I had heard, was miserable. I just heard it was awful, that you're just sitting on the toilet and you can't get off it, and you're going in your pants, and things like that just sounded horrible.

And I didn't know I was going to be completely sedated either. I thought it was going to be a light sedation and I would be aware of what's going on during it. I thought, "This is really going to be uncomfortable and it might hurt." So that was a fear I had as well.

So those were all things going through my mind, and those were all the reasons I said, "I've just got to get this done so I'm not thinking about it." So that's why.

Scot: How about you, Mitch? Is there anything that would make you put it off? Or does something scare you about it, or something that concern you about it?

Mitch: So I don't mess around with cancer. I don't know. If there is the tiniest bump, I go in. And so I know that whatever the recommendations are, I'm going to do it because the alternatives scare me a bajillion times more than the actual thing.

I was in the same boat. I just barely found out five minutes ago that you're put under. I assumed you had to be up and maybe people . . . I think I was thinking of a colon cleanse rather than a colonoscopy, right? Where I assumed that I was awake for the whole thing. No. If I'm out, I know it'll suck and there are a lot of terrible things, but no, I'm not . . . Check it. Make sure I'm not dying.

Scot: Right? It's like, "What am I going to talk about while they're doing this?" I don't know.

Mitch: Right.

Troy: Yeah. It's like being at the dentist. I'm trying to have this awkward conversation.

Nathaniel: That's exactly what I was thinking.

Scot: So another concern, and this is . . . well, this whole episode is TMI, right? Too much information, quite frankly, but . . .

Mitch: Or the perfect amount.

Scot: Well, yes. I mean, we're trying to normalize talking about this.

Mitch: And nailing it.

Scot: This is a dumb thing, but I think it's something that would keep somebody from getting it. How my butt would feel after. Would I be able to tell that there'd been a scope up there, right? Is this going to be a residual feeling I'm going to have for the next two days? Who's laughing at me?

Nathaniel: Well, you got Mitch there.

Troy: I think it's Mitch.

Scot: By the way, the answer was no. I wouldn't have known that anything happened.

Troy: Yeah, I'll second that. I will second that.

Mitch: We are so concerned that it's going to feel . . . All right. Cancer. You guys, cancer. Okay. I'm sorry. I shouldn't laugh at your concerns. My butt might feel weird, but it's also cancer, you guys.

Scot: Nathaniel, what are some of the reasons that you hear when you go out into the community that people put it off for? What are some of the perceptions out there that make people not want to get one?

Nathaniel: Yeah, a lot of the reasons that we've already talked about, right? That it's going to hurt, or the prep is terrible, or we're looking at, "Well, I know I should do it, but I just don't have the time to do it. My life is busy. I have things to do and it requires a couple of days of prep, and maybe I have to take work off." These things are pretty common that come up really, and it's great to address them.

Scot: Yeah. I mean, I'm really quite privileged and lucky, because first of all, I have good insurance that paid for the whole thing. Second of all, I have good sick leave, so I could take that day off. I had to have somebody else take the day off to drive me in and then drive me home, and then be with me for that day, right? So there's another potential.

But not everybody has that advantage. How do you make the case to somebody that taking time off is just really hard from a financial standpoint, let alone a couple of people, in addition to the other things we've talked about?

Nathaniel: I mean, it's hard. It's hard to be able to put yourself in every situation possible, but really, I think it goes back to that same mentality of the risk versus the reward and kind of the payoff, as we think about, "What are some things that I can do that really impact my health in the future?" And this, I think, certainly is one of those things, especially as we think about, "Hey, if you do a good prep and a good clean, and they go in and there's nothing in there, you're off the hook for 10 years."

Mitch: Ten years?

Nathaniel: It's not something that . . . Yeah, that's the recommendation, right? If everything is clean, we don't find any polyps, and you did a great prep, and you followed all the doctor's instructions, if you will, yeah, your next scope is going to be in 10 years.

And so it's not like going to the dentist. You think, "Oh, I've got to go to the dentist twice a year. Wow, I've just got to schedule around that." Not to go back on the dentist thing, but . . .

Scot: Yeah, we're going to get some . . . "Thanks, guys. Appreciate that."

And I guess something else maybe to consider, I don't know, but this is so hard when you're in that situation where money is tight anyway to take that time off, but if you end up getting colon cancer, that's a lot more expensive and going to take you out of work and out of your family, out of your life for a lot longer. I mean, what's it like when somebody gets colon cancer? What's that experience like that you've seen?

Nathaniel: Yeah, it's really tough. I think it's one of the cancers that you can definitely see on the outside, especially when you think of oftentimes if it's a late stage. Our surgeons are going in and actually removing large sections of your colon, which really interrupts your life as we talk about needing the use for ostomy bags and other things to help you move forward.

And luckily, we do have those advances. We do have ways to address it in the later stage, but it's just a lot more difficult, to your point, right? It requires a lot more effort, a lot more time away. And if we can find it early, we don't need to do those things.

And one of the great things about a colonoscopy is actually it's one of the only cancer screenings where we can actually do something about it during the same screen, right? During the colonoscopy, we can remove those polyps in that same procedure.

Troy: I think that's one of the coolest things about colonoscopies, is not only does it detect early cancer, it prevents cancer. If you find a pre-cancerous polyp and they remove it, it's great. That risk is gone. That polyp is out of the way. It's not going to develop into cancer. So I think that's a really cool thing about it.

Nathaniel: Yeah, you're really getting kind of that two-for-one there. You don't have to go back for an additional procedure or what have you to remove that polyp. They just do it right then and there.

Scot: For somebody who doesn't necessarily have the best insurance and there's going to be some out-of-pocket expenses, are there other resources that could help that those individuals get their colonoscopy? Or are there some alternatives that might not be quite so expensive that can help prevent colon cancer?

Nathaniel: Yeah. We definitely can look at . . . There are a lot of great free clinic resources and federally qualified health centers, which is what we call them, throughout the Valley. And they have some good resources to help with this. And there are a lot of voucher systems or being able to pay out of pocket at a reduced cost.

But you bring up a good discussion that we can have. There are other ways and other modalities for people to get screened for colorectal cancer if it is hard to go in and get the colonoscopy due to cost, or maybe even you live far away from somewhere where you can get a colorectal cancer screening test.

Scot: And what are those that are recommended?

Nathaniel: Yeah, maybe some people have seen on TV Cologuard. It's in kind of that white box, and that is one. We call that a DNA FIT kit, or alternatively, just a normal FIT kit. And FIT stands for fecal immunochemical test. Sometimes it's referred to as a fecal occult blood test.

And really what it is, is it's almost like a pre-screen to a colonoscopy. And so these tests, you can do at home. They're very inexpensive. Even if you're paying out of pocket, we're looking at like $20. And what they're testing for is just elevated or abnormal levels of blood in your stool, and that can be a marker that there might be something wrong in your colon. There might be a polyp that's bleeding or something else.

And so you can do one of these tests at home, and if this test comes back negative, then you're good. You repeat the test in a year. If it comes back positive, then you know for sure you need to go and get a colonoscopy and make that effort. If it's coming back positive, there is something we need to get a better look at.

Scot: I will say my doctor gave me that option, right? My doctor kind of laid out the FIT test or the colonoscopy. Here's what made my decision. The FIT test, you have to do your own stool sample and send it in. Am I correct?

Nathaniel: This is true.

Scot: Yeah, and you have to do that every year.

Nathaniel: Exactly. I mean, colonoscopy continues to be the gold standard. And like I said, even if you do a FIT kit, these tests do not diagnose colorectal cancer per se. They just say, "Hey, there's something going on. We need to get a colonoscopy for sure or not."

And so it's really a great resource again, like I said, for if you're unable to really foot the expense, or you really don't have the time, or maybe if you live somewhere that's hours away from a place that has an endoscopy suite. Those are the instances in which they really make a great impact and we can make sure we need a colonoscopy before going in and doing it.

Scot: And I'm going to say, risk versus reward, right? I've had to take a fecal sample before, and it sounds worse than it is. At least in my experience it was. I mean, if it's between getting colon cancer and doing that, I'll tell you what I'll do every single time.

Mitch: Right?

Nathaniel: Exactly.

Mitch: Everyone is just talking about all the potential . . . For me, it's just like, "Or you could have cancer," right? That's just me.

Scot: Isn't it funny? We're supposed to be men and we're supposed to be so brave, but this is such a thing for us, right? Isn't it bizarre?

Troy: And I will tell you in hindsight, no pun intended, that I'm glad I had the colonoscopy.

Mitch: It was intended.

Troy: It wasn't until I said it, and then I thought, "Okay."

Anyway, I'm glad I had the colonoscopy, and it was the prevention piece of it that really makes me glad I had it. I had two polyps removed. Neither of them was cancerous, but because of that, I am now recommended to go back in five years to get another colonoscopy.

If I hadn't had a colonoscopy, if I just had the FIT test, if those were not bleeding, which probably they wouldn't have been, there was no blood they saw in the colonoscopy, those would not have been detected. They wouldn't have been removed.

So the fact that they did see those, they did remove them, I'm glad I had the colonoscopy to make sure that was done, and I'm glad I know that I need to go back in five years. So I think for me it was beneficial.

Nathaniel: Yeah. And that brings up a good point. That is something, again, that's very unique to a colonoscopy as we compare it to maybe other different cancer screenings. Colonoscopy, we really can do a lot. If we're looking at getting the biggest bang for our buck, a colonoscopy, we're going to remove those polyps, we're going to take care of it, and send it for biopsy all right there.

Troy: Yeah, and that was great. Like you said, it was all one and done. It's not like I had to come back for a second procedure. They did the procedure, I was out for I think 20, 30 minutes, whatever it was, and then got the report a couple weeks later that reported what they found with the pathology results and they said, "No cancer, but recommended just getting it again in five years."

So it was nice just to get everything done at the same time and also have that prevention piece of it as well.

Nathaniel: And that's maybe another thing. I mean, Mitch, did you realize the colonoscopy really only lasts 20 or 30 minutes? It's a pretty quick thing.

Mitch: No. Everyone makes it sound like it's this whole ordeal. You go in and you are put under for 20 to 30 minutes?

Troy: You're under for 20 to 30 minutes, but yeah, it's . . .

Scot: Let me go through my experience just to give you an idea. Again, we're talking about risk/reward, but I think this is one of the reasons why this is easy to put off, right? The prep isn't fun. I mean, I'm not going to lie. I don't like the feeling of diarrhea. I just hate it.

Mitch: No one does.

Troy: I'm going to correct you, Scot. It was not a feeling of diarrhea. It was a feeling like there was a river running through my body.

Scot: Yes. Right?

Troy: It was different than diarrhea. It was so weird.

Scot: I will say after the first couple times, I got used to it. It's not that big of a deal.

Troy: Yeah, exactly.

Scot: The prep wasn't as bad as I thought it would be. It's not terrible, but it was a little bit more of a disruption in my life. Three days before, you can't eat any nuts, popcorn, granola, uncooked veggies or fruit, whole grain bread, anything with bran. I mean, I eat fairly healthy, so that was a little bit of an imposition, right? I had to completely change how I ate three days before.

Troy: Yeah, me too. That was a big change.

Scot: Yep. The day before, you have to start a clear liquid diet. No solid food at all. And dealing with the hunger, that wasn't as big of a deal as I thought it would be.

And then as far as the prep, that started for me in my instance at 4:00 that night. So I was able to work that whole day, if we're talking about time being a consideration, but that night was done because you start taking the prep and then around 7 or 8 is when the cleansing, let's say, began. I did sleep through the night. Did you, Troy, or did you have to get up a lot?

Troy: I had to get up quite a bit. Yeah. I was up every couple hours just because that stuff was flowing through my system. See, the difference between me and you, though, probably is that I had to start my prep at 7:00 a.m. the day before. I also worked an ER shift that day while I was on a clear liquid diet, which I would not do again because I was just chugging Gatorade and I was so hungry. It was just not a good thing. And then I started the prep at like 5:00, so that night, it was definitely like every two hours.

Scot: Got it. I was able to sleep through the night, and then I had to get up really early because I think my procedure was at 8:00 and you have to get up and do more prep like four hours before the procedure.

And I was really stressed that it wasn't going to be clean enough. But I'll tell you what, literally 10 minutes before, that very last time at the doctor's office before I went in, it was like, "Well, we're there." That was a little bit of a stressful situation, like, "I don't want to have gone through all of this to not be able to do it."

So then they took me into this room, like the prep room, right? And this kind of East-Coast-sounding accent nurse named Tony told me that I was the kind of guy who doesn't like to be not in control. He was funny. I actually liked Tony a lot. Tony was great. Made me laugh, made me feel pretty comfortable in the situation.

They take you into the room. The gastroenterologist introduced himself. You've got everybody else standing around. I don't know if that's when they administered the stuff that makes me take the nap, but it was almost instantly I was asleep. And then I woke up back in the prep room and went out for a burger. I mean, I was hungry and I felt good. I took the rest of the day off, and it was fine.

Just like you, Troy, they found a few polyps, they removed them, they were non-cancerous, and now I have to go back in 5 years rather than 10.

Troy: There you go.

Scot: As Mitch would say, "But, guys, cancer."

Mitch: It's cancer.

Troy: Come on, guys. Quit complaining. Cancer.

Scot: I suppose I shouldn't complain about that.

Nathaniel, is there anything that we missed that you really feel like we should get in here? You deal with individuals . . . You have the hardest job in the world, I think. You could have found an easier gig than convincing people that colonoscopies are a good idea, but maybe not. Maybe it's a super easy sell. Is there anything else that we should really talk about here before we wrap up?

Nathaniel: I think the only other thing that really applies to cancer broadly, and colorectal cancer for sure, is just knowing your family history, right? This can be another big reason why, "Hey, I should get a colonoscopy if somebody in my family's had colorectal cancer," or even a different kind of cancer.

The more and more we learn about these genetic risk factors, the more and more we find the importance of just, if you can, knowing what kind of health issues run in your family and addressing those in a timely manner.

Troy: So I guess that brings up the question then, if you do have a family member who had colon cancer in their 30s or early 40s, should you be getting screened then?

Nathaniel: Well, you should definitely be talking to your primary care provider about that. Oftentimes, yes, we do scope people younger than 45, particularly if they have extensive history of early or numerous cancers, particularly colorectal cancer.

There is something called lynch syndrome, which is a genetic syndrome that you can be diagnosed with where you have many people in your family back first-, second-, third-, even fourth-degree relatives that have had colorectal cancer.

Scot: Does your risk go up if you have relatives that just have had other types of cancer? Or are we looking specifically at colorectal cancer for an increased risk?

Nathaniel: It depends. You want to know all cancers that are coming up, and there are some cancers that share common genetic risk factors, and there are common genes that might contribute to multiple types of cancer. So it's good to know all cancers that have run in your family, and then talk those through with your primary care provider.

You might get referred to somebody called a genetic counselor. That's just a trained medical specialty that can talk you through, "Hey, these different cancers that run in your family might put you in an increased risk for this. Let's think about genetic testing and see if you have these genetic predispositions as well."

Scot: Any additional risk factors that would make you want to have that conversation with your primary care provider getting tested earlier than the 45, other than genetics?

Nathaniel: Other than genetics, we do look at diverticulitis, if we've been diagnosed with that, or inflammatory bowel disease. Some of these other gastrointestinal diseases can lead to an increased risk of colorectal cancer.

I really like to put it this way. Anything that's making your gut work harder than it should, whether that's a disease or the types of food you're eating, that's generally just not a good thing, right? And so if your gut has to work harder than it should, it is just increasing that risk a little bit.

Scot: And what is your 60-second message as we wrap this up to men about colonoscopy or colon cancer screening? What would you say if you only had the elevator pitch?

Nathaniel: Well, I think as we've heard today, it's a great opportunity to get a great nap. And as a side benefit there, we can prevent cancer. I think that's the biggest thing that I say. Colorectal cancer is something that we have a great resource for.

And as you meet these patients and their stories, and you see especially the great stories of patients who haven't ever gotten a colonoscopy and were able to get it through a program or a pilot program that we have, and we find some polyps, we remove them, that makes a huge difference on a lot of people.

And not just that person, right? I think it's important to remember that. Our health is not just our health, right? I mean, we have friends. We've got family. These people we have to also care about, and this is one of those diseases that we can address.

Troy: Nathaniel, I'll say, too, if my primary care provider contacted me today and said, "Hey, you need to get another colonoscopy in the next month," I'd be like, "Okay, no big deal." I've gone from someone who really quite honestly dreaded it to having been through the process. It wasn't a big deal, and I would not hesitate to get it done again.

Scot: Well, it's been a fun conversation. I think it's been an informative conversation, and I think the takeaway is this is not one of the easiest screenings to get, and there are a lot of kind of unknowns about it. People are kind of afraid of it. We all kind of have our own things. Some people feel like it's a threat to their masculinity, I've read. There are just a lot of reasons you might say, "Eh, I'm not going to do it." But it's just, as we learned, super important.

And it does take a little planning. I had to get the calendar out. I had to work with somebody who's going to take me there. I had to make sure I was trying to get it around a time where I could take minimal time off. So it does take a little effort, which, of course, as we all know, makes people less likely to do something. But the upside is so, so huge to get your colonoscopy.

Nathaniel, thank you for being on the show today. We do appreciate it. And thank you for caring about men's health.
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This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: Hey, Mitch. If you found a lump someplace on your chest, what would you do?

Mitch: Like, on the chest? Under?

Scot: Yeah. Maybe under the chest, under your arm, or by your nipple, or just anywhere on the chest, if there was a lump there, like a marble.

Mitch: I don't know. I legitimately would just assume it was, I don't know, a cyst or something like that. I'd probably just wait and see how it turned out, see if it went away. Yeah, I don't know.

Scot: That's a pretty standard man policy right there. It's just, "Well, let's see what happens to this thing. Maybe it'll just go away."

Troy, how about you? I mean, you're a doctor, so you're probably going to have a different answer.

Troy: Well, that's the problem. I am a doctor, so I tend to either think everything is cancer or I just ignore it. So I would probably do one of those two things. And like Mitch said, it would probably be based on what it did. If it started getting larger or more red and kind of inflamed around that area, I'd probably get it checked out, but again, I'd probably put it off for a while before I did something.

Scot: Yeah. Would you ever think it was breast cancer though?

Troy: I don't think I would. It's just not something I think about in terms of as a man.

Scot: That's not unusual. A lot of guys don't even know breast . . . A lot of people, I should say, don't even know that male breast cancer is a thing. They think it's a woman's disease. Another common thing is, "Men don't have breasts, so how am I going to get breast cancer? I have a chest. I don't have breasts."

Mitch: Okay. I'm sorry. That's fine.

Scot: "And I'm a manly man, so how can I get a woman's disease of breast cancer?" So here's the 30-second part of the podcast. If you're a man and you find a lump on your chest, you should have it looked at. While male breast cancer is rare, it is deadly if ignored. And it's really treatable if it's caught early.

So this is interesting. The time it generally takes from a man finding a lump to seeing a doctor is about 12 to 14 months. It takes over a year from noticing that lump.

So the 30-second version is if you find a lump, have it looked at. Don't talk yourself out of it. Don't give into you and your society's perceptions about men who get breast cancer and what those are. But if you want to learn more, then stick around.

This is "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men's health. Today's episode is a "Men's Health Essentials" episode, a strange one because it's about male breast cancer, something that a lot of guys don't even think is a thing.

I'm Scot Singpiel. I bring the mics and the BS. Welcome to the studio, actually remote, the MD to my BS, emergency room physician Dr. Troy Madsen.

Troy: Hey, Scot. This is a great topic. I'm glad we're learning about it.

Scot: And balancing us all out is Mitch Sears.

Mitch: Oh, I like that. But a year? A year you have a lump and we don't go talk about it?

Scot: I don't know.

Mitch: Okay. All right. I'm excited.

Scot: And we're super lucky to have an expert with us. Dr. Matt Covington is an expert in cancer imaging, and he specifically focuses on early detection and accurate staging of breast cancer. From Huntsman Cancer Institute, Dr. Covington, welcome to the show.

Dr. Covington: Thank you, Scot. I'm really happy to be here.

Scot: All right. So the first thing I want to know is I have breast tissue, huh? What? Why didn't anybody ever tell me this?

Dr. Covington: Yes. I think that's news to a lot of men. We assume that we don't have breast tissue. I think we like to think that we have skin and nipple and muscle, and that there's no breast tissue in between. But the truth is that there is a small amount of breast tissue in every male.

And as we'll talk about today, sometimes that breast tissue can cause problems and sometimes it can cause lumps that should not be ignored. And what I really hope to accomplish today is to convince everybody that if a man feels a lump in your chest, it needs to be evaluated.

Scot: Yeah. So why is the rate of mortality so high for men who get breast cancer? What do we know about that?

Dr. Covington: The mortality rate is high, and it's much higher than it should be. The primary reason for that is that male breast cancer is often diagnosed late. There are a few reasons for that that we could get into, but it's that late presentation to seeking imaging. It's that delay in getting a tissue diagnosis of breast cancer that allows those breast cancer cells to spread from where it started in the breast, often into the lymph nodes, and then unfortunately often outside of the lymph nodes to cause metastatic disease.

Mitch: One of the questions I guess I have here is how much higher is the mortality rate then? I understand cancer progresses in phases and after a certain point, it's going to be really hard to treat it, but if we're waiting 12 to 18 months, how much higher is the mortality rate in men?

Dr. Covington: So what I can tell you about the mortality rate of male breast cancer is that unfortunately, five years after diagnosis, about half of all men will have passed away from the disease.

Mitch: Wait. Half?

Dr. Covington: Yeah. We often look at five-year survival for all types of cancer, and in the case of male breast cancer, the five-year survival is something around 40% to 65%.

Scot: And is that because we are waiting so long, or is it a more insidious type of cancer than what women get?

Dr. Covington: You're onto something with both of those statements that you said. In some cases, the biology of the breast cancer is actually a little bit more aggressive, we think, in males. That principle translates the same across many cancers. If you're someone in the minority in terms of getting a cancer, if you do get that cancer, often it will be a little bit more aggressive. That's not necessarily unique to breast cancer.

The other reason why mortality is delayed is that you lose the window to cure the cancer if you wait too long. It's the same game we play with female breast cancer, and that's why screening exists for breast cancer. Things like screening mammography exist because breast cancer is curable if you catch it early enough.

That same principle applies to men. Unfortunately, fewer men are presenting with curable breast cancers because they're simply not early. They've already started to spread by the time we even realize it's there.

Troy: I was going to say, just to put that in perspective, what's the five-year mortality rate for breast cancer in women?

Dr. Covington: So that depends a lot on the stage of diagnosis, but overall, you're looking at something like 80% to 90% survival at 5 years. But that five-year survival will look similar to men if you're considering advanced stage cancers, meaning Stage 4 where it's distant, where it has already spread throughout the body. Survival for those women will look very similar to that of men.

Scot: It's just they're doing a much better job of getting women screened. Women are doing a much better job and there's a lot more awareness.

Dr. Covington: That's correct. Well, screening for breast cancer doesn't exist for most males. That's true. You have to have certain genetic risk factors. You have to have some idea that you're at high risk to even undergo some sort of screening.

That's different with women where there is recommended national screening. Starting at age 40 is what we typically recommend. For men, screening would simply be paying attention to your own body. Did you notice a lump? If so, it needs to be evaluated.

Scot: I like that. I like that linear relationship. It's easy. I almost want to put that in Caveman. "Notice lump, get evaluated."

Dr. Covington: I think that could be a great public campaign to raise awareness, yes.

Scot: That's four words. That's perfect.

Troy: That's too big a word. Just say, "See lump, get checked."

Scot: "Go doctor."

Troy: "Go doctor." I'm curious though, Matt, as you're talking about this. And obviously, it sounds like screening is a huge part of it. There are very clear screening guidelines for breast cancer in women, certainly, that don't exist in men because the disease is so rare. But with that being said, we do talk about breast self-exams. Women have been counseled to do it. I've heard evidence has been mixed on how helpful that actually is as identifying things. Should men be doing self-exams regularly feeling for lumps and bumps, or what are your recommendations there?

Dr. Covington: So I think it's definitely a good idea to pay attention to your body. And the breast is not the only area where self-exam could potentially save your life when we're talking about men's health, particularly testicular self-exam. If you notice a lump on your testicle, that's probably the most likely way that you'll ever detect that you have testicular cancer. The same is true with the male breast.

Now, let me frame this a little bit. If anybody has a mastectomy, even if, say, a woman has breast cancer and that it's treated with mastectomy, meaning that the breast is removed, after the mastectomy happens, how do we screen those patients? That's a question we can ask ourselves. The answer is self-exam and clinical breast exam.

And the reason why you typically stop doing mammography after the breast has been removed is that if there is a cancer present, you're going to feel it. You don't have all of that breast tissue that can possibly hide it, and that is essentially the situation that men are in. You simply don't have a lot of tissue. There's skin, a little bit of fat, or some people might have a little bit more fat. There's a lot of variation there.

Scot: Quit looking at me like that. It's just not cool. I'm not going to have doctors in the studio anymore.

Dr. Covington: For the record, I was not looking in your direction.

Scot: Okay.

Dr. Covington: But what that means is you have a really high likelihood of actually finding the breast cancer early if you're paying attention.

Scot: So you're telling us that there really aren't any other symptoms. It's really just kind of self-exam, lumps. Am I hearing that correctly?

Dr. Covington: So that will definitely be the most common symptom of male breast cancer, is that you've noticed a new lump. Other symptoms can include things like nipple discharge. I would hope if a man starts having anything clear or bloody . . .

Mitch: It'll probably go away.

Dr. Covington: . . . especially blood from the nipple, get that checked out. Scaling of the nipple, that's something you might not think about. If your nipple is getting pulled in, that's something you might not always think about as a sign of breast cancer. Or if you see changes of the skin over your chest like redness, dimpling, thickening, things like that, that can also be a sign of male breast cancer.

But by and large, it will typically present with some kind of lump. Whether it's painful or not does not help you know whether it's breast cancer or not. So don't use a lack of pain as a reason why this is not a breast cancer.

Mitch: Is anyone else just casually feeling themselves up right now to see if they have anything?

Scot: Well, I would, but I don't know where to feel. Is there any particular place I should be feeling?

Dr. Covington: Definitely, something we need to talk about is feeling behind the nipple. And why I raised that is we absolutely need to discuss something called gynecomastia. And that's a little bit of a complicated term, but it's very important for our discussion, and let me explain why.

Gynecomastia is by far the most common cause of a lump in a man. If you feel a lump, typically, it's going to be gynecomastia. In fact, to the degree that a lot of doctors will probably automatically assume that it will be gynecomastia, but that would be a mistake. We don't want to do that.

Let me talk about gynecomastia, if I could take a moment.

Scot: Yeah. I hope you're going to tell me what it is.

Dr. Covington: Yes.

Scot: Okay. Good. Because right now it's just a big word that I'm afraid of.

Dr. Covington: So, first of all, gynecomastia is not a tumor or a cancer. It is simply an increase in the amount of breast tissue that a male can have. And it's most common in men at two phases in life.

One is puberty, and a lot of teenagers when they're going through puberty get a little bit of swelling and tenderness behind the nipple. That is not uncommon, and it happens because hormone levels are changing during puberty.

It also is very common in men . . . and I do mean common, we see this all the time in the breast imaging clinic . . . in older men often on some sort of blood pressure, cardiac, or mental health medication. And some of those medications also cause breast enlargement to increase a little bit, and that usually will present with swelling behind the nipple.

That's usually very soft. It has a very typical feel for people who are used to identifying between gynecomastia and breast cancer, such as a breast radiologist or a breast surgeon.

And it is what we need to make sure a lump is. We want to see that your lump is gynecomastia because that means it's not cancer. The way to do that is a little bit with physical exam. If there's a really hard mass, that suggests it could be more of a cancer instead of gynecomastia. But also, a mammogram can help us here. And we need to talk about that, that men do get mammograms.

Scot: I still, though, don't know . . . So I'm feeling around the nipple for a hard . . . I still don't know where I'm supposed to feel, I guess.

Dr. Covington: So feel the entire chest. It doesn't take that long. It's not that big. You can do it.

Troy: Did you hear that?

Scot: Yeah. Again, with the looking at me.

Troy: It's not that big.

Scot: I'm going to have to go back to the gym. I'm not as swole as I thought I was, I guess. All right.

Troy: Yeah. This will only take you about two seconds, Scot.

Scot: Wow.

Troy: Hey, I'm just reaffirming what he said.

Scot: Yeah. I'm going to go do some pushups, see if I can beef things up. Troy, you have a question, right?

Troy: My question is, as we're talking about this, I'm hearing this, and certainly any time you hear about cancers and 50% mortality at 5 years, it really raises a lot of concerns. So I'm wondering are there certain people who should be concerned about this more than others? Meaning are there certain people with certain body types, risk factors, such as family history of breast cancer in women, things like that, testosterone therapy? Anything in particular where that's going to increase a man's risk of breast cancer?

Mitch: Or even if someone has a lot of extra weight and maybe they have more fat on their chest or something, is that something too?

Dr. Covington: Those are great questions. Let's talk about risk factors for male breast cancer. First of all, older age is a risk factor for all cancers, and that includes male breast cancer. Genetic mutations, things like the BRCA gene. The BRCA gene, that's what Angelina Jolie had and why she had a double mastectomy. That was pretty widely covered by the media when that happened. The BRCA gene raises risk for breast cancer in everybody. Whether you're a man or a woman, you're at higher risk if you have that.

Scot: I have a BRCA gene just like . . . Angelina Jolie and I have something in common, guys.

Dr. Covington: I hope you don't have a BRCA gene.

Scot: Oh, I don't have a BRCA gene. Just women have those?

Troy: No.

Dr. Covington: No. Men can have it too, yeah. That's the point.

Scot: Oh, you hope I don't because that would . . . Okay.

Dr. Covington: Absolutely. If you had the BRCA gene, I'd be worried that you could have male breast cancer and other types of cancer, including prostate cancer. You don't want it.

Scot: No, I don't want to have anything in common with Angelina Jolie, I decided.

Dr. Covington: But what that means is if you're a man in a family and you have a lot of women in your family that have had breast cancer, and they have genetic testing and they have the gene, that might be important for you to know about. That's definitely something you should talk with your physician about.

And if it's one of these genes like the BRCA gene, the importance of self breast exam, especially probably seeing a physician and having them do a breast exam every year on you also, is important.

Prior radiation therapy to the chest, that's something that men have. You get other cancers, say lung cancer, lymphomas, different things, melanoma, where you might have had radiation to the chest, that can increase your risk of breast cancer.

Using estrogen, we need to talk about that. Estrogen is used for gender transition, and if a genetic male is using estrogen, that does have a significant increase in breast cancer risk to the point that you might want to consider mammographic screening. There are a lot of ongoing studies about that as we speak. We'll have more information in coming years.

Other genetic conditions are things like Klinefelter syndrome where someone might have an extra X chromosome.

If you've had your testicle removed, say you had testicular cancer and it was removed, that lowers your testosterone levels. That allows estrogen levels to have a little bit more influence on your body. That can increase breast cancer risk.

If you have cirrhosis of your liver, that means end-stage liver disease, and therefore heavy alcohol use can increase male breast cancer risk.

And let's talk about weight. Being overweight or obese does increase breast cancer risk, but it's not because you might have more fat in your breast. It's because that actually increases the amount of estrogen in your body. Having more fat allows estrogen levels to rise for reasons we don't need to get into. Therefore, excess body weight is a breast cancer risk factor whether you're a man or a woman.

Scot: Man, that plays back into our Core Four that we talk about on the show, which is to be healthy now and later, you should get some activity, your nutrition, sleep, and emotional health. And of course, that exercise and nutrition is to keep that body weight kind of under control. Time and time again, when we talk about numerous diseases, body weight is such a big factor, and especially here with breast cancer it sounds like.

What about something I've eaten or some sort of environmental factors? Are those risk factors as well? Like, maybe men who work under certain conditions?

Dr. Covington: I would say those are not well understood. I can't think of anything specifically in terms of an environmental exposure that would raise your risk of male breast cancer substantially. We pay most attention to genetic mutations that cause breast cancer, like BRCA, as well as family history in terms of estimating someone's risk.

Scot: And then I also read that non-Hispanic Black men, according to the CDC, have a higher risk than other racial or ethnic groups. I just want to confirm that.

Dr. Covington: Yes, I believe that's true. But that doesn't mean if you are not in that subgroup that you should not pay attention or ignore a lump in your breast.

Scot: Yeah. It's just if you are in that group, that's just another reason why . . . The baseline is, "Lump, go doctor." I made it three words, guys.

Troy: I like it. But just to clarify, now that we've really simplified it, "Lump, go doctor," when you talk about a lump, what do you mean by a lump? If I feel on my chest, and I feel an area that's maybe the size of a pea and it feels kind of firm, should that concern me? Or is this something larger and it feels like a golf ball, or a marble? At what point should I really be concerned when I'm feeling around there?

Dr. Covington: Here's the key. You want to find cancer when it's the size of a pea or even smaller. So what I would say is if you feel a lump, even if it's only pea-sized, and you're certain it wasn't there before, you think it might be new, don't delay, go see your doctor, see what they think, and let them make that decision on whether this is normal or not. But you don't want to wait until you have something the size of a golf ball in your chest.

Scot: That would be bad.

Troy: So size of a pea. "Lump size of pea, go doctor."

Scot: No, you're making it more complicated. Just any lump. "Lump, go doctor."

Troy: I know. We'll keep it simple. "Lump, go doctor." When you go to the doctor, what are they going to do there? Do you expect they're going to do a mammogram or should I expect a biopsy? What should I be thinking I'm heading toward?

Scot: And specifically, am I going to a primary care physician or something of that nature, or do I go to an expert right away?

Dr. Covington: Typically, you'll be seen by a primary care physician first. If you have a primary care doctor, I would suggest you go see them first.

Scot: Or go to a clinic and get an appointment with a doctor.

Dr. Covington: Correct. And they will do an evaluation. They'll feel that area and see if they can confirm themselves that there is a lump. They'll have some kind of idea from their experience how suspicious that lump might be. And in many cases, they'll probably refer you to come see a breast radiologist, such as myself or one of my colleagues, and we will often start with a mammogram.

We need to talk about mammograms because they are key to diagnosis of breast cancer for both males and females, and they can be performed in males despite what anybody may see.

I just had a conversation recently with my mom explaining that men can get a mammogram, and that was news to her. It is a tool that is very valuable for men, but, for reasons, it seems to be tied very closely to females. That's not necessarily helpful when we're considering male breast cancer, because anybody can get a mammogram and it can be a lifesaving imaging study for anybody.

Troy: See, here I've got to say I'm in the same boat as your mom. I'm surprised to hear that men can get a mammogram too. I'm a pretty thin man, and I'm trying to think to myself, knowing how mammograms are done, how are you going to get my breast tissue in to look at it and actually do a mammogram on it?

Mitch: Yeah. How?

Troy: Logistically speaking here, I don't know how you do it, but it sounds like it's possible.

Dr. Covington: It is possible. Even if a woman has had a mastectomy and had her breast completely surgically removed, it is possible to do a mammogram. You can get enough tissue in the machine to get your images. And mammograms are very powerful tools for diagnosis of male breast cancer. I have yet to see a man come in who cannot successfully have a mammogram completed. It simply works.

Scot: We talked about the amount of time that it usually takes men to go get that lump looked at. Again, 12 to 14 months. And part of it is an awareness issue, I've read pretty widely. I think we've proven that men can get breast cancer, but not necessarily everybody knows that.

But there's also some stigma attached to it. Some of the stigma includes, and I mentioned some of this at the top of the show, they first aren't aware that men can get breast cancer, that men even have breast tissue. We don't have breasts. We have chests. It's a woman's disease. We're embarrassed. We feel like, if we have breast cancer, that makes us less of a man because breasts are generally associated with women.

And then there's that general documented phenomenon that men don't want to show weakness and admit something might be wrong with anything beyond even just getting a breast cancer diagnosis.

What are some of the things that you've experienced with your patients, Dr. Covington, as far as that stigma that may have prevented a man from coming in to see you earlier than they did?

Dr. Covington: I think the primary problem is a lack of awareness of male breast cancer. And the stigma is probably a secondary, but still important problem.

So, first of all, let's just spread awareness. Everybody needs to be aware that men can get breast cancer. In fact, about 1 in 100 breast cancers diagnosed in the United States is found in a male, and that translates to something like 3,000 breast cancers a year in men.

In terms of what I've seen with male patients who come in, first of all, they're often a little bit nervous, and I understand that. Nobody wants to think that there's any chance that they could have a cancer. And when they come in, after seeing a doctor who's ordered a mammogram, they're concerned about the possibility that this could be a cancer.

They often are relieved to find out that what we're actually seeing on imaging is gynecomastia. Like I said, that is the most common scenario, but I have definitely been involved with diagnosing breast cancer in men. And every time this has happened to me, it's a sobering experience.

It is always a little bit of a surprise to the patient themselves. It's typically a surprise to their primary care doctor. This usually isn't as high on people's radar as I think it should be. Again, men can get breast cancer and do. As I said, about 1 in 100 breast cancers will be in males. And unfortunately, I've seen too many males with breast cancer do poorly because of delayed diagnosis and presentation.

I don't want to freak out our listeners on the other hand, though. I don't want every man to be concerned as they listen to this that they have breast cancer because chances are you don't. But what we want to do is raise awareness that it's possible. We want to remind every man that if you feel a new lump in your chest, get it evaluated.

And we want to, as much as possible, drive breast cancer in men to an earlier treatable stage of presentation, meaning that we're finding out about it when it's the size of a pea rather than a golf ball.

That's the point of this, but I don't think anybody needs to go home and be convinced they have male breast cancer just because we're saying it's 1 in 100 breast cancers. It is still rare, but it should not be ignored.

Scot: I want to jump in. So it's great that male breast cancer is rare, right? But it also comes with some downsides, which we've talked about, lack of awareness. What about in the medical community? Is there a chance that I could go to a primary care physician, and just because it is so rare, those physicians are not going to necessarily be able to make the best diagnosis? How can I be sure that I'm getting an accurate diagnosis?

Dr. Covington: It is possible that male breast cancer won't be on the top of the list of a primary care doctor, even if you come in saying, "I have a breast lump." Of course, it's something they'll think about, but they will probably assume it's gynecomastia.

Something that you should pay particular attention to that was suggested is not gynecomastia is if your lump is not directly behind the nipple. That raises the possibility greatly that this could actually be a breast cancer.

Now, I don't want anyone who feels a new lump under their nipple not to have it evaluated again. That's part of a key message of what we're talking about. But especially if you feel something that's not under the nipple, and if you were to be told that that's gynecomastia, that would not be correct.

This is something that you just need a little bit of self-awareness, and it's probably worth asking that follow-up question, "Are you sure? Is there anything else this could be? And why do you think that?" Asking those follow-up questions can do wonders in terms of any health complaint, but including a lump in the breast. "Is there anything else this can be and why do you think this is what it is?"

Scot: And from a communication standpoint, that makes total sense, right? I think we all in our jobs and what we do get into these routines and sometimes don't consider the alternatives until somebody kind of says, "Hey, what about this?" or, "Hey, why do you think that?" And then that forces us to slow down and really kind of consider what's going on. So that follow-up question sounds really important.

Dr. Covington: Right. And also, if you have a lump that a doctor may have said is nothing to be worried about and it continues to enlarge, go back again.

Scot: If it doesn't continue to enlarge then, is that likely not breast cancer?

Dr. Covington: If it doesn't continue to enlarge and you've had some evaluation, whether a physical exam or imaging that's showed it's benign, then I wouldn't get concerned. If it goes away, it's not breast cancer. Breast cancer does enlarge over time if it's not treated.

Scot: Yeah. But it might be moving so slow I might not notice the enlargement. And regardless, I shouldn't be making that call of, "Is it not getting bigger?" I should have a professional make that call.

Dr. Covington: That's correct. But my point is if you're told you have a benign breast mass and you go home and, say, two months later, you are absolutely certain it's gotten bigger, that's when you need to go back and say, "Can we take another look at this?"

Scot: All right, guys. What did we learn today? Troy, what's your takeaway?

Troy: My takeaway is breast cancer is more common than I thought it was in men, and I can get a mammogram.

Scot: Yep. How about you Mitch?

Mitch: "Have lump, go to doctor." I guess that was the thing that's so shocking to me, is I actually have heard of and have had a friend of a friend have male breast cancer. So I was aware that it happened, but I did not realize that it's usually pretty fatal because men get in too late. So I'll be feeling my chest, I guess, on a semi-regular basis, and if I ever feel a lump, I'm going to go in and talk to someone about it.

Scot: That's good. And I love what Dr. Covington said. Just because you find a lump doesn't mean it's cancerous, but you should always get a lump checked out.

And my takeaway is there are a lot of things that are going on inside and outside of our heads as men. If we find that lump that might cause us to not get it checked out in a timely way, whether it's this threat to masculinity or whether it's, "Oh, it's such a rare disease. I'm probably okay. I don't have time to go get it checked out anyway." So fight through that stuff and just go get it checked out.

The other thing I do want to say is lack of awareness is one of the primary reasons, as Dr. Covington said, that men die from male breast cancer, and talking about it is the way to overcome that and any of these stigmas as well.

So what I would love it if you would do is share this podcast and say to somebody you know, "Hey, I listened to this podcast called 'Who Cares About Men's Health,' and they talked about male breast cancer, and it was really, really interesting. You should check it out." Who knows? You might be referring it to somebody who has discovered a lump and this might change their perception of that whole thing.

Dr. Covington, thank you so much for being on the show, and thank you for caring about men's health.

Dr. Covington: Thank you. It was a pleasure to be here.

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interviewer: For patients that were just diagnosed with multiple myeloma or have had a recurrence of the cancer, receiving the treatment that's appropriate for your situation requires an expert.

Dr. Aman Godara from Huntsman Cancer Institute is that expert. He's an expert at diagnosing and treating multiple myeloma, and we're going to get to some of those treatments and some information about clinical trials. But first, Dr. Godara, some context, what is multiple myeloma?

Dr. Godara: So multiple myeloma is a type of blood cancer, which occurs from the proliferation of plasma cells that are present in the bone marrow.

So patients who have multiple myeloma can have several complications as a result of this cancer. These complications usually involve weakening of the bones that can lead to fractures. These complications can cause low blood counts, high calcium levels, and sometimes can also affect the kidneys of patients who have multiple myeloma.

interviewer: And how does a person kind of come to realize that they have it? Are there some symptoms or signs that they notice?

Dr. Godara: Patients who are newly diagnosed with multiple myeloma, the way this disease comes to light is that these patients can have fractures very easily. So we see patients who have had a fracture recently and have a lesion that was weakening the bone there, a tumor that was weakening the bone there, that resulted in that fracture.

A lot of times, patients have low blood counts and when the testing is done to identify what the cause for the low blood counts is, that can also reveal a presence of multiple myeloma. This type of cancer produces a protein that we call the monoclonal protein that can be detectable in the blood or urine of the patients who have multiple myeloma.

And sometimes patients would also have kidney failure, and that's another population of patients when patients have kidney failure that we don't have a good explanation for. Those patients are also looked out for this disease to make sure that they don't have multiple myeloma.

interviewer: So a person would go to their primary care physician or perhaps an urgent care or emergency room because they fractured a bone. What are some of those other types of symptoms that have taken them to that first step?

Dr. Godara: So, a lot of times, patients have gone to an emergency department or to an urgent care center because they just had a fracture. And whenever patients have a fracture, they will have some imaging done of their bones, whether that is an X-ray, whether that's a CAT scan, and those things can also identify the tumors, the kind of weakening that this kind of cancer can do to the bones.

A lot of times patients end up into the hospital because they have very low blood counts, and that's also a sign and symptom of this disease.

interviewer: And how does physically having a low blood count manifest itself?

Dr. Godara: So patients who have low blood counts usually feel that they are getting tired easily with any work that they would normally do in their day-to-day life. Patients who have low blood counts could also have multiple infections one after another, and these infections usually are infections such as pneumonia. Patients who have low blood counts can also have increased bruising over their body. And these are all reasons that would lead to a diagnosis of multiple myeloma in a patient.

interviewer: And as far as the diagnosis goes, if somebody is experiencing these symptoms, they go to their primary care physician or the emergency room in the case of fractures. Is it pretty easy at that point to tell that that's what's causing these types of things when those typical tests are run?

Dr. Godara: Sometimes the answer could be a little bit complex. If somebody has a fracture and you see a tumor in their bone, the first thing that somebody should think about is that is this multiple myeloma?

But when patients have low blood counts or when patients have kidney failure, when they have come to see a doctor or they have come to an emergency department, then the answer is not really very straightforward. In that scenario, we have to look at different possibilities, different diagnoses, and ultimately confirm whether a patient has or does not have multiple myeloma.

interviewer: Tell me about the treatments for multiple myeloma. What are we talking about there?

Dr. Godara: Patients who have multiple myeloma and are just newly diagnosed with it, the way we treat these patients is a combination of three or four medicines together. And we have come a long way in the past 20 years in this regard. Twenty years ago, when patients would be diagnosed with this disease, they would receive chemotherapy as their initial treatment. But now, the treatment has become a lot more focused on the disease and the problem that causes this disease.

So the three or four drug combinations that we usually treat our patients with are medication combinations that work particularly well against this type of cancer. They have side-effects that are predictable and manageable in the hands of the clinician who is treating these patients.

interviewer: And from what I understand, multiple myeloma is not something that's ever cured. So, after a first round of treatments, they might be cancer-free for a while, but eventually, is there going to be a relapse?

Dr. Godara: Once patients are diagnosed with multiple myeloma, they will initially receive a treatment that consists of three or four drugs combined together. And the initial attempt is to control the myeloma and put it into a remission. Once that happens, we have to decide upon the next steps for the patient.

And the next steps depend on how aggressive the myeloma was at that time of diagnosis, whether there were any high-risk features associated with the myeloma, and these are genetic changes usually that accompany the diagnosis of multiple myeloma.

So, based on that decision-making at that point of time, sometimes we choose and recommend our patients to undergo a technique called stem cell transplantation with high-dose chemotherapy, where patients receive a high dose of chemotherapy that otherwise would be toxic to their bone marrow, but in this technique, patients' stem cells are collected before they receive this chemotherapy so that we can overcome the side effect of that chemotherapy on the bone marrow.

And this is a treatment that has been well-established for patients with multiple myeloma for the last 30 years, and we still continue to use it, especially in patients who have any aggressive features associated with their myeloma or have high-risk myeloma when they presented at the time of their diagnosis.

So once patients have received their initial treatment and have received either a stem cell transplant or not, they would still continue some form of maintenance treatment, at least until a few years into their diagnosis. This is to confirm that the myeloma remains in remission and does not come back early.

interviewer: And generally, how long is it before the first remission might come back then?

Dr. Godara: So this will depend a lot on what the initial treatment for the patient was, and it will also depend on the risk-staging of multiple myeloma when it was diagnosed.

On an average, when we talk about a standard patient with multiple myeloma, the time that this disease could take to come back would be somewhere around four to six years after the treatment has been initially started. But patients who have some aggressive features associated with this type of cancer, their myeloma can come back within the first two or three years of their diagnosis.

interviewer: And for that patient that then has had their first or their second remission, what are the treatment protocols at that point? Do you change up the treatment or is it pretty much the same thing just again?

Dr. Godara: So patients who are experiencing their first or second relapse, we make a determination of what their initial treatments were and how long ago were those treatments done.

If there has been a long gap between the time that the patients received those last treatments, we can certainly use those treatment options again in the same combination as they were used initially.

But if a patient experiences a relapse while they are on one of those treatments, then in that case we usually tend to make some switches to their treatment combination and start off with a new regimen for those patients who have relapsed.

interviewer: And there's been a lot of development in those treatments over the past few years. Can you tell me a little bit about that?

Dr. Godara: There has been a lot of development in the field of multiple myeloma. And when we talk about that, we are not just talking about new treatments but more innovative ways of combining these treatments together that have become available in the past few years.

So when a patient is newly diagnosed, as I mentioned earlier, patients could receive a combination of three drugs or four drugs together. So there's been a lot of focus on whether one strategy is superior to another.

And there are certain populations of patients where one strategy has been proven to be superior than the others. So patients who are not very fit when they are diagnosed with this cancer, or are above the age of 70 or 75 years, those patients are not eligible to receive a stem cell transplant usually.

And in that scenario, we have information to the effect that if we use four treatments together, they serve to be better than three treatments together, not just in terms of the duration of response that these patients get out of that particular treatment, but also it can impact survival when we use four treatments together. Patients can have a longer survival compared to when they receive three drugs together.

So that's been one area, one aspect of this disease where there is currently a lot of focus identifying what works better and what combination works better than another.

When patients have relapsed, what makes a difference there is what type of relapse we are talking about. Patients who have had their first or second relapse, we have several different options that we can easily choose from to treat those patients and put the myeloma back into remission.

But one other aspect of this disease is that the way all this progress is happening is through the clinical trials.

There are clinical trials that are focusing on patients who are just diagnosed with multiple myeloma.

There are clinical trials that are focusing on patients who are experiencing their first or second relapse, from the time that they have been diagnosed.

And then we also have a lot of clinical trials focusing on patients who have received multiple different lines of therapy before and are running out of options when they suffer from a future relapse.

So some of the clinical trials that are ongoing right now are not just looking at some innovative treatment combination, but these treatments are innovative by themselves.

So there has been a lot of focus on immunotherapies in treating multiple myeloma. So one of the antibody treatments that we use in these combinations to treat multiple myeloma became available around seven years ago and has been a game-changer for the patients.

And these treatments are particularly focused on targeting the plasma cells that are causing this multiple myeloma, and at the same time, they don't have the toxicities or side-effects that we usually associate with cancer treatment.

Now, in just the last couple of years, we have had also some other immunotherapy treatments where we are harnessing the power of your own immune system to target multiple myeloma. Those treatments have shown us that they have efficacy and they work for patients who have had multiple different lines of therapy. Their toxicities are very unique and very different, but at the same time they are predictable toxicities that we have measures and steps we can take to mitigate that toxicity that comes along with these treatments.

interviewer: So if I'm understanding correctly, somebody who has had multiple myeloma a few years back and then it has come back will have a whole different selection of treatment options possible to them that might have fewer side-effects, might be more effective in treating the disease. Is that accurate?

Dr. Godara: So that's accurate to some extent, because as we start focusing more and more on the disease, and more and more on treatments that are not having any off-target effects, as a result, there is more efficacy and less toxicity.

So one of the questions that we are commonly asked when a patient has experienced a relapse is that when we do start a new treatment, what will be the duration of the treatment? And in this regard, there has been a lot of focus to developing treatments that are just a one-time treatment and do not require any continuous administration.

One of the newer treatments for patients with multiple myeloma is Car T-cell therapy where patients' own immune cells are engineered to fight this cancer. And this treatment is given as a single-dose treatment and has a toxicity that is predictable. It requires administration of this treatment in the hospital, but once the patients are out by a few days or a few weeks from this treatment, we don't anticipate any further toxicity related to this treatment.

Then there are also some similar treatments that are, again, harnessing your immune system to fight the cancer, which require a weekly or every other week administration that requires patients to come in every week or every other week to get these treatments.

But again, these are treatments that usually have toxicities that are more pronounced at the beginning when patients start these treatments, rather than toxicities that continue as long as those patients continue on those treatments.

interviewer: Multiple myeloma is a complicated disease that takes a lot of medical expertise from different specialties to manage. Tell me how, at Huntsman Cancer Institute, you're able to provide that to the patients.

Dr. Godara: So patients who have multiple myeloma usually require a multitude of services. Patients are sometimes sent to see an orthopedic surgeon because they have suffered a fracture. Patients are sometimes sent to a radiation doctor because they have a bone tumor that requires a radiation treatment. And sometimes the effect of this cancer on your wellbeing is so immense that patients have to participate in some wellness programs to get back to where they were before this diagnosis occurred. We provide a multitude of these services under the same roof at Huntsman Cancer institute.

At the same time, all the innovation that's occurring in the field of multiple myeloma, an opportunity to participate in that is through clinical trials. We provide clinical trial options for patients who are not just newly diagnosed with this cancer, but also patients who have had their first, second, or multiple relapses in the past. We give them an opportunity to participate in clinical trials for some of these innovative cancer treatments right at their doorstep.

interviewer: What is the value of somebody getting a second opinion that has had a multiple myeloma diagnosis or has relapsed?

Dr. Godara: So patients who have multiple myeloma, I strongly recommend them to see a specialist for their disease so that not only we can discuss what's the right combination of treatments to start off for their disease, but also patients who have had relapsed myeloma, the opportunity for them is to participate in clinical trials and bring some of these innovative treatments out to the front long before they are available as an option for treatment for these patients.

The ultimate goal here is that we want our patients to live longer, we want to minimize their toxicity, and at the same time maintain a quality of life that patients can enjoy their lives with.

Interviewer: Amyloidosis is a rare and possibly debilitating disease, which affects about 4,000 people a year in the United States. If left untreated, the disease can cause severe organ damage, so early detection is critical. Dr. Aman Godara is an amyloidosis specialist at Huntsman Cancer Institute. Dr. Godara, first of all, what causes this disease?

Dr. Godara: So amyloidosis is a rare and complex disease where a protein misshapes itself, becomes the amyloid protein, and then deposits in different organs of the body causing damage.

Interviewer: So it collects in different organs?

Dr. Godara: Correct.

Interviewer: And for each patient, it could be a different organ. It could manifest itself differently.

Dr. Godara: The type of protein that's behind amyloidosis could affect what type of organ is involved in the body.

Interviewer: And the diagnosis for a lot of patients can be kind of an aha moment because it can manifest in different ways. Somebody could be experiencing some sort of abdominal pain and just really can't track down what it is, and it ends up being amyloidosis. Explain that a little bit more, that aha moment.

Dr. Godara: So the diagnosis of amyloidosis can be very challenging because, as we mentioned, there are several different types of protein that can cause several different manifestations in the body.

So usually, when a patient is being diagnosed with amyloidosis, the diagnosis requires a biopsy of an organ or a tissue in the body that we suspect would be involved with the amyloidosis.

There have been some newer developments in diagnosing amyloidosis, and that's the type of a nuclear scan that we have started using to diagnose a type of amyloidosis that we call as the ATTR amyloidosis.

Depending on the type of organ that's being damaged by the amyloidosis, the symptoms could vary along. If someone's heart is being damaged with amyloidosis, usually patients with heart damage from amyloidosis experience shortness of breath, they experience swelling in their legs, and when they go to see a cardiologist, they are usually identified to have heart failure.

When amyloidosis affects the kidneys, it can cause leakage of protein in the urine, which can manifest itself as a form of urine. Sometimes patients with amyloidosis have involvement of their nerves and that can manifest as painful neuropathy involving their arms or their legs.

Interviewer: So when somebody is experiencing some of those symptoms, they might go to their family doctor, right? And it sounds like this could be a lot of different things. Is it pretty easily misdiagnosed at first?

Dr. Godara: As the diagnosis for amyloidosis is so challenging, misdiagnosis occurs often because the type of symptoms that come along with amyloidosis can occur from other diseases and other conditions.

If a patient is experiencing symptoms of heart failure, that could manifest from a different number of reasons. When patients have kidney dysfunction, that can also occur from a list of different conditions that can damage the kidneys.

So often at the point of care, when these patients are experiencing symptoms that might be related to amyloidosis, the patients end up seeing multiple different types of specialists before they are diagnosed with amyloidosis.

And there are certainly some delays in diagnosis that, on an average, patients take 6 to 12 months to be diagnosed with amyloidosis from the time their symptoms start.

Interviewer: And that's important because time is really important with this diagnosis because the damage to that particular organ keeps occurring.

Dr. Godara: The damage from amyloidosis is progressive damage. So the longer we are taking to diagnose amyloidosis, the more damage would occur in that organ that's being affected by this disease. So timely diagnosis is of utmost importance.

Patients who are diagnosed earlier in the course of disease might have damage to that organ that could be reversible at that point. But ultimately, if we miss a diagnosis, and it takes a really long time for a patient to be diagnosed with amyloidosis, that damage to the kidney or to the heart could end up being an irreversible damage that even treatments would not be able to recover from.

Interviewer: That's really challenging because as a person that has a condition, sometimes you have to go through some multiple diagnoses to figure out what it is. Is there any piece of information that a patient might have that would indicate earlier than later that it is an amyloidosis?

Dr. Godara: So patients who are suspected to have amyloidosis usually require a comprehensive evaluation to identify the type of amyloidosis and to identify the manifestations of it. So the workup depends quite a bit on the type of amyloidosis that we are suspecting.

If we are suspecting lichen amyloidosis, that occurs from the excess of lichens, the first and the foremost test that we perform for those patients are blood and urine testing to identify if they have an excess of lichens, which could ultimately be causing amyloidosis.

If patients have an excess of immunoglobulin lichens in their blood or urine, the next step for those patients is to have a bone marrow biopsy to identify any clone in the bone marrow that might be producing these excess lichens and ultimately the amyloidosis.

The other type of amyloidosis that we commonly see is the ATTR amyloidosis, which occurs off a defect in the transthyretin protein that is being produced by the liver. Patients who have ATTR amyloidosis could either be patients who have developed this type of amyloidosis because of old age or this could also be the type of amyloidosis that runs in the family.

So if we are suspecting a patient with ATTR amyloidosis, and we suspect that they have some cardiac damage from it, there is a nuclear scan of the heart that can help us identify this type of amyloidosis. This scan is called as the PYP scan. Patients who have a more genetic form of ATTR amyloidosis, we have genetic testing that can be done either through a swab or a blood test that can help us identify the hereditary type of ATTR amyloidosis.

Interviewer: How reliable are these tests?

Dr. Godara: When patients undergo evaluation for amyloidosis, the blood and the urine testing usually helps indicate whether or not there is any damage that's occurring to the different organs in the body that we would suspect in a patient with amyloidosis. So they only tell us to a certain extent.

Ultimately, patients would require either a tissue biopsy or an organ biopsy to see that amyloid accumulation happening in that organ to have a confirmation of this type of diagnosis.

Interviewer: Many patients find information on the internet when it comes to this disease that can cause anxiety and apprehension. Why is that?

Dr. Godara: I think the answer to that lies in the complexity of the disease. When patients look up amyloidosis, one thing that they might not know at that time is the type of amyloidosis that we are suspecting that they have.

The workup for amyloidosis, the treatment for amyloidosis, and the prognosis of amyloidosis depends a lot on the type of amyloidosis that they have. So the information on the internet might not be very accurate to the fact to the type of amyloidosis that these patients have. And the generalized information can create a lot of confusion and apprehension.

Interviewer: So somebody could find out they have amyloidosis but not exactly know what kind, go to the internet, start doing some research, and then that can be scary place.

Dr. Godara: I think that's correct. When we see patients who are referred to us for amyloidosis, patients have very limited knowledge as to what this disease entails and why this diagnosis is being suspected. So my job for my patients is to explain to them why the suspicion exists, and what do we need to do to identify whether or not they have amyloidosis.

The information that's available for the patients before they have completed the evaluation could be very generalizable and might not be important to that type of amyloidosis that they have.

Interviewer: And let's talk about treatments for the condition. So you have a positive diagnosis, you know what kind it is, you know what it's impacting, I would imagine that the treatments that you would give depend a lot on the same kinds of things we've talked about up until this point.

Dr. Godara: So as there are so many types of amyloidosis that can inflict damage into the body, the treatment basically depends on the type of amyloidosis. So there have been a lot of developments and a lot of exciting work has been done for patients with amyloidosis in the last few years.

So when we see patients with lichen amyloidosis, just last year, we had a treatment that is specifically developed for patients with lichen amyloidosis that was approved by the FDA. This is a combination of four medications together that not only results in eradication of the clone that causes amyloidosis, but also helps improve the heart, kidneys, or any other organs that might have been damaged as a part of this condition.

So patients who have transthyretin amyloidosis have two different types of treatments available for them. One treatment focuses on stabilizing the transthyretin protein and preventing it from turning into amyloidosis. And the other type of treatment targets the liver and prevents it from producing the transthyretin protein, so that ultimately you cut out the source that would be causing amyloidosis.

So there's been a lot of progress and a lot of other new treatments that are in clinical trials for these two types of amyloidosis. For several other types of amyloidosis, we don't have any treatments available yet.

Interviewer: And for those patients, is it just managing the disease best you can, managing the symptoms? What's the strategy?

Dr. Godara: So patients who have types of amyloidosis that we don't have treatments for, our focus remains on the organs that are afflicted from this disease. We try to support the organs that are damaged as a part of amyloidosis, and sometimes these patients will end up receiving a kidney transplant, or a liver transplant, or a heart transplant depending on what type of organ was damaged, irrespective of whether or not we have any treatments available for that type of amyloidosis.

The first and the foremost thing for patients with amyloidosis is to identify these patients at the earliest, because the sooner we take to diagnose this condition, the sooner we can try to reverse this process.

Delays in diagnosis can ultimately hurt the patient, so we have to create awareness at all levels of our healthcare system to identify these patients who might or might not have amyloidosis so that they undergo the appropriate workup and have a confirmation on whether or not they have this condition.

So we need to create awareness not just at the level of the primary care doctor, but also the specialists that our patients see. And at the same time, we also have to increase the awareness about this rare disease with our patients, so that if they have one of the symptoms that we relate with this condition, our patients can come to us and be evaluated for the suspicion.

The one thing that patients with amyloidosis require is a comprehensive evaluation. So when we suspect amyloidosis in a patient, our patients require a multidisciplinary team to not just help identify whether or not they have amyloidosis, but also once the diagnosis has been confirmed, we can focus not just on the cause of what's causing the amyloidosis but also help support the organs that are damaged as a part of this disease.

So at the Amyloidosis Program at Huntsman Cancer Institute, our patients receive care under a team of specialists that includes representation from cardiology, nephrology, and neurology to provide the best possible care that our patients need.

If you are considering having breast implants, for whatever reason, how do the new FDA guidelines on breast implants affect you and your decision?

Breast augmentation is near the top of the most cosmetic surgical procedures. Although the number of women who had breast implants fell by one-third in 2020, probably related to COVID-19 pandemic, still 200,000 people had breast implants in the U.S. in 2020, down from the usual 300,000 implants per year. About 75% of the implants are for cosmetic reasons, and the rest are part of reconstruction after breast cancer surgery.

Recently, the FDA took some new steps to improve and strengthen the information guidelines about implants and short- and long-term consequences.

It's hard to know how women want to receive information about the risks of breast implants. They believe that they know the benefits, at least for the persons they believe themselves to be right now. They can't really assess the benefits to the woman they will be at, let's say, 60. However, the assessment of benefits is a completely personal process and will be different from woman to woman. And this includes trans women making the decision to have breast implants.

The risks are harder to communicate. Language is often very medical, numbers are hard to process, and some people don't even want to know the risks.

There are data from a randomized trial of information giving that women who received more information were happier with their decision, were less likely to experience preoperative anxiety, and were less likely to experience postoperative regret. So in the information era, I think more is better.

So what are the new components of these new FDA guidelines? First of all, they aren't exactly new. They've been worked on for several years now, and they went out for public comment and were published back in 2020. However, they became more official in the fall of 2021.

Firstly, the boxed warning, the ominous black box that comes on some package inserts of medications and devices that actually nobody really reads unless you stick it on their nose.

I'm going to quote here the example from the FDA with my own asides put in. "Warning," and this is in a big black box, "breast implants are not considered lifetime devices. The longer people have them, the greater the chances are they will develop complications, some of which will require more surgery.

"Breast implants have been associated with the development of a cancer of the immune system called breast-implant-associated anaplastic large cell lymphoma. This cancer occurs more commonly in patients with textured breast implants than smooth implants. Although the rates are not well defined, some patients have died from this." Okay, that's number two.

Three, "Patients receiving breast implants have reported a variety of systemic symptoms, such as joint pain, muscle aches, confusion, chronic fatigue, autoimmune diseases, and others. Individual patients' risk for developing the symptoms has not been well-established. Some patients report complete resolution of the symptoms when the implants are removed without replacement." Okay, that's the black box.

Well, I would want to know more about the phrase that the implants are not considered lifetime devices. There are no recommendations that breast implants be removed after some certain years, not like IUDs that have a finite effectiveness with recommendations for removal at a certain time.

Eighty percent of women who've had an implant placed still have it at 10 years. Of course, the woman that you are at 25 will not be the woman that you are at 55, and neither are your breasts, as all of us know.

"The chance of complication increases over time." What does that mean? Your surgeon should explain those complications, what they are, how often they happen, and what can be done about them.

The common ones are hard fibrous walls around the implant that can be unnatural-looking and feeling, or rupture of the implant capsule.

The uncommon one is the cancer that's associated with the certain kind of implant with a textured, not a smooth, outer covering. That cancer, which is mentioned in the black box, is called breast-implant-associated anaplastic large cell lymphoma. This is a mouthful, but is lymph cancer that arises over time, rarely.

The incidence in women who have these textured implants is 1 in 3,000 to 1 in 30,000. So it's not common. We have a great interview with Dr. Jay Agarwal on this kind of cancer and breast implants. You can find this interview at The Scope if you want to know more.

"Breast implants have been associated with these systemic symptoms." What does that mean? Some women have experienced symptoms such as pain, autoimmune symptoms, chronic fatigue. In the past, this has been somewhat ignored. But there are some women who've had fewer symptoms after their breast implants are removed. This isn't very well understood, but here it is in the black box.

To help understand the black box warning about breast implants, the FDA has created a model patient decision checklist. I think this is really great if it's given to the woman well in advance so she has time to read it or have someone read it to her and explain it to her. This isn't something to be handed out in the pre-op visit just to sign, the way you sign your permissions to your software like Google or your phone. This should actually be read word for word.

The FDA created this checklist to add to that surgeon's counseling. It is meant to be a springboard for discussion, and the patient will read and check off that they've read it and understood it.

It is long, multiple pages, with places for the patients to sign at the bottom of each topic. It includes who shouldn't have implants, at least at the moment: women who have an infection, women who are pregnant or breastfeeding, women who are having chemotherapy or have a suppressed immune system. It includes more information about the rare lymph cancer and about long-term systemic symptoms.

Actually, the example in the FDA guidelines is a really, really good one. If you're an information junkie like me and you read at, at least, the 12th-grade level, it's great.

The long-term risks of complications are spelled out. The frequency at which these things happen are attached, such as painful scar tissue around the implant reported in 51% of patients, rupture or leaking of the implant 30%, need for reoperation 60%. But those are just the biggies.

It's a really great document. It's what your surgeon should have been telling you anyway, but in the heat of the moment in the office, they might not take the 30 minutes to talk to you about this. And you might not remember. This is a great chance to take it home and read it carefully and bring it back with your questions.

And with the FDA guidelines, there's an updated suggestion about management of breast implant rupture or leakage, that 30% of the time it happens.

And last but not least, there's a card for the patient to keep forever in her wallet or personal records about what kind of implant she has, what it's made from, and when it was placed.

Now, you think you'll remember all this stuff, but you won't. And maybe you'll have them still at 80 and your memory is fading. Your surgeon may have retired or gone on to surgeon heaven. Your medical records may be lost. But at least you have a document about what is existing in your body.

If I had implants, I would laminate mine and put it next to my driver's license or my organ donation card.

I think these are really good steps in the right direction in patient information and decision-making. I know you just want what you want and you wanted it yesterday, but it's a long-term decision with long-term consequences, some good, some not so good. You should take your time and try to get it as right as you can.

Thanks for joining us on the "7 Domains of Women's Health" at The Scope.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: We're pretty excited on today's episode because we get to celebrate something, Troy. Do you like to celebrate things?

Troy: I love to celebrate things.

Scot: You know what we're celebrating today?

Troy: I do know, yeah. But I'm not going to spoil the surprise

Scot: Okay. It's Mitch's two-year quitversary from nicotine. He once was a smoker, then he was a vaper, and now he's a quitter, and he's been a quitter for two years. This is the one time that us guys . . .

Troy: That's amazing.

Scot: . . . can say that being a quitter is a great thing. So congratulations, Mitch.

Mitch: Oh, thank you.

Troy: Congrats, Mitch. And it's amazing to think it's only been two years, but at the same time I'm thinking, "It's only been two years?" So much has happened since you quit smoking. It's beyond quitting smoking. It's been quite a ride here. And the fact that you have not started smoking again in the past two years is absolutely remarkable.

Scot: I mean, I've been close myself and I've never smoked in my life.

Troy: You and me both, man.

Scot: Mitch quit two years ago. He quit on this show. We followed his progress. He quit right before Thanksgiving, which, wow, with family stuff coming up and all that stress, we kind of questioned his sanity on that. But you've managed to make it stick, which is absolutely amazing. How do you feel two years later?

Mitch: I feel good. There are a lot of positive things that have happened. I'm not afraid at any time my chest hurts that I have lung cancer. That little peace of mind is good. I'm running again, or biking recently, but I'm able to cardiovascular stuff. That's great.

My general health seems to be doing a lot better than before, and maybe that's something that we can kind of talk about today. But it's not all sunshine and rainbows, I guess. I don't know. I guess I was expecting, "You quit and then you . . ." In the commercials, you dramatically crumple up that carton of cigarettes and toss it in the trash and walk away defiantly. I still have cravings. I still have occasional ideas of stopping at that Maverik. And it's not every day, but I'm a little surprised that that's still going on. And I just wonder, "Is that just what happens now?" So, anyway.

Scot: All right. Well, to celebrate Mitch's two-year quitversary on "Who Cares About Men's Health," we have brought in somebody that hopefully can answer some of those questions. Her name is Edlira Farka. She is the tobacco cessation program manager at the Center for HOPE at Huntsman Cancer Institute, which is a service that is provided to patients at Huntsman Cancer Institute. How're you doing today, Edlira?

Edlira: Hello, everyone. I'm so excited to be here.

Scot: Yeah, this is exciting. We hope to kind of really talk about a lot of stuff today. We'd like to talk about somebody in Mitch's position at the two-year point, how is he in better health now than he was two years ago? What are some of the reasons why he continues to crave? What are some of the challenges he might face in the future?

And then if somebody is listening that still smokes, that is one of the best things you can do. I say low-hanging fruit, but that makes it sound like it's an easy thing to do, which it is not, but that's one of the best things you can do.

Mitch: No. No, it was not easy.

Scot: It's one of the best things, though, that you can do for your health. It's one of the best investments you can make.

So this is "Who cares about Men's Health." My name is Scot Singpiel. I'm the guy that kind of tries to keep everything on track. The MD to my BS, Troy Madsen. Say hi, Troy.

Troy: That's me, yep.

Scot: And then, of course, today, the reason we're wearing our party hats, Producer Mitch.

Mitch: Hey, I'm here.

Scot: All right. Mitch, I thought maybe this first part of the show, I'm going to back off the mic and let you step up to the mic and talk to Edlira about any questions that you have at two years in on your quitversary.

Mitch: Sure. So, Edlira, one of the things that I guess I would like to talk about now that I'm kind of looking back two years on is . . . This is my seventh time quitting. I guess I don't want to sound hopeless here, but for a lot of people, they don't quit on the first time. How common is it for people to . . . After two years, am I good to go? Is it going to be a constant battle? How likely are people to slip after they've hit the two-year mark? Is there a finish line where people do a lot better or . . .

Edlira: First of all, I want to say congratulations. I think it's amazing that you have been nicotine-free for two years. It's huge. And it's true it's an everyday struggle for many people.

So I will start just by saying that nicotine dependence is a chronic disease. And as such, even though we talk about the transition period a lot, the moment that you start quitting and the withdrawals, and the first two to three days are really hard, and it tends to get easier with time, there is a part of nicotine dependence that doesn't completely disappear with time due to the fact that when most of us . . .

Most people that start smoking or vaping or using nicotine in terms of chewing, any type of tobacco really, they start when they're teenagers or young adults, and our brain is . . . We've heard of neuroplasticity. Our brain responds to those chemicals, to the nicotine, and we start creating more receptors in response to that.

And when we stop using nicotine, those receptors do not disappear. They become sleepy-like. I like to think of them as flowers that are withering, and they still stay there. And that's part of the reason why you've been vape-free or smoke-free for two years and you still think about it occasionally.

Mitch: So that's pretty common then? I don't know. Maybe it's all the PSAs I see. It just looks like you quit and then your life is amazing afterwards, like you've beat the beast and you're done. But that's not what I'm experiencing.

Edlira: Yes, exactly. And what you're experiencing is very normal. And I think we have to change the way we think about it. We have to think about this as a chronic disease. So if we were talking about hypertension and a lifestyle change that helps hypertension, like exercise, we think of that as an ongoing process. It's not something that you exercise today and then you're done with that effect. It's the same kind of idea with quitting smoking. It's an ongoing process.

And you're doing great and amazing, but it doesn't mean that you're not at risk of relapsing . . . sorry, reengaging is the correct term now . . . at any point in the future.

And so it does get easier with time and your success rate is much more higher at this point since you've been smoke-free, nicotine-free for two years, but there is no guarantee that you will never think about it, especially in moments of high emotions, whether it is a life situation, life or death, or even happy moments.

Sometimes it could be routines like going to, as you said, a gas station, places where you've been before. It could be with alcohol or it could be with people you're around who are smoking and you smell the cigarette. There are many different ways you can be reminded about it and think about it.

And I think the key to that is accepting that that thought may come, but it will pass, and you do not need to engage in that thought. We have all kinds of crazy thoughts in our heads all the time and we don't need to engage in those.

Mitch: I mean, just kind of going back to what Troy did, there were times in 2020 that I was, "This is not the time to be quitting. This is not . . ." When we were doing the 5K stuff, I was jogging. It seemed like everyone and their dog had picked up smoking and every single morning they were sitting on their stoop enjoying a cigarette while I was running past, and I'm like, "Oh, I bet I could go bum one real quick. I bet I could do that."

With the episode we had before when I quit for the first time, I just held on to some low-nicotine gum. And so when I had that really bad craving after a run, I would just chew on a piece of gum.

Edlira: Exactly, yes, and that's okay to do. That's what we recommend to use, especially when you're transitioning. We recommend to use nicotine replacement therapy, combination initially, meaning using a nicotine patch, and a short-acting, like a nicotine gum.

And we work with people to slowly use less and less nicotine. Sometimes you have to use nicotine gum long-term occasionally. This is not something you'd need to do on a regular basis, hopefully, but it's always healthier than the alternative, which is going back to smoking or vaping.

I just want to say one more thing, because you said this was the seventh attempt, and I wanted just to say that is very, very normal. On average, most people take about seven attempts to successfully be able to quit just because it is so hard to do.

And the key to that is every time you try and maybe you're not successful, you learn something about what is working and what didn't work. So it's a process, and it's not about getting it right the first time. It's just about not giving up on trying.

Mitch: Yeah. And just to double down on what you just said, the thing that worked for me was that dual system, right? I had the patch, and it was the first time I really committed to the patch, and the gum. Doing them both at the same time really kind of helped ease me off. I still had mood swings galore every time I switched to a lower dose, but it was . . .

Edlira: It is tough, right?

Mitch: Yeah, it was, I think, more tough for my . . . Maybe not more tough, but it was also tough for my partner having to deal with me.

Edlira: It's always . . . yeah, smoking affects not just you and everyone else, but quitting also affects you and everybody else. So it takes a team. It helps for a lot of people to just say, "I'm trying to quit. Please be patient with me while I'm going through this process of having to readjust to lower nicotine levels."

The brain craves that, and a lot of the symptoms that you feel are being irritable or maybe frustrated, anxious, and restless as you're trying to readjust to lower nicotine levels. But it does help in the transition to use nicotine replacement therapy, or the other options are some oral medications that we can use to help with those symptoms. And it makes it easier. I'm glad that you were using them.

Troy: And I'm wondering . . . this is interesting for me to hear this because I had kind of that same impression that Mitch had. You quit smoking and everything is good and you're great. I think Mitch's words earlier before we started the show were sunshine and unicorns, and it hasn't been sunshine and unicorns. It sounds like it's been . . . It's a challenge.

But it is interesting to hear you refer to this as a chronic disease. Like you said, hypertension, managing that, it's a daily battle. But do you ever find that there is that point where a person gets to the point where they have no more desire to smoke than a person who has never smoked? Will Mitch ever reach that point?

Edlira: It's hard to say. I think that there are variabilities, and they have done some genetic testing. So some people are more likely to be more dependent on nicotine than others. And we see that even in smokers, why there are people that have to smoke 20 cigarettes a day and then you find someone that smokes only on social situations.

And so for someone who was regularly using a pack of cigarettes, which is 20 cigarettes a day, or a really heavy vaper, then they're more likely to have these memories or these cravings occasionally. And that is very, very common. The majority of the people I talk to have some kind of memory about smoking and think about it occasionally. There are also people that don't think about it anymore, and they're the lucky ones.

Troy: But it sounds like for the most part, people 10, 20 years out are still thinking about it. There still is at least more of a craving than someone who's never smoked.

Edlira: Right. Absolutely. If you've never smoked, even though we have the receptors in our brain, we don't know how nicotine feels in our brain. And unluckily, nicotine feels great.

Mitch: It does. I'm sorry. It sounds terrible.

Troy: There's a reason it's addictive.

Edlira: Right? Exactly. I'm glad I have . . . I have tried smoking personally, but I have never inhaled and I've never felt that joyous moment from it. But I know that that's what is hard. When you give up smoking, you give up that pleasure, and there's not something that we can replace to truly give you that same euphoric feeling. Unfortunately, nicotine, that's why it's so highly addicting, is because it affects our reward mechanism in our brain.

Troy: I would like to say that running provides that, but I think now that, Mitch, you've run, maybe you can contradict that. It's like, "No. There's no comparison." I'm just joking, really.

Mitch: No, it's fine. But I really do appreciate that comment because it's so easy for everyone to be like, "Oh, smoking is bad. It's the worst thing for you, blah, blah, blah. Oh, it's a filthy habit or whatever." We don't often talk about how it also makes you feel good. That's why it's addictive, right? I would not inhale that stuff that makes my lungs kind of hurt if it didn't make me feel good. And so it feels very validating almost to hear, "No, it makes you feel good, but it's super bad for you."

Edlira: Right. Exactly. It's hard because the majority of us are not smokers, and so all we're doing is looking from the outside and just looking at these people that are smoking and thinking, "You know that's bad for you. Why are you doing that?"

Mitch: I know it's bad for me.

Edlira: Right? But the fact is, how many of us engage in activities that are bad for us that it's the majority of us who do it and we still continue to do it? We can think about unhealthy eating habits. How many of us do that even though we know it's probably not the best to do? But we enjoy it and we say, "Hey, it's okay. I'm enjoying it, even though I know that there are risks with this behavior."

We can all relate to that feeling, even though we don't understand how nicotine would really affect our brain because we haven't . . . the majority of us haven't been smoking most of our lives.

Troy: More for Mitch, what have been some of the hardest times that you've experienced in the last two years? And, Edlira, I'm curious if that's typical of what you're seeing with other people you've worked with.

Mitch: So some of the hardest times for me really were March 2020. Things were bad. There was an earthquake, there was the pandemic, and everything was really changing.

Edlira, I don't know if we prepped you too much about this, but I smoked for 10 years. I started when I was very young and in college. And every moment in my past, when things got really stressful, I would go to the gas station and buy a pack of cigarettes and sit and smoke them. That is my way of dealing with extreme stress. I have a breather. I would think.

And so when that March came and everything was different and everything was hard, and suddenly we had to be inside, I didn't have that, and that was probably the hardest thing for me. I was having a really hard time emotionally because that crutch, that habit, that decade-long habit wasn't there to help when things got tough.

Scot: Decade-long coping mechanism.

Mitch: That's a better way to put it, yes.

Edlira: Absolutely. I have to agree 100%. That is what we typically see. It's very, very hard behaviorally to manage emotions, stress, anxiety, boredom, loneliness, sadness when you've created this long-term pattern of relying on smoking to help you feel better, even though we know from science that, long term, that doesn't help anyone manage emotions better.

But in the short term, like I mentioned, the reward mechanism part, how nicotine helps us feel good in the short term, that makes it hard. In the moment, you're not thinking about, "Well, what else can I do?" You're just going back . . . Your brain likes to find easy solutions. Our brain likes to find easy solutions. And so the easiest thing is, "Hey, I know that smoking helped me in the past and that was for a very long time. So can we just go back to that?"

And so finding a different way, I think, is definitely doable. It just takes a little bit of mindful practice of, "Hey, that is one way that I felt better, but I also know that that is not the best way for me to manage my emotions. What other practices can I start practicing or utilizing or think about that can help me feel better?"

I would like to ask you, because you have had to practice those things to manage your emotions. What other things have you tried that were helpful for you, Mitch?

Mitch: Well, I did running for a while. I got into running for the first time and it took a while to get it into it, but it was getting a break, getting outside, walking, listening to a podcast. It checked off a lot of the same boxes, that break, that going outside, that stopping and not thinking about all the terrible things for 20, 30 minutes.

Scot: Yeah, disengaging for a little bit.

Mitch: Yeah.

Edlira: That's great.

Mitch: So that's kind of what I turned to. And honestly, I have since quitting, oddly enough . . . or not oddly enough. Maybe because of. I have started doing some mental health stuff. I've been working with a therapist to kind of deal with stress management and anxiety and kind of fill in the hole that this habit, this coping mechanism, that I relied on for so long . . . I've been working on coming up with new strategies.

Troy: And did you find, Mitch, that it was tough not to take on other bad habits like stress-eating or things like that?

Mitch: Oh, my God. We will need to do a series where Mitch loses 20 pounds because, yes, I did indulge a little bit the last year or two. Who's looking at me during pandemic times? I'm just going to go ahead and have a double bacon cheeseburger today because that feels good. I am a junk food lover. That's me. That's the Taquito. So yes, I did indulge a little bit into that, but I'm still working on finding my best habits.

Edlira: Most of us did it. Even though we're not smokers, most of us have done that with the pandemic.

Troy: Yeah, that's why it's called the COVID-19. There's the freshman 15, and there's the COVID-19.

Scot: Edlira, what are some of the strategies that you teach people to deal with stress or any of the emotions that they used to go to a cigarette to deal with? Mitch gave some examples. Is there a core takeaway from Mitch's examples, or are there some other examples you can give?

Edlira: Yes, absolutely. So one of the things that is helpful is to recognize triggers or cues that are associated with wanting to smoke. And so I will typically talk to someone and say, "Talk to me about your day in relation to your smoking."

So common triggers are waking up in the morning, drinking coffee, after meals, taking a break, driving, before bedtime. And then obviously, it can be things like being around someone who smokes, smelling a cigarette. It can be also an emotional trigger, so feeling stressed and anxious, like we talked about.

So depending on the trigger, then you can think about activities to do to anticipate that you're going to have that thought and what else to do. Some of the things behaviorally that are helpful . . . and it can be very different for everyone. So I'm going to generalize, and maybe some of them apply to you, Mitch, but some of them don't. And that's normal, because the approach of quitting is very different depending on the triggers and the situation for each individual.

But some of the things that are helpful are holding on a pen or a pencil or carrot stick. So having snacks that are healthy but that you can chew on is helpful. Drinking from a straw. Sometimes having a straw that's cut that you can kind of hold as a cigarette, breathe from can be helpful. Toothpicks. There are toothpicks that are flavored that are helpful. Obviously candy, but we try to say use sugar-free candy if you want to or sugar-free gum.

And then in terms of the emotions, it's helpful to really try to take a non-smoking break. For a lot of people who smoke, that is one way to escape the activity that may be too stressful or too busy or tiring.

So maybe still go outside. It's helpful to change a little bit of the routine. So I'd say if you're going out the back, maybe change and go out in the front. Someone said, "I changed the entire patio outside so I wasn't sitting in the exact same place."

But it's helpful to stay physically active. That is very, very, very helpful. And think of a project that you can do. I think this really does help to start thinking of some activity that you really maybe have wanted to start for a while, like a hobby, and haven't had time or haven't thought it was the right moment. This is a good time to do that.

A lot of people will start doing new skills. Like you mentioned, running or knitting. Anything that you would do with your hands or with your body physically helps.

And then I always like to talk about the deep breathing meditation type of activities that can be very calming. But I think it's also helpful for someone who has used smoking as a coping mechanism because it does slow down the breathing. And so in a lot of ways, it can be a positive memory and help us calm down, slow down our breathing, slow down our heart rate, and kind of gather our emotions for a few minutes before we go back to what we were doing.

Mitch: I'm glad you went through all those because those were . . . I tried a bunch of those and some of them were really helpful for me. Some of them weren't. But this was the first time quitting that I actually engaged actively in finding those habits, finding what worked for me.

I wish I had known about the sugar-free though because I went straight for the . . . Chocolate-covered cinnamon bears were the thing that I would stick in my mouth any time I wanted to smoke. And after the episode, it was very sweet, people kept buying me chocolate-covered cinnamon bears and I ended up with these giant Costco-sized bags of them. It wasn't the best for my waistline.

Edlira: What did your dentist say?

Troy: They meant well.

Scot: It's kind of funny because nobody would ever buy you a bunch of cigarettes or nicotine gum, but they're more than willing to buy you these little sugar bombs.

Edlira: I do have to say . . . You mentioned the cinnamon and it does help to have strong flavors. I mentioned cinnamon steak. And spicy stuff too also can help some people, or lemony flavors. I do have a lot of patients that do use normal candy too, like Jawbreakers, Jolly Ranchers. I don't encourage it. Not to say that it's not helpful because it's a transitionary habit, and hopefully you don't continue to do it forever, but it can help in the transition.

And I honestly think whatever works, it's okay, as long as it's not something that you continue to use and hopefully not ruin your teeth and oral health.

Scot: So, as a once-smoker and then vaper and now a two-year quitter, talk us through what Mitch's lungs and health is like two years later. How much better is it?

Edlira: So the science shows that the lung function starts to improve at between one to nine months after quitting. I'm going to kind of relate to smoking mostly, because that's what most of the research is on. Ten years after quitting smoking, lung cancer death rate is half of a smoker's. So there is a lot of benefit. However, it takes time for the lungs to heal.

So that may be why . . . I don't know if you still feel like you're not breathing as well as you wanted to. I don't know if that's what you mentioned earlier. I think I heard something about that, Mitch. But it sounds like you've stopped for two years, which is great. The lungs are constantly healing and it's always benefiting your lung health, but it's hard to measure that by year.

Scot: So, Edlira, we had talked a little bit earlier about . . . Mitch has quit for two years. Is there any research that shows after a certain point you're more likely to stick with it? Has he gone over the hump, or does he still have a hump to go over?

Edlira: No, he's definitely gone over the hump.

Mitch: Yes!

Edlira: The one-year mark is usually a great sign that you're probably less likely to go back to it. It's just that we don't want to say, "Now you're done. The race is over," because it is a journey.

And like I mentioned, the chronic dependency and the nicotine part may always be a part of your life in terms of you thinking about it occasionally. The hope is that it will happen less and less often. And once you decide, which you have in your case, you always do not think of smoking as an option, similar to someone who has never been a smoker.

For me, I will handle stressful situations, but I will never think about, "Oh, maybe I need to go and get a cigarette," because that's not an option. It's not even an alternative.

And that's the idea that I would encourage for someone who has been a smoker. It's okay to have that thought. We can't control what thoughts come into our brain, but you don't have to engage into that. And you say, "Even though I had that thought, I'm not going to follow through with it."

Troy: I was going to say this is great to hear. I've never smoked. I haven't had that experience or that dependence. But so much of what you're saying is just any change in health habits in general, or trying to do healthy things. It's never easy. I think it's always a struggle. For me, it's been a lot about trying to give up sweets and give up sugars. Mitch, similar to what you've experienced, there have been many times . . . In med school, I would buy a pack of Oreos and I would eat almost that entire thing in one sitting, and it was delicious.

Scot: I've done that.

Troy: It was amazing.

Scot: There's nothing worse. Self-checkouts are great nowadays because when you get that gallon of milk and that pack of Oreos, nobody has to see it.

Troy: Yeah, you don't get shamed for it. It's like, "I'm buying this, and I'm eating this tonight." So I think it really relates to anything we try and do. There's always that trigger, whether it's stress or anxiety or loneliness, or whatever it might be, and it's always a battle. I don't have that urge like I used to have it, but I still have that urge sometimes.

And so I can't relate certainly, Mitch, on the level I think to nicotine dependence. It's really remarkable what you've done, and especially at this time. I don't know how you've done it, but . . .

Mitch: I don't know either.

Troy: I'm incredibly proud of you. Honestly, I haven't even wanted to ask you if you were still not smoking because I was just . . . I didn't want to know the answer. I was like, "I don't know how you've done it. I just don't want to know." So I'm incredibly proud of what you've done and it's remarkable.

Edlira: I think it's great that we're celebrating this, because one of the comments that I get a lot from people who are working on quitting is the lack of awareness, and sometimes it's the elephant in the room. Like you said, it's uncomfortable to say, "Hey, are you still not smoking?" because you don't want to know the answer. But that is actually important for anyone who quits.

I'm speaking in general, and, Mitch, you can tell me if that's how you feel about this. But generally speaking, you're doing something that's so difficult and no one is recognizing it as often as it is happening, meaning that you're fighting this fight on a daily basis. And once you quit, most people say, "Okay, you quit. You're done. Good job," once. But hey, it's not a good job once. It good job always, good job for rest of your life, because it's never easy, even though it's been a long time.

Troy: See, now I feel bad. I'm sorry, Mitch. I should have been asking you.

Mitch: No, you're good. And one of the things I want to talk about is that I really appreciate that, what you just mentioned. A lot of people on the outside are just like, "Well, are you done yet? Oh, you quit. Great. High five. Oh, no, you slipped up. Oh, no." It's like, "What kind of moral failing did you have?" or, "Did you not try hard enough?" or whatever.

Kind of the thesis of our show, it was actually talking about that, right? It was talking to Scot and Troy on our first episode, where I first committed to quitting. It was that talking about, "Hey, this is hard," and having people realize that it's hard and support and to talk about the Maverik cravings, I would call it, where I'd circle the block a few times trying to debate whether or not I'd go in and grab a pack of cigarettes.

That, I think, was the biggest difference this time, and why I was able to get to the two years, was being able to talk to people about what was actually happening. A lot of times, there's so much shame wrapped up in, "You should just be strong and quit. You know it's bad for you. Just throw it away."

Edlira: "It's just willpower." And it's not just willpower. I do think it's very helpful, for whoever is still smoking and can benefit from this, that once you decide that you want to do it, it's helpful to find the reason why, why you're doing it.

And the why can be very different for many people. For some people, it could be financial. Most of the time, it has to be health-related and family, or a lot of times there's a child or a grandchild. Sometimes it could be a diagnosis of some sort that really kind of shakes us to the core and then we decide, "Hey, I'm done. I do not want to be a slave to cigarettes anymore."

But once you have the why, it helps to have a plan of how you're going to do it, anticipate that it's not going to be easy, anticipate that you're going to have the triggers and what to do with that. I think it's helpful to plan things that you think may help, like having snacks or some of the things that we talked about earlier.

And it also is helpful to talk about it and let other people know. This helps us be more accountable to ourselves. It can be a lot of pressure to do that, but I think in your case, Mitch, you mentioned that it . . . And this is the majority of the time. This was helpful for you because you felt the responsibility. You didn't want to let yourself down. You didn't want to say something and not follow through with that.

So even though it's an uncomfortable thing to do, I encourage you to do that because it makes it more likely that you will follow through with that plan.

Scot: So I think I think another round of applause is in order for Mitch. Congratulations on your two-year quitversary.

Troy: Well done.

Edlira: Yay. That's huge.

Scot: I mean, birthdays, we celebrate birthdays, but really, come on. This is bigger than that, right? A lot of effort went into it. It's a daily thing. I love the analogy that smoking is a chronic disease so it needs a solution that also is ongoing.

Quitting can be different for each person. It's hard. It can take up to seven times. You've just kind of got to find your way.

Edlira, do you have a beginning step for somebody that maybe would like to be celebrating their two-year quitversary in a couple of years on how to get started?

Edlira: I think it's great to put some small goal that you can see yourself achieving. Because this is a journey, it's a process, and it's not just an on and off light switch, I think it's helpful to think about . . . If you're smoking 20 cigarettes a day, let's say you want to say, "I want to smoke 18." It's only two fewer cigarettes. But you have to practice non-smoking when you're smoking two fewer cigarettes.

So I think it's great to think about even reducing smoking still helps reduce the harm. Even one fewer cigarette helps. So keeping cigarettes away. If you're smoking outside, just take the one cigarette that you want to smoke or two, but try to limit it. Make it harder for you just smoke.

And think about why you want to do it, because your why is what's going to help you pull through with it.

Scot: And there's no shame in getting help. You don't have to do it yourself. There are a lot of great resources out there.

Edlira: There are. Yeah.

Scot: What would be a great resource that you would drive somebody to as a beginning point?

Edlira: Anyone who's a Huntsman patient, please let us know. We would love to help you. But what normally can help is a combination of counseling and pharmacotherapy. So that is using combination nicotine replacement, like we talked about, and then the two medications that are varenicline and Zyban. Those are prescription, so I do think it's helpful to talk to your provider that you're trying to quit because they can prescribe medications and they can even give you brief counseling.

And also the quitline offers free counseling as well as some free nicotine replacement therapy.

And there are also some apps that are free, like smokefree.gov, which are really nice. You can put your goal, if you want to quit. They can send you text reminders, and that can be helpful as well.

Scot: Well, congratulations, Mitch. Edlira, thank you very much for being on the show and answering some of Mitch's questions. Should we all get together in another year and celebrate three?

Edlira: What a great idea.

Troy: Let's plan for it.

Scot: I mean, should I not have said that, Edlira? Did I just screw things up for Mitch?

Edlira: I think it's great. I think it makes it more likely for Mitch to be celebrating in a year.

Scot: All right. I wouldn't want to be the undoing, Mitch.

Edlira: Thank you for having me.

Scot: Thank you, and thanks for caring about men's health.

Super sweet episode. It's always fun to celebrate things, especially something like somebody quitting nicotine for two years. Again, congratulations to Mitch on his two-year quitversary.

If you want to reach out to Mitch and say congratulations, that would be awesome. Or if you are struggling with quitting smoking and need a little extra help, you want to reach out, that's great too. Or if you have a comment or a thought, lots of ways to get a hold of us at the podcast.

You can email us at hello@thescoperadio.com. You go to facebook.com/whocaresmenshealth. Send us a direct message, or post on our wall. You can also leave a voicemail by calling 601-55SCOPE. That's 601-55SCOPE.

And most importantly, help other men that would find this podcast useful find us. If you think there's somebody in your life that would find this episode useful, share it with them. Listen to it with them together. We'd really appreciate it.

Thanks for listening, and thanks for caring about men's health.

So you just had your Pap smear or your mammogram and it wasn't that bad was it? Or your colonoscopy. Okay, it really was that bad, but you didn't remember it. Are you wondering when you can stop doing these tests?

I asked a woman I know, who is in the health and fitness business, when she thought she could stop doing her cancer screening, you know, Paps, mammos, colonoscopy. She said, "Never," with a smile. She never wanted to stop her cancer screening, "It isn't all that bad, and it makes me feel safe," she said. I replied that cancer screening decisions about when and how often is a cost, risk, benefit analysis, and there are some data to inform that decision. She said, "You go with your brain, I go with my heart."

Well, let's go with the brain for a little while, okay? Let's start with Pap smears. The recommendations about Pap smears have been changing as we know more about what mostly causes cervical cancer -- the HPV virus -- and how fast it grows, usually not too fast. Cervical cancer does not increase with age for a lot of reasons. Sexual activity and the number of partners doesn't increase with age. Well, usually. And the cervix in postmenopausal women may not be as receptive to the virus. So there are good reasons to say that when you get to 65, if you've had normal Pap smears for the past 10 years, that means you actually have been having Pap smears in the past 10 years, and you haven't had an abnormal Pap in 20 years, you can stop testing. There's some pretty solid numbers to back this up, and the U.S. Preventive Services Task Force makes that recommendation.

Okay. How about colonoscopy? Well, colon cancer does not decrease with age. But if you don't have any family history of colon cancer and if your previous colonoscopies, that assumes that you've had some, have not shown any polyps or precancerous lesions, you can stop at 75. That's the recommendation of the U.S. Preventive Services Task Force and the American College of Physicians.

Lastly, mammography. Breast cancer does not decrease with age. It increases with age. The aggressiveness of breast cancer is less in older women than it is in younger women. But women still will get treated, which can be aggressive in and of itself. The U.S. Preventive Services Task Force said there's not enough evidence to recommend for or against mammograms at age 75 and older. But about a quarter of deaths from breast cancer each year are attributed to a diagnosis made in women after the age of 74. Women as they get older are less likely to get mammograms. About three-quarters of women 50 to 74 have had a mammogram in the past two years, but only 40% of women over 85. Of course, many women over 85 are in poor health, and mammography is just not on the list of things to do. And clinicians are less likely to recommend mammography if a woman is in poor health. The American Cancer Society suggests women should continue mammograms as long as their overall health is good and they have a life expectancy of at least 10 more years.

Well, how long am I going to live? I went online and Googled, "How long will I live?" There are lots of calculators because insurance companies and pension plans really want to know. Well, I tried a life expectancy calculator that was developed by the University of Pennsylvania and has been mentioned in the mainstream media. It asks sex not gender, age, height, weight, alcohol, smoking, diabetes, marriage status, whether I exercised, ate my veggies. I didn't fudge my weight or height. This calculator said I was going to live till 93 and I had a 75% chance of living to 85.

Another life expectancy calculator from confused.com asked me just a few questions, not my height or weight,or smoking, or alcohol, or diabetes. It did ask my relationship status, and options included happy relationship and married, but these were mutually exclusive. You could only pick one. Well, this one had my life expectancy of 97. And the calculator from Northwest Mutual, a well-respected life insurance company, cranked me out at 98.

Well, I really don't want to hang around the planet all that long. But I really hope that my savings will take me up there, and I'm going to have to have mammograms for a while yet.

Thanks for joining us for the "Seven Domains of Women's Health" on The Scope.

Interviewer: Were you aware that lack of knowledge about colorectal cancer causes a significant percentage of adult deaths from colon cancer every single year? So that means just by listening to this podcast today you are going to reduce your risk of colorectal cancer.

Dr. Priyanka Kanth is from Huntsman Cancer Institute and here are the bullet points that we're going to talk about today to help inform you so you are less likely to get colorectal cancer.

So, first of all, it's one of the most common cancers, and it causes a significant percentage of adult cancer deaths. Colorectal cancer impacts men and women equally. You need to have screening even if you don't have a family history and by the time you have symptoms it can often be too late, that's why screening is so important. So let's start with the first one Dr. Kanth, colorectal cancer I didn't realize this, one of the most common cancers and causes a lot of deaths.

Dr. Kanth: That's correct. So colon cancer is the third most common cancer in the U.S. And so number one being lungs and number two being breast and prostate in the respective gender. And then third is colon cancer, and that's pretty high. And it is also the second most common cancer to cause death in the U.S. So the first is lung cancer, leading the highest deaths from a cancer, and the second is colon cancer. So it is surely that the burden of disease is very high.

Interviewer: Yeah. I think that surprises a lot of people. A lot of people don't realize that and, as a result, maybe don't take screening as seriously. Another misperception is that men . . . It's a man's disease, but it actually impacts men and women equally. Tell me more about that.

Dr. Kanth: Absolutely. So there is no separate recommendation for men and women. Both genders can get this cancer, and both genders should start at the same age. So there is no difference in recommendation. It is a disease for anyone. So anyone should get screened and now at age 45, yes.

Interviewer: And another perception is, well, my family, nobody in my family had colorectal cancer. So I'm probably going to be okay. Maybe I don't need to get screened at 45, which is the new recommendation. Maybe I can wait till I'm 60. But that's false too.

Dr. Kanth: Absolutely, you're very correct about it. A lot of time we don't think that it is a problem for us because we don't have anyone in our family, but that's not correct. It can happen to anyone. In fact, 70% of all colorectal cancer patients don't have a family history. So that's a big number. And that's why it's so important to have this screened because screening is the best prevention.

Interviewer: I also understand that there's a misperception that colorectal cancer just happens to older people, like in their 60s, 70s, and 80s, so I can put off my screening.

Dr. Kanth: Again, a very, very good point. It can happen to anyone. So age is a number. It surely can happen more in older age, but even young people can get it. And we have seen a rise in incidents in less than age 50. So it is not a disease of only old age. It is a disease for anyone to be worried about.

Interviewer: And then the other misperception that I've heard is, oh, I'll go in and get my screening when I start to show symptoms. But that's very dangerous and inaccurate.

Dr. Kanth: It is. It is very dangerous because colon cancer, especially early stages will not have any symptoms. Even sometimes late stages you'll have symptoms, very minimal symptoms. This is a disease where you don't produce symptoms, you don't think about it and it is inside you. So you have to be very, very aware of this. That don't wait for symptoms. Go ahead and get your screening.

Interviewer: And how difficult is it for treatment if a patient comes to you is at the point where they have symptoms?

Dr. Kanth: Absolutely. So if the symptoms are already there, we are worried it is a late-stage disease. And treating a late-stage disease when it has spread beyond colon is much more difficult compared to treating a stage one or two disease, when it is just in the colon. If it's just in the colon, we take your colon out. We all can live without our colon believe it or not. We can have some change in quality of life, but we can have same life expectancy. So treating an early-stage colon cancer is way easier compared to treating a stage four, late-stage colorectal cancer, yes.

Interviewer: And the two options you've got the stool test, or you've got a colonoscopy. Tell me the advantages and disadvantages of each one of those, because, you know, we know that 45 is the number we should be screened at, but some of us don't necessarily want to take, you know, the day off before and after to get a colonoscopy, so talk me through that.

Dr. Kanth: That's correct. So colonoscopy is gold standard. The reason we call it gold standard is this is the only preventive tool where we can go in, we can see a precancerous lesion, which is a polyp, and we can take it out.

Interviewer: And so it's a diagnostic tool.

Dr. Kanth: It's a diagnostic.

Interviewer: In addition too, if there's a problem at the same time, you can take care of it.

Dr. Kanth: You've taken care of it. It will never turn into cancer. Stool test are very, very, very good tests to detect colon cancer. They may not detect polyps, but they will detect colon cancer at a very high sensitivity. So it is a very good option for patients who are worried about colonoscopy. Now, colonoscopies are not without risk. It's an invasive procedure. We give you sedation. You have to go through a prep as well. You have to take time off, like you mentioned, and yes, some risks associated with the procedure itself, like bleeding or perforation. Those risks are very small, very, very small, but can happen. Stool tests on the other hand, are very safe, can detect colon cancer readily, may not be polyps, but it's a very good tool, once we find that you have blood in stool. Now remember this, if your stool test is positive, you have to get a colonoscopy. That is the next step. So just to keep in mind, any screening test result like we said, best screening test is the one that gets done. So we should consider screening whatever option works for you.

Interviewer: And the advantage of a colonoscopy too, is once you have that done, if no polyps are discovered, you're good for another 10 years.

Dr. Kanth: Absolutely. If your prep was good, if you did a good exam and no polyps were found, you have no family history, you don't have to repeat it for 10 years. So even with small polyps now we don't have to repeat it for 7 to 10 years. So the recent recommendation has changed and become more relaxed for even if you had one or two small polyps, you're okay.

Interviewer: And the stool test is yearly.

Dr. Kanth: So stool test, there're a couple of stool tests. One stool test, where you have to do pretty much yearly is called fecal immunochemical testing. The other stool test is called FIT-DNA, which is commercially called Cologuard which you may consider doing it every three years. But it is surely more frequent to do it than getting a colonoscopy done.

Interviewer: And let's talk briefly about barriers that keep people from getting either one of the two screenings. So maybe we can help talk them through and encourage them, you know, if they have average risk to get screened at 45, because that is really the best way of preventing death from colorectal cancer. So what are some of the barriers and how can people overcome those?

Dr. Kanth: Absolutely. So the biggest barrier, I think, is the knowledge. They should know that they have to get screened. So there is a provider and patient education involved either away. So if no one told them, or if they did not hear it on the radio, say they don't know. So that's the biggest barrier. So education is very important from both aspects. The other barriers are, I would say another very big barrier is, of course, insurance coverage, if you don't have insurance. But there are other tools, there are other ways, like I said, stool tests, they are very cheap. So things can still be done even if you don't have insurance. Apart from that, other barriers are just being worried about getting a procedure. A lot of people think colonoscopy is painful. I have to go through this. It's not true. Colonoscopy is a very smooth, painless procedure, honestly. So those kinds of things that this is going to hurt me, that's not correct. So those are the main things. I would say if I have to pick any, I would say education. If you're aware you're going to do it, you will do it.

Interviewer: And sometimes it's just getting it on the calendar, right?

Dr. Kanth: Absolutely.

Interviewer: Whether it's the colonoscopy or whether it's the stool test, just talk to your primary care provider. Have that discussion find out where it works out for you.

Dr. Kanth: Absolutely. Yes. And that's for average risk screening, you can choose anything, colonoscopy or stool test. There are other tests, other modalities too, but these two are the most common. If you've family history, we recommend colonoscopy, that's the usual tool is recommended. So the best way is to contact your primary care provider, talk to them what's best for you.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: Troy, I thought because we have a doctor here who's a recognized authority and he's an opinion leader, like people look to Dr. Tward regarding treating prostate cancers, that we could play a little game. You up for a game?

Troy: I'm up always.

Scot: All right. So this game is called "What do you know about the prostate and prostate cancer?"

Troy: Are these questions I'm answering?

Scot: Well, I thought I would start. I'd start by throwing out something I know like, for example, what is the prostate? What do I know about it? It gets cancer. That's about all I know.

Troy: That's all you know. That's a good start.

Scot: So this episode of "Who Cares About Men's Health" is one of our Men's Health Essentials episodes, and we're talking about prostate cancer. This is an important episode because as a man, if you understand this condition, it can help you have an informed conversation with an expert, if you do need to test or not, what it means if a test comes back positive, what choices you might have if it does come back positive, and it can really impact your lifestyle. So with me is, as always, co-host, Dr. Troy Madsen. Say hi, Troy.

Troy: Hey, Scot.

Scot: And Dr. Jonathan Tward from Huntsman Cancer Institute.

Dr. Tward: Thank you for having me.

Scot: And I'm Scot Singpiel. People ask, "What do you contribute?" I'm here to ask the dumb questions so our listeners don't have to. That's my job.

Dr. Tward, what is the prostate anyway?

Dr. Tward: Well, the tongue in cheek answer is a gland that's designed to make your life miserable as you get older, but actually what the prostate gland is, is a little gland that sits between the base of the penis inside your body and below the bladder, and the urethra actually runs through it. And what its function is, is it has a fertility role. It produces the fluid that a man would ejaculate and helps keep the sperm alive on the way into the partner. So it's important for fertility, but if you're done with that particular aspect of your life, it no longer is, I guess, functionally necessary.

But its anatomic location is such that it can create all kinds of issues as one ages, one of which is prostate cancer, as you mentioned. Also, with its proximity to the bladder and where the urethra runs through it, there's a tendency for it to enlarge with some men over age and can also cause urinary problems.

Scot: All right. So if I'm done having kids, why don't I just get it taken out? I mean, wouldn't I save myself a lot of heartache?

Dr. Tward: Well, I'm sure that would be very lucrative work for people in urology. However, the problem with just removing the prostate, which is, of course, one of the concerns with dealing with cancer in the prostate, is that the nerves that control erection are actually sort of plastered onto the underside surface of the prostate gland and it's very challenging to preserve sexual function, although it can be with a talented surgeon.

And likewise, when one removes the prostate at the level of the bladder and below the prostate, there are these two sphincters that help control urination. And so when you remove the prostate, there's a risk that you can leak urine.

So routinely removing the prostate gland is not something that we would endorse as a preventative measure because the quality-of-life issues on the back end of that procedure would be risky, which is, of course, one of the risks that we all have to discuss when talking about dealing with prostate cancer once it's diagnosed.

Scot: Troy, do you know when you're supposed to get screened for prostate cancer? What age?

Troy: I think that's the biggest question I have for Dr. Tward. Should I get screened for prostate cancer? I'm a man over 40. I've never been screened. My primary care physician has never recommended it. Am I doing something wrong here?

Scot: So just so everybody knows, I'm 50 and I think that's when it's supposed to start, right?

Dr. Tward: Well, even the idea of when is it supposed to start is controversial. Prostate cancer screening has been a controversial topic really over the past decade. And the reason why it's controversial is that when you look at screening programs versus non-screening programs, if the outcome you're measuring is death from prostate cancer over 10 years, it shows maybe modest at best, to little to no benefit.

And that led to a complicated recommendation, I believe, back in 2012, 2013 by the United States Preventative Services Taskforce that actually confused the picture, which kind of recommended against screening.

However, since that time, more information has been gathered and this particular topic is one that we could spend an hour on. But I think that most professional societies and informed physicians who work in prostate cancer would say that men at age 50 with no other underlying reasons to screen sooner should probably consider getting screened at that time.

However, if you have a family history of prostate cancer, like a first-degree relative or more than one second-degree relative that's had prostate cancer, it probably makes sense to get a baseline screening test at age 40 and see where you are. And if all is reassuring, maybe do it again in five years.

But these kinds of guidelines are set by various professional societies and they actually are not consistent, but most are pointing toward age 50 for most men.

Scot: So let me get this straight then. The whole point of screening is to save lives, whatever screening we might do, and you're saying that there's no compelling evidence to show or there's just a very modest increase in life-saving from getting prostate cancer screening.

Dr. Tward: Yeah. I think it's a myopic view to say that saving lives should be the only reason you do a cancer screen. I mean, that's the obvious reason to screen, but I think the less obvious reason and one that holds a much more powerful argument for me . . . we're talking about a quality-of-life issue. To me, the rationale for screening is not necessarily to keep somebody alive over the next 10 or 15 years. The rationale is to preserve their quality of life. Because if you can catch a prostate cancer early, you can start making decisions where you'll be able to talk about sparing sexual function, you'll be able to talk about sparing bladder function, and you won't merely be keeping men alive.

And so there's a much greater argument that preventing spread of the disease and keeping your therapeutic options open is, to me, the rationale why you want to screen and why you want to start at about age 50 unless you have family history.

Troy: But with this in mind then, what's the downside of screening?

Dr. Tward: The downside of screening is that most men using traditional metrics of screening are going to receive a biopsy that does not result in the finding of prostate cancer. So right now, what is most widely practiced across the country is to do PSA testing, and PSA stands for prostate-specific antigen. It's a little thing that normal prostate cells and prostate cancer cells produce that can be excreted into the blood. So it's very specific for, let's call it, prostate origin. We have these arbitrary thresholds where we say if it's above, let's say, the number four, you should consider getting a biopsy.

The problem with that is if you just look at all men across the country, in the United States, who get a biopsy just because their PSA is above four, three out of four of those men will not have prostate cancer detected.

And so the downside is anxiety, and you stick needles in people. That could also lead to complications, and infection, and hospitalizations. And with enough biopsies, actually, there's some evidence that you could start impacting sexual function, urologic function as well.

So the PSA test as a screen is, I would say, better than nothing, but it has its issues that a lot of people will just kind of go down a road of anxiety and needle pokes and not be found to have the cancer.

There have been some innovations in the last few years that can help us nuance that, but they're not yet sort of widely practiced throughout the United States and world, but there are ways to nuance those screens.

Scot: So again, let me see if I understand correctly. I could get a PSA test. The number can come in above the threshold. And in my mind, tests either tell you if you have something or you don't, but this test doesn't. If it comes in above the threshold, there's still a good possibility you're not going to have a cancer. But then if you take that number as, "Yeah, I better go to the next step," which is biopsy, actually, a lot of people don't.

Dr. Tward: Just having an enlarged prostate can make your PSA quite elevated. There are lots of men walking around out there with PSAs of 20 and 30 and the only thing wrong with them is that their prostate is three or four times larger than it was when they were a 30-year-old. And as I mentioned before, normal prostate cells make PSA, not just cancer. And so the bigger the prostate is, the more PSA.

There are also issues with just sporadic rises. You ejaculate, your PSA can go up. Someone manipulates your prostate with a digital rectal exam . . . if you got a digital rectal and then got a blood draw, your PSA will be elevated. You could have a prostatitis that could possibly elevate the PSA. So there are honestly just a host of reasons why this PSA would be elevated.

But of course, once you tell a man in a primary care office, "Your PSA is over four," their mind is going to go to the most worrisome thing and then you have to kind of investigate whether you want to pursue it.

Scot: Or their partner's mind or other people in their life.

Dr. Tward: Indeed.

Scot: So it's not a yes/no. It's a much more nuanced conversation and understanding. Troy, I think this really comes back to the conversation we had earlier in our last episode or one of our previous ones about being able to have an informed conversation with your physician to make informed and joint decisions.

Troy: It really does. I think, Dr. Tward, everything you're saying says that it really is a personal decision. And it sounds like it's not a hard and fast rule that you need to get screened at a certain point, but it's a tough decision. I'm thinking about this personally, and again, I've never been screened for prostate cancer. I'm not 50, but I'm well over 40 and I've wondered, "Should I get screened?" But that's the hard thing for me to think, "Well, if that number does come back, say, higher than four, then I have to get a biopsy." From what I understand, that's a pretty uncomfortable thing to go through.

What's your take? What do you tell friends, family members, patients? Do you typically say, "Yeah, do it," or what do you tell them?

Dr. Tward: Well, I think I'm at a point where I recommend screening, but it doesn't mean that you necessarily should automatically trigger biopsy just because you're above four.

I guess how I would perceive it is . . . I guess on the counterargument with the life-saving, we've seen a big shift over the past five years specifically as a result of decreasing screening where now we're seeing men with much higher stage cancers. And they are now receiving, I'll call it, multi-modality therapies to try to eradicate it. Instead of maybe a simple surgery or one kind of radiation, we have to throw the book at them.

So I guess what I'm advocating, to answer the question, is you should get screened, and that includes a PSA test, and honestly a digital rectal exam. And if there is a concern, then the discussion should go on to the next step with your urologist about the relative merits and whether or not there are some additional testings that we can do rather than willy-nilly going into the biopsy.

So there's just so much discussion, and what I would encourage is that a man gets screened. However, the first question they should ask their urologist they're referred to is, "Do I really need to proceed immediately to biopsy? Are there other tests we can do? And do you do a transperineal biopsy or a transrectal biopsy?"

Every step of the prostate cancer process from "Do you screen?" to "Do you biopsy?" to "Do you treat?" is a complicated array of choices.

Troy: I have a stupid comment, but . . .

Scot: All right. Stupid comments. Go ahead.

Troy: Okay. Well, I'm going to add this, Scot, because you didn't. I'm just going to clarify for all of our listeners. Many of them work in the tech industry. A digital rectal exam is not a virtual rectal exam. It simply refers to the use of the provider's digit. Just so people know what we're talking about. It's like, "Hey, what about the virtual rectal . . ." No. Anyway.

Scot: So we've talked about PSA tests, but we haven't talked about the finger exam, which you're not using anymore, are you?

Dr. Tward: Well, that's not fair to say. I think the digital rectal exam is complementary to the PSA test. However, digital rectal exams are very heterogeneous in detecting a cancer.

Scot: What does that mean, heterogeneous in detecting?

Dr. Tward: I guess what I mean by that is a practitioner's ability to feel something in the prostate varies amongst practitioners, number one. The length of their fingers differs. When you do a digital rectal, you can only really touch a small part of the gland. But it's basically a freebie. They don't charge you extra to get a digital rectal examination when you're seeing your doctor. But of course, men don't want things stuck in their rear-end.

However, I will tell you that there's no doubt in my mind if you're over 50 and you're seeing a doctor, they should do a digital rectal exam, because for maybe three seconds of discomfort, you might actually be able to detect something that's concerning.

Scot: So in addition to a PSA test? The PSA test does not replace the digital rectal exam at this point?

Dr. Tward: I wouldn't say it replaces it. I mean, if you held a gun to my head and said, "You can only choose one screen, what would you do?" I'd say, "Okay, give me a PSA test." However, like anything else, this goes into risk modeling. The more things you do to detect a risk, the more likely you are to have confidence in the result.

So a digital rectal exam has a certain ability to detect prostate cancers that PSA may not, and PSA has a certain ability to detect cancers that a digital rectal exam may not. Together, your confidence in a negative test or a positive test is much higher with the combination.

Scot: And before I go ask for one from my doctor . . . because how does that appear, Troy?

Dr. Tward: I'm here now. We could take care of this.

Troy: Let's do this on the air. This is like the pushup challenge, Scot, but just so much better.

Scot: It's a pushup challenge, all right.

Troy: If you want our listeners to do this, Scot, you should be the first one to do it.

Scot: So you'll notice now Scot's really interested in the evidence behind the digital rectal exam. What is the percentage that this is actually going to help? Because I heard that's actually kind of low.

Dr. Tward: It's low. But like I was saying before, part of the issue when dropping out the PSA screening is now we're seeing more advanced cancers. And actually, digital rectal can very easily detect those more advanced cancers. It's an easy thing to . . . I guess easy for me to say. Easy thing to do.

Scot: When I go into my annual physical, if I asked for that from my doctor and they're like, "Well, we really don't do that anymore," and I'm like, "Eh, but I'd rather have it," am I going to look weird?

Dr. Tward: No. You're not going to look weird. In fact, again, I don't see that the downside. I think the controversy around screening actually is revolving around PSA screening. I think there's not so much controversy at all around digital rectal exam. Again, most likely, that test will be negative. But if they do actually feel something firm and hard on the prostate, it's quite certain that that is likely to be prostate cancer. So it's worth doing.

Scot: Troy, did you know that . . . Well, first of all, if you're a man and you live long enough, you're going to have prostate cancer. That's just what it is. But did you know that you could actually have a slow-moving prostate cancer and it never impacts your life?

Troy: Oh, right. And that's one of the big things I've heard in terms of people advocating not to get screened. A lot of people will say, "You're more likely to die with prostate cancer than you are to die of prostate cancer." Meaning you may have prostate cancer and die of something else. Dr. Tward, I don't know if that's actually the case. That's something I've often heard cited as a reason to maybe not get screened.

Dr. Tward: I think there's truth to the statement that most people diagnosed with prostate cancer won't die of prostate cancer. But then again, there's a significant minority, 10% to 15% of people diagnosed with prostate cancer, who will die with prostate cancer.

What I'll say is that this inevitability that you'll be diagnosed with prostate cancer is sort of true in a technicality. And this is known from autopsies done, I believe, in Detroit where they took men who happened to require an autopsy for reasons unrelated to prostate cancer. And if you just take 20- to 30-year-olds and pull out their prostate for no reason and look to see if there's cancer in them, we'll technically see prostate cancer in about 10% of them, and then it goes up by roughly 10% per decade.

The point is these are cancers in a technicality that are indolent-behaving, and usually are growing so slowly they don't threaten. But we have ways of evaluating men with these early-detected cancers if we happen to detect them, to surveil them. And we wouldn't rush a guy right into treatment these days.

So thoughtful practitioners today, when they diagnose prostate cancer, the first question they ask is, "Okay, you have prostate cancer. Do we need to treat it or should we simply put you on an active surveillance regimen where we will treat it when we know it's required to?"

Troy: Well, a lot of what you've talked about, I think, is screening in people who just are asymptomatic, just is routine screening for prevention. Are there certain symptoms that anyone like myself or anyone else maybe in their 40s, or maybe prior to 50 years old, they might be experiencing where you'd say, "Wow, you really need to get screened for prostate cancer"?

Dr. Tward: The vast majority of men will be completely asymptomatic. The most common thing I hear is, "I had no symptoms. I can't believe it." But that's the norm. It is a very small minority of people who have cancers that are causing symptoms. And usually those cancers are, in fact, fairly advanced. If you're starting to have symptoms from your cancer, it's because there's probably a lot of bulk to the cancer and it's been growing in there for a long time, which, again, is the argument for screening. Those men who aren't screened, that's the state with which occasionally we identify it.

But the symptoms that when someone is symptomatic has, it's typically kind of frequency and urgency or weak stream if the tumor is near the urethra or bladder neck and pressing. But it could also be blood in the ejaculate if the tumor has extended up into these structures called the seminal vesicles or near the urethra. Again, though, those are pretty uncommon.

And in men with very advanced cancers who don't know, what's interesting . . . you can get to a point where you have 100 tumors in your bone and cancer all through your lymph nodes and prostate and not have known it, but then all of a sudden you're wondering why you've been tired for the last three or four weeks or maybe a bone hurts or something like that.

So those are the presentation of the very advanced cancers. Like, "I've got this pain in my spine. It's just not going away. It's kind of getting worse." That could also be a sign that you might have prostate cancer.

Scot: Is there a number one risk factor for it? Is it genetics?

Dr. Tward: Just having brothers, or fathers, or uncles with prostate cancer puts you at an elevated risk, which is why I advocate at age 40 to do your baseline screening.

Scot: And if I don't have a family history of more aggressive prostate cancers, then am I in the clear?

Dr. Tward: Well, I mean, I guess you're at a lower risk than someone who has that, but you're not in the clear. You still should very much consider screening for this disease.

Scot: Again, not yes/no. It's shades of gray.

Dr. Tward: Absolutely. Always.

Troy: And what about prevention? We talk about prevention for other cancers. Don't smoke to prevent lung cancer. High-fiber diet to reduce your risk of colon cancer. Anything that someone can do diet standpoint or anything else to prevent prostate cancer?

Dr. Tward: So I guess my short answer is there is no clear dietary intervention that we're aware of right now that clearly reduces your risk of developing prostate cancer. Where there's a connection, I guess, to prostate cancer is when you have a lot of body fat, you might have a lot of estrogen production, and that can kind of interfere with the hormone therapy pathways that may or may not lead to prostate cancer.

And I'm sorry for not being extremely clear here, except to say that prostate cancer is a testosterone-driven cancer. In other words, testosterone is sort of . . . let's call it the food supply for prostate cancer cells. And so things that interfere with your testosterone production could either put you at increased or decreased risk of, I guess, developing a prostate cancer. That's where weight and body fat sort of come into play.

But again, there hasn't been very clear proof that modification or getting under a certain BMI will lead or not lead to the development of prostate cancer per se.

Scot: But no downsides, really, to being under a certain BMI, right?

Dr. Tward: Well, there's no question that being under a certain BMI is healthy, but also, I guess if we want to relate it to the prostate cancer, if you are healthy and in shape, it's going to keep your options open for what treatments, if you need to provide them, are going to be offered. And not only that, but how you might recover from those treatments.

So one of the things that a man has to understand is that when they're diagnosed with prostate cancer, you don't just get put down a standard treatment path. You are given this large Cheesecake Factory menu. And I say that for those who've been at the Cheesecake Factory.

Scot: I hate that menu. It's so huge. Nothing against The Cheesecake Factory.

Dr. Tward: Delicious food, no doubt, and you think . . .

Scot: But that menu is overwhelming.

Dr. Tward: Yeah. It is overwhelming. And if you give somebody too much choice, they're overwhelmed. But what I'd say here in this case, especially as it relates to diet and exercise, is on the one hand you also want to keep as much choice open as possible so that you can nuance this complex treatment choice that you're going to hopefully make with some shared decision-making between your doctors, your family, and others to make one that is going to result in the best outcome and preserve your quality of life.

Scot: So staying healthy, never a bad thing.

Troy: Never a bad thing. But I'm going to ask this question because I know just about every guy listening has heard this, and maybe this is an urban myth. Does more frequent ejaculation reduce the risk of prostate cancer?

Scot: You were on Reddit. I saw that too.

Troy: It's probably on Reddit and everywhere else you've ever looked for preventing prostate cancer.

Dr. Tward: There have been correlative studies purporting to show that. And we're in the realm of sort of Level 2 evidence. There have also been correlative studies that have refuted that. I think that the most knowledgeable expert at this point would say there's really no evidence that that would reduce your risk of prostate cancer, but it might be good for the soul, depending on the individual. But I wouldn't use that as a strategy to reduce your risk of prostate cancer.

Scot: Here's how that started, Troy. I have a good idea how that whole thing started. Some guy got busted.

Troy: Some guy got busted. "It's all for protecting my prostate."

Dr. Tward: "I'm doing it for both of us."

Troy: Exactly.

Scot: Wow.

Troy: I had to ask.

Scot: We've talked a lot about screening, which is complicated. We've learned it's not black or white. We've learned that you should not necessarily jump to, if you come back positive, that, "I need to get treated for it." It's a more nuanced and longer conversation, a longer flow chart, if you will. Treatments are kind of the same way. What would you say about a man that is faced with that menu that you referenced?

Dr. Tward: Yeah, there really are at this point a huge number of treatment choices, and it's important to understand that some of those treatment choices are offered by urologists, some of those are offered by radiation oncologists, and others are offered by medical oncologists.

So what you really need to do when you're diagnosed with prostate cancer is make sure that you speak with all the relevant experts that might potentially have a treatment for you and not get all the information filtered through one particular provider.

Now, I will be the first to say that that most providers are as honest and want to do the best they can, but people do what they do and know their own specialty. So if you have a prostate cancer that's been diagnosed, and that's routinely done by the urologist, of course the first question should be, "Should you or should you not treat?"

But if you move down a path where you think treatment is warranted, I would think that that patient would want to talk to both the urologist and a radiation oncologist and maybe a medical oncologist as well just to make sure that they see a few different perspectives on it and hear the risks, benefits, and alternatives through those lenses.

Scot: Because we're dealing with some quality-of-life issues, those decisions could be very important as to what the rest of your life might look like.

Dr. Tward: Absolutely.

Scot: The types of things, some of the negative impacts that treatments have.

Troy: And let me ask just one question also with treatment. You mentioned you are seeing more advanced prostate cancers now. What's the treatment success in these cases, or is there much success?

Dr. Tward: Well, there is still success at the more advanced presentations. The problem is at the earlier presentations, for example, you get to use what I term a monotherapy. Maybe all you need is a radical prostatectomy and that's it.

But with the advanced presentations that we're seeing more commonly now, the real discussion centered around is if you're going to have surgery, you're also going to get radiation and anti-testosterone therapy as well. Or if you're going to get radiation therapy, we're also going to combine it with anti-testosterone therapy for maybe two years.

And so when you start adding two and three kinds of therapies at once to get the better outcome, you're, of course, risking the increased side effects and quality of life issues.

If you were to just get a radical prostatectomy, let's say, you might have downtime for a couple of days and be back to work in about two weeks and work a little bit on continence, but you kind of take your lick and you're done.

But if you now are saying, "And after that, we're going to do seven or eight weeks of radiation and six months of hormone therapy," you're kind of dealing with the effects of this higher stage for a lot longer.

Or conversely on the radiation side, we're at a point now where we can do a simple outpatient procedure, like Brachytherapy, one and done, go home, return to work the next day, or just five X-ray treatments. But in the advanced cases, again, "Oh, by the way, we're going to take all your testosterone away from you for two years."

Hormone therapy is something we really haven't focused on in this conversation much, but with the advanced prostate cancers and the metastatic prostate cancers, the backbone of the therapies is stealing all your testosterone. And in a men's health show, that's going to be a major item on the table.

So there are all kinds of issues that happen when your testosterone is at castrate level. Most people turn to the sexual side of it, which is important, but there's a host of other issues that include weight gain, bone density loss, muscle mass loss, risk of cognitive decline, increased risk of heart attack/stroke. These are very serious issues and they're very serious on a marriage, they're very serious on a relationship. And so these advanced presentations have a much greater impact on the man and his partner than they would otherwise.

Scot: Troy, after this conversation, where are you at on screening? I mean, you're not 50 yet. Are you going to get screened when you turn 50? Sooner? What are you thinking about?

Troy: This is so tough. It's such a tough . . . I mean, I still feel like it's just such a gray zone, but after having this discussion . . . Like I said, I had always thought, "Well, you don't need to get screened." And my primary care physician said, "Hey, you really don't need to get screened." And I knew about the U.S. Preventive Services Taskforce recommendation of not getting screened. But after hearing this, I am definitely leaning toward getting screened.

I mean, it certainly makes sense that, Dr. Tward, like you said, it's not just about mortality, which was their primary outcome, how many people die. There are so many other factors to consider.

So the next time I see my primary care physician, I will put this on the list. And I find that's what this show does for me. It creates my list of things I need to ask my primary care doctor about. So this is on the list now.

Scot: I think I'm going to get tested. I've had people encourage me to get tested, but I think what I've really gained out of this is when that result comes back, it's not a definitive yes or no. There's a nuanced conversation that has to happen after that.

I very well might have cancer detected, but it could be one of these slow-moving ones. Dr. Tward said you're really good at kind of being able to gauge over time if it becomes more and more aggressive. So that really makes me feel a lot better.

And this podcast is going to be the source of information that I'm going to use for people in my life who maybe have a different plan in mind, because I really think that this lays out a lot of great information to help men and other people in their lives make decisions.

Dr. Tward: Screening just gives you information. It doesn't condemn you to anything. And that's the take-home. The more information you have about your health, the more likely you are to make wise decisions about things that are important for you and your family.

And so I do advocate getting screened. That doesn't necessarily mean I advocate once you get screened that you necessarily go on to the next step. You just have to discuss it with providers who know what they're talking about.

Troy: And that's a great point. I think too, personally, I'd rather know what's going on and what are my options and what can I do to deal with it than just being in the dark and then just getting blindsided sometime down the road. So I think that's a great point.

Scot: Troy, Dr. Tward was telling me that in recent years there has been really an advancement in . . . is it treatments, or is it a screenings, or both?

Dr. Tward: Well, all. I mean, on the screening side, as we alluded to, we've kind of had this threshold of if your PSA is over four, you should get a biopsy. But now we're at a point where we have additional tests that you can do to kind of decide if a biopsy is likely to yield fruit. These are molecular tests. Some of them are done in the urine. There's a company that's FDA-approved called SelectMDx that could look at a urine assay and tell you what is the probability if you actually get biopsied that you'll find cancer. There's also something called an OPKO 4K test that is kind of a . . . let's call it a more robust PSA screen that likewise . . .

So I think where I personally am . . . and I am exactly 50 years old and I'm at that stage myself where I am pondering this. I'm absolutely going to get a PSA test. However, if it came back elevated, there's clearly no way that I'm going to go directly into a biopsy. The next thing I will do is ask for some additional molecular testing and also imaging, like perhaps MRI, to help guide the decision of whether or not I should have needles stuck inside me.

Troy: I like that. That actually really makes me feel so much better because I've always heard "PSA elevated, biopsy." And I've heard about the biopsy. It's something that goes in the rectum. It's got these little prongs that pop out and into the prostate. It just sounds so uncomfortable. So I like that there are additional steps to avoid that if that PSA is elevated and then make that decision on the next step.

Scot: And as we've talked in past episodes, if your physician or provider is not offering those, have that conversation. Ask, "Hey, I understand that there are some other things we could do." Again, you could use this podcast as a source of reference or you could just ask, "Aren't there other things that we could do?"

Dr. Tward: Absolutely.

Scot: Just have those honest conversations with your provider.

All right. Dr. Tward, thank you very much for coming in. That was a lot of information, but I think it's important information for us as men to have because prostate cancer can radically impact your life, if not in mortality, in quality of life. And being told you have cancer can be really, really scary, and the treatments can be really, really scary, but knowing that there's some in-between before you have to get to some of the scary parts has been very useful. So thanks for being on the show and thanks for caring about men's health.

Dr. Tward: My pleasure. I really appreciated this opportunity, and I hope that this is valuable to the men out there. And don't be shy to talk to your doctors about this problem.

Scot: Hey, you're still here. Cool. This is Scot from "Who Cares About Men's Health." Well, I hope that Dr. Tward made the case why you should get screened and then what to do afterwards if the result comes back positive.

Prostate cancer, dealing with it at a later stage, just is not fun. A lot of terrible side effects. It's just not enjoyable to go through, as you heard some of them on the show. So get screened if it's that time, and then just take it nice and slow and figure out how you're going to progress after that point using the information in this podcast.

This episode was one of our Men's Health Essentials, health topics that impact you, particularly as a man. It could be very unique to men or just ones that we struggle with more than perhaps women.

So if you like this show and you want to hear some other Men's Health Essentials, just go to our podcast page, whocaresmenshealth.com, and you can scroll through there.

Reminder, we also have episodes focusing on the Core Four. If you're looking to improve your nutrition, activity, sleep, or your mental health, those episodes will help.

And then we have our side show where we do talk about health, but it's a little looser, and it's a kind of more in abstract terms, and it's just actually discussing the concept of health and men and how we process it and how maybe we can process it a better way.

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And as always, if you found this episode useful, share it with somebody in your life. That's the way we can grow this podcast together and this movement of men who understand and know and care about their health. Thanks for listening.

Interviewer: It used to be 50. Now it's 45 and there's a good reason for that. Huntsman Cancer Institute and University of Utah Health says more lives can be saved if men and women who are at average risk of colorectal cancer get screened at 45 instead of 50 years old. Dr. Priyanka Kanth is from Huntsman Cancer Institute. Why the change? What happened?

Dr. Kanth: Over the years since mid-'90s to early 2000, we have noticed an increased risk, increase incidence, and mortality. Actually both. So increased cases and people dying from colorectal cancer. And that was the main reason people started looking into it, researchers started looking into it and came up with this studies, modeling studies. And that's why this recommendation was changed.

Interviewer: Yeah. And the reason that's so important is because unlike other disease that perhaps might show symptoms, and then you would go get treatment. That's not how colorectal cancer presents. It really is screening is the best way to save lives.

Dr. Kanth: Absolutely. You're very right about it. So most of the early onset cancers or any colorectal cancer, early stages do not produce symptoms. Polyp usually starts with a polyp, which is a little bump in the colon and it changes into colon cancer. These polyps do not produce symptoms and they grow slowly, and you will never know you have one. So that's the biggest problem with colorectal cancer. And by the time you have symptoms, it's fairly late. So screening is the best strategy to prevent this cancer.

Interviewer: And this new research has just really shown that people between 45 and 49 because catching it early is the best defense that a lot of good can be done by having it at 45.

Dr. Kanth: Absolutely. Absolutely. There are certain research which has shown that there was a drastic increase even between age 49 and 50. So one study showed that there was an increase of almost 46% between age 49 and 50. So if we decrease it from 50 to 45, we are really hoping to capture that colon cancer patient. And this would be very, very beneficial between that age group.

The other thing I would like to say that this is also an incentive, an added benefit to increase screening from age 50 to 55, 50 to 54. But traditionally, it has been on the lower side if you do it from 50 to 75. There's slightly decreased screening rates in screening uptake between age 50 to 55. So this will help patients who are thinking about it at age 50, but did not get it till age 55. Now they're like, "Oh, you have to get it done at 45, let's get it one at by age 48." Something like that. So this will be very helpful at that point.

Interviewer: Is there a perception that colorectal cancer is an older person's disease?

Dr. Kanth: Yes. I think a lot of us, a lot of our patients in general public we think cancer is an old person's disease, especially colorectal cancer. That's not the case anymore. This is still true. Most colorectal cancer will still be diagnosed when you're older, but there has been a rise in patients who are younger than age 50. Some of it is because of genetic causes, but the rise has been in the average risk. So this perception should be changed. We should consider 45 as new 50 to start screening now.

Interviewer: And really that number, age 45 is the most important number. It's not do I have a family history? It's not do I have symptoms? It's not am I a man or a woman and think I'm less likely to get it. Really as soon as anyone hits that age of average risk of 45, that's the trigger you should go get it checked.

Dr. Kanth: Absolutely. Very correct. So 50 was . . . the same recommendation was for anyone, any gender, male, female. Any person who hits 50, you should get a colonoscopy. Now that has changed to 45. So it doesn't matter if you have symptoms, you should get it checked, especially if you don't have family history. If you have family history, that's a different story. If you don't have family history or average risk, please go get checked at age 45.

Interviewer: How is this going to impact those that do have an increased risk? Not an average risk, an increased risk? Does that also drop their age that they should go in down or do we know?

Dr. Kanth: So, at this point, if you have a family history, we usually start screening early. Most of the time we start screening at age 40. Or if somebody had colon cancer, I'd say whatever age, 10 years before they had colon cancer. So that may not change so much. It's possible we can look at the data and that may change again, but at this point, this recommendation is only for average risk. So family history is a different cohort of patients. That is still a very good point for primary care physician for all of us to ask that history from patients, "Do you have a family history of colon cancer?" Because your risk might be very different from the average risk.

Interviewer: So have that conversation if you're above average risk with your physician, your provider is whether or not you should get it earlier.

Dr. Kanth: Absolutely. Yes.

Interviewer: All right. And for the recommendation, is a colonoscopy okay? The home stool test, is that impacted by this age going down to 45?

Dr. Kanth: The best screening is the one that gets done. So that's another message which has to be delivered by providers. Colonoscopy is not the only screening test. Colonoscopy is gold standard because you can see the polyps you can remove it before it turn into cancer. But there are other very, very good stool tests which can detect colon cancer easily. They are non-invasive, you stay at home, you don't have any logistics around it. And those are good tests to be done. So that's a big message which everyone should know that colonoscopy is not the only way to detect cancer. There are other very good stool tests, which everyone should consider. If you're declining colonoscopy for any reason, do go for a stool test.

Interviewer: So if it's a stool test or if it's the colonoscopy, it doesn't matter. Average risk needs to be 45 now.

Dr. Kanth: Absolutely.

Interviewer: All right. And also, I understand with the new recommendation that Medicare, Medicaid, and also your commercial insurance will cover either one of those screenings starting at 45.

Dr. Kanth: That is correct. And that's what we believe after the new recommendation which has been endorsed by pretty much all the societies that all these should be now covered under preventive care just that how we had it at age 50. Even now, some insurances are already covering at age 45, but that was more sporadic. So now we expect this to be 100% covered.