Peter Attia MD343–The evolving role of radiation: cancer treatment, low-dose treatments for arthritis, & much more
EVERY SPOKEN WORD
150 min read · 30,098 words- 0:00 – 1:34
Intro
- PAPeter Attia
Again, hearing you say this, Sanjay, the listeners are gonna be thinking, "What?"
- SMSanjay Mehta
Yes. [laughs]
- PAPeter Attia
'Cause we're all so brainwashed into believing that radiation is horrible. I don't think we can have this discussion without giving people some understanding of what radiation is.
- SMSanjay Mehta
Essentially, the bottom line is that the low energy stuff that is non-ionizing cannot damage tissue. Fallacies about your cellphone giving you brain cancer and all are just that. They're, they're fallacies.
- PAPeter Attia
So first off, which patients are typically being radiated?
- SMSanjay Mehta
It comes down to two things. You want, you wanna be cured, cure rate is key, but quality of life is equally important, if not more important for most people. And so now that cure rates with our modern focused radiation allow it to get such a high dose into the prostate, uh, we can say that they're essentially equivalent to surgery.
- PAPeter Attia
Let's use that as a bridge to talking about using radiation to enhance tissue.
- SMSanjay Mehta
You usually see, depending on the joint, somewhere between a 60 and 80% success rate where the pain is, if not zero, at least markedly decreased.
- PAPeter Attia
I don't think patients will have any patience for turf wars.
- SMSanjay Mehta
Yes.
- PAPeter Attia
Right?
- SMSanjay Mehta
That's true.
- PAPeter Attia
And so if I'm a patient, every doctor needs to be a fiduciary.
- SMSanjay Mehta
Mm-hmm.
- PAPeter Attia
They need to put my interest-
- SMSanjay Mehta
Right
- PAPeter Attia
... ahead of their interest.
- SMSanjay Mehta
It's highly underutilized at this point, and the Europeans have shown us the way. It clearly works, and America just has to catch up.
- PAPeter Attia
Yeah, this is definitely an area where we are way far behind. [upbeat music] Hey, everyone, welcome to the Drive podcast. I'm your host, Peter Attia.
- 1:34 – 4:47
How radiation oncology became a distinct, rapidly evolving medical specialty
- PAPeter Attia
Sanjay, welcome back to Austin.
- SMSanjay Mehta
Thank you, Peter. Pleasure to be here.
- PAPeter Attia
I think this is the first time we're together not driving, right?
- SMSanjay Mehta
I think so, yeah. [laughs]
- PAPeter Attia
Yeah.
- SMSanjay Mehta
That is true.
- PAPeter Attia
So I don't know, somehow we're gonna resist the urge for most of this discussion to not talk about cars.
- SMSanjay Mehta
[laughs] Don't wanna bore your audience.
- PAPeter Attia
I know. It, it is called The Drive.
- SMSanjay Mehta
This is true.
- PAPeter Attia
So I feel like we have r- we will reserve the right to have some automotive discussions at the end. For listeners, Sanjay might be one of the most knowledgeable human beings on cars.
- SMSanjay Mehta
[laughs]
- PAPeter Attia
Uh, he's also a very dangerous friend to have-
- SMSanjay Mehta
[laughs]
- PAPeter Attia
... um, because he's always the bad one on the shoulder when you're contemplating a new set of wheels or a new something for your cars. Um, but in his other life, in addition to being the founder of MD Motorheads, right?
- SMSanjay Mehta
That's right, yeah. [laughs]
- PAPeter Attia
Yeah.
- SMSanjay Mehta
Absolutely.
- PAPeter Attia
Which is a, a Facebook group of doctors who are gearheads. But y-
- SMSanjay Mehta
We're about to crack 3,000 members. It's, it's exploded, yeah.
- PAPeter Attia
That's awesome. So shout out to MD Motorheads. Uh, you're also a radiation oncologist, which we also spend some time talking about.
- SMSanjay Mehta
Right.
- PAPeter Attia
And, um, I guess we thought it would be a really fun idea to do a podcast for a couple of reasons. Um, one is just the bread and butter of what you do as a radiation oncologist is a bit of a black box to many people, myself included, if I'm going to be completely-
- SMSanjay Mehta
Sure
- PAPeter Attia
... truthful.
- SMSanjay Mehta
Yeah.
- PAPeter Attia
Um, even training in surgical oncology, I feel like I had much more familiarity with the medical side of oncology than I did with the radiation side of oncology. So for myself, for the audience, I think it would be wonderful to understand more as it's a field that has evolved a lot, right?
- SMSanjay Mehta
Sure, tremendously.
- PAPeter Attia
I'm guessing the last 25 years-
- SMSanjay Mehta
Yeah
- 4:47 – 8:48
Defining radiation, & common misconceptions about radiation exposure
- PAPeter Attia
The second thing that I wanted to talk about on the radiation front, um, is this idea of using very low dose radiation to heal injuries.
- SMSanjay Mehta
Right.
- PAPeter Attia
And I actually-- I think that while people will be incredibly interested to understand the ins and outs of radiation oncology, again, given the ubiquity of it in treating people, I, I think a lot of people are gonna be very interested in this idea that why aren't we using low dose radiation more to heal some of these nagging orthopedic injuries that, that people have? And of course, we'll, we'll, we'll go-
- SMSanjay Mehta
Right
- PAPeter Attia
... far down the rabbit hole on that. But I don't think we can have this discussion without giving people some understanding of what radiation is. Um, and, uh, I'd, I'd, I would like us to do it in a way that's both rigorous enough that we can really get into some of the science of this, um, but also get into it gently enough-
- SMSanjay Mehta
Right
- PAPeter Attia
... that people that maybe don't remember high school physics well enough-
- SMSanjay Mehta
Sure
- PAPeter Attia
... uh, can come along for the ride and not get lost. But once we-
- SMSanjay Mehta
Absolutely
- PAPeter Attia
... sort of get into Grays and millisieverts and all that stuff, I want everyone to be fluent when we start talking about doses.
- SMSanjay Mehta
Right, right, right. So you know, um, radiation itself, w- the, the term itself has kind of got a bit of a negative connotation, but basically it's part of the electromagnetic spectrum. So you know, we have everything on the one, uh, th- in, in, uh, in the, uh, range of increasing energy of d- of, uh, photons, which are just particles of light. On the one end you have radio waves and microwaves, on the other end you've got infrared, uh, excuse me, you've got ultraviolet, and then you get into X-rays and radio waves. And now in the middle of all that is the visible spectrum. So when you see, I'm sure everyone's seen the graphs where you've got the rainbow: red, green, blue that we can see. The human eye can only perceive a tiny little narrow spectrum. And then on the, on the low end, you have radio waves.
- PAPeter Attia
And these are, these are wavelengths. That's the-
- SMSanjay Mehta
These are actually wavelengths-
- PAPeter Attia
Yep
- SMSanjay Mehta
... and energies which are, which are, uh, the very low-end, uh, energies you have things like radio waves. And th- in that, in that situation, both radio waves and microwaves are what they call non-ionizing. And I know you've talked about this on some of your previous podcasts. I know you had a really good one with, uh, Atari Walla from, uh, Prenuvo, where he went, it really, it was a really nice, uh, in-depth discussion. But essentially the bottom line is that the low-energy stuff that is non-ionizing cannot damage tissue, and that goes all the way up to visible light. Then when you start going to the higher energy X-rays, that's when you get, uh, both X-rays as well as ultraviolet light, and then the hi- the high, and then the higher particle stuff. But basically the higher you go in the energy l- in the, in the energetics of the particles, the more likely the exposure to these, uh, packets of energy are gonna cause damage to your DNA.
- PAPeter Attia
And why is it that the shorter the wavelength, 'cause that's what's changing as you go-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... from radio waves to microwaves to visible waves-
- SMSanjay Mehta
Right
- PAPeter Attia
... to ultraviolet to... Why is it that as the wavelength gets shorter, the energy gets bigger?
- SMSanjay Mehta
Yeah, I'm not sure what the reason is. They're just, they're, they are inversely proportional to each other. I don't know that... I guess I'm probably not enough of a physicist to answer-
- PAPeter Attia
Okay
- SMSanjay Mehta
... that question precisely. But having said that, that, that is the, the, the, uh, uh, the characteristic of this. And in doing so, that's one of the big reasons why all the, uh, uh, fallacies about your cellphone giving you brain cancer and all are just that. They're, they're fallacies because even having a cellphone on your, on your ear for hours a day, it's, it's non-ionizing radiation. And standing too close to a microwave oven, again, non-ionizing radiation, so that cannot damage your cells the way-
- PAPeter Attia
Right
- SMSanjay Mehta
... that the other end can.
- PAPeter Attia
The, the radio wave is too long.
- SMSanjay Mehta
That's right.
- PAPeter Attia
The, the microwave is too long.
- SMSanjay Mehta
Mm-hmm.
- 8:48 – 14:28
How radiation doses are measured, real-world examples of radiation exposure, & safety practices
- PAPeter Attia
how these are measured. How do we quantify them? Because people on the podcast-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... have heard me talk about this, I suspect.
- SMSanjay Mehta
Right.
- PAPeter Attia
We talk a lot about calcium scores and CT angiograms and PET/CT, and so the, uh, I, I think the-
- SMSanjay Mehta
Right
- PAPeter Attia
... the, the frequent listener will have been somewhat familiar with how we talk about how to dose those things.
- SMSanjay Mehta
Right. So radiation dosage, there's a couple of different terms that we talk about. The main one we talk about when we're talking about patient treatment is c- is the unit called the gray, and that's an SI unit that essentially is joules of energy per kilogram of tissue. So that's what they call absorbed dose. So that's in tissue, whereas when you're talking about exposure in the general, uh, like in the air and just in, in, in, in general exposure, it's in the air, and that's, we usually use the term sievert for that. And actually both those terms for the most part are equivalent. It's just that, uh, the sievert itself will take into account if you have different types of, um, uh, of, uh, of X-rays, different qualities of X-rays that have different degrees of, uh, potential to be ionizing, that they have a q- a quality factor you'll multiply it by. But for the most part we use the term gray when we're talking about... For example, w- when I treat a prostate patient, they're gonna get somewhere between 70 and 80 gray, but it's fractionated into small daily doses as to be tolerable for the body. And then when we talk about like millisieverts like we're going to, that's really just a measure of exposure, not, not, uh, absorbed dose in tissue per se.
- PAPeter Attia
And what's the relationship between a gray and a millisievert? Is it a one-to-one relationship?
- SMSanjay Mehta
Yeah, so a gray and a sievert technically. A lot... So the, the, the gray also, if, if anyone's kind of old school, you read, you listen to older stuff, you hear the term rads. A lot of people-
- PAPeter Attia
Yep
- SMSanjay Mehta
... have heard of rads. So one rad is equal to one centigray. Uh, 100 rads is a gray. It's just an SI unit versus the old, the older terminology. And a sievert is the equivalent, only it's in air, not in tissue.
- PAPeter Attia
But a sievert is a gray?
- SMSanjay Mehta
Correct. Correct.
- PAPeter Attia
So when you give ni- 70 gray-
- SMSanjay Mehta
Right
- PAPeter Attia
... you're giving 70 sieverts or 70,000 millisieverts over the course of the treatment?
- SMSanjay Mehta
That's correct.
- PAPeter Attia
Okay.
- SMSanjay Mehta
That's correct, yeah.
- PAPeter Attia
Um, and just so people can kind of anchor this to things that are familiar-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... uh, living at sea level exposes us to one to two millisieverts of ionizing radiation a year?
- SMSanjay Mehta
That's exactly right. And then of course at, at, uh, altitude it could be double that actually.
- PAPeter Attia
That's right.
- SMSanjay Mehta
Yeah.
- PAPeter Attia
If you live in Denver-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... it's easily double that or triple that.
- SMSanjay Mehta
Right, right.
- 14:28 – 25:10
Radiation doses from common medical imaging tests, & why benefits of routine imaging outweigh risks
- PAPeter Attia
So let's talk about some types of X-rays that people are familiar with and give a sense of radiation dose, and I'm also curious as to how much this depends on the size of the individual. In other words-
- SMSanjay Mehta
It does
- PAPeter Attia
... does a person that is larger receive more radiation for the same test-
- SMSanjay Mehta
Sure
- PAPeter Attia
... like a chest X-ray?
- SMSanjay Mehta
Sure, uh, and, and they certainly do because you have to use more energy to get into a larger person. Having said that, there's two different things here, 'cause in what we normally deal with when I'm talking about dose to a tumor is the dose actually at that spot, uh, versus a whole body dose, which is a very different, uh, metric. And so for someone who I'm treating with, say, eight weeks of radiation for prostate cancer, their prostate may get 80 gray in two, 1.8 to 2 gray fractions per day, but that's literally only to a small volume, roughly the size of the prostate gland itself. And when you even get just a few millimeters away from that, that dose gets cut in half, and then it's exponentially lower because the intensity of the radiation varies with the square of the distance. So as you get even, you know, a couple of feet away, that goes down significantly. But typically, a patient who is getting, you know, 80 gray is a, if 80 gray was a whole body dose, that would obviously be lethal.
- PAPeter Attia
Yeah.
- SMSanjay Mehta
Uh, but, um, the, the whole body dose is, is more like a few milligray in that sort of situation. So we typically don't see like full body sequelae or anything from doing even the heavy duty diagnostic treatment. Now, for the CT scan, we almost consider that negligible in our area, 'cause again, I'm dealing with, you know, mega voltage, high dose cancer killing radiation. And so when they get a CT scan, which is gonna be just a few millisieverts or milligray, um, that's almost considered rounding error v- versus what they're getting to the, uh, to the tumor area.
- PAPeter Attia
But let's take something like a chest X-ray.
- SMSanjay Mehta
Sure.
- PAPeter Attia
So a chest X-ray, again, I, people should anchor to this idea for what it's worth-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... and we can come back to this. NRC says, "Hey, limit your annual radiation-
- SMSanjay Mehta
Right
- PAPeter Attia
... to 50 millisieverts."
- SMSanjay Mehta
Mm-hmm.
- PAPeter Attia
Uh, you got 2% of that just being alive-
- SMSanjay Mehta
Correct
- PAPeter Attia
... 'cause you happen to go outside and e- be exposed to the sun.
- SMSanjay Mehta
Right.
- PAPeter Attia
So the other, you know, uh, 98% might come through flying-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... diagnostic. Let's say you fly a lot.
- SMSanjay Mehta
Yeah.
- PAPeter Attia
That might get you up another 10%.
- SMSanjay Mehta
Right.
- PAPeter Attia
Um, so let's talk about a chest X-ray.
- SMSanjay Mehta
Mm-hmm.
- PAPeter Attia
You got a cough, you go to your doctor, they do a chest X-ray. That's how many millisieverts for a normal-sized person?
- SMSanjay Mehta
Normal-sized person, it's, it's a fraction. It's probably less than one millisievert actually, so it's-
- 25:10 – 29:11
Therapeutic radiation oncology: the evolution of breast cancer treatment toward less invasive surgery combined with targeted radiation
- PAPeter Attia
Um, is it safe to say that the majority or the most prevalent or common type of radiation oncology treatment would be for breast cancer?
- SMSanjay Mehta
Uh, breast and prostate are the number one-
- PAPeter Attia
The two. Okay
- SMSanjay Mehta
... and number two, depending on what patient population you're talking about. Prostate may even be a little bit higher. And this goes back to the '80s when the trend from doing a Halstedian type of, uh, radical mastectomy was, uh, falling out of favor, and the randomized data was, uh, was obtained in the '80s showing that a lumpectomy, breast conservation, which is lumpectomy followed by radiation, has the same, uh, outcomes in terms of overall survival as a full mastectomy. That's when breast really took off in the '80s, and around the same time is when prostate radiation started becoming a thing. But at the time, ra-radical prostatectomy was obviously still king. But now in the 2020s, uh, I think prostate has taken off, and it's probably close to matching breast cancer now. Those are number one and number two, but we also do, depending on where you are in the country and what your affiliation with the hospital is, tons of CNS, lung, lymphoma, GI, uh, not colon, but more rectal and anal distal GI cancers. Um, even, um, in the pediatric world, we try to avoid radiating children, but it's, it's a very big part of that, uh, as well. So we use it for almost, almost all types of cancer now, actually, all solid tumors anyway.
- PAPeter Attia
Well, let's, let's talk a little bit about breast cancer, given the, how common it is. Um, and I'll, I'll tell you something funny. Despite training at Hopkins, I never once did a radical mastectomy.
- SMSanjay Mehta
Is that right?
- PAPeter Attia
I mean, it was already long gone-
- SMSanjay Mehta
Right
- PAPeter Attia
... uh, from clinical practice 25 years ago.
- SMSanjay Mehta
Right.
- PAPeter Attia
Um, and, and again, just for listeners to make sure they understand the difference between a radical mastectomy and a mastectomy or, um, what's called-
- SMSanjay Mehta
Modified
- PAPeter Attia
... now a modified radical mastectomy, the current version of a mas- of a mastectomy removes all the breast tissue, uh, along with the, uh, lymphatic tissue in the axilla. Uh, and though certainly I did more than my fair share of those, but the radical mastectomy, the Halstedian procedure, removed also the entire musculature-
- SMSanjay Mehta
Right
- PAPeter Attia
... of the pec, uh, pec major, pec minor, the whole thing. It basically was a disfiguring operation-
- SMSanjay Mehta
Debilitating, disfiguring
- PAPeter Attia
... that left the woman with nothing but ribs here. And can ima-imagine what it's like to not even have pec muscles. You sort of take for granted-
- SMSanjay Mehta
Right
- PAPeter Attia
... what you need to, uh, do to move your, your humerus. Um, and yeah, to think that it's only been 40 or 50 years-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... that p- someone had the courage, I think it was probably Fisher.
- SMSanjay Mehta
Right, Fisher's big study in the '80s-
- PAPeter Attia
Yeah
- SMSanjay Mehta
... which now we have 40-year data-
- PAPeter Attia
Yep
- SMSanjay Mehta
... from that. And it's interesting how now, um, even the modified radicals are, are relatively rare. We still have some advanced cases that they have to go that route. But we see tons and tons of patients now who are so much happier, their quality of life is much better by just having a simple lep- lumpectomy, uh, sentinel node biopsy, and if it's all negative, especially if they've had their mammograms, you get a small T1 or T2 tumor. Uh, we give radiation to the whole breast following that, and, uh, the radiation is again fractionated into small daily bits. They'll get somewhere in the neighborhood of, uh, these days it's actually only about three weeks of treatment, maybe about, uh, uh, say 40 gray in roughly 15 fractions. Uh, we used to give, even when I was in, uh, in just, just really a couple decades ago, we were giving, uh, 50 to 60 gray. It was quite a bit higher dose. Uh, but the 40 gray and 15 fractions to the full breast, and with the modern technology, we can cover the breast tissue without, uh, a significant heart or lung dose. We can even use tangential beams, even if it's a left-sided tumor, to stay away from the heart, which are things that we couldn't do very well in the past. And so the, the overall and disease-free survivals are pretty much comparable to someone who had a modified radical.
- PAPeter Attia
Yeah. For folks who wanna know more about that, um, Siddhartha Mukherjee in, I think it was in The Emperor of All Maladies-
- SMSanjay Mehta
Yes
- PAPeter Attia
... um, has a chapter on this.
- SMSanjay Mehta
Fantastic book and one of your best podcasts. Love that guy.
- 29:11 – 42:47
Modern radiation oncology treatments for breast cancer—minimizing risks & maximizing patient comfort & outcomes
- PAPeter Attia
let's talk about that. Okay, so, so a woman has a stage one or a stage two breast cancer. Typically these days, I think they're moving mostly to neoadjuvant chemo before resection?
- SMSanjay Mehta
Yes, uh, in a more advanced case. But if it's a typical T1 or even a small T2 that we see, they may not need any neoadjuvant therapy. They just will, uh, have their lum-- if it's a, like you say, a one and a half centimeter, um, mass that's, that's easily resectable, they'll remove that just without any neoadjuvant treatment.
- PAPeter Attia
Okay.
- SMSanjay Mehta
And we'll do adjuvant radiation and then potentially, depending on the receptor status, adjuvant hormone therapy as, which is the domain of the medical oncologist, but we still work with them. So just surgery followed by, uh, the, the three to week, three to four weeks of radiation.
- PAPeter Attia
How long after surgery can you begin radiation?
- SMSanjay Mehta
Wound healing, we give them a little bit of time. We generally do our CT-based simulation and three-dimensional planning maybe three, two to three weeks after their, their surgery, and then by the time, it takes about a week to do all of our computer programming, and then we'll, uh, start the treatment within three to four weeks post-op.
- PAPeter Attia
So tell me a little bit about that. I was completely unaware of that. So I'm a woman. I've had a, a lumpectomy. Sentinel node was negative. So I've got an incision about this long.
- SMSanjay Mehta
Right.
- PAPeter Attia
For the listener, you know, five centimeter, six centimeter incision. Uh, they've probably closed it with beautiful internal sutures. I've got some Steri-Strips. They're off in a week, and I've got a nice little scar a week later.
- SMSanjay Mehta
Right.
- PAPeter Attia
When I come and see you, how many weeks after that?
- SMSanjay Mehta
I usually will see patients for consultation. A lot of times the breast surgeon will send them prior to anything being done. So I'll see them for their initial consultation ahead of time. But then we plan on doing what's called a, a planning procedure or a simulation where we're gonna put the patient on the table and essentially do a dry run for their treatment, usually a couple of weeks after treatment, and that involves essentially positioning the patients. Typically for a, a breast patient, they'll be prone with their arm behind their head. We call it the, the movie star pose-
- PAPeter Attia
Okay
- SMSanjay Mehta
... to get the arm out of the way of the axilla, essentially.
- PAPeter Attia
Okay.
- SMSanjay Mehta
And so by putting them in this position and then putting them on a wing board that'll slightly elevate their torso, we can-- and there's a lot of different geometry here that we can use. Uh, back in the old days, they had all kinds of ways of doing plaster casts and things like that, but what we essentially do now is we will, uh, we'll use a, a what we call a Vaclock, essentially a beanbag with a vacuum port, and they s- the patient sinks into the bag. We suck all the air out of and lock it. It becomes a rigid cast of their body, and that way they fit into the groove that we've made for them. We'll actually f- we'll kind of, uh, form it and mold it around their elbow so they're comfortable. Many times with patients who've had an axillary dissection, they may have a little bit of, uh, scarring, a little decreased range of motion to be able to get their elbow back there, so we'll work with them the best we can. Whatever position we get them in, we do a CT in that position, and that's the position we have to reproduce for the daily treatment. And the key there is that when they have their arm out of the way, we have to have room so that the machine can move around from different angles. The actual radiation machine has a gantry that can move really three hundred sixty degrees, can treat from any angle you want, but we have to be able to model tangential beams. We don't want direct anterior field that's gonna radiate the breast, but the photons are gonna go right into the chest. By using an angle, we can kind of cut across the surface and actually shape the beam to match the curvature of the chest wall. So we cover the entire thickness of the breast tissue or even a, in many cases, in a, the case of a advanced, um, um, um, more maybe a T4 patient, something like that, we may even do this post-mastectomy, so you're treating the full chest wall. And we go a little deeper below, in, into the ribs, into maybe the first inch of lung tissue below that. But by using these tangential beams, that really minimizes the treatment, the, the, the photons damaging the, uh, the lung tissue. So all of that is planned ahead of time when we do a CT scan.
- PAPeter Attia
Sorry, just to be sure, planned pre-resection because you're seeing the tumor itself and you-
- SMSanjay Mehta
Actually, no. I, I, what I meant was pre-treatment.
- PAPeter Attia
Got it. So post-resection.
- SMSanjay Mehta
So post-resection-
- PAPeter Attia
Yep
- SMSanjay Mehta
... you'll, we, you'll see a tumor bed. The lumpectomy cavity is obviously clearly visible.
- PAPeter Attia
Yep.
- SMSanjay Mehta
It's a fluid pocket on CT. So I'll scan the, I'll scan the whole chest. Uh, it takes about a week. I have a whole team. I have a wonderful staff, a radiation dosimetrist that helps do the computer planning, and then a radiation physicist that actually cal- calibrates the machine prior to actually starting the patient. So we do the scan. Of course, the CT scan is two-dimensional slices, but we have three-dimensional modeling software, so I have a full 3D model of the patient I can look at from any angle.
- PAPeter Attia
The slices are how thin?
- SMSanjay Mehta
Uh, it, it varies. Usually we don't need-- This is not a diagnostic scan or anything, so usually something like two millimeters-
- PAPeter Attia
Okay
- SMSanjay Mehta
... three millimeters. We don't have to go super high resolution. And so that way, uh, once it's, once it's, uh, reconstructed, then I can have a nice idea of what angles to bring the beam ins at, because, beams in at, because every person has a slightly different curvature to the chest wall. You're gonna have to customize the anatomy. Different breast sizes. We have all kinds of different techniques, so I won't go too much into the details, but if someone is very large-breasted, we could even treat them prone to get the, have a special pillow to allow the breast to hang down.
- PAPeter Attia
And it's also, I'm guessing, where the tumor was in the breast. So if you have large breast-
- SMSanjay Mehta
Yes
- 42:47 – 48:01
How advances in radiation dosing, technology, & treatment precision have significantly reduced side effects
- PAPeter Attia
in time to 25 years ago, 30 years ago versus today-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... what are the typical side effects that a woman experiences from this tre- treatment?
- SMSanjay Mehta
Sure.
- PAPeter Attia
And by the way, was she typically getting 40 gray 25 years ago, or was that a little more, I think you said, and now they've come down a bit, it was sort of 50, 60 gray back-
- SMSanjay Mehta
And, and so l- then this brings up a point I need to kind of emphasize. It's not so much the total dose, it's the dose per fraction, so how quickly are you getting it. So the standard of care was actually 50 gray rather than today's 40-ish gray, but it would usually be given in two gray per fraction d- daily doses rather than the 2.6, 2.7 that we're using now. So the effective dose, when you take into account, there's a whole radio biology lecture that we're not gonna bore people with, but m- taking into account the dose per fraction and the total dose, the biologically equivalent dose, or the BED, is roughly the same now at 39.9 gray given in f- in 15 treatments versus the old 50.4 gray that was given in, say, 25 to 28 treatments. So it was a longer process, you're c- you're right. Uh, and we still do that in some cases, and this comes back to another question you asked about, about the homogeneity of the dose. And so our goal, of course, is to have 100% coverage of the whole breast, but the reality is when the, the way that photons are gonna be interacting from different beam angles and whatnot, you're always left with hot spots and cold spots. And so the biggest difference between what we're doing now versus the old days wasn't so much the total dose, it was the actual homogeneity that you touched on.
- PAPeter Attia
Mm.
- SMSanjay Mehta
You, you-- So the heterogeneous, heterogeneous old way of doing things with a cobalt machine or with a low-energy X-ray unfortunately meant that there were hot spots and cold spots in the breast. And that, of course, could either be manifested as scar tissue if it's a hot spot or, heaven forbid, a, a geographic recurrence if there was a, an area that was underdosed. So with the modern computer planning, we're, we're much more homogeneous. So even though you may say, "I got 50 gray back in 1995, and now I'm getting 40 gray," you're now getting 40 gray in two and a half gray fractions, which is equivalent to the old 50. Plus, we don't have 150% hot spot and a 60% cold spot. We have a nice 100% match all the way across, and that can-- that's all, uh, it's like a CAD/CAM type of thing. I'm about as close to an engineer as a, as an MD can be, and so we do actually simulate the dose of the r- the dose distribution of the radiation in the tissue. And so with a nice-- to the modern days, we get a nice homogeneous dose, and therefore, that goes to your next question, which was what is the, what is the patient experience? Uh, maybe not so much 20 years ago, but more like 30, 40 years ago with the older cobalt machines, they would get a terrible dermatitis. Like, many times it was moist desquamation confluently over the whole course of the ch- over the whole chest wall. Axillary d- desquamation is always bad 'cause of the friction of the arm.
- PAPeter Attia
Yeah.
- SMSanjay Mehta
Uh, but with the modern treatment now, with, uh, first, first of all, not using cobalt, using linear accelerators, the energy of the photons is higher, which means the skin dose is slightly lower. So you're getting maybe 100% on the skin rather than 150% like you once did. So we don't see anywhere near the skin reaction [coughs] that we used to. It's more of a, you know, maybe a grade one or a grade two erythema, so mild redness or maybe sometimes a little bit of, you know, like it's a sunburn, but nothing as severe as we used to. So these days, patients do still get a sunburn. We give them a little, uh, some free samples of Aquaphor or, uh, they can use an aloe vera plant if they have it, just, you know, your normal type of skincare stuff, as opposed to the old days when we were actually treating essentially burn victims with silver sulfadiazine and heavy-duty narcotics and things like that.
- PAPeter Attia
[chuckles]
- SMSanjay Mehta
The modern era, it's so much better that a lot of the patients, especially if it's someone that doesn't have a very large breast, there's less energy being put into a smaller sized person, uh, they don't get anywhere near the skin reaction. And that's why if you did have a very large patient, we actually still use the old 50 gray in 25 because you're giving less dose per day, and when you do have a very large breast where you're going to have areas that are going to have hot and cold spots, sometimes that's still needed. So we have to tailor it to the individual is, is I guess my bottom line there.
- PAPeter Attia
Did anybody ever look at the-- when you had the very disparate hot and cold spots and follow women for recurrence and-
- SMSanjay Mehta
Yes
- PAPeter Attia
... was there any association between the cold spots and recurrences?
- SMSanjay Mehta
There certainly is. And, and so the problem was is that the cold-- in the old days you didn't have computer modeling, so w- n- and actually the old school physicists, gotta give your hats off to those guys that had slide rules and probably abacuses or whatever the heck they had back then.
- PAPeter Attia
[laughs]
- SMSanjay Mehta
Where you couldn't really, you couldn't really tell exactly where the hot and cold spots were by, by actually having a computer show you. You had to go based on the fact that you're, you use what energy. You choose a photon energy, and you know what the dose distribution at various depths is. And so you would try to minimize that by, again, having beams coming in from different angles, and then by using, uh, multiple angles and multiple fields you could paint in the dose as best as you could. But, um, yes, certainly there were issues where as you get deeper into the tissue, the dose would be lower, and then, and this is, again, before my time, but there certainly were, were studies showing that there were geographic misses, and, uh, there was, that was obviously not good, which would sometimes would lead to like a salvage mastectomy or something like that. But in the modern era, not so much.
- PAPeter Attia
Uh,
- 48:01 – 51:55
How breast implants affect radiation treatment
- PAPeter Attia
what is the impact of breast implants in this type of treatment, either saline implants or, uh, the older, uh, impl-- actually, they're not older now. They're back in vogue, right?
- SMSanjay Mehta
They're back in vogue, right?
- PAPeter Attia
Yeah, of course.
- SMSanjay Mehta
The silicone.
- PAPeter Attia
Silicone implants.
- SMSanjay Mehta
Either way, what we can-- so the, the photons, the, the X-rays we use, they are, they are not at all affected by that 'cause it's essentially tissue equivalent.
- PAPeter Attia
And I, my-- pardon my ignorance.
- SMSanjay Mehta
Mm-hmm.
- PAPeter Attia
I completely forget.
- SMSanjay Mehta
Mm-hmm.
- PAPeter Attia
Are those implants typically under the pec or between the pec and the breast?
- SMSanjay Mehta
So we see both.
- PAPeter Attia
Okay.
- SMSanjay Mehta
You know, it's interesting how there's a, I guess a sub-prepectoral-
- PAPeter Attia
What's the current standard?
- SMSanjay Mehta
I'm not sure what the current-- I think most of them we see are actually under the muscle. That's-
- PAPeter Attia
Okay
- SMSanjay Mehta
... I, I don't know. I've actually seen both even recently.
- PAPeter Attia
Silicone under pec?
- SMSanjay Mehta
Mm-hmm, but I've seen 'em both. Even, I even think even now the plastic surgeons have different, uh-
- PAPeter Attia
Okay
- SMSanjay Mehta
... criteria for that. But regardless of what it is, our whole-- if it's under the pec, then of course it's really a little farther away.
- PAPeter Attia
It's irrelevant, yeah.
- SMSanjay Mehta
It's not, not a huge issue. But we still-- the radiation will still affect that area, but typically these, these implants are pretty, pretty tolerant of that. The only issue down the road is they may have a capsular contracture or something from fibrosis. The bigger challenge we run into is for our post-mastectomy patients who are gonna be reconstructed, and they have expanders put in, and that's where y- the relationship between the radiation oncologist, the surgeon, and the plastic surgeon is key.
- PAPeter Attia
Yeah, explain to folks what expanders are-
- SMSanjay Mehta
Sure
- PAPeter Attia
... how that works surgically.
- SMSanjay Mehta
So essentially what's happening is when you have a full mastectomy, if a patient wants to have their breast reconstructed later on, the, uh, uh, the surgeon, the, the breast surgeon will remove the breast, but then the plastic surgeon will come in and place some sort of a placeholder to allow the, the soft tissue and all the connective tissue and the, uh, and the skin to stretch to allow for future implant placement. And so those tissue expanders, typically they can actually inject, uh, saline into 'em with a port and gradually stretch them with time. And so that's normally what they would do if there was no radiation involved. But if it's a patient, and again, most mastectomy patients really don't need radiation 'cause this gets away from what we mentioned earlier, where breast conservation is lumpectomy only. But there are some patients with a full mastectomy who are gonna get reconstructed, so they come to me, and when I do their CT scan, they have this expander in place from the breast surgeon. So we have to, again, modulate the beams, and we treat the entire chest while we make sure we're covering everything, but simultaneously, we have to make sure that we don't have those hot spots in the area of the expander where potentially you could cause scarring and fibrosis and cause the, uh, the expander to have to be removed, have the plastic surgeon have to revise it. That becomes a whole 'nother hill of beans there that we don't like to mess with.
- PAPeter Attia
Sure.
- SMSanjay Mehta
But we have techniques now to be able to keep the dose off of 'em. And again, as you mentioned earlier, whether it's silicone or, or saline, it's roughly the same density, but some of these tissue expanders have bits of metal in them. They may have, uh, other artifacts, and so when I'm treating, uh, with photons, with X-rays, depending on what you're hitting, it, the, the, the effect is based on the density, the atomic number of that tissue. So metal behaves very differently from-- bone behaves differently from air. But when you're in the spectrum of saline, tissue, water, it's all basically the same. We can model all that, very much like-- I, I'm getting ahead of myself, but very much like when we have a prostate patient with a prosthetic hip, a piece of metal right next door, we're able to compensate for that with the modern computer treatment planning systems.
- 51:55 – 59:56
Radiation therapy for prostate cancer: advancements in precision, effectiveness, & patient selection criteria
- PAPeter Attia
off, which patients are typically being radiated?
- SMSanjay Mehta
Mm-hmm. And so that, the answer to that has been evolving. There was a time as recently as probably 20 years ago where, uh, we only treated patients who were probably medically inoperable, that the, the urologist would say, "Hey, you know, this is a high-risk anesthesia patient. Let's send him to Dr. Mehta for radiation." And that's a big reason why a lot of the older data was not as good for radiation, because of the patient selection criteria. Uh, but in the modern era, as we've gotten more and more precise and our side effects have gone down and our cure rates have gone up, now it's pretty much wide open where pretty much anybody who's eligible for surgery would also be eligible for radiation. So there's not that big of a divergence as there once was.
- PAPeter Attia
So I, I notice you, you've gotten to know Ted Schaeffer, um, who's not only-
- SMSanjay Mehta
A great guy
- PAPeter Attia
... on the podcast, but is, is-
- SMSanjay Mehta
[laughs]
- PAPeter Attia
... equally, um, let's just say interested in cars.
- SMSanjay Mehta
He sure is.
- PAPeter Attia
So, so you, you, me, and Ted have a lovely little text thread about cars.
- SMSanjay Mehta
He and I may have another text thread in case our teams meet in the playoffs as well. He's a big Ravens fan, so, and I'm from Houston, so-
- PAPeter Attia
Yeah
- SMSanjay Mehta
... I'm hoping we get there.
- PAPeter Attia
Um, so l-let's talk about a, um, kind of a, a patient that comes in to see Ted for a biopsy. They've got a Gleason three plus four, um, and then another patient who's a Gleason four plus four or four plus five or something like that.
- SMSanjay Mehta
Right.
- PAPeter Attia
How does that patient navigate their way through the system as to whether or not they need radiation, or should they undergo surgery? And does androgen deprivation therapy necessarily come with radiation, or is there a scenario where you undergo radiation but you don't require androgen deprivation?
- SMSanjay Mehta
Sure. So to answer your last question first, androgen deprivation for high-risk disease is certainly standard of care, uh, Gleason eight or higher for sure. The Gleason sevens are always a, a, uh, sort of a gray zone, and so a four plus three with high volume disease typically also do get concurrent and adjuvant androgen suppression along with radiation. Uh, but one of the things that's really changing now is I know Ted talked a lot about s- with the Decipher score, where they can look at the chromosomes of the actual cancer cells and have a much more granular view of exactly are they, are they truly high risk, or can you di- can you, uh, uh, maybe say that this one three plus f- three plus four is more like a three plus three. So we can-- So for a lot of the three plus fours now with the Decipher test, and there's also an Ar- an AI test, I know you had a really interesting discussion with your AI, uh, expert a f- n-not, wasn't too long ago, uh, called Artera, and we're using that. That's actually in the NCCN guidelines now, so that Artera test can help us differentiate between a unfavorable and a favorable intermediate risk patient. And essentially, I'm actually, I treated my own father not too long ago. He was the first person I did this on. Uh, the Artera test is essentially they just use the actual images of the H&E slides that were already done from the pathologist, and it's in-interpreted by a machine, uh, machine learning computer that has been trained on hundreds of thousands of prostate images from the old RTOG studies, the 94s, all the, all the stuff that was done back in the '90s, and it can now come back and say, "Okay," very much like Decipher, it can say that this is a three plus four, but it's a favorable or an unfavorable person in that s- in that subgroup. And so because of that, we can stratify better and actually tailor it to where maybe a three plus four doesn't need androgen ablation at all, and maybe even some four plus threes, if they come back low enough on the scale where you could ma- You always have to talk about the side effects and whatnot, but the standard of care was always to give concurrent androgen ablation for intermediate risk, but now we're able to really take some of those people out of the equation with these new studies.
- PAPeter Attia
And is the main selling point, because most patients just want things taken out, right?
- SMSanjay Mehta
Mm-hmm.
- PAPeter Attia
I have cancer, take it out.
- SMSanjay Mehta
100%.
- PAPeter Attia
So is the reason that a person might select radiation therapy, especially if it comes with androgen deprivation therapy-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... because of the sexual function and urinary func- Like, w-what's the main advantage?
- SMSanjay Mehta
Those are number one and number two. Yeah, lack of incontinence and lack of impotence, but of course, when you have androgen ablation, that sort of clouds things a little bit. Uh, but typically the number one thing we see is, uh, uh, patients who don't want to deal with diapers. And for the most part, although, uh, incontinence is still described, uh, to some degree in the literature, in my personal experience, I don't think I've seen a single patient who came in continent who left with anything less than that. There's no pads, there's no nothing. Um, and then of course also being, uh, uh, you know, w-with our, as I talked about with breast cancer, we can also focus very precisely on the prostate itself, so the dose to the penile bulb, the dose to the rectum, the dose to the pros- to the, uh, bladder are so low now that, uh, the side effect profile is essentially zero from a radiation standpoint. Now they may be having hot flashes from the androgen deprivation, uh, and decreased libido and fatigue, as you know. But on the radiation side, because we have all these tricks now, very much like with breast, the way we can avoid the heart and the lungs, in the case of the prostate, we can almost completely avoid the bladder and the rectum and even the, uh, the penile bulb now. So the quality of life, those are the reasons why people tend to choose radiation.
- PAPeter Attia
And I know we've talked about this before, um, you're just not seeing the proctitis.
- SMSanjay Mehta
Yes, almost none. In fact, uh, now, um, I know, I think, uh, Ted had mentioned in his last talk, there's a, there's a gel spacer that, that is often inserted. It's an, it's an injection that's done transperineally, and it s-separates the, the rectum from the, um, from the bladder. But in my years of doing this, when you're very diligent about how you do this, very much like a, you know, it's, like a surgeon pays attention to detail, so do we. I can actually trim the dose off of the posterior prostate and just make s- make sure the dose falloff between the posterior prostate and the anterior rectal wall is so rapid that the anterior rectal wall is always gonna get some dose, but usually it's not clinically significant. And e- and, and what we do to, to manifest, to make sure that that is, is a daily thing, 'cause we're talking about treating patients for multiple weeks, we actually coach the patient to come in with a full bladder and an empty bowel. And by being diligent about that and imaging daily to double-check that in fact the bowel is empty and the bladder is full, that, that allows those two organs to separate from the prostate. And even a few millimeters of separation is all we need to take advantage of our modern focused radiation beams.
- PAPeter Attia
And does the patient need to be coached to time their breath or anything as the beam is at that most delicate edge of the rectum?
- SMSanjay Mehta
Sure. Great question. So not, not so much for pelvic patients, but we do that for breast cancer, especially left-sided breasts. So just to go back to that, uh, you actually have a deep breath hold, which will get the chest wall away from the heart. So we do that in the case of thoracic tumors, but in the pelvis, the, the diaphragmatic position doesn't really make any difference. It's more about bladder and rectal filling and emptying, respectively. That's much more important.
- PAPeter Attia
Everybody I've talked to who's had LASIK eye surgery always says they're so worried that they're gonna do something-
- SMSanjay Mehta
[laughs] I know
- 59:56 – 1:11:42
Radiation therapy options for inoperable prostate cancer or those seeking alternatives to surgery
- PAPeter Attia
What about patients that are inoperable? Um, first of all-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... you know, what leads to a patient being inoperable?
- SMSanjay Mehta
Sure.
- PAPeter Attia
And how do they show up?
- SMSanjay Mehta
So, you know, typically the urologists have already screened the patient because th- everyone's first, uh, i- first, uh, exposure's gonna be to what the urologist tells them. And luckily, in this day and age, I'm lucky we have, uh, people much like Ted, who are very open and who are very, uh, o- open to not just doing surgery, but who actually look at the other options and present everything to the patient. But typically a patient who maybe was medically inoperable will, will certainly come to me, but even somebody who maybe is on the borderline who wants, wants to see both sides of the token, a general urologist will send them to a, a surgical specialist and to me, and we'll go through all the pros and cons of everything. And really what it comes down to, to not, to not, uh, you know, belabor the point, it comes down to two things. You want, you want to be cured, cure rate is key, but quality of life is equally important, if not more important for most people. And so now that cure rates with our modern focused radiation allow it to get such a high dose into the prostate, uh, we can say that they're essentially equivalent to surgery. So we don't have that deficit like we did 20 years ago when our fields weren't as precise. It was sort of the shotgun approach versus our, you know, sniper approach. Now, um, b- because the cure rates are better, then it really comes down to, uh, the quality of life changes, and that's where there's a spectrum of things.
- PAPeter Attia
Now, is this an apples to apples comparison? Because the patient who undergoes the robotic prostatectomy today-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... does not go on androgen deprivation therapy.
- SMSanjay Mehta
Right.
- PAPeter Attia
Right? They get to walk around. In fact, you've probably heard Ted on the podcast. He says, "We'll give those patients TRT if they're hypogonadal."
- SMSanjay Mehta
Right, right.
- PAPeter Attia
Um, why does the patient after radiation therapy still need to be androgen deprived if, in theory, the radiation is as effective as the surgery?
- SMSanjay Mehta
And that's, that, that comes to a key point where you have less surgical side effects. You don't have... It's, it's trading one thing for another.
- PAPeter Attia
Yep.
- SMSanjay Mehta
You don't have the incontinence. You don't have the, at least the short-term risk of impotence like there is from surgery. You don't have the, you know, the penile shortening or whatever other sort of things that they have to deal with. But you have to deal with hot flashes and decreased libido and whatnot. But again, most of the patients who, uh, are intermediate or high intermediate risk are going to... If, if they, if they end up, uh, not having a, uh, a negative margin or a seminal vesicle invasion after prostatectomy, they're still gonna come to me for radiation anyway.
- PAPeter Attia
Mm-hmm.
- SMSanjay Mehta
And they're still gonna need to be on androgen ablation. So there's a significant number. Now, it's, these days we'd certainly treat a lot less Gleason 6 than we used to. We observe most of them.
- PAPeter Attia
Yep.
- SMSanjay Mehta
But there's a lot of Gleason 6 folks that even in this day and age will choose to have radiation just because it's maybe a little bit more aggressive form of watchful waiting, and in that case, there is no androgen ablation and they just, you know, s- they just, uh, glide-
- PAPeter Attia
Has there been a trial-
- SMSanjay Mehta
... through the whole process
- PAPeter Attia
... of Gleason 3+3 watchful waiting versus XRT no ablation?
- SMSanjay Mehta
No. Unfortunately, there's no actual trial. There's just observational studies. That's, that's kind of what we're dealing with there.
- PAPeter Attia
Oh, gosh.
- SMSanjay Mehta
But, uh-
- PAPeter Attia
And, and obviously you can't figure out what the biases are.
- SMSanjay Mehta
Somewhat.
- PAPeter Attia
But what do those observational studies show?
- SMSanjay Mehta
Yeah. They show, you know, essentially, 'cause people don't die from Gleason 6 disease, as we all know. They really do-- Because quality of life, they do so well with the radiation, there is just less of a chance of it progressing to a-
- 1:11:42 – 1:14:44
How patients can effectively evaluate & select a radiation oncologist
- PAPeter Attia
Anything else you wanna talk about on the oncology side of this as far as what, what should people know-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... as they're engaging with a radiation oncologist?
- SMSanjay Mehta
Sure.
- PAPeter Attia
Uh, what questions should they be asking? What-- You know, it sounds like it's no different than surgery, where there's clearly a difference between good surgeons and not so great surgeons. There-
- SMSanjay Mehta
There is
- PAPeter Attia
... presumably are people that take the kind of care you take and agonize over the details. Um, how can somebody find out if their radiation oncologist is kind of practicing in your philosophy?
- SMSanjay Mehta
You know, it's, it's difficult in terms of, uh, actual metrics. Very much like an even, even for the surgeons, like, you know, Ted is, has excellent outcomes, but it's not like it's a published series. You just have to kinda-
- PAPeter Attia
And not only that, the best surgeons often are treating the hardest cases.
- SMSanjay Mehta
True.
- PAPeter Attia
So-
- SMSanjay Mehta
So it, it's a handicap right there
- PAPeter Attia
It's a handicap right there. Yeah.
- SMSanjay Mehta
Hundred percent. So, you know, it really comes down to finding someone who's got, got the experience, and in my case, because we do so much prostate, I think I've done something close to, in the modern era, 7,000 cases, probably 10,000 when you include the pre-image guided radiation days. Um, someone who specializes in the area that, uh, that the cancer is located in. So someone like me, I may be extremely experienced in breast and prostate, but maybe, uh, for a pediatric malignancy, you're not gonna come to me. You're gonna go somewhere or a CNS or something that's unusual. You have to find the right tool for the job. But you have to just interview your doctor. I don't think there's anything specific to radiation that's really, uh, a determining factor.
- PAPeter Attia
And asking about complications, right?
- SMSanjay Mehta
I think being very open with them, saying... Yeah, exactly. And so, uh, ideally, maybe you, you come to someone who knows something. Like, I get a lot of patients who aren't familiar with the field, but they'll have a patient-- or they'll have a family member that's a nurse or a dentist or a veterinarian or whatever it is, someone that has some medical background. They can say, "Okay, let me ask the more specific questions." And these days, with, with the internet, you can do all kinds of research in terms of... Like, when I'm, when I'm talking about matching my, my volume of the dose distribution to exactly conform to the tumor volume, that's something that's very easy to talk about. But, I mean, for a, for a, uh, educated patient, they can ask to see the actual computer simulations. A lot of my engineering patients-
- PAPeter Attia
I was just about to say engineers probably have an easier time than-
- SMSanjay Mehta
They do
- PAPeter Attia
... medical.
- SMSanjay Mehta
My l-- My, my engineering patients are really the only ones who do this, and I'll be-- I usually pull out all the graphs. I show them dose volume histograms with area under the curve for each organ, and you can see, okay, the prostate dose area under the curve is huge. The dose to the bladder and the rectum is super low. You can actually quantify that. But for a lay pr- lay patient, it's, it's hard. You know, it's not that easy to do that. You really gotta go with-- I think a lot of it, you have to go with your gut, too, in terms of this guy's had a lot of experience, and the initial consultation is where it all comes down. I'll spend an hour with a patient and go through every little nuance of what could and couldn't happen. And my main-- I think my main MO is to sort of overprepare them and have them be pleasantly surprised maybe when the side effects aren't as bad rather than the other way around. And you just-- It's, it's hard to find the right person, but there's a lot of good doctors out there, so.
- 1:14:44 – 1:25:33
Radiation therapy for brain cancer: the shift toward precise, targeted techniques that minimize cognitive side effects, & remaining challenges
- PAPeter Attia
Uh, let's spend a minute just on the, the brain, um, and b- because I guess, like, that's sort of a, a unique case.
- SMSanjay Mehta
Yeah.
- PAPeter Attia
I know it's not where you are, but, but I'm sure, you know, the br-
- SMSanjay Mehta
Still do a lot of it.
- PAPeter Attia
Oh, you do?
- SMSanjay Mehta
Yeah. Mm-hmm.
- PAPeter Attia
Okay. All right.
- SMSanjay Mehta
Not as much as prostate and breast, but yeah.
- PAPeter Attia
Okay.
- SMSanjay Mehta
Both primary and metastatic.
- PAPeter Attia
Yeah. So again, because the brain is such a sink for mets-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... you know, A, it's a source of a lot of primaries, but it's also where a lot of cancer spreads.
- SMSanjay Mehta
Right.
- PAPeter Attia
Um, it's often a place where you can't operate, uh, either because the, the t- the tumor, the met or the primary is too close to, say, the brain stem or something, uh, too vital. Um, so, so radiation is a pretty common tool there. So talk about the history of radiation in the brain-
- SMSanjay Mehta
Sure
- PAPeter Attia
... and, and the spectrum of everything from whole brain radiation to gamma knife and stereotactic and-
- SMSanjay Mehta
Sure
- PAPeter Attia
... all sorts of things in between.
- SMSanjay Mehta
Sure thing. So, uh, really the, the main differentiating factor for brain patients is whether it's primary or metastatic disease. And although primary brain tumors are relatively common, they are dwarfed by metastatic disease. So the vast majority of what most radiation oncologists see when you're treating CNS is going to be, uh, usually lung, especially small cell, uh, based brain met- metastatic disease. And so in those situations, the, the trend used to be where everyone would get whole brain radiation. But now with the advent of stereotactic radiosurgery, which is more focused, precise radiation, uh, the newer data shows that you can actually just treat the area of metastatic disease as, as a, as a delineated on an MRI scan and not necessarily radiate the whole brain like we used to. But for decades, everyone got whole brain radiation. And for the most part, they did all right, but the problem was you're look- looking at a patient population that maybe doesn't have that much of a life expectancy. Now that systemic therapy, immunotherapy, everything has gotten better, especially in the case of lung patients, they're living longer, um, we, we have evolved where we've been finding [coughs] people that were previously radiated to the brain were having cognitive issues years down the road. Not for the short term, they would tolerate it well, but maybe they'd start to have more forgetfulness, an in- inability to remember numbers and names and whatnot. And so the modern era now, we-
- PAPeter Attia
And this was from whole brain radiation.
- SMSanjay Mehta
Whole brain radiation.
- PAPeter Attia
And give me some doses.
- SMSanjay Mehta
So we're talking about 30 gray to the whole brain given in 10 fractions of three gray each. That was a typical sort of a three gray times 10 was a-
- PAPeter Attia
Wow
- SMSanjay Mehta
... was a sort of a standard thing. And the-
- PAPeter Attia
Again, this is a staggering amount of radiation.
- SMSanjay Mehta
Yes. And that's why-- And when we consider that, again, it's to the brain, so it's a different story.
- PAPeter Attia
And, and just to be clear-
- SMSanjay Mehta
Mm-hmm
- 1:25:33 – 1:31:49
Origins of radiophobia & how it influenced perceptions of radiation use in medicine
- PAPeter Attia
but, but maybe let's, let's use that as a bridge to talking about using radiation to enhance tissue, um, as opposed to eradicate a t- a subset of tissue.
- SMSanjay Mehta
Sure.
- PAPeter Attia
What... W- Does it, does it stem from, you know, nuclear accidents? Is that largely where radiophobia comes from?
- SMSanjay Mehta
I've done a deep dive into this this year, which goes along with all these benign cases that I'm treating now. They're essentially, you know, arthritis, tendonitis, which we'll talk about, and what's really interesting is that this radiophobia is largely a US-based phenomenon because the first cases... First of all, X-rays were discovered in 1895 by Röntgen. In 1898, there was the first case described of actually radiating a, uh, both arthritis type things or ankylosing spondylitis or other arthritides, and also tumors. Even back then, we had no idea how it worked, but there were cases pre-1900 that were already being used for that. And then in the subsequent now 120-plus years, we have this divergence where Germany and the UK are using, and all of Europe really, are using radiation routinely for arthritis and tendonitis. But in the US, it seems to be a basic... It, there was a, a lot, a lot of a nu- was nuclear phobia, the Cold War, like you mentioned. But another thing that's, that's been talked about, there's a guy named Jason Bechtel that has a really good podcast on the subject. He's out of Vermont. Um, Standard Oil, the Rockefellers and all actually had a massive lobby group that were actually actively promoting oil over nuclear power plants, and they, the, the amount of spread went from just the, the energy industry into the, just the general zeitgeist of the, of our entire country. And so at that time, the r- radiophobia just caught on, and it was, of course, um, uh, bolstered by World War II and seeing what happened in Hiroshima and Nagasaki. And then on top of that, you had the, you've probably heard about the radium dial workers. Uh, there was a movie, and it's actually, it's called The Radium Girls. These are essentially, uh, women in the 1920s that were using radioluminescent phosphorus paint to paint the watches.
- PAPeter Attia
Watch dials, yeah.
- SMSanjay Mehta
Being a watch guy, you'll probably appreciate that, but they literally, that was the only source of illumination they had. So in order to keep the brushes very fine, they were literally, uh, dipping it in the radium paint, and then after each brush, they were licking the brush to keep the f- the tip real fine.
- PAPeter Attia
Mm.
- SMSanjay Mehta
And so they were ingesting bits of, of radium. And, uh, so there were a, a number of cases where they ended up getting... The, the radium is metabolized like, uh, calcium, so it was actually incorporating into the mandible, and they were getting o- osteoradionecrosis of the jaw and things like that. So all of these different phenomena kind of added together became a, became a big deal because prior to that, people were using [chuckles] radiation for all kinds of crazy things. It was in suntan lotions and waters, and there was something called Vigoridine that they were using for ED that you could [chuckles] topical salves that had radiation in them. It was, there was literally no end to it. And then when all the sequelae started to come out that, hey, maybe this isn't such a good idea, that's when things took off. But now that we look back, the reality of it is, is that a lot of that was really overblown, even so much so that those radium dial painters, which we, we hear about this from day one in our residency training, there was only a small percentage, like I think 50 out of 1,500 roughly, that actually had toxic sequelae. So most of them didn't.
- PAPeter Attia
Is there a way to quantify how much exposure they had to radiation?
- SMSanjay Mehta
And that's the thing. You know, they, they've licked different ways, but there, there have been some basic ideas. It was, again, we're talking about, uh, it was probably a- a- at that era, it was probably a couple of millisieverts to the, to that particular area, but it was daily for decades.
- PAPeter Attia
Yeah.
- SMSanjay Mehta
And so part of the reason why they, they, the, if you actually look at the numbers, it was probably a super high exposure, but when you spread that out over such a long period of time, that's sort of the general trend. Like I mentioned earlier, it's not just the dose, it's the dose over time.
- PAPeter Attia
Yep.
- SMSanjay Mehta
It's, you know, and the denominator matters a lot, and so that's why most of them actually did very well. They even used to use radium internal na- internal nasal applications in the 19, I guess 1920s to 1940s, essentially a, a radia- a, a, a radiation equivalent of a tonsillectomy or adenoidectomy, and it was done in something like-
- PAPeter Attia
Hmm
- SMSanjay Mehta
... a half million to two million children in the US and even in the armed forces. It was done routinely back then, and there's been very few adverse sequelae that were reported. I don't even know what the dose was, but it was high. So there's a lot of cases where the exposure based on our 50 millisievert rule we talked about would just make people fall out of their chair.
- PAPeter Attia
[chuckles]
- SMSanjay Mehta
But the, the actual reality of it is, is that, uh, many times the, the actual, uh, end results aren't as bad as we had expected.
- PAPeter Attia
Again, hearing you say this, Sanjay, the listeners are gonna be thinking, "What?"
- SMSanjay Mehta
Yes. [laughs]
- PAPeter Attia
'Cause we're all so brainwashed into believing that radiation is horrible.
- SMSanjay Mehta
Right. Right. I can tell you so many stories. You know, I got patients who I've had to treat-- I had actually had a guy who was involved in nuclear testing at Los Alamos in the 1940s. He's passed away now, but I saw him in his 80s, so this was in the early 2000s. This was 60 years after that. They had very little monitoring back then, but he was close enough to feel the heat from a thermonuclear bomb. And by the time I saw him, he had had thyroid cancer, as you would expect. He'd had, uh, one or two lymphomas. I think I ended up treating his prostate. So he'd had at least four or five different malignancies, but the guy was a- as functional as most 80-year-olds are. The guy was still walking and talking and doing just fine. And it's actually seems that the-- when you look at the population studies that were done outside the blast at Hiroshima and Nagasaki, when of course you g- the, the initial concentration, everyone dies from the thermonuclear energy, but as you get several miles out, not only are the cancer rates actually roughly s- the same as the background, you actually see, again, evidence of hormesis, where you have some patients in whom-- or maybe not hormesis, but some sort of radioprotection where you actually have lower rates of leukemia and thyroid cancer when you get a few miles farther out than you did in the general population. So it's all very much dose dependent, time dependent, but I think the human body, w- we- we're evolved really to handle this to a larger degree than we realize because, again, mammalian DNA, we came from, you know, the background of, of the animal kingdom where there was tons of exposure from natural cosmic rays and whatnot and then, you know, our, our predecessors had to be able to survive. Our DNA had to be somewhat resilient in order to get to this point. And I think it's more resilient than a lot of people give it credit for.
- PAPeter Attia
So this first
- 1:31:49 – 1:38:57
Treating chronic inflammatory conditions such as tendinitis & arthritis low-dose radiation
- PAPeter Attia
came up maybe a year or two ago when, when I was lamenting-- It must have been two years ago, I guess, 'cause I was kind of lamenting, um, my Achilles tendon, which wasn't-- I wouldn't say it was injured. I just had a little bit of tendonitis.
- SMSanjay Mehta
Mm-hmm.
- PAPeter Attia
It was just bugging me a little bit.
- SMSanjay Mehta
You and me both, brother.
- PAPeter Attia
And, um-
- SMSanjay Mehta
I know exactly what you mean.
- PAPeter Attia
And, uh, and, and so it was through that discussion-
- SMSanjay Mehta
Yep
- PAPeter Attia
... that, that y- we, we got into what we're talking about now-
- SMSanjay Mehta
Yeah
- PAPeter Attia
... um, which seemed crazy. You know, I just decided I didn't feel like driving to Houston all the time to undergo therapy, and-
- SMSanjay Mehta
[laughs]
- PAPeter Attia
... my Achilles is fine now.
- SMSanjay Mehta
Yeah.
- PAPeter Attia
I just did sort of standard therapy. But-
- SMSanjay Mehta
Right
- PAPeter Attia
... um, I've sent a c- a few patients to you who have had similar injuries.
- SMSanjay Mehta
Mm-hmm.
- PAPeter Attia
Uh, both, you know, high hamstring tendinopathies, uh, uh, Achilles tendinopathies. So, so talk a little bit about this idea.
- SMSanjay Mehta
Sure.
- PAPeter Attia
How prevalent is this type of treatment in Europe? Who el- You know, how-
- SMSanjay Mehta
Sure
- PAPeter Attia
... prevalent is it here?
- SMSanjay Mehta
Right. So prior to probably 1970 or maybe 1980, it was very prevalent even in the US.
- PAPeter Attia
Mm.
- SMSanjay Mehta
It was very widely done. So this is kind of everyone, when I talk to them about it now, it sounds like I'm doing something experimental and radical. But if you go over to Germany, again, going back to ankylosing spondylitis papers in 19- 1898, uh, they've done-- They do something like, I hear, between 20,000 and 50,000 patients a year in Germany, and there, there's tons of-- It's mostly observational studies. There's very few randomized trials. But, uh, low-dose radiation for tendonitis, osteoarthritis, plantar fasciitis, all the itides you can think of, bursitis, um, a low dose of radiation has a similar anti-inflammatory effect to what you would get from a cortisone injection.
- PAPeter Attia
And let's define the dose.
- SMSanjay Mehta
So now we're talking about very low dose, meaning 50 centigray or 50 rads given, uh, six times over two weeks. So three gray, .5 times six is three gray, to the affected joint, um, and, uh, using a very low energy machine. So this is, especially in the s- case of someone who's got a hand, you're talking about electron beam radiation.
- PAPeter Attia
Wait, sorry. Let me just make sure I got that straight.
- SMSanjay Mehta
Mm-hmm.
- 1:38:57 – 1:45:11
Low-dose radiation to treat spine injuries, scar tissue, fibrosis, keloids
- PAPeter Attia
Is there any literature looking at this for, uh, spine injuries? Uh, n- and by injuries, let me be clear what I mean.
- SMSanjay Mehta
Mm-hmm.
- PAPeter Attia
Right? So when you think of all the times that people are getting spinal epidurals-
- SMSanjay Mehta
Right
- PAPeter Attia
... for irritation of spinal nerves, herniated discs, things of that nature, is there any reason to believe this could have any efficacy there, if indeed there's some efficacy, which there clearly is, due to, uh, spinal injections or epidural injections?
- SMSanjay Mehta
There, there is some data for spinal osteoarthritis specifically. Uh, it's less robust than all the extremities. Uh, I've actually done a few cases, and it's actually worked quite well. We've even got, you know, essentially Medicare actually does, uh, reimburse for these things. The issue with the spine is it's such a multifactorial area, where if you've got a nerve root compression or a disc issue, I can't fix that part of it. But there is limited data that I've seen out of Europe that did show some degree of relief, but it's not the 80 to 90% that we quote for the extremities. It's probably-
- PAPeter Attia
Interesting
- SMSanjay Mehta
... half that.
- PAPeter Attia
And do you think it's because of patient selection? Like, if you, if you knew you were dealing with a facet arthropathy-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... that should, in theory, respond well.
- SMSanjay Mehta
It should, and it does. I've done a few of those. SI joints seem to respond quite well, and that's in the literature. That's included. So hips, SI joint, lumbar spine, those sorts of things. Uh, they are described. They're just not as routinely treated. There's not as the level of experience that we do have with everything else.
- PAPeter Attia
But your ability to center the beam-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... is remar- Like, you're using the same high-fidelity equipment you're using-
- SMSanjay Mehta
Same equipment
- PAPeter Attia
... for rad onc.
- SMSanjay Mehta
100%.
- PAPeter Attia
So you can hit a pea inside if you want to.
- SMSanjay Mehta
Well, you could, but that's exactly what you don't want to do because you're basically trying to eliminate all the macrophages in the region. So you're actually better off treating larger fields.
- PAPeter Attia
I see. Yeah.
- SMSanjay Mehta
So it's the exact opposite of what we do with cancer therapy. And because the dose is so low, you're not really gaining anything by being too cute with the small fields. You actually want to treat the region. It's like almost like an abscopal effect for the whole area.
- PAPeter Attia
So when a, if you're treating somebody that comes to you and they've got an Achilles tendinopathy-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... usually there's a point of maximum tenderness.
- SMSanjay Mehta
Right.
- PAPeter Attia
But it usually hurts up and down the whole-
- SMSanjay Mehta
Exactly
- PAPeter Attia
... Achilles. How do you position the beam?
- SMSanjay Mehta
Sure.
- 1:45:11 – 1:50:49
Barriers preventing widespread adoption of low-dose radiation therapy for inflammatory conditions
- PAPeter Attia
So I think the question is, do we need more radiation oncologists, right?
- SMSanjay Mehta
[chuckles] Yeah.
- PAPeter Attia
Because how are you making-
- SMSanjay Mehta
Yeah
- PAPeter Attia
... room in your practice-
- SMSanjay Mehta
Yeah
- PAPeter Attia
... to treat these patients when your cancer patients are probably ringing you off the hook as well?
- SMSanjay Mehta
And that's a big reason why it hasn't caught on. I think there's a component of just, you know, when you've got eight hours or 12 hours a day that the linear accelerator can run, we're, we're busy with that. But one of the things is that, uh, because f- un- unless it's a deep hip or something, for most of the superficial, for all the other joints, you can use one of those old style orthovoltage machines that I mentioned earlier, like what they use in Europe. They still sell those here. There's a company called Extral that still makes them, and they're perfectly acceptable for all the joint stuff, except for the very deep ones, like maybe a, a, an SI or hip joint. Um, but you could have a, you know, a small center set up, and those types of machines don't even require the shielding 'cause the energy of the photons is very, very low. So yeah, this is something that could be-- It, it's highly underutilized at this point, and the, and the, and the Europeans have shown us the way. It clearly works, and America just has to catch up.
- PAPeter Attia
Yeah, this is definitely an area where we are way far behind.
- SMSanjay Mehta
But it's truly exciting. I mean, I love treating cancer patients. It's really personally very rewarding to tell someone that they're NED, there's no evidence of cancer in their body anymore, their PSA is low, their, their mammograms look good. It's a, it's, it's-- That's what's kept me going this long. But the amount of immediate relief we're seeing from, from all these inflammatory conditions, right away, it's just like, it's a night and day. Patients come in one day, they can't grip a doorknob or lift a gallon of milk out of their fridge, and after six treatments, they can, and they're just, they think you hung the moon. It's, it's an amazing thing.
- PAPeter Attia
Yeah, I, I, I, I really-- I, I'm, I'm hopeful that people listening to this, so if there's a million people listening to us have this discussion, and, you know, one in seven of them, let's just say one in ten of them, at some point in the next couple of years are gonna experience the type of injury that would benefit from this. How can they go about finding-- You know, they can't all come to Houston to see you.
- SMSanjay Mehta
[laughs]
- PAPeter Attia
I'm trying to get you to move to Austin. But regardless of where you end up-
- SMSanjay Mehta
Yes
- PAPeter Attia
... they're, they're, they can't all come and see you, so where-
- SMSanjay Mehta
Oh, that's-- You already said the answer. I'm just gonna move to Austin. We're just gonna do this full time and-
- PAPeter Attia
[laughs]
- SMSanjay Mehta
... drive cars in the, in the, on the weekends. No, but seriously, uh, it's, it's, there's a uphill battle because w- as I've been going out and trying to get the medical community in Houston aware of it, you have a lot of pushback because, number one, you've got orthopedic surgeons, podiatrists, hand surgeons who are looking at this like, for, number one, "What are you doing? What are you talking-- Are you..." They look at me like I'm crazy. And number two is like, even if this actually works, the concern is when someone's got maybe a knee arthritis that's been nagging them, and maybe they're gonna need a total knee at some point, their concern is, "Wait a minute. Is, is this taking surgery off the table?" They have all the-- Which it's not, by the way, 'cause it's such a low dose. There's, there's been plenty of cases of surgery after the radiation. It's not an issue. Or you're taking away from, like, your, when you had your plantar fasciitis, I'm sure the podiatrists billed something for when they do those extra corporeal shock treatments and steroids and whatever it is. It's, it's a different, uh, paradigm that, uh, would potentially be taking away, that these-- A lot of pa- a lot of doctors are very negative about it. Most of them at, at this point are very negative. But I think that tide is gonna turn just like anything else. It's just gonna take a lot of education, a lot of time, a lot of talks like this.
- PAPeter Attia
Well, I think at the end of the day, look, I don't think patients will have any patience for turf wars.
- SMSanjay Mehta
Yes.
- PAPeter Attia
Right?
- SMSanjay Mehta
That's true.
- PAPeter Attia
And so if I'm a patient, uh, every doctor needs to be a fiduciary.
- SMSanjay Mehta
Mm-hmm.
- PAPeter Attia
They need to put my interest-
- SMSanjay Mehta
Right
- PAPeter Attia
... ahead of their interest.
- SMSanjay Mehta
And what's interesting is that I think you can have your cake and eat it too, and the reason I say that is many times this is an adjuvant for other things. So if you've got a podiatrist that's doing all these PRPs and the other things, I'm actually looking at starting a protocol. I just treated a nurse in Houston who's, who's a NP who does stem cells off-label, but she does them routinely, has a, quite a big practice. We're gonna look at maybe you can do radiation with adjuvant stem cell treatment. There's, I think, a lot of reasons, 'cause it's such a low dose, this may be a, uh, the sort of combined modality thing down the road that we haven't really, uh, approached, where there may be options to do other things still.
- PAPeter Attia
But again, the fact that Medic- I mean, for Medicare to improve something-
- SMSanjay Mehta
Yeah
- 1:50:49 – 1:55:15
Durability & versatility of low-dose radiation therapy in treating chronic inflammatory conditions
- SMSanjay Mehta
I mean, it's-
- PAPeter Attia
And do we, do we have a sense of the durability of this?
- SMSanjay Mehta
Yes.
- PAPeter Attia
So for example, I have a little bit of, um, osteoarthritis at my AC joint on the right.
- SMSanjay Mehta
Right. Right.
- PAPeter Attia
Um, it's-- it barely bothers me, but every once in a while, if I'm-
- SMSanjay Mehta
Yeah
- PAPeter Attia
... doing something really violent overhead, you know, reaching for something, or I play a ton of football with my son, it'll bug me for like three weeks.
- SMSanjay Mehta
Right.
- PAPeter Attia
I'll take a little bit of Advil. It's fine.
- SMSanjay Mehta
Right. Right.
- PAPeter Attia
If I did a treatment there, would it be done, or am I doing this treatment annually? How, how would it work?
- SMSanjay Mehta
And that's, there's a lot of variability there, depending on what the actual anatomy that's causing it. If there's, you know, uh, if it's literally just a straight up osteoarthritis case with no physical structural issue, I've seen cases, I've-- Now again, I've only been doing this about a year, so I don't have the 25 years of experience I do with cancer, but I've talked to, there's a, there's a couple of doctors who do this routinely. They've been doing it for 20 years in LA. One of them treated his own neck, shoulder, and spine. He's 15, I think he's at 15 years out. Anecdotal obviously, but never had to retreat himself. Typically, the German studies allow for two treatment, two re-treatments. Because the dose is so low radiobiologically, I don't see any reason why you couldn't do it, I don't know about annually, but you know, maybe every few years or something like that. But there seems to be a fair bit of data that a lot of patients who don't have other struct-- like a, like a knee that's bone on bone, it might only last them-
- PAPeter Attia
Yep
- SMSanjay Mehta
... a month or le- it may not even work. But, uh, for the other ones, like the, the hands and all, it seems like it's certainly longer lasting than any sort of cortisone shot, but I think months are very reasonable and probably years for most people.
- PAPeter Attia
Now what about non-osteoarthritis, like rheuma- re- rheumatoid arthritis and things like that?
- SMSanjay Mehta
Yes.
- PAPeter Attia
Is there any reason to believe that this could help with sort of the debilitating injuries that those patients-
- SMSanjay Mehta
So I've done three cases of rheumatoid arthritis and one guy that had a gouty arthritis as well, because again, it's a systemic disease. I'm not gonna pretend to be able to cure that with a local treatment.
- PAPeter Attia
Yep.
- SMSanjay Mehta
But to a single knuckle that's driving them nuts, it's still an, an, an inflammatory process, and yes, it works great for that. So I've done that.
- PAPeter Attia
So if a patient has rheumatoid arthritis-
- SMSanjay Mehta
Mm-hmm
- PAPeter Attia
... where they're really experiencing a lot of deformation in the hands-
- SMSanjay Mehta
Yes
- PAPeter Attia
... you, you think you can help, uh, that, that patient with, with the local part of it, which is the-
- SMSanjay Mehta
Yes. It won't reduce the deformation necessarily, 'cause a lot of that is, you know, longstanding, and if they've got-
- PAPeter Attia
But if it were treated early enough in the course of the disease.
- SMSanjay Mehta
Yes. I think it, uh, that there's no strong data to support that, but I don't see why it wouldn't work personally. And it definitely, from a purely palliative standpoint, just to reduce pain, it does work. You just have to, you have to manage their expectations.
- PAPeter Attia
What are some other examples of where this could be used in your, at least in your experience so far, in terms of reducing, uh, reliance on NSAIDs or-
- 1:55:15 – 1:58:15
Sanjay’s talent as a drummer
- PAPeter Attia
Yeah, we failed to mention at the outset that, that you're also a remarkable musician. Uh-
- SMSanjay Mehta
[laughs] I don't know about that
- PAPeter Attia
... um, how, how much do you still play the drums?
- SMSanjay Mehta
Uh, I try to play with... I got a couple of, actually a couple of doctor buddies. We get together and jam every, every week or two, and one of them is actually a guy now who's actually got his own YouTube channel and Spotify, and he was actually a professional musician before becoming a cardiologist. So we may actually start touring again. But back in the day, we had a full, uh, full doctor band, a full, uh, '70s rock cover band called Ultrasound. [laughs] So-
- PAPeter Attia
So nerdy
- SMSanjay Mehta
... those were the good old days. Yeah, we used to play, you know, Journey and Rush and, and Led Zeppelin all day long, so-
- PAPeter Attia
Yeah
- SMSanjay Mehta
... it's good stuff
- PAPeter Attia
... I was commenting recently on a podcast how much I regret not seeing Rush during their last tour.
- SMSanjay Mehta
Yeah, yeah. Again, because of a GBM, tie it back into what we're doing here.
- PAPeter Attia
Yeah.
- SMSanjay Mehta
Neil, Neil was a, was a genius.
- PAPeter Attia
Uh, so greatest drummer of all time, are you going with Neil?
- SMSanjay Mehta
No.
- PAPeter Attia
Are you going with Bonham?
- SMSanjay Mehta
Neither, because after coming-- I went to, went to college here at UT, and that opened my world, opened my entire eyes up to the world of jazz. And so the jazz drummers can all drum circles around those guys in terms of pure technical ability. But yeah, feel, rhythm, not necessarily being able to, to wow people the way the jazz guys can, but yeah, probably N- Neil and Bonham are both right up there on the rock side of things.
- PAPeter Attia
Would you put them at the top of the rock list?
- SMSanjay Mehta
Yeah. I would put Neil first. I'm just partial to Rush. And a lot of that has to do with their music, not necessarily... Now, Neil was obviously an, an innovator, but as a 16-year-old, I'm sitting there trying to imitate every single note on his, his drum solos, um, everything like that. So Neil, number one, but Bonham and, uh, I mean, there's plenty-- And that, the n- the new generation rock guys are incredible. The guys that grew up with Neil as an in- inspiration, now you've got, you know, 12-year-olds who can do this stuff in their sleep, and then all these math metal bands. You got, you know, uh, Dream Theater, and, uh, you've got, uh, uh, things like, um, Animals As Leaders. Some of these guys are doing things I- I- I pride myself as a drummer on being able to analyze the music really well. It's getting to the point where it's almost more math than music. Like, it's so intricate, the modulation of the, of the time signatures and things like that. It's, it's actually getting beyond where I, even I'm having trouble understanding it now. But these guys-
- PAPeter Attia
And can you appreciate it from an auditory perspective? Or is it-
- SMSanjay Mehta
Yeah
- PAPeter Attia
... is it l- is it, does it get too technical where it's hard to appreciate and distinguish?
- SMSanjay Mehta
It's a fine line because when you think about it, math-- music is just math with emotion added in, and it gets to a point where some of it is not appreciable anymore, at least not to me. Some of these guys love it. But that's where the jazz side comes in, where it's all about feel. But even the jazz guys will m- be extremely, uh, you know, talented in terms of their ability to, to feel the beat and have it be pleasurable to the ear, but they're doing such intricate things. And you can, when you can balance those two things out, that's, that's heaven as far as I'm concerned, when you can, when you can have the emotional side and also have it be technically challenging and not just playing a straightforward... You know, the straightforward stuff is great too, but it gets a little bit tedious sometimes.
- 1:58:15 – 2:16:32
Peter & Sanjay’s shared passion for cars & racing
- PAPeter Attia
So we met actually driving.
- SMSanjay Mehta
AMG Drift Academy, I think it was.
- PAPeter Attia
Yeah, yeah, yeah.
- SMSanjay Mehta
[laughs]
- PAPeter Attia
Which by the way, not to crap all over it, but it was like, I ended up doing it because at the last second, I got a phone call from my driving coach.
- SMSanjay Mehta
Yeah.
- PAPeter Attia
And he was like, "Hey, I'm doing this AMG driving school."
- SMSanjay Mehta
Right.
- PAPeter Attia
"And they got an extra spot in the advanced drift school. Do you want to come?"
- SMSanjay Mehta
Right.
- PAPeter Attia
But I'd already been to, you know, the Drift Academy with my friend Josh Robinson.
- SMSanjay Mehta
Yeah.
- PAPeter Attia
I was like, "Yeah, sure, I'll go."
- SMSanjay Mehta
Yeah.
- PAPeter Attia
And I was like, "Well, this is the last time I ever do one of these schools 'cause-
- SMSanjay Mehta
Josh's school is 100 times better
- PAPeter Attia
... it doesn't compare.
- SMSanjay Mehta
It's not even close.
- PAPeter Attia
Like, if, if you want to learn how to drift-
- SMSanjay Mehta
And it's, and it's cheaper [laughs]
- PAPeter Attia
... yeah, if you want to learn how to drift, you go to the Texas Drift Academy.
- SMSanjay Mehta
I want to make-- I want to go to Minnesota with him and do that ice class.
- PAPeter Attia
Are you going, uh, on this, on this run?
- SMSanjay Mehta
I don't know if I'll be able to make it or not. I'm trying to.
- PAPeter Attia
Okay. Yeah.
- SMSanjay Mehta
Yeah.
- PAPeter Attia
Um, so anyway, we, we met and, uh... But it was totally random, right? Like, it was just-
- SMSanjay Mehta
Well, I knew who you were 'cause I've been a member. I've been a follower for years. I was like, "That's Peter Attia over there." So luckily, we got paired up in the same group, and that's kind of where it started.
- PAPeter Attia
Yeah.
- SMSanjay Mehta
It was totally random. I was actually just-- It was a last-minute thing. It-- That was actually a level two, so I was like, "You hadn't done the level one."
Episode duration: 2:25:05
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Transcript of episode xtgQUiBuGVI
