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Summary:
In this episode of the “Relentless Vitality” podcast, Dr. Eric welcomes Dr. Clifford Gluck, a renowned urologist specializing in sexual health and wellness. Dr. Gluck, with over 34 years of experience, shares insights into treating erectile dysfunction, hormone therapy, and prostate health. They discuss the importance of maintaining a healthy lifestyle and managing testosterone levels for both men and women. Dr. Gluck highlights advanced treatments like platelet-rich plasma (PRP) and low-intensity shockwave therapy for erectile dysfunction and explains the benefits of high-intensity focused ultrasound (HIFU) for prostate cancer. Emphasizing personalized care, Dr. Gluck advocates for proactive and non-invasive approaches to sexual health and cancer treatment.
Dr. Eric: Hello everyone, it’s Dr. Eric, the fitness physician. I’ve got another episode of the Relentless Vitality Podcast. I’m super excited to have an awesome guest on, a fellow physician colleague of mine from World Lake Medical. We actually met at a conference down in Texas several months ago, Dr. Clifford Gluck. And he’s a very well-known urologist in the greater Boston area. He’s a board certified physician and a specialist in erectile dysfunction, advanced sexual wellness for women and men and more. He does a lot of cool cutting edge procedures and techniques, transforming the landscape of sexual health and wellness. And he’s out there in Hingham, Massachusetts. And I got him on the show. We’re gonna talk all things related to the above. So Dr. Cliff, welcome my man.
Dr. Clifford: Thank you very much. I appreciate the invitation, Dr. Eric.
Dr. Eric: Absolutely. Yeah, for me, I just do the Dr. Eric because nobody gets my last name right. So I just left it out.
Dr. Clifford: Well, that makes two of us.
Dr. Eric: Right. So Cliff, man, tell me, I guess, just for our listeners, you don’t have to do a deep dive, but if you want to say anything about your background, and then we’ll just talk about maybe a little bit about your practice, what you do, and then I’d love to ask you a bunch of questions about erectile dysfunction, about hormone therapy, and then definitely want to talk about prostate stuff too, because I’m sure you have a lot, and I know I have a lot of clients that are always asking about prostate issues and erectile function issues. So I’d love to dig into that.
Dr. Clifford: Sure, I’m a urologist. I did my undergrad at Stanford, I did medical school at UCLA, and then I did my residency at Harvard at the Harvard program in urology. And I’ve been in practice now, this will be 34 years coming up. So it’s been a while. Nice. I trained as a urologist to do big cancer surgeries, et cetera. And eventually, came to the realization because urology is an interesting specialty. We do a lot of surgery, but we also do a lot of medicine. And I came to the realization that it would be better to try to keep people well than having them get sick and then having to take care of them as sick patients. That’s the hardest time to take care of them. So why not try to help people to stay better? And that’s what got me interested in world-like urology.
Dr. Eric: Awesome.
Dr. Clifford: Our practice, as you mentioned, we have a practice specializing in sexual wellness. We do that for both men and women. About half my patients are women. But I also have a special interest in a non-surgical, non-radiation approach to curing prostate cancer. And that’s called HIFU. Maybe we can talk a little about that later on.
Dr. Eric: Definitely, I would love to get into that for sure.
Dr. Clifford: That’s excellent.
Dr. Eric: Well, that’s cool because I know I definitely want, you know, a lot of my lady listeners to stay tuned too, because you treat a lot of women. So that’s good to know. Well, let’s talk.
Dr. Clifford: I was gonna say that, with that, that, you know, there’s a lot of similarity between treating sexual dysfunction in men and women because women have, although different anatomy, a lot of the same functional parts. And it all applies to both male and female physiology.
Dr. Eric: Right, yeah, absolutely. You’re right, you’re absolutely right. I think one of the things, and maybe you could talk about this too, I love to, especially the discussion about libido or sex drive versus erectile function in men or orgasms in men and women, I guess, but because I don’t know how for you, but so many guys I read online or on forums or even some of my clients are like, whenever you think, oh, my, my drive is down. It’s gotta be my testosterone. And it’s not always, it’s not just about the testosterone. It has to do with dopamine and other neurotransmitters, psychological factors, your overall health, stress. I mean, there’s so many factors that come into play, but what’s your take on, I guess, on drive, and then we’ll get into the, the start, you know, actual function.
Dr. Clifford: I think most of the people that we see that have low libido have low testosterone. And as we know, low testosterone means different things to different people, where some people might function very well at the lower end of the scale. Other people really need to be optimized in order to be functioning in a normal way. And it’s receptor activity. I think we don’t have a complete understanding about everything that’s going on, but we’re learning as time goes on. And we’re learning that adding testosterone to men is simple because men make a lot of testosterone in general. And if they’re not making a lot of testosterone, when we add it back, it can certainly improve their libido as well as all the other benefits that testosterone provides, mood, energy. It’s the best antidepressant that we know. It helps prevent osteoporosis and dementia and heart disease, all these good things. In women though, it’s not so clear cut because although women do produce testosterone, if we give them more testosterone, we’re liable to cause them to be masculinized. And that’s only if we’re giving them ridiculously high doses. So physiologic doses of testosterone for women can improve their libido greatly, improve their mood, their energy, give them better strength. And it really has a lot to do with their sexual health. There are drugs that are available. There’s a commercial drug that’s come out. It’s basically a peptide that we were, is a PT-141, bremelanotide.
Dr. Eric: Yep, I’ve used that.
Dr. Clifford: And bremelanotide can be very helpful for increasing libido, but it also comes with a host of side effects, not the least of which is like a headache, just feeling upset stomach or miserable. And it’s also super expensive. So although you can prescribe that, there’s a much cheaper and simpler way to go and it’s just called testosterone.
Dr. Eric: Right.
Dr. Clifford: But improving libido and drive is one thing. The things that you mentioned about just general wellbeing, getting enough sleep, eating the right foods, eating a healthy diet, and exercising. And also sometimes some psychological counseling. Those are things that can also help improve libido and sex drive.
Dr. Eric: Have you ever seen men with, for lack of another phrase, too much testosterone, the guys that are really on higher doses, they start having a decrease in function, and then you take them off it for a little bit or you lower the dose, then it kind of gets better. Some guys think it’s from the testosterone, some guys think it’s from the estrogen, which…I think estrogen is fine.
Dr. Clifford: It should be.
Dr. Eric: Most guys are still thinking it’s better to be low. You and I both know it’s better to be a little bit on the higher side, but I don’t know what the response to testosterone, if it’s a receptor issue or what, but if you see, I know I’ve heard a lot of people, a lot of our colleagues have talked about this, but have you seen this much yourself or what’s your take on that?
Dr. Clifford: Um, what I generally see is people find a level of testosterone that works well for them. Yeah. And then they want to be on that constantly. And for some people they’re injecting twice a week, some testosterone or other people, they’re just applying a gel or a cream once a day. But then there are other people who seem to go through periods where they need testosterone and then they can come off it for a while. And when they come off their testosterone, they may start to make their own testosterone at a rate that’s sufficient for them. So I’ve seen all of those different permutations. I think trying to reset somebody by taking them off their testosterone is not a bad idea sometimes. You have to let somebody bottom out for a moment and then give them back their testosterone. And maybe that has to do with resetting some receptor activity. But overall, I’d say most men without testosterone are very unhappy men. So give them their testosterone. And that applies to women as well. Women patients and take away their testosterone, they’re gonna be quite unhappy if they’ve gotten used to how good it makes them feel.
Dr. Eric: Oh, for sure.
Dr. Clifford: My ladies, they definitely liked it to have the testosterone makes them feel big uptake and drive energy, sex drive, and they very much like it, yes. And the interesting thing about testosterone is also how it interacts with the erectile physiology. And of course that applies to both men and women. So testosterone is really important for the cellular function of the smooth muscle cells lining the corpus cavernosa in men and women. So if you don’t have enough testosterone, you’re not gonna have optimum function of those smooth muscle cells. They’re not going to relax. The endothelial cells that are there are not going to allow the smooth muscle cells to relax, and you won’t be able to produce a good solid erection.
Dr. Eric: Yeah. Well, you gave an excellent talk during the last conference on erectile function. Maybe you could speak to that a little bit? Obviously, I don’t want you to repeat the whole darn lecture, but maybe some of the high points in terms of like treatment options. And you had a good case study where you got into a little bit about supplements and lifestyle diet, things like that. But yeah, nitric oxide, we could talk about all those things. But yeah, if you wanna do a little mini talk on ED or anything you want to say about it or whatever, and we’ll go from there.
Dr. Clifford: Sure. When I see a man with erectile dysfunction, the first thing I’d like to know is, does he have risk factors here? Does he have diabetes? Does he have hypertension? Is he a smoker? Does he use alcohol or any other recreational drugs? And by trying to adjust the lifestyle component, you can make big improvements because every time someone takes a drag on a cigarette, and nicotine is causing constriction of the arteries, but it’s also causing constriction of all the smooth muscle cells in the penis, they aren’t able to get as good an erection. And over time it leads to severe cellular damage. Our biggest enemy in erectile function is oxidative stress. And if we can remove things that cause that oxidative stress and keep people on things like antioxidants that might help to prevent some of that, then we can keep the cells healthier in time. When I see somebody with erectile dysfunction, I like to check a serum testosterone. If it’s low, I’m gonna do testosterone replacement therapy. And then I like to optimize their phosphodiesterase V activity. So there is an enzyme located in our bodies, pretty much everywhere. but it specifically pertains to the penis that degrades cyclic GMP, which is causing a reaction to let smooth muscle cells relax, open up and allow blood to flow into the penis. And the phosphodiesterase will degrade that cyclic GMP to GTP. And if we inhibit the activity of that enzyme, we can create more GMP, we can create more smooth muscle relaxation. That is the fundamental way Viagra works, as well as Cialis and Ivanafil, all the different PDE5 inhibitors work this way. And if we can balance the phosphodiesterase V activity so that the smooth muscle cells have enough nitric oxide in the mix, then we can actually improve the overall function and people can auto rehabilitate. So when I see a man with erectile dysfunction, the first thing I’m gonna do is check his testosterone and then add some Tadalafil, five milligrams daily. Tadalafil is a generic for Cialis and that will help to allow the penis to open up and allow more blood flow on a regular basis. Now, blood is flowing in. on a regular basis every night as a man goes through REM sleep cycle. When we dream, we have an erection. And if we wake up with an erection, it means we’re waking up from a dream. But we don’t wake up with an erection. We probably weren’t dreaming. We were in a different stage of sleep. But that is one of the things that we do in history, taking for patients with erectile dysfunction, we ask them about their morning erections. Do you have morning erections? Do you have more? Someone who has morning erections has a pretty good function of the penis. It just might not be working when they want it to work. So, Tadalafil helps that too, because if you take Tadalafil every day, then when you wanna have intercourse, the penis should be cooperative. The thing I like to add to Tadalafil is L-Arginine. And L-Arginine is an amino acid, one of the building blocks of proteins, building blocks of DNA. And L-arginine is cleaved into L-citrulline and nitric oxide at the nerve endings by an enzyme called nitric oxide synthase. So the nerves that innervate the corpus cavernosum, the erectile body of the penis, release nitric oxide synthase, which transforms that L-arginine into nitric oxide. And nitric oxide kicks off the cascade. of creating cyclic GMP. And that creates sequestration of calcium which relaxes smooth muscle cells. So that’s basically the physiology in short of how we let blood flow into the penis. To increase your nitric oxide, you can increase L-arginine and it’s a nice, easy to get over the counter, can come in pills or powder. If we give men with erectile dysfunction, both the daily to dollophyll and the L-arginine, then they’re more likely to have spontaneous erections, nocturnal erections, and also be able to achieve and maintain their own erection. So I say that’s step one when I see a man with erectile dysfunction.
Dr. Eric: You ever give just citrulline versus arginine? I know a lot of people, like I’ve done that myself, because some people just don’t convert well and they have a better response. Have you tried that as well or are you using both?
Dr. Clifford: Definitely can use both. The advantage of citrulline is that you can give it once a day and it’ll convert back to L-arginine. Also citrulline might be easier for people to take. Sometimes it’s a powder. They throw it into their smoothie on a daily basis. The L-arginine can come in big bulky pills and you have to take it three times a day.
Dr. Eric: Right, right. But the L-arginine…
Dr. Clifford: The L-Arginine has a more direct way to get the nitric oxide. The L-Citrulline has to be processed by the body back to L-Arginine and then to nitric oxide. But either one can work. And I think it’s really just patient preference. Thank you, Ryan. I’ve tried both. I know I’ve not had a problem with either. I know some people have had issues with the arginine but most people do just fine. I’ve tried both. I like the citrulline because I use it as, I think a lot of people use it like a pre-workout or I’ll do it at nighttime. Sometimes I use some of the nitric oxide supplements. There’s a few decent companies out there. There’s a lot of junk ones, but it can all be helpful. Or just load up on your greens and your beets and things and that kind of stuff too.
Dr. Eric: So, okay, excellent, excellent. I’d love for you to talk about medications too, because that always comes up. I know you mentioned a few during your talk about, because I see a lot, so many patients have.
Dr. Clifford: Ranzo-B medications of course, that can affect erectile function, sexual function, men and women, certainly of course, things like blood pressure medicine, STATs, anti-depressants, you know, opiates. I mean, there’s so many of course, but blood pressure is a big one. Maybe you could talk a little to that effect too, like which ones you prefer, which ones have a good effect versus a bad effect and things like that. Right. Blood pressure medication is probably the number one medication that will affect erectile function. And… beta blockers are notoriously bad for good erections. So if a patient is on a beta blocker or even a diuretic or a calcium channel blocker, if they can be switched over to an angiotensin receptor blocker, then that can actually help erectile function. There was a really interesting study done where they injected angiotensin receptor blockers directly into the penis of rats and they produce erections.
Dr. Eric: Wow. And yeah, it’s dramatic. So if a man can change over to that kind of, there are many different angiotensin receptor blockers now, but just that class of drugs is a better way to treat hypertension if you’re trying to limit the side effect of erectile dysfunction.
Dr. Clifford: Right. And I know that In primary care, there’s been this sort of stepwise approach. You start off with a diuretic, maybe you move to a calcium channel blocker, maybe you move to a beta blocker or vice versa. And I think people have limited their use of angiotensin receptor blocker. I’m not sure why, but I’ve suggested that over and over again to the internists that they try to make that switch.
Dr. Eric: Yeah, yeah, I agree.
Dr. Clifford: The other things that you mentioned, are also really important. Somebody’s on anti-psychotic drugs, if they’re on antidepressives, if they’re on any kind of narcotics, those are things that can also inhibit good sexual function.
Dr. Eric: Gotcha. And then of course you do a lot of treatments in your office, things that we call shockwave therapy, platelet-rich plasma, things like that. Feel free to talk about that if you want to or plug what you have there. I used to do that when I had my office as well. I know it works very, very well, but maybe you could talk about, and for women too, they’ve got the Thermiva and some other new procedures now, I’m sure.
Dr. Clifford: Well, thanks for bringing that up. When medication stops working, or if somebody wants to have just a stronger erection, there’s only so much that you can do by switching blood pressure medication and by starting daily to dollophyll and L-arginine. When those things don’t work, it’s really about cellular function. The cells themselves are not working well. And a way to reboot those cells could be through stem cells, could be through using exosomes, those little cellular parts that we inject. The FDA frowns on those two things. So we have PRP, platelet-rich plasma, and locked up in our platelets are all these amazing growth factors, the things that actually allow us to heal wounds. If we cut ourself, platelets go to work and fix it. And platelets are something that I think we’re still learning a lot about. We’ve identified at least eight growth factors that come from platelets. And PRP is platelet-rich plasma. It’s just concentrating platelets in a pure plasma away from white cells, away from red cells and injecting them wherever in the body needs healing. If you inject them into the corpus cavernosum, the erectile body, then the erectile body will actually start to heal itself. The cellular function will, And we see that in about 80% of men that we inject PRP into. So what men report after they have a PRP injection might be an increase in their ability to get an erection and ability to maintain an erection and also many times an increase in girth and also an increase in sensitivity. And it’s interesting in some of the science, the basic science stuff.
PRP, if you have a rat and you cut the nerve leading to the corpus cavernosa, it’s the nerve of erection, and then you inject PRP into the corpus cavernosa, the rat who’s not getting erections because the nerve was cut after the PRP, they will start getting erections again, because the nerve actually grows back. Amazing. And on a microscopic level, you can see that the nerve endings that are inside the corpus cavernosum, those nerve endings which are secreting nitric oxide synthase and creating the pathway to have an erection, they start to branch out and grow more. There’s actually an induction of improvement in cellular architecture that occurs with the injection of PRP. Amazing. And to supplement that or to compliment that, we can use low intensity shockwave therapy. The low intensity shock waves are not shocks at all really. It’s a pulse. It’s an acoustic pulse that’s created in many different ways. And by directing this at the architecture of the corpus caranosum, we can attract stem cells into the area. You can radio label stem cells and actually see them migrate into the penis actively during low intensity shock wave therapy.
So we don’t have to inject stem cells. We can use the patient’s own stem cells to help create vascularity and improve the cellular architecture as well. And I think that’s one of the reasons that shockwave therapy also can work on its own, but I think it works better and it’s complimentary when you add PRP and shockwave together.
Dr. Eric : Gotcha, gotcha. Yeah, that’s amazing stuff. I mean, you’ve probably had new iterations. I remember when the original one was out, the Gainswave, and I used to-
Dr. Clifford: Uh-huh.
Dr. Eric: I know there are all kinds of forms now. So, and you’re getting, sounds like you’re getting great responses with both those treatments.
Dr. Clifford: Yes, yeah. The literature says that there’s about an 80% response rate. And that’s what I quote to the patients. And that’s about what I see in the practice. I never promised anybody that they’re going to be a hundred percent, that they’re going to definitely be the one to have the response. But I tell them it’s about 80%. And we won’t know until we try it. And I try to assess whether or not they’re a good candidate. Now you can really use it in almost anybody. One of my good friends and colleagues, Abe Morgenthaler and I, were talking and Abe was telling me about a man he had removed a penile prosthesis from. And of course, the penile prosthesis just replaces the entire blood flow inside the penis. It’s an artificial balloon placed inside your penis. And when you remove it, you’re just left with scar tissue. Right. So the penis would be, you know, pretty non-functional after moving that. And Abe told me, said, I didn’t know what else to do. So I injected him with PRP. He goes, and you know, he got back some function. So this is one man’s experience. It’s very anecdotal, but it’s a dramatic story about restoring function where there should be absolutely none. It’s kind of like the rat who had his nerve cut and then he got his erection back.
Dr. Eric: That’s amazing. That’s absolutely if you think about it, the physiology of it is like, Whoa, right.
Dr. Clifford: Impressive.
Dr. Eric:Very impressive. That’s very cool. Well, let’s just be aware of your time. I just want to flip gears before we forget. I definitely want to talk about prostate for sure. Maybe we could touch base, talk a little bit about prostate. You know, what do you do with an elevated PSA before, during and after treatment with hormones?
Dr. Clifford: I love to talk to you about, as I mentioned, diagnostic tools, like your workup, your treatment, biopsies, HIFU, everything that you were talking about. We could probably talk for hours just about that, but I’ll let you go. Sure. Most of my patients will be referred to me either with prostate cancer or just with an elevated PSA. When I’m treating somebody with testosterone replacement therapy, I’m very, very mindful about what the PSA number means. Now PSA in and of itself really doesn’t mean very much. It’s really about a trend in PSA and I think every man has his own PSA number. So once you establish a baseline you want to follow from year to year and make sure that that PSA doesn’t rise more than 0.75 in a year. If it does then that’s a signal that that person should have further workup and that workup should include an MRI to look at the prostate to look for any abnormal areas. MRI will pick up 80% of prostate cancers. That means it misses 20%. And then after an MRI, even if it’s negative, to go to a prostate biopsy, it’s usually done with ultrasound, either transrectally or transparently. And the prostate biopsy takes little tissue samples in order to see if there’s cancer or not.
Now, if somebody has prostate cancer and they’re on testosterone, the question is always, do we have to remove the testosterone? Just today, I had a patient call me up. He’s been on testosterone replacement therapy for three years. He had something called prostate intra epithelial neoplasia. So this patient had a biopsy. He had PIN, which is not cancer. It’s some abnormal cells in the duct. It’s almost like a carcinoma in situ.
Sort of situation and there’s really no treatment needed for that. But his internist and his cardiologist told him that you have cancer and you have to get off your testosterone. And so the poor patient was frantic and I scraped him down off the roof sort of. Calm things down. I told him you do not have cancer and what’s more important is that you have low testosterone. And we know from the literature that if we supplement you with testosterone, then you have less chance of developing prostate cancer. And it’s interesting, when I first diagnosed him with PIN, this carcinoma in situ, that’s when we started his testosterone replacement therapy. And his PSA came down over time. Wow, interesting. And I actually had a follow-up with him. We had to do a rebiopsy on him a few years later and we found no carcinoma in situ at all. It was all benign prostatic hyperplasia.
Dr. Eric: Wow.
Dr. Clifford: So he’s going to continue his testosterone replacement therapy because he feels great with it. And it really has nothing to do with prostate cancer. We do have special situations where we remove testosterone from a man when they have advanced prostate cancer, but in day-to-day activity, even if a man’s been diagnosed with prostate cancer, I keep them on their testosterone replacement therapy. And if a man’s been treated for prostate cancer, if they’ve had radiation, radical prostatectomy or HIFU, I would keep them on their hormonal therapy unless they have an advancing cancer and we have to use the gross instrument, the blunt instrument of androgen deprivation therapy.
Dr. Eric: Right, right, for sure. Yeah. So you mentioned HIFU. Men have options for treatment of prostate cancer. One is radiation, one is surgery, and both of those carry a lot of consequences in terms of complications. But something called high-intensity focused ultrasound has been around since 1994.
Dr. Clifford: It first was used in Europe, in Germany and in France, but it was actually invented in the US. And the United States has been late to the ball where they’ve been using it all over the world, HIFU. The United States hasn’t approved HIFU until 2015, and it’s still very limited in its use across the country. But it’s an outpatient procedure using ultrasound waves, which are focused like a magnifying glass focuses the rays of the sun and it burns the tissue, but it burns it very precisely with laser-like accuracy and it doesn’t injure any of the tissues around. So you can’t do that with surgery, you can’t do that with radiation, but with HIFU, you can spare the nerves of erection and spare the sphincter muscles in the bladder neck. So the risk of complications is very, very little with HIFU. It’s a two hour outpatient procedure and a man can get back to his regular activities the next day. So there’s really no downtime after a HIFU. And the next question I always hear is, why wouldn’t anybody do that? Why doesn’t everybody do that? And part of the problem lies in coverage.
Dr. Eric: Yeah.
Dr. Clifford: We’ve been very, very provincial here in the United States. Right. But I have a long experience with HIFU. And with hundreds of men, the overwhelming vote is that they would all do it again. They’re very happy. But we do know that there are limitations. If you take a man’s prostate out, surgically, if you do a radical prostatectomy, there’s still a 25% chance that that man will be dealing with prostate cancer again in his lifetime. And the same is true with high food. It’s a 25% chance that that prostate cancer can return. So with radiation that goes up to about 66%. That could change, it will return. Radiation has a much higher failure rate than either surgery or HIFU. The other thing that’s interesting about HIFU is that you don’t have to treat the whole prostate and you can further limit any possible complications by treating the side of the prostate that contains the cancer. So if you have all cancer on one side of the prostate or the other, then you can leave the healthy side alone and continue to follow it.
Dr. Eric: That’s excellent. Yeah, I didn’t know that part about the HIFU. So that’s pretty interesting.
Dr. Clifford: That’s right.
Dr. Eric: Sounds very good… Interesting. It’s just unfortunate. Do you think there’ll be more, you think that’ll get more acceptance among, in the urology world, more centers offering it or not sure?
Dr. Clifford: Well, the AUA keeps saying, we need more data. We need more data, but we have hundreds of studies on HIFU. And they’re waiting for some kind of double-blind randomized controlled study, but nobody will do that. And it’s going to take 20, 30 years to get the information that they want out here. So I think the real problem is that folks are very invested in radiation centers and hospitals with surgical robots and operating rooms they want to fill up. And policy just follows the money, I think.
Dr. Eric: Politics and economics like right.
Dr. Clifford: That’s right.
Dr. Eric: So what do you do with someone?
Dr. Clifford: I mean, I guess if we have someone who wants to send someone your way for urology evaluation, and my gentleman who has an elevated PSA where he’s on testosterone therapy gets a bump. Like you said, I tell them the same thing you said is that it’s about the trend. Or obviously, you do retest if it’s really abnormal or sometimes I’ll do a percent free PSA to get a little bit more data, but if it’s still high or still off, then of course the next step would be referring for an MRI. That’s usually what I recommend.
Dr. Eric: What’s your take on next steps?
Dr. Clifford: Yeah, if somebody’s got an elevated PSA, elevated PSA velocity, meaning it’s going up more than 0.75 in a year, I would get a 4K score. I think it’s the most helpful blood test right now. 4K score can indicate whether or not there’s a chance of significant prostate cancer. It gives you more data to make a decision from. Getting an MRI is excellent. Referring that patient to a urologist. I see lots of folks that are referred in for exactly those kinds of things. And generally we look at all the data that’s presented there and many of them go under biopsy. And then if we find prostate cancer, present the options and decide on a treatment.
Dr. Eric: Right, right. Just for the listeners, do you mind explaining the 4K score?
Dr. Clifford: The 4K score, it stands for four-calocrine. So PSA is a member of a group of enzymes called the calocrine. PSA is just produced by the prostate. It helps to dissolve the clot of semen after it’s ejaculated so that the sperm can swim free up into the uterus and fertilize an egg. That’s what PSA is, it’s an enzyme. And the 4K score looks at the way PSA associates with certain proteins in the bloodstream and the percent free PSA, which you mentioned, which in and of itself can be a parameter for suspicion of prostate cancer. If the percent free PSA is below 20%, then that’s suspicious. So most PSA should be unbound or a higher percent, at least 20% or more unbound. The 4K score is an algorithm. It looks at some information that’s contained from both the blood specimen and also the history of the patient. Has the patient had a previous biopsy? Does the patient have a nodule? Does the patient have a family history? And they put those things together and they come up with a percent of suspicion that the patient has significant prostate cancer. And that’s an interesting term in and of itself.
Dr. Eric: What is a significant prostate cancer? Yeah, what does that mean?
Dr. Clifford: So we know prostate cancer is graded by Gleason score. And the pathologists decided that we were only going to use Gleason 3, 4, and 5 out of a scale of 1 to 5. So every cancer is either a 3, a 4, or a 5. And we take the two most common patterns, add them together, and give a Gleason sum. So a significant prostate cancer would be something above a Gleason 3. So that might mean a Gleason 3 plus 4, but some of the Gleason 3 plus 4s are okay if it’s only in one biopsy specimen. So a lot of this, is it significant or not significant, according to the National Cancer Institute guidelines, doesn’t make a lot of sense to me because it’s still cancer. And we know it happens to men who we don’t treat. If we’re just observing them, it’s called active surveillance. We have a couple of large studies from Scandinavia, Denmark and Sweden, where they followed men for 30 years on active surveillance with these Gleason 3 plus 3 cancers. And what happened is two thirds of the men ended up needing treatment within five years. A quarter of those men who got treatment already had metastatic disease at the time of their treatment. So it was a roll of the dice to do active surveillance and they missed their chance for a cure. And I always tell that story to patients when we talk about active surveillance to let them know that, you know, sir, you have a Gleason 3 plus 3 cancer and one or two biopsies. I said you’re a very good candidate according to the NCCN guidelines for active surveillance. However, I want to tell you what active surveillance means and about what the science behind that says. So that people, if you have a 50 something year old guy, he’s likely in his lifetime to go on to develop a much more aggressive prostate cancer and maybe miss the boat for being able to have a cure. And dying of prostate cancer is a lousy way to die. So if you develop, if you find an early prostate cancer in a man to give him the option of a treatment, that actually will cure the prostate cancer without causing a lot of side effects. And that’s HIFU. And when all the literature on active surveillance was written and continues to be written, nobody mentions HIFU. They’re just talking about surgery and radiation. And they’re talking about the treatment of prostate cancer is worse than the disease. So let’s not treat it.
In fact, let’s not even find it. Let’s stop doing PSAs. Let’s stop doing rectal exams and let’s see what happens. And that’s exactly what has happened over the last 10 years. When the US Preventative Task Force came out with a D recommendation or a D minus for PSA, people stopped drawing PSAs, they stopped doing rectal exams. And now 10 years later, we see what the effect of that is. There’s been a giant rise in the number of men presenting with advanced prostate cancer, not curable anymore.
Dr. Eric: Right. We get a lot, lots unpacked there for sure. People are reading.Yeah. And so, well, Cliff, I’m going to start wrapping it up because of your time. I appreciate it. What’s, are there any, I always ask this question on my guests, is there any non-medical books that you’re reading right now or that you have liked to read? Do you do any non-medical reading?
Dr. Clifford: I do. I like to read a lot of history. I like to read a lot of American history and I like to read some biographies. So those are the kinds of things. Right now I’m reading a biography about Hans Rose. He was a German submarine captain in World War I and he made an incredible journey underwater across the Atlantic.
Dr. Eric: Wow, that’s great. I’ve heard that story. That’s pretty interesting.
Dr. Clifford: Yeah, but he was kind of a gentleman because before he would sink the ship, he would warn them and he would give them all the chance to get off the ship and get into the lifeboats. And then he would torpedo the ship. The gentleman torpedoer.
Dr. Eric: A torpedoer. Yeah, yeah. So he’s an interesting character. What was his name again?
Dr. Clifford: Hans Rose.
Dr. Eric: Hans Rose, interesting story. I just learned, so I like history as well. I’ve not heard that one, but that’s pretty interesting. I like that. Well, good. Well, thank you. Cliff, feel free to plug your clinic, your website, if you have your own website, any social media, anything you want to, feel free to go ahead for our listeners.
Dr. Clifford: Oh, thank you, Eric. If anybody’s interested in learning more about me and what I do with my practice, I’m at CliffordGluckMD.com. It’s CLIFFORDGLUCKMD.com. Or you can just Google Dr. Gluck’s Wellness Center. And that’s my practice’s website there. And you can reach me through that. You can reach me through our office phone at 781-337-6737. I thank you very much for the opportunity to be a guest on your program here.
Dr. Eric: Absolutely. I had a great time.
Dr. Clifford: Absolutely.
Dr. Eric: No, I appreciate you jumping on here with me. We’ll do a round two in the near future. So everyone, Dr. Clifford Gluck, feel free to check him out online. And Clifford, thank you so much for being on. You threw out a ton of useful information. I think my listeners will get a lot of value out of. So I thank you for that.
Dr. Clifford:Thank you, Eric. Appreciate it.Dr. Eric: All right, you’re welcome. Bye-bye.
