Transcript generated from the episode’s automatic captions. Speaker names are not identified, and automatic captioning may misspell names and terminology. Please refer to the video for the authoritative version.

Well, I want to thank you for uh joining us on today’s episode of the Cancer Project podcast. We’re really privileged to have Dr. Aay Botnagger on with us. Um he is a radiation oncologist but I want to make sure that I say this correctly and actually an interventional oncologist and he’s going to explain why he prefers interventional oncologists over radiation oncologists. Um and he is also a renowned expert on breakchie therapy for prostate cancer. So we’re going to talk about that and just what it’s like to be practicing as a doctor in 2026 and navigating the world of YouTube and Instagram and LinkedIn and Tik Tok and how to meet patients where they’re at today as a doctor.

So, Dr. Botniker, thank you for joining us. Thank you for having me. I feel really privileged uh this I got to watch some of your videos last last few weeks and uh really impressive show. I must thank you on your your really great podcast. Well, um so just maybe a brief introduction for you. I know you have a little bit of a unique story. You were born in England uh and then moved over here, ultimately went to medical school at the University of Pittsburgh. Um, so just talk to us a little bit about your upbringing and how you ended up becoming a doctor. Yeah, exactly.

So I grew up in London, England, but we immigrated here to the states about age four or five and I grew up mainly in the Philadelphia area most of my life. Uh, and I actually went to University of Pennsylvania to do my undergraduate degree in bioengineering. My dad was an engineer and you know he said that you know if you studying engineering undergraduate will will help you gain the fundamentals and principles uh for anything you do in life whether it’s you know business law or even medicine you know but gaining those uh fundamental principles of engineering uh will really help you for the rest of your life.

So, I studied bioengineering. Um, and uh I really did enjoy it, but it was hard. It wasn’t easy. Um, and that’s actually one of the difficult things about going to medical school, you know, when you want to sort of do an easier subject. Engineering is not one of them. But, uh, Right. Right. But but but it was but you know it really allowed me to gain a greater understanding of science, physics and engineering which led to my interest in radiation oncology because uh I even at that time the bioengineering department had a pretty good relationship with the radiation oncology department there at the University of Pennsylvania.

Um so I already even knew about it. I mean most med students let alone college students even know about radiation oncology. So it gave me a couple steps ahead. But then when I was at uh University of Pittsburgh Medical School as a third year medical student, I got to see a prostate seed implant. I went to the O with Dr. Russell Fure, uh God rest his soul. Um and I fell in love right away. I was like, “Wow, this is exactly what I got to do. ” And he was like, “All right, well, if you want to do this, this is what you need to do.

” Boom. Boom. This is not easy. You got to do research. You got to get, you know, you got to get this. You got this is all the things you want to do. Um but you still have to be a general rationalologist. I mean, this is just a small part, but I really enjoyed uh the prostate break therapy. I got to do a lot of that in my training in residency. Um, but then after Pittsburgh, I I really enjoy warmer. I wanted a new life uh lifestyle and uh wanted to go out west. I I most of my life was in the east. I I really uh didn’t care for the weather out east and I enjoyed uh you know the the the whole weather and atmosphere and the culture out there at that time in two early 2000s.

It was still a very vastly growing city in Phoenix. Um and uh I also took up a hobby called golf and that’s a great place to play golf. It’s a good spot. Yeah, that’s a good spot. And so uh in 2007 after finished my training I I started uh practicing in a city called Kasa Grande in a general uh cancer center, radiation oncology, medical oncology center and the urologist there actually I owe him a lot of credit. He um had done training where he was also very familiar with prostate breakchie therapy and really encouraged me to do uh prostate breakchie therapy and you have to remember this is the time when IMRT started to explode.

Okay. Right. And so uh this is when and really the death of of breakchie therapy as at that time. But he was very adamant that we continue to offer this for our treat for our patients. You know given that we were in you know central Arizona in between Phoenix and Tucson and people coming from all sorts of different distances that this was a really important treatment to be able to offer to our community. Um and so yeah, we we always uh had a program to offer this um treatment and you know that led to me starting my own practice solely focusing on TW in 2021 uh 2022 about this and if it wasn’t for him if it wasn’t for me to be able to do that and keep these skills up uh in prostate breaky therapy I would not be where I am today.

So I really need to thank him Dr. Beerren Patel actually. And so tell us about the practice today, Prostate Cancer Institute of America. Just describe what that is and and what your guys focus is. Yes. So this is a practice uh solely focused or at this point on lowdos rate prostate breaky therapy uh where we provide services in various communities throughout the country. I am based in Phoenix, Arizona, but we do have practices in various states. And so, you know, everyone talks about uh prostate breaky therapy and like the parents are like, “Wait, how how are you doing this? There’s there’s really no money in this.

How can you make money in in prostate breaky therapy? ” And that’s not exactly incorrect about that. But, you know, in business, it doesn’t take an MBA to figure out it’s not about how much money you make, it’s actually about how much money you keep, right? Uh and so you I was able to really understand and leverage the efficiencies of LDR breaky therapy that no other radiation modality has. I mean it is purely a very efficient and cost-effective way. So I don’t have a linear accelerator, right? I don’t have expensive staff. I don’t need a radiation therapist, a medical doymmetrist. I do have a a part-time physicist who helps me on the on the side.

But really it’s this is a very lean mean operating machine. I don’t even have an office actually. I uh subleasase for my my my colleagues um and do mainly consults from right here uh my my home do virtual consults and so um you know that’s one of the benefits of co uh is is that patients are very comfortable uh with uh seeing patients virtually. I thought that would be an issue uh with patients not feeling comfortable with me doing surgery uh and not seeing me in person, but they’re actually pretty used to that now with all sorts of distance. So most of my patients at this point I do not see in person until I see them at the time of their procedure.

Even in Phoenix, even though I have an office in Phoenix, I actually patients around this area still would rather see me virtually. That’s interesting. Okay. And so one of the things that you’ve focused on is I think on your website you describe it as inoff breakchie therapy and this would be as opposed to doing the procedure at a hospital or a surgery center. So just talk about why you chose to do that and why why or how you still make it safe and effective and efficient for patients coming into the office versus going to a hospital. Yeah. So let’s talk about inoffice breaky therapy. So first of all, breakchie therapy.

This is lowd dose rate breakchie therapy where we’re using these radioactive seeds implanted in the prostate that’s slowly giving off radiation. So these seeds are permanently implanted in the prostate slowly giving off radiation and directly at the source. Okay? And so that u requires uh basic a qualified radiation oncologist knowing the skill set of how to place these seeds. The main tool that we use is an ultrasound. So we have a rectal ultrasound that guides us and we place needles through the paranneeium and place these seeds into the prostate. And so that can be done in the operating room. It’s typically done in the operating room.

But Dr. Ken Walner, one of the godfathers, the OG of breakchie therapy that was in Seattle uh VA um uh developed a technique where we could use only local anesthesia at his facility in the VA that he it was impossible to get O time. So he had to figure out how he could treat these patients uh without going to the O. So he developed uh a technique what we call inoffice breaky therapy using local anesthesia alone um where uh we’re able to adequately take care of these patients in the office setting by using a local lidocaine block. It’s a pretty intense local lidocaine lidocaine block but um yes it can be done and it does require a very good skill set.

So I mean doing breaky therapy in the O setting when they’re asleep requires one level of skill but then to be able to do this in the office is a completely another set of skill set and you really need to be experienced and that’s really the other issue now with prostate breakchie therapy is that there’s very few people trained in it because it’s not easy as a radiation oncologist to be overseeing a big external beam radiation center and then having to do breakchie therapy on the side. I mean when I was doing this uh on the side I we once a month uh you know my skill set was okay decent you know but now doing breaky therapy every day since I no longer have the responsibilities of overseeing an external beam machine it’s infinitely that much better and so two years after starting this practice from 2022 I started this practice in 2024 I started doing in office breakchie therapy Dr.

Dr. Kander came and trained me and uh ever since I’ve been doing it uh um really extensively patients especially the older patients that don’t want to go under general anesthesia and yet don’t want to do hormones or don’t want to do external beam it’s a great option uh and so I commonly will ask patients of how they tolerated the biopsy and if they tolerated the biopsy pretty well that this is very similar if you do the right block and the right technique it’s really not much different than the prostate biopsy. Okay. So yeah, but it it’s another level of skill set that barely even I mean most radial colleges can’t even do breaky therapy in the O setting, right?

So now to be able to do it in the office setting is almost unfathomable. I mean, right, it’s one of those things that if you’re doing maybe one every two weeks, you probably shouldn’t do that in the office. I mean, this is something one every two weeks. Most range oncologists are doing regular one every two months, you know. Yeah. Right. I mean and so you know and that that’s really the big issue uh with this and it’s we haven’t treated it like a surgical subsp specialty and it it really is uh and so because this is a very operator dependent procedure and I think a lot of the outcomes is based on who the operator was and so many people’s experiences including doctors urologists patients are ba their perceptions are based on that operator and so Yes, there can be bad outcomes when the operator is not as experienced or trained in doing this procedure.

Um, and so that’s one of the things and I’ve been able to um really uh break down is that perception that breaky therapy is an old antiquated inferior technique where actually in for the right patient in the right hands in my opinion it’s actually the best treatment out there. So talk a little bit about the right patient. So you mentioned with the right provider so you obviously have a lot of skill. Who are the right patients for breakchie therapy? So that’s a great question. Um the right patients uh first of all are patients uh uh with localized prostate cancer low intermediate risk whether it’s favorable or unfavorable intermediate risk prostate cancer that have a prostate size less than 60 grams.

You know, the cut off used to be 80 grams, but I can tell you from my experience that even treating these guys with 70 grams, they’re they’re they’re miserable. Um, and so I have a cut off of 60 grams. Um, and a good urinary function because sometimes, you know, people can have a lot of obstructive urinary symptoms, still having uh a prostate size of 40 grams or 35 grams. And so addressing that before breaky therapy is really good, really important. And so I work very closely with urologists uh with uh addressing these symptoms and whether they need to do a TURP or URL or just medical management.

We want to make sure that they have good urinary function before undergoing breakchie therapy because if we do that afterwards assessing these obstructive symptoms it’s way more difficult and that’s when these urologists do not like me you know and so you know having a collaborative approach with them about these patients provides a great outcome for everyone. So Dr. Dr. Boter, you’ve mentioned LDR and HDR and breaky therapy. And maybe for somebody that’s not familiar with some of these terms, would you just give us the lay person explanation of what all of that means? HDR breakchie therapy is a temporary seed implantation of the prostate. Okay.

Um by actually a remote afterloader. Um and so uh here now we have to have the patient go to the operating room uh have these catheters placed throughout the prostate and then instead of um placing seeds in there permanently the these catheterss are connected to this remote after loader where there’s a a a high uh dose uh source called aridium 192 and that’s temporarily placed into the prostate where it’s being treated. So um this can actually take several hours um you know because you have to go to the operating room have the catheters placed then you have to have a CT scan and do the treatment planning and then you actually have to do the treatment delivery because you’ll have like 10 12 channels or even more and the seed has to go in there and place and dwell each position.

Um so it’s not uncommon to be you know anywhere up to four even longer 6 hours. Um and some patients are awake some patients have breaky suites where they’re asleep. Um and that requires actually not just one but actually two or three sessions if we’re actually doing definitive treatment. So if we do a boost it’s only one treatment but then it’s also it’s two or three for um uh for monotherapy basically two. Now um but the advantage is here with HDR breaky therapy is that the skill set of the doctor isn’t necessarily required because now the remote afterloader is doing the work. Okay. Okay. And so um you know what we and the and the treatment planning right.

So the once we have the catheterss in the treatment planning techniques will again do the optimization of where the seeds need to be dwelled within those catheters to to give a good outcome of adequate dose with adequate sparing of the urethra and rectum. And so um that that’s one big advantage here is that now um if you don’t have that skill set in LDR breaky therapy um you can still actually offer breakchie therapy. However um it takes a lot longer um the outcomes actually are different um and uh it requires several sessions. Um and from a radiobiological point it doesn’t make sense to me. Okay, here we have a slow growing tumor.

Prostate cancer slowly dividing, slowly growing. So the so with a permanent seed implant, LDR, you have the seeds permanently implanted, slowly giving off radiation, being able to attack those cells in that sensitive cell cycle phase that’s going slowly and be able to to maximize cell kill. So with HDR, you just have a very rapid pulse burst of a slow growing tumor. So that you know and so therefore that doesn’t really make sense. The only thing that makes sense is that we now are able to offer any breaky therapy for for these patients when you don’t have that ability or skill set to do LDR breaky therapy because also remember HDR breaky therapy is not cheap.

You need to get a vault. You need to have an afterloader a physics. You have to this. Now you’re talking about millions of dollars of skill set. I can do this in an operating room in a hospital. You cannot do HDR breaky therapy in a hospital o you need to have a vault you need to have a shielded vault actually what happens commonly I mean now more sophisticated places will have a breaky suite that has all ends but for me for for some places they’ll they’ll go upstairs they’ll go to the o um and they’ll have these catheterss and they’ll actually create a cushion that that cuts out their their buttocks area so the catheterss are laying in there and then some places will even take an ambulance to go to the radon department or they go downstairs to start that whole process so you know logistically not very pleasant doesn’t um radiologically it doesn’t make sense but at least it’s something better than nothing but as you can see I’m highly biased right you can see you know here I can do every 30 minutes very conveniently you go home the same day one session uh in the O um you know with um you know minimal downtime so you know I mean the so when I when I present it like that I mean what would you want to do yeah as a patient I’m thinking okay I’ I’d give me the in the office uh LDR option.

So yeah, or I mean some patients are afraid. Okay. Some in office I do like uh but some patients like you know what that biopsy was painful. I do not want to go that I need to be knocked out. I’m like okay. So I I commonly will give patients the option. Yeah. Yeah. I I give patients the option in office or or O what would you like to do? There is one advantage of the O of doing that two for one special but you know my older patients they they don’t want to do they don’t they’re afraid. They don’t want to be under they don’t they want to wake up.

And so within office they are awake the entire time and so um that is definitely an advantage for patients that have that would not be a good candidate for general anesthesia. So then what’s the recommendation if you get a patient that has a larger prostate or maybe has some of these coorbidities that you’re talking about or maybe has high-risisk disease that’s even spread to the lymph nodes. How are you suggesting that that patient approach a treatment? Okay. So first of all for high-risisk disease or very high-risisk disease I commonly will recommend combination breakchie therapy and external beam to the pelvic lymph nodes that treatment has a significantly higher disease-free survival rate than doing external beam alone and very important there was a recent randomized study done in Japan where they randomized these high-risisk patients that got breaky therapy and external beam and they randomized them to 30 months of ADT hormones versus 6 months of ADT and there was no difference.

So for patients that I see with high risk or very high-risisk disease, I can tell them we can reduce their duration of ADT to only 6 months if they do combination treatment. I mean I think that’s a game changer. Um well a lot of times those are the worst side effects right? It’s is from the hor therapy completely. So uh and so therefore um you know I I don’t I have offered monotherapy uh Dr. J. Sesi in Cleveland Clinic does a lot of monotherapy for uh high-risisk disease using breaky therapy alone and sometimes some patients that are older um and don’t want to do complete treatment.

I I can understand that there’s even a lot of data uh for people men over 80 that the even the benefit of ADT regardless is limited. So um yeah and so uh generally speaking for high-risisk patients I offer combination for a certain subsect that you know maybe are older we could do break therapy alone and with good reported outcomes by the Cleveland Clinic in terms of your uh ask uh about these patients with um you know larger prostate or urinary symptoms um first if they do have obstructive urinary symptoms there’s a lot of uh BPH management uh options for them um whether it’s actually the classic TURP or whether it’s you know a ural lift procedure or resume or aqua ablation they’re very all these urologists are very well tuned with these symptoms uh symptoms on how to manage them so I definitely would want them to get that procedure before and then 6 weeks later or 12 weeks later we can do the uh procedure I mean actually with these aqua ablation or or even um your lift I mean we can do it even way quicker than 12 weeks it’s that’s usually more from the turpp we wait several months for the prostate thighs.

Obviously, ADT is a great way to shrink the prostate. Um, but if you have low-risisk disease or risk disease and don’t want to deal with the symptoms of of ADT, I can understand that. So, there’s a new procedure, not actually new, it’s really growing actually, the treatment called the prostate artery embleization, P AE, and uh that’s an outpatient procedure done by an interventional radiologist. And I’m seeing about a 50 to over 50% reduction in prostate size with that. So if patients really want breaky therapy, they still can get that. Um but yes, if they don’t want to do that, I I’ll I’ll refer them to another option.

I mean this, you know, I you know, I do not want to uh patients have to I don’t I don’t want the patients mad at me. I don’t want the urologist mad at me. So I you got to do the right thing, especially community private practice. I mean I mean there I mean my reputation means a lot to grow this business and you know you got to do the right thing. I mean that’s that’s really important. So I’m a patient. Let’s say I have low or low intermediate risk disease and I’m saying imagine I’m in my 50s healthy otherwise and I’m saying Dr. Botnagger I’m trying to decide between surgery and breaky therapy.

What are the pros and cons of each or how how would you answer that question for that patient trying to make a decision between those two treatments? Yeah, so surgery uh is the standard treatment. It’s an excellent option. You know being your 50s you seem very healthy. you’re probably going to recover well. Um, you’re going to, you know, you probably will recover from the incontinence and the impetence. Hopefully, that should be an is shouldn’t be an issue. I mean, you you know, but, you know, for those guys that are obese or diabetic, you know, they can have issues. You don’t look like that. So, you’re you look you and by the way, I’m not in my 50s.

I’m in my 40s, but I’m I’m I’m co-playing a patient in their 50s. Hey, I’m in my 50s. Okay. So, there you go. No judgment here. There’s no judgment, but just saying like, you know, assuming you were a healthy 50-year-old, you know, surgery is going to be a good option. It’s not something that um you do bad with, but no, if you were unhealthy, you know, in terms of being obese or having diabetes or or some sort of severe medical cobbidity that would, you know, make you high risk or sometimes men who have had hernas, you know, hernia is a contraindication to surgery. So this breaky therapy is a nice alternative because you know I’m not a big fan of external beam radiation for young men um because you know there is a risk of secondary malignancies um you know you can get erectile or bladder cancer um you know 10 20 years down the road and 10 20 years down the road from women in your 50s is in your 60s or 70s that’s not insignificant you know I mean fine that’s not maybe not as relevant for a 75 or 80 year old patient but you know younger men that that’s that’s an important topic and breakchie therapy has been shown known not to have an increased risk of secondary malignancies for prostate cancer because the radiation is directly focused in the prostate and therefore the volume of radiation is related to the risk of secondary malignancy and with external beam radiation there’s still dose around the low doses throughout the pelvis even with proton beam right there’s still entrance dose and so there is a risk of that and that’s the reason why I am pretty adamant about trying to avoid external beam radiation for younger men now for this man that’s healthy and but is busy.

He’s working. He’s very active. He doesn’t have time to be down at home. He doesn’t have time to deal with cat. He doesn’t want he’s, you know, very uh very uh proactive. Wants to maintain working out. Wants to maintain working. Breakie therapy is is is a great option because now we don’t have to deal with the significant downtime and potential to toxicity of surgery. I mean, I can get patients working the next day. I I have a great example for you. Uh I had a gentleman in his 50s who was diagnosed with prostate cancer uh intermediate risk and was told that he needed to have surgery but he owned a pool company and he said the doctor said no well you wouldn’t be able to work for your pool company in cleaning pools.

He’s like well I can’t run I have to run my business I I’ll go bankrupt you know I’ll have to shut down. And he’s like well I’m sorry you know you’re not going to be able to do that uh for a few months. And so he was devastated devastated. and um he found about he found out about me came to me we we we did the we did the breaky therapy procedure and he was going to work the next day. So the advantages of the break therapy there is that we have a lot less downtime. Um toxicity is mainly just a urinary s short side effects but the long-term side effects in terms of erectile dysfunction or urinary incontinence are really really low.

I mean erectile dysfunction in terms of erectile function preservation breakchie therapy has been shown you know multiple data sets that is the highest erectile function preservation rate um compared to surgery or external beam radiation um and then in terms of urinary incontinence that’s sort of unheard of with breakchie therapy I mean one thing you can sort of see is a urethal stricture um uh as a long-term late effect but you know with the using a peripheral loaded technique and real-time planning using the advancements in breakchie therapy that we have now you don’t see that uh and of course patient selection but um you know I think uh for patients that are wanting to avoid surgery uh for whatever reason um this becomes a good option but um you know for that young healthy male I I I don’t want to disclo discredit surgery as an option too I mean let’s face it that’s still the standard option yeah no and and and I think that’s one of the challenges with prostate cancer is that there are a lot of good options out there so it’s almost like the decision itself becomes overwhelming because you’re presented with Yeah.

Go ahead. You’re completely right. But no one, very few people are told about breaking therapy anymore. And and and so why why do you think that is? I mean it it walk us through because you mentioned that you know you started your practice in the early 2000s. That was probably peak breakchie therapy utilization. It was as many as 20 one in five prostate cancer patients were getting breakchie therapy at that point. that dropped down to maybe one in 10 10 years later. So, walk us through why that happened. This is a great treatment. Why are more patients not getting breaky therapy? Yes. So, like I tell everyone, the story of prostate breakchie therapy represents exactly what’s wrong with our healthcare system today.

Here you have the most conformal radiation treatment for men with localized prostate cancer. But since it’s the most cost effective, i. e. the least revenue generating. No one wants to offer it anymore because of the more lucrative treatments available mainly IMRT. So IMRT was developed around the early 2000s and it was a great treat it still is a good treatment for prostate cancer. Um but uh you know the when IMRT is very cost intensive there’s a lot of resources involved to develop an IMRT center and at that time the business models developed with urology radiation oncology joint uh business models to what we call the Eurorad model where they had built IMRT centers throughout the country and you know and when you’re developing and building a $10 million facility you know you got to feed the beast Right.

Right. And so and and so when you I mean you and so when you have to do that I mean breaky therapy got sacrificed. But then it got even worse. Right. Because then it got to be so long that now there’s no one even trained in it. So it’s now not that and so even if people wanted to offer it now they’re not even able to. And so yeah they may have done it 10 or 15 years ago but that really means nothing. I mean that mean would you want a surgeon who did prostate break uh surgery 1015 years ago to do your prostate surgery on you?

No. So I mean you know and so therefore if you can’t offer it anymore then how are you going to be able to disclo you know how are you why are you going to tell patients about it and so that’s the issue is that now um it’s not even more about the finances it’s also being having adequately trained doctors and for the doctors is there really any motivation to learn this anymore they’re really busy in your external beam radiation center you know having to do this and leave the uh clinic which now is very difficult with a physician supervision rules and so you know I remember when I was um in my last few years of where I was practicing in the general radiancology center we had to hire locals for me to go to the o for that day and that was not easy that was a pain so uh and so now you’re saying okay I got to hire a locoms doctor to go do a treatment that’s going to make less money than my IMRT and and and so this isn’t making sense for me here.

Why why should I be doing this? And so and let’s face it, radiation oncologists in general aren’t really surgically inclined. Okay, this is a surgical and that’s the reason why I call myself an interventional oncologist, you know, and so you know that’s why you know it does take a surgical skill set to do this and it takes proper training, experience and constant cases. You can’t just do this over a weekend course. Um because now transparental procedures are very important because it’s not just breakchie therapy. Now we have rectal spacing. I do barager gel spaceor rectal spacing. That’s a very important procedure. Transparal prostate biopsies. I also do them.

So these are all very important procedures that can be done by an interventional oncologist. Right? Having that skill set is very important. So I’m hoping that there may be some more desire to do this because it’s not just LDR breaky therapy anymore. We also now have um rectal spacing and transparal prostyopsies which urologists don’t really want to do right now even though the data shows that it’s a much safer treatment and patients are are much safer biopsy and patients are looking for doctors who perform this. So talk about the spacing. I do want to touch on that um because you brought that up and that’s something that’s on your website.

So talk about what the role of spacing is, what that procedure looks like. What should I be thinking about as a patient when you talk about rectal spacing? Yeah, in this day and age, I think any patient getting radiation therapy should be considered for rectal spacing. Okay. Um, and so whether it’s external beam or breakchie therapy, especially combination treatment. Okay. And this is a very quick procedure again another transparental procedure where we go into this specific fat plane called a denin vase fascia. It’s a fat plane between the prostate and the rectum and basically we use barel is a hyalonic acid. We use this material to lift the prostate off the rectum and thereby sparing the rectum from any radiation damage.

And so generally speaking, they like to have 1 to 2 centimeters of spacing to allow for the external beam is dose levels to be fairly low to the rectum. But with breakchie therapy, um getting even just a 5 millimeter lift will be allow me to have my seeds very posterior. And so uh I I I do commonly perform rectal spacing for breakchie therapy. Even though I initial thoughts are like, well, why do you need rectal spacing when you’re doing breaky therapy? I mean this is conformal but remember the re the rectum is literally right next to the prostate right I mean that anterior wall of the rectum is adjacent to the posterior wall of the prostate and so if I have the seeds that are literally right there at that posterior border you know the the wall of the rectum will get dose um and very high dose and so by having bear gel or spacor or even bioteact any of these rectal spacers uh we allow the prostate to lift off the rectum and thereby giving this space and sparing the rectum from uh getting damaged and you know I do a lot of combination therapy.

Uh that was one of the criticisms of uh combination break therapy and external beam was that it was very highly toxic but now with rectal spacing there’s minimal rectal toxicity with that. So and and that was the about a time you know about a decade ago is when this really started and a decade ago is when that ascent trial came out showing the benefits of combination breakchie therapy and external beam for these high-risisk patients but there was an aversion or hesitation to do that because of the high risk of rectal toxicity. So the rect the rectal spacing um really allowed for me to start that process and then that’s how I started doing rectal spacing was in this high-risisk subset that was getting combination treatment but then it slowly added oh okay now we have hypofractionation external beam so they warranted too now and then I added breaky and so then now I offer for everyone there’s no reason for me to not uh offer it for everyone I do see the benefits for each subset of patients but that’s how I started um in uh rectal spacing yeah I’m a big fan of it.

Um, and I I believe that all patients should be able to have access be offered it before they undergo any sort of radiation for their prostate cancer. Another thing that you can get especially for proton beam by the way. Yeah, because proton beam can actually increase the rectal dose because of the beams I’m shaping and so they really benefit from uh rectal spacing. And another thing that you get better at the more you do. Exactly. As well there’s good rectal spacing and there’s bad rectal spacing. Completely agree. And you I mean you’re talking a guy that does and I actually do it sometimes at the same time as breaking therapy.

So if I’m in the O, I’ll do the seeds and then I’ll do the bear gel right at the same time. I call it the two for one special. I call it the two for one special. And patients like that. Um you know in office breaky therapy I can’t do that because the payers won’t let me. They won’t pay for it. And so it’s very frustrating. Yeah. Even in ASC settings. Yeah. So it’s it’s uh it’s it’s a little bit frustrating on that end. So I sometimes have to break it up into separate procedures if they want in office or want in the surgery center.

But in the hospital setting um I’m able to del uh offer both at the same time and patients really do appreciate that. Um but yes, uh my erectile spacing um technique and skill set obviously has gotten a lot better in the last 10 years. And just doing it every day constantly, it it allows you to keep your skill set. And as a radiation oncologist, I know what we want, right? I know where where we need a space. And it does seem like the apex is very important to have adequate spacing there. We don’t necessarily need to have 2 centimeters of spacing in the seminal vesicle region, right?

So, you know, we we want to know we and we want it to be symmetric and and so, you know, compared to a urologist, having a radiation oncology perspective allows me to give the spacing of what is really needed for them and and so yeah, I do think there is advantages of a radiation oncologist doing spacing because they we they know we know what we want. However, the skill set still lies primarily with urologists because I think from what I understand urologists are still the main uh providers or the doctors. I hate where the word provider actually the main doctors offering uh rectal spacing from from what I from what I know.

So, one of the things I want to shift gears a little bit. One of the things that you mentioned before we got on the call is that maybe 60 or 70% of your patients are actually self-referred to your practice. And I do think so one touch on how important it is for patients to seek a second opinion or be their own advocate when they’re trying to decide what treatment is best for them. And then also how have you navigated this paradigm of having to be on social media and go directly to patients and talk to patients? Yeah. So know patients with low or intermediate risk prostate cancer have time.

There’s no urgency. Okay. And they need to understand that and that’s really important. Okay. And sometimes they just put that pressure on themselves. It’s not that the doctor said that, but they just have it in themselves. They have that C-word and they need to get it out. Okay? And that’s usually the first person they see. And then sometimes for many patients, uh they may regret it because they didn’t they didn’t take the time and effort to learn about all their options. Um and as we mentioned right now, right now mainly there are you know the two options of surgery and radiation, but there are other options too.

But it is important for patients to be aware of all the options and so sometimes you know when they see a radiation oncologist that only offers external beam you know breakchie therapy is commonly not discussed um and so um I have learned in the last few let’s face it social media has become the ultimate source of information for people whatever it is and it has become important for physicians to get on to social media to help combat all the misinformation out there. Okay. And so for me, I uh wanted to use it to help educate everyone to educate them. A first of all, getting a second opinion is not a bad thing.

It’s actually really good. But the the men, they almost look at it like cheating on their wives or cheating on, you know, they look at it that way. They do not they feel very loyal to their doctor. They don’t want to upset them. They don’t want, you know, they they feel guilty, but they shouldn’t feel that way. They I mean, any doctor that that um where the patient actually tells them, “Hey, I want to get a second,” they should honor that. They should be happy about that. I have patients commonly will gang third, fourth. I I I I um And you say, “Go do that, please.

” And that’s and I think that’s a sign of a good doctor. But uh and so they inherently will have that sense of guilt or apprehension. And so, uh, I do think the social media allows them to learn and get more information without having to actually cheat, right? Go to see another doctor because they just learn. Um, and so I have started a social media campaign on the short form videos um, using Instagram and Tik Tok and you know there that just piqus their interest. But what I have found to be really important is the long form content on YouTube. Um, and I think people really learn and and especially this uh age demographic, you know, the old older men, I think they much more attuned to going on to YouTube than Tik Tok.

And uh, I started a YouTube channel um, about prostate cancer and breaky therapy. But one is just dedicated on the importance of a second opinion and having time. You know, there they need to really understand that there is no emergency with intermediate or lower risk prostate cancer. So, they should take the time to be able to be comfortable and confident in the decision they made. No one should feel rushed in going into the decision. That’s really important. And I think uh this type of information that’s available out there to help support that really helps them a lot. Uh because yes, they they really feel guilty.

They they and and I respect them for that. I mean, they you know, they they you know, they they just have been going through a relationship with their urologist. They may have just put all these needles up their rectum for the prostate biopsy. A lot of tr Yeah. So there’s a lot of trust there. I I I get that. But you know the there are many options out there that they should be aware of. It’s not and so as long as they have been informed of all the options that were available to them and now they can make the right decision. That’s great. But I’m telling you that’s not the situation right now.

Yeah. So uh how how do you well I remember you know 10 years ago 15 years ago as Google was becoming more prevalent a lot of doctors would tell patients like don’t get on Google don’t go to Google doctor you’re not going to know how to navigate you’re not going to know what’s real what’s not real I think today we’re kind of past that right like we just know that half of America spend is on social media every day and a lot of people a A lot of those people are going to social media for medical advice and there’s a lot of medical advice out there.

So I don’t think it’s reasonable to say just avoid it to a patient like just listen to me and don’t get online because they’re going to want to go online. And so how do you kind of walk that fine line and talk to patients about hey it’s okay to go online and look for information but here’s how to be thoughtful in how you do that. You definitely want to support them getting information. Okay. Yeah. and whether getting information is whether they’re seeking a second opinion from doctors, they have friends, family members that had prostate cancer and of course, yes, the great world of the internet.

Um, I actually like this website called uh prostatecancerfree. org. It actually goes through all the different risk categories and all the different treatments and compares the outcomes. So, I commonly will give them that website. of course they’re going to Google and go on their own and do that. But uh there’s you I don’t think we want to um scold them for doing that because you know that that only looks bad upon you and there is now more posit good information. Okay. Yes, there’s there’s bad information too. I mean yesterday I was going through one of my comments of my latest video um that’s actually getting quite a bit of views.

Um and he this man was gentleman was telling him how his PSA is 40 and uh he definitely does not believe he needs a prostate biopsy and he had other replies supporting that other men would say yes we don’t need to do prostate and so you know and and and and then ivormectin they can just take ivormectin and so all this information uh misinformation has to be combed with correct uh balanced information from medical professionals and that’s the reason why I it’s not just me I encourage all my colleagues to get on there so that way there if there’s more information from trusted medical professionals of more adequate correct information then than the misinformation that’s out there then at least um you know these patients these men are will be able to get informed uh correctly or at least be able to look through and be able to be a judge on themselves to say okay yeah that doesn’t look right.

Yeah, this all these guys here and this information from this doctor and he’s a trusted doctor. That doesn’t make sense. So, no, we we really need to use this importantly because um it it the the influencers are gaining on us and outcomes for and and that’s leading to bad outcomes for patients and that’s what’s sad, you know. Uh and so it’s it’s it’s really sad. Um and and so I think I saw a Tik Tok yesterday where this um breast medical oncologist talked about her patient who was diagnosed with an early stage breast cancer and she was the patient though went through a chat group and was told to take ivormectin and they ivormectin and um guess what her cancer continued to grow and eventually died of metastatic breast cancer.

Right? So I was I was applauding that that oncologist to display and to talk about this and she said yeah that you know she that patient never went back to that chat group about this you know progression of disease showing the effects or the lack of effects of and so you know it’s very important for us um to do this but yes it’s a problem because we’re busy as doctors I mean when you already have a very busy practice to be able to dedicate time to this it’s not easy and so I I can understand why um you know there there’s an aversion to doctor for doctors if they’re already so busy why do I need to do this um and yeah I I can and also they may not be interested in getting on camera and talking and speaking but uh you know hopefully you know maybe the younger generation you know will will sees the importance and sees the need for for doing this and and getting uh correct information out there uh It it it is really important and so uh while we are very busy with our uh practice this is uh very important for me luckily starting a new practice um I needed to do something I had you know and I also had the time you know I mean starting at doing so I I had the time to be able to invest in this but I can tell you even now four years in uh you know um it’s it’s a sacrifice to be able to offer this I have gotten efficient now I have this at my own house right and and set Yeah.

Yeah. And be able to speak quicker and just have fun, you know, and have fun with it. It just the the like with anything, the more you do, the better you get at it, right? Yeah. And and so you can’t just do a TikTok one uh one video a month and be good. Just like you can’t do one breaky therapy and be good at it. So you just have to get comfortable. You just got to be and you know, be vulnerable, you know, and get uncomfortable. That’s I mean, and that’s really important. It’s actually really important in life, you know. I I think for me, you know, I I was probably too comfortable for many years in my life.

Uh and and now when I started this practice myself, yeah, I got uncomfortable. And you know, you got to enjoy getting uncomfortable. Uh and so uh yeah, I’m I can tell you I’m having the time of my life doing this. I I’m so happy about it. It it’s it’s led to a lot of professional satisfaction, personal satisfaction. patients are um really reaching out to me and you know really appreciative of what what I’m trying to do because yeah I I could have just you know kept going and doing what I’ve been doing and and probably made more money um but I really you know this is the reason why I went into radio oncology was that I saw dying going away and not only that people even my own colleagues were talking weren’t even were talking negatively upon it and I was like wait this is not right?

This is this is just not right. I I you know, I have to do something about it. Um and that’s actually why I’ve actually started a foundation. Um okay. And so I started the Prostate Cancer Institute of America Foundation to help generate funds for not only patient awareness, but also physician education and training. Uh I I’d actually love to start a fellowship one day with transparental procedures, not just break therapy, but transparental prostate biopsy, rectal spacing, LDR breakchie therapy, so we can train other radiation oncologists to become interventional oncologists, right? Right. Because, you know, I can’t have this die with me, you know, this needs to go on.

And just like with Kent Warner, he he he’s the one that developed in office breaky therapy. And I told him, you know, hey, I’m interested in learning. I need your leg. I I will I want your legacy to continue. Um and yeah, he was nice enough to come down even though he doesn’t really do prostate breaky therapy anymore. Um you know, moved on to more cardiac breakchie therapy at the University of Washington. You know, he when he came down that day, he he had a little bit of itch. I saw it. I saw it, you know, maybe I should get back, you know, jump back now.

It’s hard, you know, he’s had so many years, you know, and and and so do you really want to subject patients to that, you know, and and that’s the issue now. How how do you get started back in? It’s I I don’t see how and without proper adequate training uh and and I think that’s a big deficit and that’s the reason for this foundation. I really would love to start a training program for this to grow because you know I you were talking about do you do I see breaky therapy coming back? Not really. I I I I mean we you know um you know there that new I don’t know if you’re familiar with that new radiation oncology uh bill out there that called the rocker the radiation oncology cancer program right yeah they have breakchie therapy outside of that and so there is a theory that this will increase that because you know if you have a prostate cancer patient they they’ll get external beam through the rocker but then breakchie therapy can be built fee for service outside of that so therefore there could be some motivation to want to do breaky therapy Um, but if you’re not trained in it, how are you going to be able to do it, right?

I mean, I think that’s the biggest issue right now. So, it’s not even about the motivation or interest, which may may or may not be there. It’s just the ability and and because this treatment is highly operator dependent and so you know, you don’t want to subject this patient to a bad outcome. I mean, I don’t know if you’re familiar, uh, but the 2000 early around another reason why breaky therapy died in those early 2000s was the Philadelphia VA incident. I don’t know if you’re familiar with that. No, no. Yeah, tell me about that. So, um, at that time, uh, the University of Pennsylvania racial oncologists were servicing, um, the Philadelphia VA.

And the Philadelphia VA reported that there were over 50 patients that had prostate cancer that had seeds placed in the uh, bladder or tissues outside of the prostate. Right. Okay. And it became a federal investigation. It became a really big deal. In fact, Dr. Steve Han who was the chairman of PEN that he had to testify before Congress at that time and explain. And so um that right there um became justification for them to stop doing breaky therapy. But for me that’s just proof to show that you need to know what you’re doing. Okay? Right? Bad things can happen. But in the right if but if you do know what you’re doing, I mean the outcomes are excellent.

I mean the PSA drops with breaky therapy are so much lower. um you know really really low and the outcomes I mean there is ur short-term urinary toxicity but after that I mean you know I actually like to use palladium 103 that has a shorter halflife um 17 days versus iodine is a 60 days and that was a more traditionally used one and so I I meant to ask you about that because you do have two different types of seeds listed on your website three actually there’s three oh there’s three okay yeah there’s cesium 31 there’s palladium 103 and iodine 125 yeah so expand expand on that because if I’m a patient, do I have to come in and pick one of those or do you recommend one or how do you how do you make that choice?

So, uh there’s iodine 125 is a traditional one that has a half life of 60 days. Um there’s a palladium 103 that has a half life of 17 days and that’s my favorite and then there’s cesium 131 that has a half life of eight days. Okay? And so with I125 halfife of 60 days, the side effects tend to linger a lot longer. Okay? So if you have a halfife of 60 days and three half- livives okay is is a basically a 90% reduction or dissipation you know so after 60 so after 180 days 90% of the radiation has been delivered and so that’s when the symptoms sort of subside and so that’s 180 days after the treatment so that’s 6 months and so patients have to live with the side effects for 6 months versus if they use palladium that has a half life of 17 days and so then three half lives would be 51 1 days.

So basically two months. So in in two months 90% has been delivered. Whereas you know with iodine it’s not even one halfife has been delivered. So therefore that uh half-life advantage uh allows for um a lot more tolerated treatment. Uh so then why not use the seven yeah the 7-day halflife? The energy is higher and they it can be a bit more intense. The symptoms are a lot more intense. So got it. So that so that 11 days that you’re buying isn’t worth that increased toxicity. I mean because they’re they’re they’re really toxic. I mean you know I know some of them were using like I guess uh the reported results I guess I saw that they used um stero steroids uh medall dose pack for everyone.

So that so I I guess for those patients for the data that shows that the the toxicity wasn’t as intense it was it was because they used medall dose packs and you know I don’t use medall dose packs for all my patients. Maybe if they have a larger prostates and want to reduce the swelling but not for everyone. Um and so therefore in my opinion I’d rather have them just slightly longer duration of symptoms but much less intense. Okay. And so that’s the reason why I was I did CZM131 for a long time. Um okay and but then I noticed that and even actually my urologist was like hey these are patients are being really you know what’s going on here.

Um and so then we we went to palladium and I have found that palladium has been a really nice balance and you know there’s actually some data uh um to show that maybe palladium has a better outcome than iodine. It’s just retrospective. Interesting. But but um you know but just for that half-life reason it really becomes a lot more patient friendly. So you’ve used the word outcomes a few times. So I would love it if you talked about that because if I’m a patient and I’m coming in and I am coming to talk to you Dr. Botner. My first question is is I want this cancer gone, right?

I I want it cured, which I know that’s not necessarily always the right word to use, but how do you talk to patients about outcomes and and feel free to kind of bifurcate it however you want. Ah yeah, you know, so outcomes that’s actually excellent point and so um you know we have you know what we call our cure rates and then we also have quality of life outcomes. Okay. So when we talk about the cure rates, you know, prostate cancer, you know, the dise overall survival is not necessarily the best parameter for prostate cancer because we know you live so long you may die of something else.

So the disease-free survival is very important. Okay. How long? Okay. And with breakchie therapy with for lower and intermediate risk prostate cancer, you can have over a 97% cure rate. Okay. with 97% disease free of a 10-year disease-free survival right for low and intermediate risk without using ADT by the way that’s another important point my for my intermediate risk patients I do not offer break ADT uh unlike for patients with external beam that commonly will get a short course of six months um and so that’s another big advantage for breaky therapy for the intermediate risk category where um they can just get breaky therapy alone and so even with just breaky therapy alone uh you can see over 97% % disease free-free survival at 10 years and that’s hard to beat.

Okay. Uh then the quality of life okay uh the erectile function preservation rate at when you’re is 76%. Okay. Uh versus 55% with external beam 34% with surgery. Okay. And these is data. This is concrete data that I can show you with uh evidence. These aren’t just numbers that I make up. But I can tell you in terms of erectile function preservation rate, in my hands, if you come in, it’s all about what the level of function you come in with. If you’re coming in with good function, you’re going to come out with good function. If you’re coming in with bad function, this is not going to make it better.

Okay. Right. Right. Right. But but the guys with borderline function, the guys with borderline function, I think, you know, those are the guys that we need to work on. Those guys we need to optimize. And so giving them like maybe a low dose of scalis you know during their you know those first two half- livives could be keep that blood flow open can further um improve uh their preservation rate and it also helps with their urinary symptoms too by the way. Okay. So yeah so it’s so it can serve two purposes. So those so so you know we have a very in-depth discussion and so if these guys are yeah you know they yeah it’s I think you know that I see a decline in the quality and you know I’ve already been starting to use these medicines.

So yeah, we we will have them on that during the first two half lives, first one month and um to to maximize that preservation rate. But the guys that come in with good function, yeah, they come out with good fun. They and and uh that’s that’s something that I I’m very confident about uh because you know, just with the doymmetry of of breakchie therapy, you know, the dose to the penile ball or nerves is is negligible and that’s the reason why we could have such great outcomes. and talk about maybe how Yeah. talk about how maybe focal therapy uh or focal breaky therapy, how is that different than regular breaky therapy?

Um and then maybe talk about how you’ve incorporated this real time AI planning into your process as well. Yeah. No, great questions. So focal therapy in general for prostate cancer is where only the cancerous portion of the prostate is uh treated thereby sparing the remaining prostate and thereby preserving quality of life. That’s the whole function of this. Okay. Um there are different ways to offer focal therapy. Commonly urologists have to do high. They’ll do a high frequency ultrasound ablation just to that focal area. But breaky therapy is actually a great way to offer focal therapy where I place just the seeds right in that area of of of involvement because now we have advanced detection methods, MRI, MRI, PSMA where we now can actually know exactly where the prostate cancer is in these early stages and be able to just address that area.

And so now with breakchie therapy, focal breakchie therapy, we can now use advanced techniques with MRI fusion, PSMA fusion in my breaky therapy planning software to be able to know exactly where we’re treating, exactly where to place the seeds. Fine, we place a nice margin on it, but still we we don’t have to treat the entire prostate. And for some patients, that’s a big benefit because remember, we went back to my uh size criteria, you know, uh about being 60 grams. I commonly will treat these uh patients with 80, 90, 100 grand prostates with focal therapy because that allows them to not have to shrink down their prostate and deal with the miserable side effects of treating the whole gland, especially if they only have one focus there.

So for these patients that are not wanting to do active surveillance, but not wanting to do a full treatment, it’s a nice compromise. However, I must say we need to follow these patients closely because there’s a risk of them recurring in the untreated regions. Okay? And so I have had patients recur outside the untreated region and then I went back to do repeat focal breaking therapy in that side. So it does make them eligible to do that. Um and again uh we were talking about the advanced planning techniques. we can now uh the breakchie therapy software now allows us to fuse the images u of the MRI and PSMA to make sure we can actually know where we’re placing the seeds and then with real-time planning what we can do now is that we can acquire the image of the ultrasound right in the O and put it into the laptop and then uh create a plan it’s basically an IMRT plan for breaking therapy it’s like a dose optimization module where we basically put a constraint we we del we dedic we uh delineate the region of interest, the prostate and we give it a target dose and then we delineate the regions of avoidance like the urethra and the rectum and we put uh priorities on them and so it has a cost function analysis and comes out with the number of seeds and the placement of the seeds of of what needs to be done in order to achieve your goal there.

So very very much like IMRT an external beam so we can with with breaky therapy. So I mean a big criticism of real-time planning is that it takes too long to do it takes you hours. I mean with with that uh optimization module in the vered does it in seconds and so it really I mean realtime planning just takes me few minutes again for someone that’s doing this constantly you know I mean it it becomes very it doesn’t add any significant time that makes it not worthy of doing because using a pre-plan based on a pre-operative image isn’t you know things change if they’re on hormones, they prostate can change in size and like uh the even the way the ultrasound is placed in the prostate may be positioned differently may of differently than the pre-implant image that you use.

So, you know, you really need to make sure that these seeds are far from the urethra to minimize the symptoms. Okay? And so that’s why the peripheral loaded technique is really helpful with that and that can be done in a um real-time fashion because a lot of patients will tell me or doctors will tell me, “Hey, this guy had a Turp. He’s now contraindicated. ” I’m like, “No, actually these guys patients with TUP are actually great candidates for breaky therapy because they now have good function. I can just now with real-time planning, I can make sure the seeds are placed outside the defect, you know, and but with a pre-plan, you know, you’re just going in there blindly.

Yeah, there’s is there a possibility that could those seeds aren’t are in the defect that that could happen. But with real-time planning, we can make sure that these seeds are outside of that defect and allow for a great outcome. So, uh you know that was a common relative in contraindication before the real time planning era. Um you know actually I did write a book a couple years ago called uh you know I saw that. Yeah. Yeah. Modern LDR break therapy a practical guide for you can get it on Amazon. Yes. And it’s actually not a practical god for your practical god for anyone even patients.

I have patients getting it. I mean yeah I mean it’s free on Kindle. Um but it goes through the data uh because what’s interesting is that even though the utilization has died the data most recently has become even more robust right we like I was telling you about that trial for um you know the for ADT for 6 months versus 30 months for the high risk but that that was just a year and a half ago. There was a RTOG study about the intermediate risk patients getting combination external beam and breakchie therapy versus breakchie therapy alone and that showed that breakchie therapy alone had better outcomes than combination treatment for intermediate risk.

So that’s why breakchie therapy alone is is reasonable for intermediate risk. The ascend trial showing the combination having a significantly improved disease-free survival rate versus external beam alone. And again there was a criticism about there was no benefit of overall survival. But when has overall survival been a parameter for uh um evaluating prostate cancer? I mean, that doesn’t make any sense. They’re just trying to justify doing what they do, you know, because, you know, it’s hard, you know, I mean, when you don’t have this tool in your toolbox, it’s really hard to offer it, right? And and and that’s and and basically just because you’re a radiationologist doesn’t mean that’s your tool.

I mean you have to be adequately trained and adequately doing it proficiently to be to be to really call it your toolbox. Um and that’s where um what I have been able to trying to with social media educate everyone and even urologists I can tell you I I work collaboratively with urologists because you know they they they do have an ability to be involved with the procedure placing the needles transparent placement. So for urologists that are interested in working with me, I I commonly would be collaborative with them and even if I’m not, I’ll talk to if they have patients that have obstructive symptoms, I I I want to make sure that they’re involved in their process of care because it’s really important and and actually the patients really like that.

They they they really like that. So um you know, it’s important. So I want to be respectful of your time. Uh I really appreciate you coming on today. My last question for you, Dr. Botnagger, and you’re a wealth of information. People should absolutely check out your YouTube channel um and some of your other social media platforms. But what what should people know about you as a physician that you haven’t already talked about? Ah man. Well maybe something personal because I I I sense a lot of kind of passion for you and really care about the industry and about patients and about where things are headed in this country.

So just kind of summarize that um and and tell us a little bit about you as a person and as a physician. Yeah, I feel I feel really grateful of where I am today. Um to be able to do what I’m doing and it wouldn’t be possible without the family and friends support I have this uh in a few weeks. It’s going to be marked my uh two-year anniversary of my father passing away from head and neck cancer. Um, and I know he’s up there really proud of what I’m doing because um, and so all this inspiration and I I feel is all because of of where I my background, my family, my wife, kids, and my and and um, you know, I I I feel blessed to be able to do this and to have I I’m having so much fun.

uh um but I do really feel grateful and gratitude to allow patients to give me that opportunity to take care of them which and my family that supported me throughout this whole time to do this. So I I am I feel really blessed to to to be where I am today. And um I I I want them to know that this would not have been possible without you know the parents that I have, my wife that I have and you know this just was not a one person thing. And I I hope they see that I genuinely want the best for everyone. And I think that comes out very clearly because uh of the passion that I have.

I mean it all starts you know when I was in med school and I I saw this treatment and even in college even before that in college I and my dad telling me to study engineering it all it all come it’s all it all comes forward of of what I’m doing here and so um but I want to make sure that people know that this this is all accumulation of everything that’s happened in my life and you know with this being my father’s two-year anniversary coming up um I I want to make sure that he uh he knows and he’s he’s up there. He he’s he’s proud and I’m I want to make him proud.

Yeah, that’s amazing. Thank you, Dr. Botnagger. And I I can feel your passion coming through the camera here. So, um I really appreciate your time today and I would love to have you on again. I don’t feel like we even covered everything. So, um we’ll have to schedule another time part two uh at some point. And again, thank you so much for your time. Good. And part three. Yeah, let’s keep it going. I mean, there’s lots of topics to cover. Hey, no, I I I I I really appreciate what you guys are doing. Like I said, we need to get more information out there. I saw that your last episode with the lady with the pregnant female with breast cancer.

I mean, it was an amazing inspirational story. You keep doing what you’re doing, too. and and and and so with the amount of uh you know of I don’t want to say good whatever good information out there or accurate information uh we’re going to be able to um combat all that misinformation and that’s really important right yeah well thank you so much uh and we’ll talk to you again sooner project podcast is made possible by the Oklahoma Proton center, a state-of-the-art cancer center where precision in treatment meets real compassion in care. We’re grateful for their support and for you for spending this time with us.

If you’d like to learn more about the Oklahoma Proton Center, you can visit their website at the link below. And if something you heard today resonated, we’d love for you to stick with us. You can subscribe to the podcast and follow along on our socials linked below for more conversations like this. Honest stories, thoughtful perspectives, and the kind of support people don’t always know where to find, but do truly need. At the end of the day, this podcast isn’t just about cancer. It’s about what it means to be human inside of it and how we keep living, connecting, and moving forward together. We hope you leave each episode feeling a little bit more informed, a little bit more supported, and a lot less alone.