David Raubach: Welcome our viewing audience here. I’m really excited. We have Dr. Mark Story, radiation oncologist at the Oklahoma Proton Center here with us today. And uh one of the things that I love about Dr. Story is he is a prolific writer on Substack. If you want to know anything and everything related to oncology, cancer screening, cancer treatment, he probably has published something on Substack or has something that’s coming up. Um, and so we’re going to kind of hit on a a variety of topics here today. Um, the approach that patients should take as they get diagnosed with cancer, his background as an oncologist, what are some things that have changed over the last 20 years uh during his career. Um, and so we’re really excited to talk to Dr. Story today. So, uh, Mark, welcome.

Dr. Mark Story: Hey, uh, great to be here. This is gonna be fun.

David Raubach: Yeah. Is this your first ever podcast?

Dr. Mark Story: Uh, second, I think. Second podcast.

David Raubach: Second podcast. Okay. All right. So, you’re an you’re an expert then.

Dr. Mark Story: Um, so I understand uh that you had a little bit of a before we get started, you had a little bit of an adventure today. Um, you were kind of a savior for some kids that wrecked a golf cart. Well, at least I I tried to help them is uh yeah, uh golf carts these days go fast.

David Raubach: Kids were driving around a roundabout and the cart flipped and uh we were my wife and I were walking with try to get out and walk and exercise and uh cart flipped, heard it crash, ran over, tried to help basically calm people down. Uh thankfully the two kids were fine. Um I say that they both probably went to the ER. One probably broke a foot, one probably needed stitches in a hand, but realistically they weren’t really hurt from the accident. Um, yeah. So, it was a it was an adventure.

Dr. Mark Story: They were lucky a doctor was in the area.

David Raubach: They were I They were lucky that they weren’t hurt.

Dr. Mark Story: Yeah. Right. Right. Right.

David Raubach: As a radiation oncologist, I don’t know that radiation was the uh they needed. That’s what they needed. Yeah. Well, uh, you know, it’s good it’s good that you’re looking out for the community and, uh, public service announcement, be careful with golf carts. Even golf carts can have accidents.

Dr. Mark Story: Absolutely.

David Raubach: Um, so, uh, tell us a little bit about your background. How did you become a doctor? Was that something that you always wanted to do? What kind of led into that career path?

Dr. Mark Story: I wish I had a great story. I mean, it was kind of uh, stumbled into it. I u was always good in math and science. My dad was a car dealer, so I grew up in a business environment. Um, but was good in math and science, went to Vanderbilt, did engineering to avoid a foreign language because I don’t like foreign languages.

David Raubach: And um, so did engineering, was able to substitute like a programming language, as odd as that is, for a foreign language, so I didn’t have to take French or Spanish. I took Cobalt or Pascal.

Dr. Mark Story: So hard a harder language.

David Raubach: Yeah. Exactly. So, uh, I messed up there, uh, and then just never got sidetracked and then went to med school and then stumbled upon radiation oncology. I had a great one-day outing to a radiation oncology facility and there was a physician there uh, who was just laidback, strolled in, kind of talked to us about what he did. And in the big scheme of things, as you’re aware, it’s it’s the most technically advanced field in medicine. Um, we have huge capital requirements. The machines that we use are super fancy. Uh, they allow us to put the radiation exactly where we want to. They allow us to miss places right next to that. And, um, it’s all driven by computers. It’s all driven by software. I spend a significant portion of the day in like almost like a video game environment.

Dr. Mark Story: Yeah. drawing where I want the radiation to go, circling the things that I don’t want to get treated, and then working with a team of people to try and come up with the best plan as to how to get that person’s cancer treated. Um, so it’s just kind of something I gravitated into. Um, yeah. Um, ended up going to MD Anderson, blessed to have trained there, trained there from 97 to01.

David Raubach: And then I’m from Arkansas. Um, so I’m reasonably good at keeping things simple.

Dr. Mark Story: And simplifying some of the complexities because I do think in cancer when you get there, um, it’s like a roller coaster.

David Raubach: You get so much information that that a lot of it is trying to slow things down and get across a few big points to the patient so that uh they can feel a little bit at ease. And um, so I think that’s an important part of the job. But, uh, went to Anderson, went back home to Arkansas, practiced there for 18 years, and then kind of decided in about 2017, I think, when we first kind of met, um, thought protons were going to be the next step forward, the next use of technology to try and help us put more of the radiation where we wanted to and spare more tissues. And so, uh, yeah, six and a half years ago, kind of had the midlife crisis and packed up from a successful venture in Arkansas to come here and work on the, uh, on restructuring and getting the Oklahoma Proton Center back to treating a lot of people here in Oklahoma and taking good care of those people. And it’s been a it’s been a wonderful experience the last six and a half years now.

Dr. Mark Story: So, tell me, you made a comment that I want to touch on.

David Raubach: Yeah. You said that protons is part of this effort to get more radiation to the tumor and less radiation to healthy tissue. And I think that’s a little bit of the way to describe the whole premise behind radiation oncology. Maybe expound on that a little bit. Like when you when you explain what you do as a radiation oncologist to the average person, you meet somebody at church or at the bar and you say, “I’m a radiation oncologist.” How do you explain what it is that you do?

Dr. Mark Story: Uh, you know, again, I think the the goal is pretty simple. The goal is to kind of replace surgery in a lot of cases. Sometimes we we help support surgery with a local treatment, but a lot of times these days, we’re actually replacing surgery. Um, and the goal is to put a lot of radiation into the cancer and put as little as you can other places. And the difference between traditional radiation and protons is that protons go into a depth and they stop. Um, and that allows you to use less radiation. My the best math number I know is uh if for prostate cancer, it’s pretty common, pretty consistent. Uh, so the numbers are pretty reproducible. With traditional radiation, four units leave the machine and end up in you to get one to the target. Um, with protons, 2.2 units leave the machine, end up in you to get one to target. So, it’s almost twice as good at eliminating radiation other places. And so, um that’s I mean that’s really why we designed it back in the day, why these machines are out there. Uh but they come with a lot of complexity. Uh they come with a lot of capital costs. So, they’re not everywhere. But I do think as we continue to move forward, the goal is kind of get cure rates really high, which I think we’re doing better and better at, but as cure rates go up, then the next goal is to get the side effects down.

David Raubach: And uh I think protons are going to help us over the next decade and two to be able to push limits, treat the cancer at a higher dose, get rid of it more often while uh decreasing the side effects from that. So, uh, talk to me a little bit about how radiation fits into the whole field of oncology because I think a lot of patients they get diagnosed, it’s a little bit overwhelming. It’s something new that they haven’t experienced before and maybe they have to go meet with a medical oncologist and a surgical oncologist and a radiation oncologist. So talk a little bit about the interplay with some of these different treatments and some of these different doctors and how it kind of all fits together to do what you talked about which is get rid of the cancer, extend life and minimize side effects.

Dr. Mark Story: Yeah. I think uh so first I think even backing up one step far one step more um when you get the diagnosis of a cancer it’s that’s that’s a lifealtering experience. I mean that kind of throws everybody off the rails. And then radiation has been bad forever. Right.

David Raubach: Right. I mean, no one wants radiation. It’s um there was an old 60 Minutes or 2020 analogy to where like surgery they like picked it up and put it in the bucket and I forget what radiation. Radiation was like kicking the bucket across the stage. Yeah.

Dr. Mark Story: I mean, radiation has always been the bad answer. Um and so uh I think we’ve had an uphill climb to fight that. But radiation in simple terms is kind of used as a as a local treatment. Chemotherapy they give to you and it flows throughout the whole body and treats everything everywhere. Um so if your disease is spread to many places, we really have to rely on chemotherapy. Uh we use surgery for local spots and then we use radiation to be able to cover. Now we can substitute and we call it like radio surgery

David Raubach: as a way to use radiation to substitute for surgery but traditionally a lot of times we used it if we thought the cancer could have little fingers that leaked out other places.

Dr. Mark Story: And with surgery when you go in you can see the main mass but you can’t always see the microscopic little fingers.

David Raubach: And so radiation allowed us to more easily treat a bigger area than surgery. Um so for example in the brain surgery is required um for most cases um there’s always exceptions but generally you do surgery first they remove the mass and then you worry about cancer being in the inch around that brain tissue and it’s a good example because you can’t just go in and take out more and more brain just because you think it might have something bad with it. But with radiation, we can give a moderate amount of radiation to that area, hopefully sterilize those cells, keep the cancer from coming back, and kind of use it as an additional local treatment. So, um, radiation’s kind of closer to surgery than it is to chemotherapy. It’s a local treatment, but we use them kind of oh, in different patterns for different different cases.

Dr. Mark Story: And what are the different types of radiation? You talked about protons, and protons are different than other types of radiation. So what are the when a patient is recommended radiation what should they be thinking about is well these might be my options for how to get radiation.

David Raubach: Well I think we you know we try to make it overwhelming.

Dr. Mark Story: Yeah. Right. Right. Yeah.

David Raubach: So we have protons and then you change one letter a little bit and you make it photons.

Dr. Mark Story: Photons is the traditional treatment.

David Raubach: Um these days honestly it’s really good. Um I mean I treat still a lot of people with with photons. I’ve treated people over the course of my career for 20 years with photons. It’s a really good treatment, very computerized, but the beam you can’t control the depth. And so when you can’t control the depth, you end up giving a little bit more like we talked about before. Um, but that’s photon radiation. And then we have all of these, like everything else in the world today, we have all these anacronyms to where you call it like IMRT. And again we do the same thing with protons and we call it imppt. Uh we have uh electrons which are other kinds of particles but they’re used mainly for skin cancers. Um so again it it’s a complex landscape and I think uh when you come in for the consult that’s why a lot of times the consults we still spend 40 minutes or an hour talking with patients trying to answer questions trying to give them an opportunity to kind of hear things for a second or third time

Dr. Mark Story: so that they can get some grounding because again the the whole process is overwhelming. And I think we’re blessed in radiation oncology to have a slower pace,

David Raubach: Most things in medicine these days, you come in and it’s it’s almost like you’re on a treadmill for the procedure.

Dr. Mark Story: Uh things are moving fast and you’re lucky if you can slow down and kind of ask some questions. And I think radiation oncology for the history of my career has always been essentially the number one rated like from the patient perspective patient satisfaction surveys. It was that way in India Anderson.

David Raubach: It was that way when I moved to Arkansas. It’s that way at the proton center.

Dr. Mark Story: Especially that way at the centerpiec at the proton center.

David Raubach: Uh but again I think you know we’re we’re lucky it’s a slower pace. We get to answer questions and uh you get familiar with the environment and people know who you are when you walk through the door

Dr. Mark Story: and uh the treatments take some time a lot of times. Um so like a course of treatment uh used to be much longer probably the average used to be six or seven weeks of treatment. Uh these days uh it’s as short as three or five. Still most commonly it’s probably four or five weeks of treatment. And in a way that sounds intimidating and that sounds scary, but I think at the same time it gets back to some level of routine. You figure out the process. You have opportunity to ask questions. Generally speaking, patients are doing well. They’re not sick. They’re just coming in for a 30 minute visit. uh most of them are incredibly brave and do incredibly well throughout the treatment course and uh I think oftent times they leave thinking that the time there was not the negative they thought it was going to be at the start.

David Raubach: So this is a question that I’ve always had. Why do we spread out the radiation over multiple days or multiple weeks? Like if I’m a patient I would say well Dr. Sorry, I have this prescriptive dose of radiation. Just give it to me all at once. We can get rid of the cancer that way, right? So, why why do we spread that out? Why do we fractionate?

Dr. Mark Story: I think we’re moving there. And I think in my lifetime, more and more cancers will be treated with a single shot. But the problem is back in the day, we didn’t have the technology that we have even today. And we needed to spread it out to be safe.

David Raubach: You weren’t as precise in hitting the target. You didn’t as precisely know where the cancer cells were. So, you needed to treat an extra extra area. Like back when I started, literally you drew the cancer on an old X-ray

Dr. Mark Story: and you took two fingers as scary as this is.

David Raubach: You took two fingers and you drew your your block around the edge of the two fingers plus the cancer. So, the cancer’s here and you drew a block around it using your two fingers.

Dr. Mark Story: That was the magic.

David Raubach: Sounds very sophisticated.

Dr. Mark Story: Very sophisticated. Now, we are down to literally like trying to do CT scans just for comparison. watching the cancer move and then adding two millimeters uh tenth of an inch. So,

David Raubach: which is like the width of a human hair.

Dr. Mark Story: Not quite that precise, but we’re down we’re down,

David Raubach: we are very precise in hitting the target, missing the things we need to miss.

Dr. Mark Story: Um and so with that, so back in the day, we had to spread it out. And my my simple analogy is uh the cancer cells are broken. the radiation damages DNA and um so we cause damage let’s say on Monday treating everything the healthy cells are healthy they recover they recover significantly better than the cancer cells uh the cancer cells are broken so their recovery processes don’t work as well and so on Tuesday when they show up there’s damage still in the cancer cell and the healthy cells have healed up and so you repeat that process and at the end of the six weeks there’s a whole lot more damage in the cancer cells than there are in the normal cells.

David Raubach: So that’s why we spread it out. I do think in the big scheme of things, we’ll figure out ways to give more and more and more in a single dose exactly to where the cancer is and be able to shorten them like we have. Uh one good example is uh for prostate we used to treat to 44 treatments. So that’s nearly 9 weeks and uh these days most people are getting treatment in under six weeks and then a larger and larger number are offered the opportunity to have five based on some categories. So again I think we’re we’re moving that direction. Uh but the important part is when we move to that direction you don’t just move to that direction for convenience. I don’t think that makes as much sense. If side effects are exactly equal, saving times makes a little bit of sense. But the more important part is to make sure the cure rate stays high,

Dr. Mark Story: Uh we got to first I mean I think the first goal is get rid of the cancer, get everybody to where we’re curing 92 plus% of people. And then once you get to that level, then you can start trying to mess with side effects reduction. So, one of the things, shifting gears just a little bit, one of the things that I’ve read a few articles about that you kind of see on social media and some of the data that the American Cancer Society has put out recently is that we’re seeing cancers that normally used to primarily present in an older population show up in a younger population. Is that something that you have observed in your practice

David Raubach: or is that what what’s your kind of

Dr. Mark Story: I think it’s real. Like it’s hard for me to say that I’ve that I’ve noticed it for certain in my own practice, but I do think it’s real.

David Raubach: I don’t have a good answer for why. Uh like the the most common example that you see right now is colar and rectal cancers showing up in younger and younger people a lot in their 30s. Uh we don’t even recommend screening until about about 45. I haven’t looked at the recommendations recently, but about 45 is when you typically will do a colonoscopy. Um but I mean we’re finding them in 30 year olds, 28 year old I mean like

Dr. Mark Story: very young patients. Uh and so

David Raubach: which is really not something that you would have heard of 30 years ago or

Dr. Mark Story: No, I don’t think so. I think I think something’s different and I’m not sure I’m not sure whether it’s diet. I’m not sure whether it’s general. I mean, I think that’s why there has been a renewed look at what are we doing in healthcare? What what are our main goals? Uh how do we work on diet for the general population? I think obesity is part of it, but not all of it. I I just don’t have good answers and I don’t even if you read the studies they’ll document really well the rise right

David Raubach: in the incidents in young people and in young patients it’s almost impossible to change that with screening because

Dr. Mark Story: it’s still really uncommon and it’s hard to it’s hard to find uncommon stuff. So the answer is not for people in their 20s to go get a colonoscopy. That doesn’t make any sense either,

David Raubach: Um we’ve got to figure out the underlying problem. But even in those studies, and I’ve read several of them this year, they don’t have an answer. Maybe it’s diet, maybe it’s stuff in the I I don’t I I I don’t

Dr. Mark Story: I don’t know.

David Raubach: So the So we So I guess the kind of the long and short of it is we know that there’s a an increase in the incidence rate in the younger population, but we don’t know why,

Dr. Mark Story: right? I have heard you touch on a couple of things which is diet, obesity, uh some other things that I’ve heard is exposure to uh toxins or carcinogens in the environment. You’re starting to see uh some studies looking at the correlation between microlastics and potentially DNA damage leading to cancer incidents. So all of that leads me to think there actually could be ways to prevent cancer. Is that a I mean is that a fair statement? Like if

David Raubach: we need to be working on I mean that you know the only thing I like you see all that and then you see the the opposite comments kind of saying like well physicians just want this because that’s what they want to take care of that’s where all their revenue. I think those are silly as well. We we need to be doing everything that we can to prevent it. Um, I think it’s a difficult puzzle to figure out, but I do think there’s a renewed interest in the country to try and figure out with more of a level playing field where it’s coming from and why it’s happening. And I think that’s beneficial. And I think going back to the young cases, probably the best thing you can do if you’re young and worried about a family history would be just be to read up on simple symptoms for the diseases that you’re most worried about that might run in your family and be aware. And if you see something, go to a physician and be evaluated and see if there’s additional tests that need to be done. what you need to do.

Dr. Mark Story: So you you have uh kids that are what in their early 20s, late teens. They comes

David Raubach: 20s. Okay. Well, that makes you old.

Dr. Mark Story: Yeah. Exactly.

David Raubach: Exact. Yeah. Uh

Dr. Mark Story: so they come to you and they say, “Dad, uh we want to reduce our life. We want the playbook to reduce our lifetime chance of getting cancer.” What What are the three things that you’re telling them?

David Raubach: kids, you this is what you should do. So this week, so I read smoking. Smoking is an amazingly powerful.

Dr. Mark Story: It is if you smoke, the data says, and I I can’t believe it because I just read it this week again, uh 10 years off your life.

David Raubach: So if if the average American lives to 78 and you smoke, it’s essentially 68. But if you stop before you’re about 30 or 40,

Dr. Mark Story: essentially all of that returns.

David Raubach: Okay? If you stop when you’re 55, 60, not near as much of it returns.

Dr. Mark Story: So, kids, put down the marbor lights as you’re watching this episode.

David Raubach: Yeah. Yeah. Absolutely. And I, you know, I think for a moment, like again, this, and this is where I think people have a hard time going online and then figuring out like what’s real, what’s right.

Dr. Mark Story: Um, seven years ago or so, eight, maybe time flies. I’m like you said, I’m old, right? Um, probably nine or 10 years ago, I was recommending to my cancer patients to switch to vaping.

David Raubach: Cuz that was what medicine thought we should do,

Dr. Mark Story: Um, now I don’t think that’s right. You’re better off. You just got to stop. I mean,

David Raubach: just stop it.

Dr. Mark Story: You got to figure out. Yeah. I mean, if you’re presented, I mean, even once you’re diagnosed, the most powerful thing that is in your control is if you smoke, stop smoking.

David Raubach: I think second behind that is diet.

Dr. Mark Story: Okay. uh maintaining a healthy weight. I think it’s incredibly important. I think it’s been underemphasized. It hadn’t been discussed enough, but I think maintaining appropriate healthy weight and uh the next thing is probably exercise.

David Raubach: So, smoking, diet, exercise, probably the big three.

Dr. Mark Story: I think uh and I’d love to get your thoughts on this. I think what I’ve heard uh in my research on Tik Tok, you know, where you get all good information these days

David Raubach: is that it’s not just about a healthy weight because there’s things that you can do to maintain a healthy weight like for example uh doing ompic or one of the GRP1 uh drugs, but it’s also there’s a diet component too. It’s it’s maintaining a healthy weight by making the right nutritional decisions. Yeah, I think uh the ideal answer is controlling calories and exercise. I think that’s that’s the perfect answer.

Dr. Mark Story: I think um but hon I think I think Ozmpic and some of the

David Raubach: GLP ones.

Dr. Mark Story: Is it GLP? Yeah, not GRP. Okay. Yeah.

David Raubach: I’m just a podcast. You’re the doctor. So,

Dr. Mark Story: but that’s not my wheelhouse. Uh the uh I think they’re going to be good for society. I think obesity is such a problem that I I think they’re going to have side effects. I think they’re going to have toxicity,

David Raubach: but I think the toxicity

Dr. Mark Story: uh will be outweighed by the benefits of less cardiovascular disease.

David Raubach: Okay. Well, that’s that’s an interesting

Dr. Mark Story: less probably cancer diagnosis down the road.

David Raubach: And so I think they’re going to be a win on some level. Um I think they’re far from ideal. Like you said, I think

Dr. Mark Story: ideal is and that’s what you know I think America’s tough place right now. I mean like saving money is really hard. It takes

David Raubach: a thousand 10,000 good daily decisions all of the time to be able to save money,

Dr. Mark Story: Same thing for weight. It takes 10,000 I mean you can’t make it one good decision,

David Raubach: right? Um, it is a daily routine that takes years and decades um to really drive home, I think, the benefits. And that’s they’re they’re incredibly difficult and and so is smoking. I mean, like I almost feel bad like it’s easy to tell somebody to stop smoking,

Dr. Mark Story: It’s really difficult to do. They are addictive. Um, it’s a hard transition.

David Raubach: But I think those things are important. I think the weight loss uh concept is is really interesting because we do think about the association between obesity and like cardiovascular disease,

Dr. Mark Story: but it is it’s it’s fascinating to know that there’s actually this link between cancer incidents and obesity as well. So

David Raubach: really the point with that is obesity can lead to all kinds of problems down the road. So, uh, going back to getting information on TikTok, I know that, uh, that’s probably something that’s changed for you as an oncologist from when you first started practicing to today where there’s a lot more access to just this broad scope of information. I mean, and so I’m I’m sure that I can imagine patients are coming in and talking to you and say, “Well, doctor, I saw this or I read this or I heard about this.” um how how do you manage through that and and what would be your recommendations for patients about how to approach them maybe doing their own research uh versus um what you’re talking to them about about treatment regimens. How are you kind of managing through that phenomenon? Um, like I I don’t I try to listen probably as my first like I think like I see the patient, they walk in and you see them walk in and you know what they’ve got and you know the primary thing that you’re supposed to deal with. Um but you haven’t lived with them and you you they know their body.

Dr. Mark Story: Um even if they don’t have like a medical background education, they know what they’re going through. they’ve generally looked online and come up with some pretty reasonable thoughts. And so I think first step is to listen, try and figure out where they’re coming from, see what their concerns are, and see uh then if you think they’re on the right track or if they’re lost down some bad part of Tik Tok, You know, um

David Raubach: there are bad parts of Tik Tok.

Dr. Mark Story: I think I don’t I don’t actually have an account. So, um, but yeah, uh, there are bad there’s bad information on the internet, but I think in general it’s been good. I think, uh, you got to trust patients to be involved in their care. You got to trust them to help you. You’re on the same team. You both want the same thing. You want it to be as smooth and as good of an outcome as you can ever get. You want them to have the least side effects. You want them to roll through treatment and look back and be like, “Yeah.” So, you need to be on their team, listen to them. Um, I think, uh, and if you listen, I they’ll talk to you a lot more. I mean, I probably have three patients that I can think of off top of my head who tell me they’re on alternative medicine,

David Raubach: treatments who then go to, if you were to name the top five total comprehensive cancer centers in the US. They go to those centers and they don’t tell their physicians there that they’re doing the things,

Dr. Mark Story: right? because they think they’re just going to get told to stop it and get out of the room.

David Raubach: Um, I think the the better way to approach it is to listen, talk to them. Sometimes it’s pretty reasonable. Sometimes I think they’re off course, but I think you need to listen to them, have the conversation, figure out where they’re coming from, and see if that makes a lot of sense. And I’ve got some people who are doing some alternative treatments, and I think it’s been good.

Dr. Mark Story: Mhm. it’s it’s it’s helped them. Um, and I think other times it it makes no sense. And so if you if you don’t listen to the patient, you can’t get their side of the story. And if you don’t get their side of the story, you never even hear about it. And so, you know, they’re going to these cancer centers around the US and then not telling them and they don’t even know that they’re getting these treatments. So I think uh so I love that and I think that’s part of what we’ve tried to do at the Oklahoma Proton Center is create this safe space where you as a patient can come in and talk about anything that you’ve heard about or read or want to try or are trying and we want to have that conversation with you. Um and then as you mentioned you’re not afraid to say keep doing some of those alternative treatments. So you so you mentioned that uh you have a couple patients where you think maybe there’s some alternative approaches that have helped them.

David Raubach: What’s an example of that?

Dr. Mark Story: Um well I kind of group it into two things. Right. So just just to be clear there is the initial diagnosis. We’ve got really good standard of care treatments that have a really good chance of curing you that we know improve survival. to jump from there into a post on X and decide that you’re going to do these three or four steps instead of proven treatment,

David Raubach: Is almost never the right decision. Um, there are other cases to where you’ve been through five standard treatments and for whatever reason they haven’t worked or it’s five years later now and it’s back and you’ve just failed the fifth line of treatment and we’re running out of options. Those are two very different scenarios. Um, I think so that’s kind of how I group it. Um, and then I I don’t have a crystal ball I think um on whether or not some of these andazol and things like that uh ivormectin whether or not they’re they’ll they’re helpful harmful they generally don’t interfere with radiation of any kind whether it’s traditional radiation or protons they don’t interact so I don’t worry about them too much I think medical oncologists who are giving chemotherapy worry about them more um so I I’ve allowed it to kind of continue regardless. I think uh diet changes I I don’t think we know enough right now. I think we should be farther along in our science of what good diet is.

Dr. Mark Story: Um and just as a society that hasn’t been where we’ve focused for the last 30 years, right?

David Raubach: We like quick pill fixes.

Dr. Mark Story: Yeah. And I think we’ve leaned too much on that and too far away from what we put in our body. And I think on some basic level controlling what you put in your body makes a whole lot of sense. Uh and I think it can benefit people. So, let’s go down the the rabbit trail of uh ivormeckin and fenbendazol because that’s certainly a hot topic and uh the second most popular podcast uh in the country be behind this one Joe Rogan has talked about it a few times.

David Raubach: So, what how would you somebody comes to you and says uh Dr. story. I’m I’m thinking I’m going to do an over-the-counter Fenbendazol or Ivormectin treatment regimen. What do you say?

Dr. Mark Story: Um, and why do you say what you say?

David Raubach: I I guess I’d look back and figure out what the cancer is, what the what the game plan is, what our standard treatment is, and why they’re looking in that direction. Um, you know, I think uh if it’s chemo, then they really need to run that question. I mean, I’m open to listening. If it’s a chemotherapy needed diagnosis, then they’ll need to run that through their medical oncologist to make sure that the drug interactions aren’t potentially harmful. Um, if it’s just radiation alone, most of them come in and say, “Well, I’m taking this and I’m going to keep taking it.”

Dr. Mark Story: And I’m like, “Okay.” Uh, and generally it’s been well tolerated. I’ve had a few people stop it for various reasons along the way. Not really as a combination from the protons and the and the drugs, uh, but just for side effects from the drugs. Um, again, I I don’t have my main priority there is to emphasize that so in prostate a lot of the guys would cure 95 96% of the time. there’s little need for extra risk and taking extra things adds some additional risk. Again, that’s completely different than somebody who has failed five treatments and is now looking at a treatment that the doctor looks at them and says it might work a third of the time,

David Raubach: Those are two very different scenarios. We really need to make sure and and prioritize really good treatment. Uh when we have good frontline, second line treatments that we know work, that we know improve survival, we can’t substitute those things in. I think in all cases, you can still work on dietary improvements and even there I don’t have a crystal ball. I think uh less processed foods, more things that you can identify. I I I’ve moved towards a little bit more protein. I think in the US we generally don’t get enough protein. Um, so I think

Dr. Mark Story: fruits and vegetables,

David Raubach: fruits and vegetables, things that you point to and you say that’s a pecan,

Dr. Mark Story: That’s a green bean.

David Raubach: Those are those are healthier for you

Dr. Mark Story: the things that you didn’t want to eat as a kid that your parents told you to eat. Turns out they might be good for you. There might have been a reason that they were telling you

David Raubach: those were wrong all the time. Yeah.

Dr. Mark Story: So, uh, just shifting gears a little bit. So, we we’ve talked a little bit about cancer prevention and some different treatments and alternative treatments. Um, so before we wrap up today, I do want to talk about cancer screening. And one of the big stories obviously recently is the diagnosis of President Joe Biden uh of prostate cancer. And one of the things that kind of shocked everybody I think a little bit was the fact that he hadn’t been screened for prostate cancer or he hadn’t done a PSA test. So the prostate specific antigen test for prostate cancer I think in over 10 years. I think he got diagnosed this year and the spokesperson for the president said his last PSA test was 2014. So, how did you as a radiation oncologist take that story? What what was what were you thinking as you as these facts started to come out about his diagnosis and kind of what you were reading about his screening and where he ended up being at with the diagnosis?

David Raubach: It was kind of a it’s been a crazy couple of weeks. I mean, I this is an area to where I spend a lot of time. If you go on the Substack, I write way too much on PS

Dr. Mark Story: out to the Dr. Mark story substack. Check it out. Lots of good information there.

David Raubach: Yeah. And it tries to read. It’s probably not quite like a technical journal. It’s probably one step down from there. Still got a lot of uh obvious like references and it’s very detailed,

Dr. Mark Story: but uh it’s one step down from reading like a journal article.

David Raubach: Um and I try to integrate some stories into it. Um so this was crazy. Uh I mean again I I keep a database. I’ve probably got 2500 PSAs in a database that I keep and I update daily. Uh, this has been my wheelhouse of what I’ve done. There was one tremendous misinformation all over the news on almost every expert who I saw talking day one. I mean, there were some good points by some people, but in general, the best thing to do was just be quiet for a couple of days, let things calm down.

Dr. Mark Story: So, this is right. So, this is when the the story first came out.

David Raubach: Story first he’s been diagnosed. diagnosed metastatic but we didn’t have all the details.

Dr. Mark Story: Yeah, we still have very few details but just to kind of give you some stats. So the the preventative cancer screening recommendations in the US have been all over the map. Back in the day we used to screen everybody. uh prostate cancer deaths once we de developed PSA. PSA rolled out I think FDA approved in 1994 became widely used for screening in the early 90s from the ‘9s till about 2010. Year-over-year deaths in men from prostate cancer, every age category every year pretty much tracked lower.

David Raubach: per 100,000 men, fewer and fewer men died. The thinking was though at the time that we were treating too many men with these early prostate cancers and they’re all doing so well that we don’t need to screen all these people. So in and there was a pendulum uh that the swings, right? We’re doing everybody now. We’re not going to do anybody.

Dr. Mark Story: Um and in 2012 they decided to not screen anyone. That was the recommendation in the US at that time. Let me remember the stats. the death rate in um oh the presentation rate for men to present with like Joe Biden did with metastatic disease was one in 14 men over 75 diagnosed with prostate cancer.

David Raubach: So we stopped screening in 2012 2018 I believe we reversed part of it and said younger than 70 we can screen. the older men were still not going to screen. Today, the number for men over 75 has gone from one in 14 men diagnosed with metastatic disease to one in five men.

Dr. Mark Story: So, the screening recommendations to not screen people are clearly wrong.

David Raubach: The death trend was lower. It went flat. And as many people now pass away per 100,000 men from prostate cancer now as they did in 2012 when they reversed those

Dr. Mark Story: screening recommendations. The number of men diagnosed with metastatic cancer has risen and then we’ve kind of made an arbitrary cut off and the the cut off they’ve decided on is 70. Um again I so I I disagree with the screening recommendations. I think people should be screened. I don’t think the problem is with PSA. The problem is too many downstream decisions based on a PSA without good conversations about risk and benefits. Um, yeah. So, the rate in in men over 75 has gone from 1 in4 to one in five. we’ve made this arbitrary cut at age 70 saying well these are so old not my words but I guess this is the thoughts of the screening recommendation that those men have other competing risk that shouldn’t then put them through a PSA and a potential biopsy to figure out what’s going on u the problem is those men are showing up with increasingly more metastatic disease like the president so the comments that you saw saw on the news where it’s incredibly uncommon. It’s not incredibly uncommon. It’s one in five.

David Raubach: In his age group.

Dr. Mark Story: Uh the risk of a 75y old showing up with metastatic prostate cancer compared to a 50year-old in the US is about 400fold. Wow. Basically, no one who is young gets caught with metastatic prostate cancer. And the and you would say the reason for that is that there’s more regular screening at a younger age.

David Raubach: Yeah, we’re more there’s probably two or three things. One, prostate cancer is more common as you get older.

Dr. Mark Story: Two, there’s some evidence that maybe even it’s more aggressive when you are older. Maybe because you’re not in as good a shape, your immune system’s not as strong. I don’t have great answers. Uh and then uh three, I think part is screening. you know, you’re obviously trying to find them in younger men quicker. Um, but but I think in in totality, there is no doubt that the screening moves away from screening uh in 2012 were wrong and the partial unwind is probably not enough. And unfortunately, Joe Biden, I I my hope is that that case will become a realization of the data to where we reassess screening recommendations and reinstitute them in in men. Honestly, I’m not sure a long time. I think y’all just have educated educated decisions. I think the the problem with our current medicine uh or the current protocol for prostate cancer is not the PSA, it’s what do you do with an elevated PSA? Do you move forward with the biopsy? Do you not move forward with the biopsy?

David Raubach: Um but again, trend lines back when we decided to unwind it prostate screening prior to 2012, if you got diagnosed with low-risisk prostate cancer, about 15% of men were observed almost. So eight and a half out of 10 got treated for prostate cancer with low risk disease. Today 25% of men with low-risisk disease get treated. We w instead of treating the vast majority of patients, we now watch the vast majority of patients.

Dr. Mark Story: And that and that’s a term that you might hear is active surveillance.

David Raubach: And so really the idea there is you have prostate cancer but it’s very early stage. uh we we’ve taken the biopsy, let’s say, uh we’ve we’ve uh looked at genetic biomarkers and we’ve determined this is not an aggressive cancer at this point, so it doesn’t require immediate treatment.

Dr. Mark Story: Yeah. So, I think like you touched on a couple of things like again 2010 we uh we didn’t have many options. We didn’t have any good way to image the prostate routinely. So, we couldn’t look and see look for the cancer.

David Raubach: Today, we have PSA. You can look at not one PSA, but you can look at a pattern of PSAs. And to me, there’s way too little emphasis on the pattern of PSAs. A PSA that goes three to 3.2 to 3.4 is different than a PSA that goes from one to three and a half to seven. Those are different scenarios. Um, but we have PSA pattern, we have MRI, and then if we decide to do a biopsy, you can stick the needle where you think the cancer is on the MRI. Um, and so that’s helped us to get better information about the cancer, find the highest risk disease in the prostate. Um so we have and then you talked about genetic genomic test to where in the old days uh pathologists looked under the microscope and said

Dr. Mark Story: this cancer is a gleon and they gave it a gleon score. There are some cards. They literally look at three different cards and they say if I had to guess I’d say this one looks like a three,

David Raubach: And then if I had to say the second number I’d say well it looks like card four. And that’s literally what they do. They have three cards, three, four, and five. They pick which one it looks the most like.

Dr. Mark Story: And then you add those two together.

David Raubach: Add those two together, right? So for Biden, he either had a four plus a five or a five plus a four,

Dr. Mark Story: And that just means like which one’s more common. Which one the pathologist looked in the microscope and said, well, if I had to, my first guess would be, and it’s not really a guess if you’re a pathologist.

David Raubach: Uh my first idea would be five based on these criteria in the pictures. Um, but now we can look at the DNA in that cancer and give a numeric outcome like we think your estimated risk of this showing up in the bones in 10 years is 9.7%. Or 1% or 30%. And so we have a tremendous wealth of information that can help us steer those patients appropriately. And so when you think about it, you know, the president was having at least annual blood draws,

Dr. Mark Story: for something cholesterol,

David Raubach: Looking at A1C, looking at basic info. Had to have,

Dr. Mark Story: And then they just run extra tests in the lab and you get information back. Well, that’s how simple it is.

David Raubach: So I’ll stop you right there because I don’t think we’ve touched on this. Maybe explain for those that don’t know what a we keep Oh, yeah. saying PSA test.

Dr. Mark Story: PSA is just a blood draw,

David Raubach: So, when you’re in for the blood draw and they pull out four different vials and one’s got a purple top and one’s got a green top and one’s got a red top. They may add a white top. The white top’s the PSA and they they run it they run it through a test and it’s about a hundred bucks,

Dr. Mark Story: right? And uh but I think it gives really good information and again I think the data says it clearly helps prevent these bad case scenarios to where we find it once the prostate cancers out of the prostate and the bones. If your PSA is less than 10, the odds of it being some other place is incredibly low. Not zero. Nothing in medicine is zero, but it’s very low. So low that like if you showed up,

David Raubach: we probably wouldn’t even get tests to look for it other places. you would just say, “Well, it’s here. How do you know your PSA is low?” And you move on.

Dr. Mark Story: So, to kind of tie a ribbon on all that,

David Raubach: Your recommendation is if you’re over the age of 70, you’re healthy, you probably have a number of years in front of you. There’s no reason not to go ahead at your annual physical when you’re getting a blood draw anyways to say, “Can we also measure my PSA?” I I will do it. I tend to be conservative. I tend to underdo probably medical recommendations in general. That’s a no-brainer to me.

Dr. Mark Story: I don’t want to put words in your mouth.

David Raubach: No. Sounded like my simple rule is kind of and like none of the guidelines really do this very well, but my simple rule is and and again this is not in the guidelines. This is not formal medical recommendation, but it works pretty darn good. Um take your age, divide it by 10. If your PSA is higher than that number, probably you need to have it looked at.

Dr. Mark Story: Um it’s that’s a little generous for young people. If you’ve got a family history and you’re 50, realistically, your PSA ought to be down closer to one.

David Raubach: Um but rarely will that formula miss something really bad. The worst case scenario is your PSA is three and you’re 50 and you decide to come back and you follow it and it moves to three and a half and you decide to follow it and it moves to 4.2

Dr. Mark Story: and then you can get your MRI and talk to your your urologist at each of those visits and decide when the two of you think you ought to move forward based on family history and what’s been going on.

David Raubach: But I think it gives you options in time and it’s super easy. Well, when we when we talk about cancer prevention, there’s preventing cancer from ever presenting, but there’s also preventing cancer from spreading or metastasizing. So, there’s there’s kind of two components to cancer prevention. Y

Dr. Mark Story: and screening plays into that second aspect of cancer prevention, preventing

David Raubach: preventing the cancer from presenting more advanced.

Dr. Mark Story: That’s correct. So, uh, my last question for you today, and this has been fantastic, uh, such good information, is what are you most excited about as an oncologist as you look forward over the next few years, five years, 10 years when you think about where the field’s headed? What What are What’s something that you’re really looking forward to? Oh, I I just think probably most globally is just the continued use of better and better technology to do better,

David Raubach: see better outcomes, be able to do the things we talked about, put more cancer, I mean, put more dose into the cancer, get rid of it more often, decrease side effects, potentially shorten the treatments up. Uh, and I think protons are going to be an important part of that. Mhm.

Dr. Mark Story: I think uh in the last uh few years we’ve seen great data on this is going to be complex but like cranio spinal treatment

David Raubach: for adults with metastatic cancer in the spine. We’ve seen great data for protons improving outcomes in lung cancer. We’ve seen great data for protons improving outcomes in esophageal cancer. And I think in the next year we’re going to see it in um head and neck cancer. Um so I think uh it’s just the use of technology and then it’s going to be a ride while um AI comes along

Dr. Mark Story: and helps integrate some of these things even more quickly. Speeds up the speeds up the progress hopefully.

David Raubach: Yeah. And that’s a tool that we’re using and that you’re uh very in tune with what’s happening and how that kind of interplays with oncology and how we can use it to our benefit as we treat patients.

Dr. Mark Story: Yeah. Again, I think that goes back to our field being the most technologydriven and I think uh probably we have one of the larger avenues to integrate it into our field to improve outcomes, make things more efficient, quicker, yeah, better.

David Raubach: Well, that’s great. Thank you, Dr. Story, for your time. If anybody would like to talk with Dr. Story and has more questions, um they can get a hold of you at at the Oklahoma Proton Center. Uh we’ve got a website okcproton.com. Um you can find the phone number on that website. And I will say I’ve worked with a lot of oncologists. Dr. Story is absolutely one of the best when it comes to staying out in front of advances in medicine, advancement in treatment techniques, ways to use different types of radiation. Um, but the other thing that I love about you and I see this on a regular basis and we get feedback from our patients is that you have great patient care and I think you mentioned that earlier that part of your approach is listening to patients when they come in and we see that and we get that feedback in the patient surveys at the facility. And so that’s also you got to have both to be a really good doctor. Know the medicine, know the technology, but also really care about the patient and we have that with you. So um again thank you so much for being with us today.

Dr. Mark Story: Absolutely. Yeah. Thank you very much. Very kind words. Thank you.