Episode 3

More than a Cure Part 2: Q&A With an Oncologist Answering Your Toughest Cancer Questions

Episode 3 Dr. John Chang Medical Director, Oklahoma Proton Center ~38 minutes

Episode Summary

In this follow-up conversation, David Raubach welcomes back Dr. John Chang, Medical Director of the Oklahoma Proton Center, for Part 2 of their oncologist series — a candid Q&A session built around the real questions patients bring to the clinic. Rather than a lecture, this episode is a dialogue: the kinds of honest, detailed answers that often take years of patient advocacy to obtain, now offered openly to anyone navigating a cancer diagnosis.

The discussion opens with breast cancer and tackles one of the most common misconceptions patients arrive with: the idea that they can choose proton therapy instead of surgery or chemotherapy. Dr. Chang explains that breast cancer treatment is rarely a solo act — surgeons, medical oncologists, and radiation oncologists typically convene as a team and recommend a coordinated course of care. He walks through why lumpectomy combined with radiation is considered equivalent to mastectomy in terms of survival for early-stage disease, and why radiation after surgery is not redundant: it eliminates microscopic cancer cells that surgery cannot see, reducing local recurrence rates from as high as 30–40% over ten years down to roughly 5–10%. That reduction, he emphasizes, doesn’t just prevent local failure — it saves lives.

Prostate cancer takes center stage for a substantial portion of the episode, with Dr. Chang outlining the full spectrum of options: radical prostatectomy, external beam radiation (photon or proton), brachytherapy, and active surveillance for low-risk cases. He addresses the surgery-versus-radiation question with nuance, explaining that side effect profiles differ in timing — surgery carries higher early rates of urinary incontinence, while radiation may produce more urinary and bowel effects during the treatment course — but long-term outcomes are broadly comparable. He also highlights how PSMA PET scanning has transformed the management of biochemical recurrence, allowing physicians to pinpoint exactly where cancer has returned and deliver targeted salvage therapies with far greater precision than was previously possible.

The conversation broadens into territory that is often left to the margins of oncology appointments: pain and side effect management during treatment, the ability to keep working, the profound emotional weight of a cancer diagnosis, the underappreciated burden carried by caregivers, and the long road of cancer survivorship that begins the day active treatment ends. Dr. Chang closes with an impassioned reminder that outcomes today are dramatically better than they were even a decade ago — and that patients should advocate fiercely for themselves, seek second opinions, and refuse to walk the cancer journey alone.

What You’ll Learn in This Episode

Multidisciplinary Treatment Planning: Breast cancer care is coordinated across surgery, medical oncology, and radiation oncology as a team. Patients don’t choose one modality over another — the team recommends the optimal combination based on each individual’s diagnosis and biology.
Lumpectomy + Radiation vs. Mastectomy: For early-stage breast cancer, clinical evidence shows that lumpectomy followed by radiation achieves survival outcomes equivalent to mastectomy, while preserving the breast — making it the preferred approach for many patients.
Why Radiation Follows Surgery: Even a technically successful surgery can leave behind microscopic cancer cells invisible under a microscope. Radiation eliminates these residual cells, reducing the ten-year local recurrence rate from 30–40% down to approximately 5–10% — an improvement that also translates into improved long-term survival.
Prostate Cancer Treatment Options: Newly diagnosed prostate cancer patients may be candidates for radical prostatectomy, external beam radiation (photon or proton), brachytherapy (radioactive seed implants), or active surveillance — the right choice depends on tumor risk, anatomy, and personal preference.
Surgery vs. Radiation Side Effects: Surgery tends to carry higher rates of urinary incontinence immediately after treatment; radiation more commonly produces urinary and bowel symptoms during the treatment course itself. Long-term outcomes for most patients are broadly similar between the two modalities.
PSMA PET Scanning and Targeted Salvage Therapy: When prostate cancer recurs (detected by rising PSA), PSMA PET scans can precisely locate the cancer — enabling targeted salvage treatments directed at specific sites, a major advance over older imaging approaches.
Radiation Is Not Painful: The radiation beam itself produces no sensation during treatment. Sessions typically last 20–30 minutes. Side effects — fatigue, skin changes, urinary frequency — develop gradually, are site-specific, generally manageable, and typically resolve after treatment concludes.
Working During Treatment: The majority of radiation therapy patients maintain their normal daily routines and continue working throughout treatment — a major distinction from chemotherapy, which is more likely to interrupt daily function.
The Emotional Dimension of Cancer: Anxiety, depression, and fear of recurrence are universal experiences for patients and families. The Oklahoma Proton Center addresses this by embedding social workers, counselors, and strong patient-staff relationships into the treatment experience.
Caregiver Burden: Spouses, children, and other caregivers manage their own fear and grief while simultaneously coordinating logistics and providing support. Dr. Chang emphasizes that caregivers deserve active support from the medical team, not just acknowledgment.
Cancer Survivorship Care: Survivorship begins when active treatment ends and encompasses long-term side effect management, structured surveillance to detect recurrence early, and psychological support. Many survivors also report profound positive shifts — renewed purpose and more intentional living.
Patient Self-Advocacy: Ask questions, seek second opinions without hesitation, understand your diagnosis thoroughly, and lean on every available support system — family, community, mental health professionals, and patient support groups. The cancer journey is too demanding to navigate in isolation.

Whether you’re facing a new diagnosis, supporting someone you love, or simply trying to understand what cancer treatment actually involves, this conversation with Dr. John Chang delivers the kind of candid, expert perspective that changes how patients walk into their next appointment. Part 2 of More Than a Cure is essential listening — and a reminder that knowledge, advocacy, and human connection are as central to healing as any treatment protocol.

Full Transcript

Read Full Transcript

David Raubach: Thank you for joining us today on this episode of the Cancer Project. We’re really privileged to have Dr. John Chang, medical director of the Oklahoma Proton Center, back for part two of a conversation with an oncologist. And today we are going to answer the questions that you’ve always wanted to ask an oncologist. So, we’ve compiled a a list of questions that our patients have asked as they’ve come to this center, and we hope that those are going to be really helpful and educational for you. Um, so again, questions you’ve always wanted to ask an oncologist with Dr. John Chang, medical director of the Oklahoma Proton Center. So, here we go. We’re just going to we’re going to dive right in. Um, so one of the disease sites that we treat pretty frequently at the Proton Center is breast cancer. Um, and one of the questions that we get asked a lot is, can I do proton therapy and not do surgery or chemotherapy? So, for that type of question, how do you approach answering that question? Well, what I usually tell them is that when you get a diagnosis of breast cancer, usually the surgeon, the oncologist, and the radiation oncologist usually all kind of convene and talk about the patient approach. Um, because it is really a triodality or all three medical disciplines really need to weigh in on what the best approach is. to really kind of address that question. It is very dependent on what the cancer is, the extent of it is to know how much surgery they need, whether they need chemotherapy or hormone therapy and where radiation plays a role. Just as a generic answer to that question, typically radiation cannot substitute for surgery. And if chemotherapy is needed, radiation usually cannot substitute for that because surgery is something that removes the bulk of the cancer. And then chemotherapy kind of treats the whole body. And so, so radiation is really focused on the cancer in the breast. And we typically want the surgeon to remove as much of it as possible. So when the radiation hits it, the area that’s left is hopefully just microscopic cancer cells and that’s where we’re going to be most effective for breast cancer.

Dr. John Chang: So for a a breast cancer patient, they’re getting radiation. Another question we get is why would I get proton therapy versus photon therapy? Isn’t radiation radiation?

David Raubach: Yeah. From the standpoint of killing the cancer, the protons and the regular radiation photons is similar in its ability to kill the cancer. The difference is is that when you use regular radiation, it’s just a beam of energy. So when we shoot it into the body, it goes in one side and out through the other. Protons are like tiny little bullets or tiny little particles that we send in, goes to a spot, hits what it stops, hits what it stops at, and doesn’t damage anything else beyond it. And so it really minimizes the chance of causing collateral damage. And the breast sits on the chest wall. So everything underneath it, if the beam were to penetrate any deeper, could hit the heart, could hit the lungs. And even at different angles that we’re trying to use with regular radiation to try to minimize that, there’s still going to be more exposure to those tissues with regular radiation than you would ever get with protons. And that’s going to be critically important, especially on the left side where the heart is closest to the chest.

Dr. John Chang: So the heart is not in the middle of your chest. No, it’s

David Raubach: it’s more towards the left.

Dr. John Chang: Okay. So, I and and again, I’m I’m imagine I’m a patient here. So, I went to a facility and they told me, well, they’re going to do this fancy technique uh where I hold my breath. Uh I think it’s called deep inspiration breathold, right?

David Raubach: And that’s going to keep the radiation from hitting the heart. Doesn’t that do the same thing? Doesn’t that accomplish the same thing as what you’re talking about with proton therapy?

Dr. John Chang: It’s trying to it’s trying to expand the lung to try to push the chest wall further away from the heart and that is sometimes successful in minimizing the dose but then now you’re expanding the lung into the area that we’re going to treat even if you’re using angles on that. So, so yes, it can improve the heart dose but it doesn’t change the lung dose so much. And with protons, we can do that either with that approach which can enhance our ability to shield out the heart from the treatment field or we can do it without it very safely. So, so in that type of situation, we have both modalities at our facility. We have regular radiation and the protons. We can actually do a comparative plan between the two to really look at the difference to see if the difference is worthwhile to using protons over regular radiation. Typically, when it’s on the left side, it is.

David Raubach: So, it sounds like, if I could if I could dumb this down a little bit, with protons, you kind of get the best of both worlds where you get the physical benefit of of proton radiation being able to be stopped

Dr. John Chang: inside the tumor.

David Raubach: And on top of that, if we need to, we can also have you hold your breath during treatment if that keeps the heart even more out of the field.

Dr. John Chang: So, you get the best of both worlds. So, we have a late breaking question from our producer.

David Raubach: Uh, and I think this is a great question because we get this from patients a lot.

Dr. John Chang: Is protons radiation? So, we’ve talked about radiation and we’ve talked about proton therapy. Are those the same thing or what’s the difference between the two?

David Raubach: Yeah, protons are a form of radiation. So, simple answer is yes. Protons and photons are radiation. It’s just the different physical characteristics of what they do in the body. Right? So with protons we can stop them. With photons it’s just beam of energy passing through. So when we talk about which one we would use, right? The difference is not usually whether one’s going to be more effective in killing the cancer over the other because both are equally effective from that standpoint. is are we going to gain a significant advantage in protecting our normal tissues in the body? And so we can actually run simulations, right? People do simulations all the time of different things that could possibly happen, right? So what we do is we set up a treatment with protons. We set up a treatment with regular radiation. We compare them side by side to see how much dose is getting to the cancer and how much are we able to minimize dose to the normal tissues. And the one that basically does best with that is usually what’s treated or what’s used to be treated. Typically protons are never going to be inferior to the photons or the regular radiation. It’s going to be at least equal and when it’s better then we utilize protons in that situation. So you have the ability as a doctor to quickly put together a plan or a treatment using proton therapy and assess that against a plan using photon radiation or so it’s proton radiation and photon radiation and you can look at both of those plans and say

Dr. John Chang: which one gets all of the radiation to the tumor that we need

David Raubach: but then also keeps as much radiation off of healthy tissue as possible. Correct.

Dr. John Chang: And then you’ll say patient this is this is the best way to go for you.

David Raubach: So then I’m a patient and I say and and imagine I’m a breast cancer patient. Uh well how many how many treatments am I going to get?

Dr. John Chang: Right? So that is something that has been studied pretty extensively now because the goal has been in the most recent I would say 5 to 10 years of trying to get the treatment done a little bit quicker to number one have obviously less downtime for the patient to have to come back and forth for treatment but also to maximize the time the time away from any treatment. Right? So, so we’re trying to shorten the number of treatments by increasing the dose per treatment and we’ve done the studies to look at what achieves that maximum uh effect. Basically, still the concern always was that if we turn up the radiation dose every day, are we going to get more side effects? Um, and with a very focused treatment like protons, the the chance is that we’re not going to worsen the side effects profile, but still improve the chance of being cured.

David Raubach: So, it’s uh give me an example of a number of treatments that a patient may get. What’s what’s the range? The shortest possible treatment and the longest possible treatment.

Dr. John Chang: Yeah. So the studies that have been done recently, it used to be traditionally most women would get about 6 to 7 weeks of radiation every day Monday through Friday. So anywhere from 30 to 35 treatments. We were able to probably about starting about maybe 15 years ago shorten that down to roughly about 15 to 20 treatments. The most recent studies that came out of the UK recently have shortened it down to like five treatments. There are different parameters in each of those studies that we have to be careful of, you know, in shortening the number of treatments, how aggressive the cancer is, the extent of the area that we have to treat. Those are parameters we have to look at in order to make a determination as to what is the safest approach. Typically, what we would say that is kind of the standard of care now is roughly about 15 to 20 treatments and there are some scenarios where we can do five treatments. Um so we would basically I would say to patients talk with your oncologist ask them what number of treatments is the best approach for their cancer and have them explain to you why as to safety versus aggressiveness of the cancer extent of the cancer. Why is it that they’re suggesting one number versus another? And so just I I just want to step back a little bit on so so we’ve talked about the number of treatments. If I could summarize with with proton radiation, what we’re really trying to do is get most of that radiation to the tumor.

David Raubach: And it sounds like what you’re saying is that critical structure, one of the most critical structures that we’re looking at is the heart,

Dr. John Chang: right? Tell me a little bit about the dose or the amount of radiation that we’re talking about. Like I So I’ll give you an example. Uh I went to the dentist recently and I got a dental X-ray and I had to wear a lead shield or a lead apron

David Raubach: and the dental tech walked out of the room and they did the X-ray and it seemed like okay well that’s probably a lot of radiation. How does that compare to the amount of radiation that we’re having to deliver to kill cancer cells? Yeah, it’s on the scale it’s probably 10 to 100 times more when we’re using radiation to kill cancer cells. Now, the caveat to that is it’s a much more focused radiation as opposed to an X-ray that you’re just doing for the teeth or something like that or chest X-ray, things like that. So, it’s much more focused. With protons, we can focus that even more. And so what I you know what we’ve talked about in trying to limit the number of treatments using a very focused treatment like protons because we’re focusing much more and limiting the exposure to other tissues. We can then even further increase the dose that we give every time because there’s less chance of damaging everything else to try to be more successful at curing the cancer with less treatments and even sometimes even escalating that dose a little bit to improve our chances of cure for some of those cancers.

Dr. John Chang: But that dose that you’re talking about, I I heard you say 10 to 100 times. So if that dose does spill over to the heart, you’re talking about pretty significant complications potentially down the road,

David Raubach: right? and and really the important aspect of what we look at for heart dose is really the heart arteries that are very close to the surface. So the heart sitting underneath your ribs and your lungs is basically a structure that almost looks like a football basically, right? And on the surface is the arteries or the blood vessels that supply the heart. And that’s what’s actually closest to where the ribs are. And if you’re exposing even a little dose to those arteries, that’s enough to kind of scar them down to the point where the circulation is not getting to your heart muscles very well. So the studies that were done back you know uh 2013 actually uh New England Journal articles showed that even just a little dose probably

Dr. John Chang: a 1/100th of the dose that you give to the breast for the cancer that dose already translates to almost 10% increase in your risk of heart related

David Raubach: damage 5 to eight years later. So if you think about that and you really expose that blood vessel, then your risk can be upwards of, you know, 20 to 30%. And so that’s what we started to see in a lot of breast cancer patients. We used to think that any dose was safe as long as we kind of come come in at an angle and really kind of skim the heart. But what we didn’t realize is when we’re skimming the heart, that skimming is right along those blood vessels and that blood vessel translates that damage to that blood vessel translates into heart related issues, increased chance of, you know, shortness of breath, chest pains and heart attacks. You know, probably that’s the biggest thing uh down the road. So, so that’s why it’s so critical in breast cancer patients to protect the heart.

Dr. John Chang: It’s imperative to protect the heart. It’s imperative to keep that dose off the heart and protons a lot of times are the are the best way to do that.

David Raubach: And then I think I’ve heard and again I’m I’m I’m putting myself in the shoes of a patient. I think the chemotherapy drugs that patients take for breast cancer can be cardiotoxic. They they can actually cause comp heart complications. So then when you layer on top of that any type of radiation dose that can really exacerbate any heart issues.

Dr. John Chang: Yeah, definitely. So there are chemotherapy drugs and also there are some receptor hormone type of medications that increase your cardiac risk just on their own. And so if you add radiation on top of that, it really kind of magnifies the whole issue with uh possible cardiac or heart damage.

David Raubach: So uh so that I think that’s a that’s a great summary. Got to keep radiation off the heart. Know what your heart dose is as a patient. Um and and be sure to check out all of your options. So, uh, I’m a patient and I say, “What can I be doing to, uh, maximize my chance of all of these different treatments working? Are there things that I have control over?” I think that probably the biggest thing is to advocate for yourself, to talk to your doctors, um to ask them questions about, you know, what they’re looking at when they talk about treatment and what the possible downsides of treatments are. So, so that is probably the strongest message I would have to patients is um don’t ever take anything for face value. ask them the rationale so that you can fully understand. For me, when I talk to patients, I always talk about the fact that I want them to have as much time to ask me questions as possible and I want to give them all the information possible because that also takes some of the anxiety out of the whole diagnosis of cancer. When you take away the fear, then they can be their own advocates and understand what the best approach is. What do you uh what do you think about things like diet and exercise and mental health? How does that play into cancer cure or cancer survival?

Dr. John Chang: Yeah, I mean the nutrition aspect of it. Um I’m not a huge believer in fat diets or certain diets that can help. I think having a very balanced diet is very important. I think activity is very important. exercise all those things have been linked to mind and body right so things when you are very physically active also help with your mind frame or your mindset um and all those things will help you in the recovery aspect of it so yes I always talk about you know never stay stagnant um when your body will tell you when you need to rest but the times when you’re not needing that then don’t be sitting on the couch and you know just uh and being you know kind of lethargic and

David Raubach: which is good advice any anyways but it almost is more important when you’re going through something like cancer treatment.

Dr. John Chang: I had a patient recently that I talked to and and she was she talked about being right at the kind of nadir the worst part of the chemotherapy and her goal was I’m going to get up and I’m going to walk around the living room table

David Raubach: and then I’m going to go back to bed. M

Dr. John Chang: but she made that goal every single day and and for that worst part those worst couple weeks that was her goal like you talked about don’t be sedentary do what you can right

David Raubach: and that’s so important and it helped her mental health too just having that goal and then accomplishing that goal each day

Dr. John Chang: yeah no and there was actually a study um you know because I treat a lot of kids there was a study that was kind of pivotal in helping kind of explain how to recover after treatments ments especially because there is a fair number probably the the second most common type of malignancy in children the number one being leukemia but uh or kind of hematic type of uh cancers. The second most common type of cancers in kids is really solid tumors of the brain. And so with kids when we’re treating them what they found is they actually did a study on activity, exercise, things like that. So 20 to 30 minutes of solid exercise focused activity for three times a week for children who have gone through brain tumor treatments helped them preserve their IQ better than those who were basically stagnant and basically not doing. So they actually showed that that actually improved their school functioning ability, memory, those type of things. They kind of tested them with actual concrete tests and they found that activity helps with the mind and body. So it’s it’s basically mind and body are very well connected.

David Raubach: Yeah, that’s amazing that that’s uh so that’s really the encouragement. If you say what can I be doing doctor

Dr. John Chang: eat healthy but really also exercise as as much as you can.

David Raubach: How do I know that the cancer is gone? Do you see it disappear during treatment?

Dr. John Chang: Yeah. So that is always a difficult question to answer especially because different tumors respond different cancers respond in many different ways. Um many cancers basically as we treat them with radiation or other modalities like chemotherapy and things like that they sometimes will shrink but they don’t always disappear. And I was kind of, you know, probably my best analogy is think about a grape that turns into a raisin. It shrivels. It dries out. It likely is dead as far as how we follow it and we do scans and things like that, but it may never completely disappear, but as long as it’s kind of just dead tissue and scar tissue, it may look like there’s still something there, but as long as it’s not growing, it’s obviously not a problem. There are certain scans that look for activity.

David Raubach: And so those are the scans that sometimes we use to try to see if you know what’s left over still has any activity to it. And in those type of situations, if there is still some activity or some concern about activity, then we talk to a surgeon about maybe just removing that to see if there’s anything left.

Dr. John Chang: Tell So when you say there are some scans, are you talking about PET scans?

David Raubach: Yeah, PET scans are metabolic scans. Um there are other different types of metabolic scans that can be done as well. Different types of cancers have different ways that show their metabolic activity. So it’s not always just a PET scan, but in that similar type of vein.

Dr. John Chang: So a lot of breast cancer patients get a genetic test as part of the the treatment regimen or or deciding how to treat um ahead of time. If I’m a breast cancer patient, am I going to get a different treatment based on the results of that genetic scan?

David Raubach: They can. So, some genetic testing can show that they are either susceptible to another breast cancer sometime down the road or sometimes they could be susceptible to another cancer in different parts of the body. uh breast cancer can be associated with ovarian cancer sometimes with certain genetic uh factors. And so if that’s the case, there are sometimes for certain patients if they have a very strong genetic pattern that could make them more vulnerable to that, they may have surgeries to not only remove their breasts, but also remove their ovaries or uterus or those type of things. uh gynecologic structures that could be at risk with certain type of genetic uh predispositions.

Dr. John Chang: And that’s based on the genetic test is based is that’s a blood draw.

David Raubach: Yeah, that’s a blood draw.

Dr. John Chang: Okay. Yeah. What uh so if I go through all of this treatment and I get surgery and I get chemotherapy and I get radiation and I do hormone therapy and the cancer comes back two or three or four years down the road

David Raubach: then what are my options? Yeah, it’s very individualized because it depends on if it’s the cancer that was originally there because there can be if there’s been at least a five-year gap from the time that you had your other cancer to the new one, it could be a brand new cancer. So, we always test the cancer to see if it’s very similar to what you had before. Also, depending on where it’s coming back at, if it’s in the same location, if it’s in a different part of the body, we have to kind of tailor the treatment based on that. There are different ways and different approaches and it’s like kind of coming up with a new strategy again. Again, the surgeon, the medical oncologist, the radiation oncologists usually come together to kind of talk about what was done before and what can be done now. And so, so again, it’s basically just going through the same process of looking at options with all the different specialists.

Dr. John Chang: Okay. That’s that’s that’s really helpful. So the I think the what I’m hearing you say is that there are options down the road.

David Raubach: Yeah. The it’s never a dead end. Yeah. And we just have to look at the whole picture and and decide what can be done next.

Dr. John Chang: So this is a very uh this is a question that we get a lot

David Raubach: and I know it’s a hard one to answer. What is the cure rate for breast cancer?

Dr. John Chang: Yeah. And that is a difficult question because it is based a lot on the extent of the cancer. um what the patient was able to get from the standpoint of treatment. Um so it is highly dependent on a lot of tiers to what the parameters of the tumor are. So it can be in the very early stages you know well above 95% and obviously depending on how extensive it is it drops from there and how aggressive it is. So, so it can be very highly curable um as with many cancers if you catch it early.

David Raubach: So, it’s stage dependent. Yeah.

Dr. John Chang: Is what you’re saying.

David Raubach: So, what where does what’s the role of screening in this process for you as an oncologist? How important is screening especially? Let’s maybe stay on the topic of breast cancer screening. Yeah, it’s critically important because the earlier you catch any cancer is gives us options as far as what to do for treatment and on top of that um the treatments are more effective when there’s less cancer to deal with. So I want to uh shift gears a little bit. We’ve talked about breast cancer quite a bit. Um another cancer that we treat a lot of and and part of this is just the fact of that there is a lot of this cancer is prostate cancer. Um so what’s the role of proton therapy with prostate cancer?

Dr. John Chang: Yeah. So prostate cancer has many different options for patients. You know the traditional one is surgery, right? And then you have radiation seeding and then you have external radiation of which protons is one type and then photons or regular radiation is the other. So protons are just one tool we have to help take care of this cancer. Now when we talk about level invasiveness of the treatments, surgery would be obviously number one. The seed implantation would be a little bit less invasive and then external radiation with either regular radiation or protons is the least invasive. Right? So there are different ways to kind of approach things and patients have different you know kind of conceptions about how they want to approach their cancer. So proton’s role in prostate cancer is the one of least invasive treatment with the least amount of collateral radiation exposure which means the least side effects. Right? So so that’s where its role is. And so if a patient is looking for a treatment that is just as effective as surgery, just as effective as seed implantation, sometimes even more effective for you know the aggressive nature of the cancer, then protons plays that role and it can play that role with the least amount of collateral damage.

David Raubach: And so when you say effective, what do you what what do you mean by effective?

Dr. John Chang: Like the chance of being cured of your prostate cancer can be upwards of 90 to 95% or better. So if you catch it early enough and that goes back to screening and for prostate cancer we check our PSAs and if we can catch the cancer at a very early stage then treatment with any of the modalities can be above 95% especially with protons and with its least invasive nature and less collateral damage can be the least impactful on negatively on the quality of life. When you treat prostate cancer with protons, are you treating the whole prostate?

David Raubach: You are. So when we talk about treating prostate cancer, traditionally surgery removes the entire prostate. Okay?

Dr. John Chang: When we put the seeds in, we put seeds in over the entire prostate. So when we treat it with external radiation, we treat the entire prostate. And so with protons, we treat the entire prostate.

David Raubach: And how do you know that the cancer is gone? So I’m done with treatment. when and how do I know that that cancer is gone?

Dr. John Chang: Yeah, the PSA is actually the only true test of any cancer that can be very specific to that cancer. So that it’s actually a great surrogate in knowing how much cancer there is or the possibility that the cancer is gone. So the PSA after we’re done should drop very close to zero. So basically below one to zero is where we expect the prostate PSA after we’re done for it to be fully gone.

David Raubach: So you mentioned seeds.

Dr. John Chang: What do you mean by that?

David Raubach: Okay. So radiation can be given internally for prostate cancer. And the way we do that is with these tiny radioactive pellets that we put into the prostate that can last anywhere from a month to 3 months, giving off radiation internally. So, it’s giving radiation from the inside out. And these little radiation seeds, these little radiation pellets, basically emanate radiation from inside. It’s such a low level of radiation that really there’s not a lot of radiation going outside the body, but it’s just more focused on putting radiation right where the source is. It’s something called breakchie therapy.

Dr. John Chang: So breakchie therapy, that term comes from the Greek word that talks about proximity. So it’s basically using radiation in proximity to the tumor. So that we’re placing it either next to the tumor or inside the tumor. And so for prostate cancer, we’re putting it inside the tumor. It’s something that has been traditionally done for years and years. We do it at the center at the Proton Center. We have that capability to do it. And for patients who have lowgrade localized disease, it’s actually kind of a a nice way to take care of prostate cancer because it’s one time and you’re done, right? It’s kind of like surgery, but it’s not as invasive as surgery. Doesn’t have the same side effects as surgery. it’s much easier to kind of do and for lower grade cancers and localized cancers, it can be just as successful as any of the other modalities.

David Raubach: So, one thing that I’ve heard is that if you’re younger, you should get surgery and if you’re older, you should get radiation. Is that true? Well, so really the the reason or rationale behind that really is that patients who are younger recover and heal much better than older patients just because the tissues come together easier. So when you do surgery and remove the prostate, the healing that has to happen afterwards really is key to being able to retain your ability to control urination afterwards. the leakage factor basically.

Dr. John Chang: And so as patients get older and you remove that prostate and reconnect the bladder to the urinary tract or reconnect the plumbing, you kind of lose the valve that helps control the urination. And if you lose that and you don’t have good healing of the tissue, you could have to wear a pad or diaper the rest of your life. And that’s a huge quality of life issue. Yeah.

David Raubach: So that’s why in patients who are younger, if surgery, if surgery is what they want to do, and usually it’s the patient who has the mentality of I have a cancer inside of me, I need to get it removed.

Dr. John Chang: They’re the ones who are going to go that route.

David Raubach: Now, from the standpoint of effectiveness, whether the patient’s 40 or 80, radiation can be just as effective,

Dr. John Chang: right? So younger patients can still get radiation. They can still get protons. They can still get seeds. But from the standpoint of surgery, the patients who are younger are going to do better with surgery than the patients who are older. So typically even the surgeons don’t like to do surgery on patients who are 70 or older just because they don’t want to have to, you know, really deal with the patients having incontinence and and complaining.

David Raubach: It can be a more challenging recovery as you get older. Yeah. So, but but that’s a good point though. I think I like what you said and in our last episode we actually talked about treating pediatric patients with proton therapy. There’s no age constraint on being eligible for proton therapy or benefiting from the fact that proton is the most targeted most precise form of radiation that we have available today as within the radiation oncology community.

Dr. John Chang: Correct. So, um, to wrap up, um, just a couple more questions. What are some other types of cancer that benefit from proton therapy or how would I know as a patient whether or not proton therapy would be a good option?

David Raubach: Right? Just as a quick kind of overview of what you know the way I think about it is protons is a beam that basically is able to be kind of focused and honed in on on a target and have less collateral damage. So if you think about it that way, anything in the body, any tumor in the body that’s close to a critical structure would benefit from protons, right? And basically anything from head to toe, you know, unless it’s on your leg or your extremities, anything basically in the torso and your head would benefit from proton therapy. All right. So, we’ve seen the studies now and there more data really coming out very soon that head and neck cancers would benefit from proton therapy because we’re not going to damage the swallowing muscles as much or the vocal cords or because some of the cancers are close to the brain, we can minimize any chance of damage to the brain. So, head and neck cancers would benefit from proton therapy. We’ve actually seen the data showing that there’s less chance of needing a feeding tube.

Dr. John Chang: Okay. Wow. with head and neck cancer when you treat it with protons as opposed to regular radiation with esophageal cancer. So you’re swallowing to from basically your neck on through to the stomach. There’s been a randomized study that showed a significant advantage in the chance of severe side effects when you’re using cheone radiation for esophageal cancer which all esophageal cancers typically need. We’re seeing now with anything in the upper abdomen, your liver, your pancreas, that’s close to critical structures. We’ve seen benefit in that situation as well. So basically, anything in the body that’s close to a normal tissue and like I said, head, neck, your whole torso, those are the areas that would benefit. The best thing to do is talk to your doctors and ask them whether they think proton therapy would be something that would be helpful in their situation. And if they don’t know, then reach out to a radiation facility that has protons to be able to kind of speak to that. Well, and I think that’s a good point is that the field is is evolving so rapidly and there may be cancers that we didn’t treat with protons five or 10 years ago because we hadn’t developed the techniques or the protocols or the the planning software hadn’t evolved enough to be able to treat that particular disease site. And so, it’s going to be a doctor that’s regularly using proton therapy that’s going to be most knowledgeable about what types of cancers could benefit from proton therapy. And that’s why it’s important to talk to someone like you who has access who does breakchie therapy, who does proton therapy, who does traditional photon radiation. Um, and as we talked about in the last episode, really works uh collaboratively with medical oncologists and surgical oncologists to decide how that treatment fits in this entire treatment regimen for patients. Um because as we talked about, it’s all about maximizing the quality of life while also maximizing the cure, right? More than just a cure, also the quality of life. Um so, uh just uh last question for you. A patient walks in and they say, I isn’t radiation bad? Like, I’ve heard that radiation is bad. What? Why am I getting radiation for my cancer?

David Raubach: Well, it is bad, but we want to make it bad for the cancer cells, right? And so that is again kind of back onto the kind of the drive of what we’re trying to do is that we’re using this beam, which is bad for cells, to try to target only the cancer cells and not the normal cells. And so, so yes, radiation can be bad. It destroys things, right? But our goal is to use it to destroy the cancer cells and to miss all the normal things so that we can improve the chance of the patient beating the cancer.

Dr. John Chang: Well, that’s great. I I really appreciate uh the way that you put that. So, radiation is toxic to cells, but we’re going to focus that toxicity. We’re going to focus the killing power of radiation on cancer cells while preserving the healthy tissues.

David Raubach: Well, I really appreciate your time, Dr. Chang. Um, and thank you for everybody who joined us for this episode of the Cancer Project. As always, um, subscribe. We’re on multiple channels, YouTube, Spotify. If you have questions, leave them in the comments. If you do have questions about a particular cancer diagnosis for yourself or a loved one, and you want to talk to a doctor, talk to somebody like Dr. Shang. Um, feel free to reach out to us at the Oklahoma Protown Center. And again, thank you for joining us.

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