Conversations with Cal Ripken, Jr.

Jamie Bearse: Hi, everyone! Welcome to ZERO’s Virtual Summit. I’m Jamie Bearse, and I’m coming to you live with our mission speaker leading off the evening, MLB Hall of Famer, 19-time All-Star, two-time MVP, Cal Ripken, Jr. Many of you know him as the “Ironman” of baseball, but Cal is also a prostate cancer survivor. We’re also joined by Cal’s urologist, and an all-star doc all on his own, Dr. Ronald Tutrone Jr., Chesapeake Urology. Dr. Tutrone, Cal, Thank you both, and ExosomeDX, for stepping up to the plate for patients and families at the ZERO Summit. You all ready to take some swings at some questions I have for you this evening?

Cal Ripken, Jr.: [laughs] A lot of baseball references. First of all, you said I’m leading off. I’m never leading off anything in my life [laughs]. I hit second a couple of times, third most of the time, and they added me to clean up, so I’m very uncomfortable being the lead-off here.

Bearse: Well, a little bit of both, you’re leading off tonight and cleaning up. We’ve got a ton of people watching ready to go, and ready to hear about your experience, hear about your story. I think it’s going to inspire a lot of patients and a lot of people who are at risk for prostate cancer to take an active role on their health. So, Cal, let me throw this at you. How did you find out that you had prostate cancer?

Ripken: It’s been almost a year since I had the surgery and everything’s perfect. So, trying to go back, in some ways you want to put that behind you but the message is so important to be able to go back and do that for other people, and I feel really good that I’ve been able to share my story and help other people. In the beginning, I was changing docs, you know, I had a doc down here in Annapolis, and he was going through trying to find me a cholesterol medicine that I could take, and some of them were giving me side effects. So we did the blood work every once in a while and he ran a PSA test at the same time. And the PSA started to slowly move, but he didn’t like that it started to slowly move, and it was still well within the range of being normal for my age. I think it might’ve been 3, starting at 2.5 or something. So then he referred me and said “You need to go see a urologist,” so I called up Dr. Tutrone and I went down thinking that I’m just gonna get this confirmed, it’s nothing. I’m riding a bike outside a lot, that’s probably why my PSA number was up, but sure enough, on the examination, there was a little issue. The ExoDX test was the one that gave me the confidence to go through with the biopsy, because he said, “I have a couple of other tests” that would give me an indication of what to do because we don’t want to do an unnecessary biopsy. So when I did those tests, I waited a little, but I think I went to Hawaii in the middle of that, and Dr. Tutrone didn’t want to call me in Hawaii, but he did and I knew that meant I was going to come in for the biopsy. After the biopsy, it showed prostate cancer. And I laugh a little bit now because I can, but if you ever sit across from  a doctor and they tell you you have prostate cancer, you want the next words out of their mouth to be “We caught it early.” We did catch it early, but COVID was starting at the time and hospitals were starting to look at necessary surgeries, I don’t know what the exact word for that, but anyways, my surgery might’ve been thought of as something you could wait on a little bit, and I didn’t really like that idea a lot. And so I didn’t wait, I went in and had surgery and a happy ending came out but at first, when I was told I had prostate cancer, I didn’t want to tell anybody. I wanted to keep that to myself I didn’t want to let anybody know that something was wrong with me. I have this reputation as the “Ironman,” as you know; I’m supposed to be invincible in some ways. And then once I started to understand it and my story had a happy ending, I said maybe the position I’m in as a baseball player maybe I can convince a few other people that are stubborn, a little like me, to go out and get a test and get regular tests and regular physicals. And I was someone in baseball, you know, and all these years and we had medical around us and every spring training you didn’t really have to have a doc, everything was provided for you. But then you retire and get into a little bit of a lull. I just want to encourage everybody the importance, especially when you reach a certain age, of getting a test every single year and catching it, and maybe we can save a few lives in the process. 

Bearse: By the way, I think the only time that anyone should call you when you’re in Hawaii is if it’s really, really important. You talked about being an athlete, Cal, and obviously the reputation of being Ironman, nothing ever happens, never any injuries, never been sick a day in his life, that’s sort of the whole persona that comes with it to the public, but I’m sure during all that time you’ve gone through quite a few injuries and illnesses at that time. How did that help you prepare mentally, or even physically, to battle prostate cancer?

Ripken: Well, I’m sure it did. I’m not sure that I can articulate how much it did, but the misnomer is that because I played in all those games in a row that I never was hurt and never was sick, all that kind of stuff, I was. I would think that the physical part is that you learn you can play in the game less than 100%. You’re challenged every single day, I will say in the Big Leagues, the only time you’re 100% is probably the first couple of days of spring training, then everything from there kinda goes down because you do it every single day. You get nicked up, your arm is sore, you get hit with a pitch, you slide into a base wrong, you hit the base wrong. There’s always something that’s bothering you. I pushed through all those injuries, so I learned that I could do it. I could compete, I could play at the highest level and play really well at something less than 100%. So the mental part of that, getting over that hurdle, I knew that I could. I would think that there’s something in there that when you’re faced with a situation that I was faced with with the prostate cancer, you put your trust in the doctors, they’re the experts, and then you try to do whatever they want you to do. I think I’ve always been a rule follower, I’ve always been someone that wasn’t afraid to work at it, and so maybe that sort of mental strength ability helped me. But, I gotta tell you, now that I’ve learned a little bit about a Gleason Score, my Gleason score was seven, three plus four, right, doc?

Dr. Ronald Tutrone: Yes.

Ripken: A three plus four is different than a four plus three, and learning that it was slow-moving and all contained in my prostate, that was what the determination was. I knew I could get surgery and I could be rid of the cancer altogether with a successful surgery, and hopefully, the pathology report would come back good, and it did, and all that stuff was great. Maybe the every day pushing yourself mentally and physically as an athlete certainly has to help you when you’re faced with challenges of health. 

Bearse: I’m sure that mental toughness also played into the factor of when you first heard that you had prostate cancer.

Ripken: Yeah, I can expand on that a little bit. I mean, one of the things you learn by doing it is, in baseball, you deal with failure quite a bit. So you could spiral down when things are going bad because things are failing a lot, and you’ve gotta stop yourself from spiraling down. It’s as simple as training your attitude to be positive and look for the positives in the things that you do and not really dwell on the negatives. If you start to dwell on the negatives and you spiral yourself down, you’re going to increase your slumps, its gonna be a longer period of time, and you might ruin a whole year and you can’t really get out of that sort of funk. I knew how damaging that was because sometimes you’d spiral down a little bit, and you would learn that lesson. By large, I’m someone that even in the worst of times, you look for something positive to focus on, something that you can do every single day, that gives you a sense of purpose and a sense of direction, and that you’re moving in the right direction, and then trust the fact that things will come out right. I’m sure that factored into my diagnosis and the way that I looked at it. 

Bearse: That’s a wonderful and positive mindset, for sure. Now you had touched on this Cal but you had surgery about a year go, just get underway with the pandemic going on like I said you touched upon this and said it was important for you not to wait, even though maybe you could’ve, give us a little more on that of what was the back and forth like to the decision in spite of the pandemic to go forward and have it done.

Ripken: You know it was all new to me, and so when I came in Dr. Tutrone was educating me along the way and I was skeptical a little bit thinking “Okay is this something really caused by my bike or not” and the PSA number say it’s within my normal range, it’s not moved a whole lot, it’s just as you age this happens. I kind of wanted to cling onto that and then when we did the ExoDX test and that came back and then’s when I started to think more seriously about needing a biopsy and I need to find out for sure what it is. I think at first what I was told was that you don’t have to make this decision tomorrow, it’s a slow-growing cancer and you might have six to eight months to think about that, and the notion of letting something growing inside of me for six to eight months, when you look at it and really learn more about it, it seemed really obvious at my age that the best solution was to have surgery, and maybe it was better that COVID was there at that time. I remember thinking “Well, can I get this done as soon as I can?” and the answer came back “How about Friday?” I said okay, and I was in the hospital Friday morning at about 4:30 in the morning, I think the surgery was somewhere around 6:00 [in the morning], I was out of surgery before 8:00 [in the morning], I was up and walking around at about 1:00 or 2:00 in the afternoon, and I was released from the hospital at 6:00 [in the evening]. I didn’t stay the night, which I think they didn’t want me around the hospital because of COVID and I didn’t want to be around the hospital because of COVID, and I came out of the anesthesia really good, so that was good for me to go home. Quite honestly you think that your life is going to change, the risks of what’s happening down there, how it affects the nerves, and all that; that was some concern going on. Knock on wood, I’m virtually the same person I was when I went in. Sometimes it feels a little different riding your bike [laughs] but besides that, I feel whole, I feel good, I feel fine, everything that I could do before I can do now, so I do consider myself one of the lucky ones. I think that’s why it’s so important to me to try to convince men out there who get a little stubborn and say “I haven’t been to the doctor in a couple of years” that you want to go, you want to catch this as fast as you can and it’s not invasive; the ExoDX test was just urine, it’s not invasive at all. But I mean when you’re thinking about sticking so many needles, how many needles doc? Twelve?

Tutrone: Twelve.

Ripken: You stick so many needles in your prostate and if you’re thinking it’s for no reason you know because everything’s healthy then that’s not good for your prostate either and so I needed something else to go on to give me confidence that that was the right thing to do. The ExoDX test was that confidence booster

Bearse: Absolutely, we have a lot of comments coming in just to share one with you, somebody says that “So honored to hear from you Cal and you’re a hero to patients and families everywhere” is what one of the comments that’s coming in are saying. I’m sure alot

Ripken: I will tell you I had a story told back to me it’s kind of interesting once you go public with this you go to the grocery store and people want to share their story with you and then tell me that they got tested because of me and I’ve always been very recognizable and very approachable so that’s a part of my life that I’ve kind of enjoyed that baseball has given me that. But now that I’ve gone public stories come to me a little more readily about their own health issues and the story about there were five police officers that were all buddies and they got together and said okay we should do what Cal Ripken said we should all go get tests they all went to get tested at the same time and one of them came back with the detection of early prostate cancer and so four of them were okay but one of them came back and you know essentially by catching it that early you have tons of options and you know it worked out the same way for him as it worked out for me so that makes me feel really good when I can impact people enough to take that first step.

Bearse: That’s great your story saving lives. Saving lives all comes down to early detection Dr. Tutrone we know that early detection is important because we want to be able to catch aggressive disease and treat it appropriately and then some prostates keep prostate cancer grow so slowly that it really never needs treatment but will you take us through why early detection for prostate cancer is so important and explain that to our viewers

Tutrone: I’m happy to comment on that but first I want to say that Cal you’re a hero to so many people but you’ve really elevated that to a much higher level now with what you’ve done coming out and being such a great spokesperson for early detection of prostate cancer and treatment. You were effortless being out on field, fielding balls and talking to the press afterwards. This is much more personal so I really want to thank you for coming forth and doing this because just that one person who you texted, that one police person, you may have impacted them enough that you saved his life by doing that so its really admirable what you’ve done and you’re and even greater hero for what you’re doing coming forth with this and you were spot on about detecting things early it makes sense in cancer if you catch something early you can cure it because the fact is once prostate cancer because metastatic and it spreads outside of the prostate we can’t cure it. The fact is that prostate cancer is the most common cancer detected in men most men are going to die with prostate cancer not from it. Believe it or not the leading cause of death in fact is heart attacks, but its the second leading cause of cancer death in men and that’s just a testimony to how prevalent it is how many people have prostate cancer we have been at fault the medical profession in over diagnosing it and over treating it and this goes back 10, 20 years but we didn’t know better so we used to just diagnose people and say well you have cancer we have to treat it. We have changed now so that many cancers and Cal mentioned the gleason score he was a seven. Seven’s an intermediate risk. Eight, nine, ten is bad, five or six is good. Those five or sixes now we know we can watch a lot of those patients and not treat them and put them on an active surveillance protocol. But what happened in 2008 and 2010, the United States Preventive Healthcare Taskforce came out with a recommendation saying that PSA testing to screen for prostate cancer is not good and what happened was it dropped off and many physicians and many internists stopped screening and stopped doing PSAs. Well now when this year at what’s called ASCO the American Society for Clinical Oncology, they presented a paper looking back at all the data and what they found was the effect of that negative recommendation for prostate cancer screening actually led to an increase in detection of metastatic prostate cancer and that’s incurable so that will translate to greater death and mortality from prostate cancer. They have since reversed that and said that there should be a shared decision-making between a physician and his patient and decide is this test good for me? Do the benefits outweigh the risks of doing this? And so now we are back to screening regularly and it’s a lot more accepted. So to Cal’s point you really need to be proactive and it’s not terrible. You go in once a year you get checked get a PSA test, have what’s called a digital rectal exam which is a prostate check the old finger wave and that’s it and that’s what Cal was doing annually. His PSA was not terribly elevated but it was the change and the rapid rise in it. It wasn’t a very high number but it was enough that it raised the eyebrows of his family physician to say hey we’d better get this checked. Now, I wasn’t that impressed. The exam was normal, the number wasn’t that high, so I wasn’t convinced he really needed a biopsy so I recommended that he do a urine test what Cal mentioned the EXO-DX test and that’s separate from PSA. It looks at 3 genes in the urine that are associated with prostate cancer and it could tell you hey don’t worry the number’s low below 20 or worry its above 20 and Cal’s was up in the 40s so it gave him a better than 4% chance of having prostate cancer and he did give me the permission to call him in Hawaii I’ll say and give him that result. I wouldn’t have done that but I did and I said look we need to go ahead with the biopsy which he did and it all turned out well.

Bearse: That’s great and tell us more about when Cal was first diagnosed, what over advice did you have for him because if there was a some thought that maybe he could wait because of the pandemic and I know you eventually went to go with the EXO-DX test to be able to tell what the risk was of having prostate cancer and jumping on it to treat you know. Can you dive a little bit more into that?  

Tutrone: Sure so first of all its one of the worst things you have to do is sit down with a patient and tell them they have prostate cancer and so because we have limited time with a patient you tell them they have prostate cancer then you kind of talk about what is prostate cancer and then you go through some of the treatment effects but as Cal has said in the past all the patient really hears at that point is I have prostate cancer and the rest is like the Charlie Brown show, you really don’t hear much else so my advice to patients is to do your homework we give them an information packet all about prostate cancer. I always tell patients to write down any questions they have go on the internet look at a lot of the good websites. The AUA has great websites, the NCCN guidelines, do your homework, study it and the best to come back with someone else. If you have a significant other, bring them with you and that’s what Cal did because its always great to have somebody else there. I always bring my wife to a lot of important doctors meetings because I don’t listen very well. Its nice to have somebody else there in this battle with you and really to do your homework, write down the questions, ask a lot of these questions, and then you’ll make a better informed decision.

Ripken: So doc let me ask you the question next. I remember considering I mean radiation or seeds or other options there but for me at  my age I just turned 60 it became clear, you know you always have the option if you have surgery and then something ends up coming back or something happens you can do a radiation later but if you do the radiation first you can’t do the surgery later. Do you remember that conversation?

Tutrone: Yes I did and I do tell patients, if you’re choosing radiation it’s really not an option afterwards, it’s not a great option to have surgery because the complications and the risks are much greater trying to do surgery after radiation. But surgery is not for everybody and you remember what I told you Cal, I call surgery the gold standard in long-term cure and in prostate cancer long-term cure is not 5, 10 or 15 years its  20, 25 years. So surgery is a good option for anybody who has a better than 20 year life expectancy. So at age 60, your insurance life expectancy tables, you’re going to lift at least 85 or longer so that’s 25 years, that puts you in sort of the sweet spot for being a good candidate for surgery. Radiation will get you prostate cancer free survival that’s equivalent to surgery at 5, 10, 15, even 20 years but after 20 years, survival is better with surgery. On the flip side of what you said Cal, if you have surgery and the prostate cancer was not contained within the prostate and maybe some cells escaped outside locally, you can have radiation after surgery, what we call salvage radiation. If your PSA becomes detectable after surgery, you can get radiation afterwards, but hopefully you won’t ever have that. 

Bearse: Now tell me about, Cal, what was the first question you had for Dr. Tutrone after getting diagnosed. And Dr. Tutrone, how did you answer that? Maybe we’re circling around that or was it uh?

Ripken: Yeah I don’t know whether I’m laughing to cover up or just looking back over it. When he said that, Charlie Brown and the teacher’s voice (makes sounds), that is so true. As soon as you hear that you have prostate cancer your mind goes to, um, you know, uh, it’s almost like it’s a shock. It’s sort of the end of your life, sort of feeling really quickly. And the process, then you don’t hear anything anymore after that. So, then it was good that we actually then had a second meeting to come back, or we talked about some of the options after that, where I could absorb and listen to what that was. But there’s fear that comes across you right away. You don’t really know what that means. The “cancer” word when I grew up, anybody that ever had cancer around me, it was sort of a death sentence. You’d see some people that got beat up by the radiation, thaty somehow, they would come out the other side. But that was so rare. So the cancer word, you know, they’ve made such great, I mean in the prostate area, they’ve made such great strides in treating this. And, again, that’s why it’s really important for me to get the word out there to get checked, because you want to catch this really early and then you have viable options on treatment and cures. You can be rid of it! But the first time you hear the word “cancer” that’s associated with you, it’s a shock. Now, I would say even the effect now having gone through that at 60 years old, you start to think about the rest of your life anyway, you kind of see where you’re at the end. When you’re younger, you know, you think that’s way in the future and I don’t have to worry about that. I will say, for my own personal thinking about my life, between 55 and 60, you start to see you know, the other side. You start thinking about how you want to spend your time. How do you want to spend your time? How many times you say yes when you should probably start saying no to preserve that time a little bit more. Who do you want to do things with, and all that. You know, the first time I walked out of Dr. Tutrone’s office with that sense of “I have cancer”, then there almost seems to be an immediate urgency to your life, to live life even more each day, and appreciate that. Now that’s kind of calmed down a little bit, once I went through the process and then had the surgery, everything was fine on the other end. And then you realized that now you just continue the thought process that you had before. But it’s true, when you sit down and hear cancer, you don’t hear much else. 

Tutrone: I also want to say, you know you said what do you recommend to patients, again it’s all about education and learning about the disease. Know your enemy, know the art of war — sun tzu— you know your enemy. And that’s always good to do your homework, learn about the disease, and what Cal did also is to get other opinions. Seek out other opinions. It’s always good to hear from another urologist, a surgeon, a radiation oncologist… they’ll all give you different opinions and then you could distill all that in the end and make a decision. And Cal ended up, I’m just going to say, he had his surgery at Hopkins with Dr. Mohamad Allaf because he was able to get him in fast and get him home fast, so he wasn’t at risk for getting COVID in the hospital setting. And they did a great job there, and took care of him. So, do your homework.

Bearse: Great, no Cal, you had mentioned that you were sort of private about your diagnosis early on. What was the tipping point, or what was the one thing that sort of changes… 

Ripken: That’s a good point, because going back into it, I didn’t want anybody to know. I didn’t want them to think that something was wrong with me. I didn’t want them to feel sorry for me. I guess I had a great deal of pride in what you do, and you don’t want anyone to feel sorry. That was a big thing to me. I just don’t like the feeling that somebody would feel sorry for me and change their behavior towards me. As I learned more and as I got to the other side, and then after the pathology report came back that it was all contained in the prostate, it gave me a good feeling that everything was going to be alright. And then it was about three months later, I had the PSA test that came back and showed that I didn’t have a reading, which was fantastic. There was no evidence that it was there. I think at that point I started to think, baseball has given me a wonderful platform to do good things. Our foundation, serving kids, I’ve always been community minded and I’ve always understood the value of that; of how you’re thought of in the public. And even the trust and credibility that you gain by watching yourself and doing things the right way. I thought I could use that influence in the most positive way. And, you don’t start out by saying, “I’m going to help every man in the country” but hopefully you do. You start out the same way you did with the kid’s initiatives and the Cal Ripken Sr. Foundation — let’s help one kid at a time. Let’s have substantial help on one child. If we could change, if we can influence one child and have him move in a different direction than the direction he was headed in then we would be successful. So you really start locally, you start thinking about it one at a time. And because I’m known nationally, you know, I have credibility to some people; they’ll stop and listen to me for a little whole. And I thought that was a good use of that “celebrity” that you’re given and I do feel really good about it. I’ve heard from a lot of people, friends all the way across the country, and the message has resonated around and I feel good about it because I get the feedback from all across the country. So that message is reaching people. Joe Torre, I thought what Joe Torre did when he was diagnosed with prostate cancer was so cool. I even asked myself “If that ever happened to me I don’t think I’d do that,” but he was transparent, open, high-profile, could help many people and he did. And I remember thinking how great that was that he took that step but I wasn’t thinking about doing that at all until I got to the other side, and my story had a happy ending. And I thought, “Okay, let me go out there and pay that back.”

Bearse: What Joe Torre did was absolutely incredible. I’ve been in the cause long enough and I sat down with him at a press conference he did with the New York Daily News shortly after he came out that he had prostate cancer and his story really changed a lot of the way people thought about prostate cancer. It was more in the open and being discussed more and I think it saved a lot of lives and you coming out here, as well, is really doing the same. I want to push you a little but, Cal. You said that at first you didn’t want to talk about it cause I don’t want people to feel sorry for me, I don’t want to be vulnerable, maybe.

Ripken: Yep.

Bearse: I want to challenge you to be a little vulnerable. I heard, there’s this shoelace story that dates back, back to the minor leagues. Why don’t you share a little bit about that. 

Ripken: [laughs] That’s a funny story. You know, you see bloopers on the screen all the time in the Big Leagues so I’m thankful that I didn’t do something that got caught on tape in the Big Leagues where they play on the big screen over and over again. But no matter how long you play the game there’s certainly a- you’ve got the sun coming in on me now, let me give you a break, let me see if I can move my camera. This is live! There we go. That’s a little better. So story with the shoelaces, basically I was in the minor leagues, a fly ball went out to left field, I tried to backpedal trying to be cool because I had been playing pro-ball for as long as two years now. And I went back to get under it, in a cool sort of way to catch it, and I stepped on-I stepped kind of funny and my foot crossed over and my cleats caught my shoelaces and tripped me, and I fell down, the ball landed safely for a double, or a couple runs scored, and I’m embarrassed and whatever else I’m thinking “I just tripped myself, I was clumsy and did that to myself.” And I look down and did that to myself and I look down and there was a golf ball sitting in the grass because sometimes the coaches and stuff like that early on if they need to be in the ballpark early, they take their golf clubs out and practice their chipping in the ballpark. So they must’ve missed one golf ball so luckily enough I picked up the golf ball, shook my head, and threw it off to the side as if the golf ball tripped me. But the golf ball didn’t trip me, I tripped myself over my shoe strings. So I’m thankful, sometimes you need one of those humbling things to happen to you because you don’t need to drift back on the ball and be cool. You need to go back there and catch it. And sometimes you learn a lesson, you’re humbled by some of the dumb things you do. But I’m thankful that I didn’t have one of those for the big screen for all those years.

Bearse: Thanks for sharing that. We talked a lot about catching, catching prostate cancer, we talk a lot about the ExoDX test, and ExosomeDX is a supporting partner for the summit. And this is for the both of you, tell us a little bit about the ExoDX prostate test. We talk about it but let’s give people a real sense of why should they take it, why should they even consider taking it. 

Ripken: To the technical reason I’m sure that Dr. Tutone could cover that really easy. But I will say simply, for me, it gave me the confidence that I needed that the right thing to do was get a biopsy. Because I didn’t have that confidence before I had the results of the ExoDX test and then I went up. Now I’m not thinking that it’s just from riding my bike or I’m not just thinking that my prostate has gotten enlarged slightly and everything’s gonna be normal because sometimes it is and it felt like to me that I didn’t want to get that biopsy. And after the ExoDX test and it was explained to me the results of that by Dr. Tutrone, that was the confidence that I needed to say “Okay let’s schedule a biopsy, and schedule it right away.” And so there’s no messing around after that.

Bearse: Thanks, Cal, and Dr. Tutrone, elaborate. Is it a blood test? Do they take a whole pint of blood and test it? What is it just in case someone has no idea what we’re talking about.

Tutrone: Cal could actually explain this a whole lot better than I can but I’ll give it a shot. PSA is a very inpricice test. A good cancer screening test should only register if there’s cancer. PSA’s not like that. If you have a prostate you have a PSA, so it’s not a great screening test and there’s no “normal” value for PSA. The way we utilize PSA is looking at it’s change over time or the velocity. And the problem is that there’s no norm. We like to say that we don’t like to see it go up more than .7 a year. And Cal’s actually was within that range, it was less than .7, it was just gently rising and so what happens is we get into a quandary and we say “Well, it’s rising. We don’t like the velocity of that about the rise, so maybe we should do a biopsy.” Well, a biopsy is not innocuous. You could have rectal bleeding, you could get an infection, it’s not comfortable to do, and so the ExoDX is a very good adjunct that we use in men who are over 50, whose PSA is in sort of the grey zone between two to ten and rising and we’re really not sure whether we need to proceed with a prostate biopsy. And what it is is we collect a small amount of urine, just about ten ccs first, and it has to be collected through a special device where a man urinates in this device and it collects the first ten ccs that come out and discards the rest. That is sent to the headquarters of Exosome in Boston, where they run some testing and they look at three different genes that are associated with high-risk prostate cancer and you get a score. It’s a binary test. If your score is below 15.6 that’s a good result, meaning we can tell a patient that it’s a 92% chance that there is not a high risk of aggressive cancer. If it’s above 15.6, then we recommend possibly proceeding with the biopsy. Now the higher the number is above that, the higher the risk. Meaning if it’s 30, there’s a relatively 30% risk of having prostate cancer and so on. If it’s 40, 40% risk and 50, 50% risk. So the higher the number the worse. The good thing when CareFirst did a trial with us at Chesapeake Urology we looked at a thousand men we did this on because they wanted to say “Should we offer this test to our clients.” And it was called the Clinical Utility Trial, which we did publish, and it was very favorable, the results, which led to this test being covered by Medicare and CareFirst in the state of Maryland. The good thing that happened during this pandemic was that a patient can’t urinate for an hour before doing this test. So when a lot of men come in the office, they give a urine sample, they pee beforehand and we can’t get the sample in the office because they have to wait an hour to collect it so they have an at-home test which makes it a lot easier for patients and physicians to order this test, because we can just go online, order this test, the kit gets shipped to the patients home with instructions, they collect it at home, ship it up to Boston through FedEx and we get the result in our office. So many times patients come into the office and they have a PSA drawn because they didn’t get one beforehand, the PSA comes back and it’s elevated. Well, now we can just pick up the phone and say “Hey, your PSA’s rising a bit and I’m a little concerned. I’m not convinced you need a biopsy, so maybe we should get this ExosomeDX test. I’ll ship the kit to your home and get it done.” And that’s really what Cal did, it’s been a really good tool to have to aid us in making that decision to biopsy or not. 

Bearse: Great. So what I think I’m hearing, Cal, even though whole career in Baltimore, you had to turn to my hometown of Boston to help get the help you need.

Ripken: [laughs] You know I will tell you, I’ve always been – let me see, I’ll add a little flavor to this interview. I was asked to be a consultant to a movie, and it was called The Fan. Robert De Niro was in The Fan, and the backdrop was supposedly, it was written in Boston, about a Boston Red Sox fan, but it changed in the movie and all that kind of stuff. But the book was really fantastic, and Robert De Niro met with me, and I met with him for lunch for about three hours and he was asking me, “Tell me the differences in baseball fans. What are the fans like?” And I said “Well, in Boston, they’re crazy for their team. Almost fanatical for their team, obsessive. You do something to beat the Red Sox and they might hate you for the rest of your life. So they might respect what you do, but they don’t have to like you.” And I said that with Yankee fans, they see it as they’re part of the entertainment. They think that they can yell at you and get you off your game, and then you end up beating them then Yankee fans will say, “Ah okay I’ll see you tomorrow.” Like we’ll do the same thing all over again tomorrow, I’ll get on your nerves and you’ll say something back to me and you know maybe we win, maybe you don’t. So explaining the fans, I think the Red Sox fans are the most intense fans because it’s a regional thing. They grow up with it, it’s in their blood. It’s something really cool to behold. My last year through the league,  there were many stadiums or many teams that were saying goodbye to me. Last time in, they would do a small little ceremony, which Boston did, too. My kids came out and I think threw first pitches out to Carlton Fisk and Dewey Evans, I think, you know. They came out, did a nice thing, but the coolest part about that was I had four games in Fenway Park, my last four games, and everytime I came to the plate, they stood up and gave me a standing ovation. Unprompted, which is the coolest part, is when you don’t need to tell a Boston fan what to do, when to do it ever. So the coolest thing was that they got up on their feet and gave me a standing ovation for 16 at-bats, four bats a game, all the way through. And each time it wasn’t just a little clap, they gave me a really resounding send-off and I think it’s really cool. I thought at one point in my career after my dad got fired in ‘89 that I was gonna get traded to the Red Sox for a lot of prospects and play in Boston because that was the place that if I was going to leave Baltimore, that was one place that I would really go.

Bearse: Well we would’ve won the World Series much sooner if that happened but you had an amazing illustrious career in Baltimore. I was at one of those games, in ‘95, right?

Ripken: In ‘95?

Bearse: Was that ‘95 the last season?

Ripken: No, my last season was 2001.

Bearse: No, I mean the season in which you broke the streak was ‘95.

Ripken: 1995 was the- so that’s the-

Bearse: You don’t have to do the math.

Ripken: -25th anniversary this year. How bout that? It’s been 25 years since 1995. 

Bearse: That’s terrific. 

Ripken: It doesn’t feel terrific to me [laughs]. I think I want to be back in 1995.

Bearse: I remember watching the home run on your first at bat the day you broke the streak. 

Ripken: Yeah we had three games against the California Angels during that time 21-29, 21-30, 21-29, was the tying game and 21-30, which is the record breaking game. I had a home run in each one of those games cause it was important, the California Angels were in a Pennant Race, we had fallen out of the Pennant Race, and so it was important not only to celebrate the record for an attendance record so to speak, it was important to play well and win. And so we won all three games and I got a home-r in each one of those games and that made the whole experience that  much better.

Bearse: And now switching back to prostate cancer, tell me a little bit about the ExoDx prostate test. Do you have to have had a homerun against the Angels in order to get one? How does one get one?

Ripken: [laughs] No, I think it’s pretty easy, I think in some cases you might have to ask about it. That’s the whole idea. I feel really good about sharing my experience and the value of that and hoping that all other doctors will also agree that this is an important test to have, and it is. The biopsy is a little invasive so you want to be sure that it’s needed. But the ExoDX Test is not invasive, you can do it at home. So if you’re on the fence about whether you should get a biopsy or not the ExoDX is for me the confidence booster to be sure that going to the next step is the right step. Again, I trust the doctors. I trust Dr. Tutrone and he’s gonna tell me exactly what it is. But it doesn’t mean, I think in your own little world there’s some doubts, some skepticism about “Okay, what is a biopsy? You’re gonna put 12 needles where? And how are you gonna do that?” And you’re asking all those questions and I’m thinking for me, that might not be necessary. And so the ExoDX test made it necessary because that was the result that came back that said I got a 40% chance of having it, I got to go to the next step.  

Bearse: Now Dr. Tutrone, Cal mentioned sort of a confidence boost, can you speak to that? How does a test sort of give a sort of a confidence boost to patients who are going through a prostate cancer diagnosis?

Tutrone: Yeah, it goes both ways, Jamie. Cal said it gave him sort of a confidence boost but we as clinicians, sometimes, many times, we’re on the fence. Should we really proceed with this biopsy. Sometimes in certain patients PSA is really rapidly rising, going up by one or two points, it goes from, say, from one, to three, to seven, if they have a family history of prostate cancer, we’re convinced, we know they need to get this done. But like Cal said, the patient can be skeptical like “Ah it could be a false elevation. It may not be anything, I really don’t want to go through this test.” They look for any reason not to have an invasive test done. Well when you get the ExoDX test and it’s elevated, it kind of helps not only give the patients confidence that this needs to be done, but also the clinician. It helps us to have further data for the patient.

Ripken: Hey, doc. Remember the stat you gave me about how many people walk out of the office, they’re supposed to schedule the biopsy.

Tutrone: That was shocking. That came from the Clinical Utility Trial we did where we went back in time and looked at patients with an elevated PSA who were recommended to have a biopsy. And I was shocked to find out that less than 50% of them proceeded with the biopsy. It was really only about 40% of patients, and so 60% chose not to proceed with the biopsy when recommended. That’s just terrible. Men are more like ostriches, they tend to just hide their head in the sand and not do anything unless they’re feeling pain or there’s like a giant growth on your neck that really shouldn’t be there when you look in the mirror. With prostate cancer, you won’t know you have it, and a simple elevation of a blood test you kinda like “poo-poo” it and men tend to blow it off. And that’s why the biopsy rate was so low. When the ExoDX test was utilized, we found in our trial that in patients who were given the results of the test, and it was elevated, there was over 70% concordance, meaning that the patients proceeded with the biopsy that was recommended. So it jumped from 40% to 70% so it really did help detect a lot more high grade cancers and probably saved a lot of men’s lives. 

Ripken: So maybe Dr. Tutrone was really good, but the prostate, or the biopsy, wasn’t as invasive as I thought it was going to be. It wasn’t as bad. Thinking about all those needles or taking a sample, I was a little fearful of that at first, but then, going through the process, it wasn’t nearly as invasive as I thought it was gonna be. 

Tutrone: Yeah we’ve really refined the procedure now Cal where we do what’s called the block, like how the dentist numbs your tooth when they fill a cavity or you get a root canal. With the area down there, the hardest part is above your shoulders, just thinking about it. It’s not that painful. But again, if you could avoid it it’s always nice to avoid it. That’s where the ExoDX test helps, when your PSA is rising or more on the fence, if that number is below 15.6, it really gives us the confidence to say, “Hey we could avoid doing this biopsy and putting you through that.”

Ripken: Yeah. 

Bearse: And for all those watching out there, the test we’re talking about really is a diagnostic tool that helps you be able to determine what’s a slow growing disease, what’s a rapid growing disease, some other diagnostic tools, even tell you what treatments may work better on you versus others. And all this week right now part of what we’re doing is we’re fighting for Access to Care issues and being able to increase prostate cancer research funding. There a program that’s called the Prostate Cancer Research Program that exists within the Department of Defense, a lot of people don’t know this, but the Department of Defense plays a crucial role in the War on Cancer, and going to Congress and asking for increase in prostate cancer research funding is absolutely critical so we can be able to find not only new treatments, but even more diagnostic tools like the one we’re talking about today. Now, Cal, as a prostate cancer survivor, what do you want men to know about the disease?

Ripken: That it’s very treatable if you catch it early. You know, if it gets outside of the prostate and spreads into your bloodstream and bone then it’s a whole different ball game you have to deal with so I mean the simple message I think I guess because I was poked around and looked at as a baseball player during spring training, you have all your medical staff down there, you go through the orthopedic exam, you go through all kinds of stuff and when you get a little older you have your rectal exam, and when you’re younger that’s not necessarily the case, but if there’s a simple bloodwork, and a simple test, that you get every single year that can give you the basis of your medical records, that happened to me naturally. I didn’t have to make that happen. Many other people have to make that happen, schedule their appointments, and get the work done, and so, I would just say it’s nothing to get your bloodwork done, get a PSA, get some sort of indication, and it’s nothing to have the ExoDX test, period because that’s just a urine test. The biopsy if you ever need it, again, you want to catch this thing super early and if you do all of the things you’re supposed to do, getting medically checked and having a regular physical, I think it’s probably – Dr. Tutrone, you can tell me if I’m wrong – you don’t have to do it anymore than once a year but you know maybe if you’re worried about your family history then you get it every six months or so, you don’t want it, once it starts to show itself, you don’t want it to get to the point where it grows outside the prostate so schedule your physicals, get the test, take action, because if you do get that news, you want them to say that it’s early and all contained in the prostate.

Tutrone: You’re spot on with that Cal and it really is an important message to get out to men and I’m going to echo that, what Jamie said. A lot of it really does have to do with the research and the ground breaking technology that we’re developing through medical research, the assays, the treatments, it’s grown exponentially in the past ten years but we’re still behind diseases like breast cancer. I think there’s ten times the funding going into breast cancer than there is prostate cancer.  And it’s because men just aren’t as vocal about prostate cancer as women are about breast cancer, and that’s a sad state, but this is why it’s important for guys like you to get out and talk about this. It’s a great service. 

Bearse: And Cal, one more question, just cause I know so many guys out there watching.  Through your prostate cancer journey, through your diagnosis, any mistakes you can think about along the way where you kind of just looked at the scoreboard behind you and it says you’re E6 and you’re like “Ugh I should’ve learned from that.” Anything that you learned from that or anything you learned from your journey that might help-

Ripken: Well, I was a Gleason 7. Since I was a Gleason 7, three plus four, that’s a medium, and I was thinking to myself, “Could I have been more aggressive before that?” And really there was no indication, I was getting yearly physicals, and there was no indication, we went back, and looked at all the bloodwork that I had done, my previous ones, and it was showing there was a slight move. But there def was a move ever so slightly a little more aggressively when I went and saw Dr. Tutrone. That was the reason my doctor sent me there to begin with. But again if you really look at it on the surface, I’m well within the norm for my age, so it wasn’t overly alarming but there’s no errors here. I feel really good that we were able to identify it because you could really miss that slow movement. I think that because of the cholesterol medicine, trying to find the right medicine, I was getting a blood test probably once a month just to gauge the effectiveness of the cholesterol medicine. And each time we ran that we ran the PSA number, and that was my doc that did that, so I’m thankful. He could’ve just ran the regular test for cholesterol but he ran the PSA, as well, and he was able to get a different section of that, and that’s when he said “I don’t like this movement, so let’s go get it taken care of.” So I don’t see an error. I think I got lax a little bit when I first retired from baseball of having my physicals each year at the same time, cause it was always at spring training. I should’ve just kept it at that. Some times it would stretch out a little over a year but I don’t think that caused me any problems. But now that I know what I know, my advice to people my age, even though there was no history of prostate cancer in my family, now there is, and so you’re telling my brother Billy who’s four years younger than me make sure you don’t miss your physical and make sure you don’t go more than 12 months, get a blood test at least every time. Be really strict about it and disciplined about it, that would be the only lesson that I would be the only lesson that I would learn. Because if the timing wouldve been different and I would’ve let it go lag, 18 months or a year and a half or something, you’re giving the cancer the chance to grow outside the prostate so you want to know at the earliest stages, and so I think just being disciplined with your yearly physicals is the way to do it. 

Bearse: Yeah you have a great point too around your health. We know now, well we’ve known for quite some time but it’s good to get the message out, that what’s heart healthy is also what’s prostate healthy. So Cal, I want to thank you so much for sharing about your prostate cancer journey with us, we know that your story is saving lives, and thank you Dr. Tutrone, for your wonderful insights, as well. Thank you both for joining us in the summit.

Ripken: I’ve enjoyed being able to reminisce about baseball just for a minute, in Fenway Park, that pushed some adrenaline through me. 

Bearse: There you go, maybe someday we’ll see you there we can have live baseball again where we have fans in, can’t wait for that to happen.

Ripken: Yeah, me too.

Bearse: Now I hope everyone who’s joining in will join us not just through the rest of the summit, but in person, hopefully, real soon at next year’s 2022 summit, which will run from March 6 to March 8 in the Washington, D.C. area. To everyone watching, our virtual summit continues tonight. I know he doesn’t lead-off hardly ever, but he led off tonight. We’ve got a full lineup of content coming your way, so I’ll see you there. Once again, thank you Dr. Tutrone, and thanks, Cal. Thanks for sharing. 

Ripken: Thank you.

Tutrone: Thank you all very much.