Christopher Weight, MD, Urologic Oncologist, Glickman Urological & Kidney Institute at Cleveland Clinic, talks about a new method of treating men with prostate cancer.
WEIGHT: This is a new, exciting treatment for men with prostate cancer. We know prostate cancer comes in a lot of different types from the least aggressive type, which shows up and can often be safely watched for years and years, to the more aggressive types which require aggressive intervention. Even with intervention, still, about 20 to 30 thousand men die each year from prostate cancer and so in that wide gamut of risk of prostate cancer, this high-focused ultrasound really is ideal for the early stages of intermediate risk prostate cancer. This is the stage when it’s progressed from the early stages to the risk level where we’re starting to see some aggressive features. In these cases, we know that that the average man benefits from treatment, but the tumor may be small and be able to be treated with a ‘smaller’ treatment that comes with a lot fewer side effects than some of the more traditional treatments for prostate cancer.
Could you kind of expand upon who would be a good candidate for this procedure?
WEIGHT: The ideal candidate for HIFU is a man who has low volume, intermediate risk prostate cancer. Again, the very low risk cancers, we still prefer to watch those men because the majority won’t have any trouble over 15 years. So, it’s best deployed as they move from low risk to low intermediate risk. The ideal candidate also tends to have one lesion or two lesions that happen to be on the same side. If we can see them on MRI, that’s even better because then we kind of know where we need to treat and we can make that treatment and more focal and thereby minimizing the side effects for the men who receive this treatment.
Then since this is considered a therapy, so to speak, I mean, how often does someone have to go or is this a one-time procedure?
WEIGHT: The beauty of this treatment is it’s a one-time treatment. You come into the hospital. We do this in the operating room under general anesthesia. There’s really minimal bother or pain associated with this. It has the advantage over surgery of having no incisions. It has the advantage over radiation of having no ionizing radiation that penetrates through and hits the other tissues so it really focuses on a very small area of the prostate that we can tell has the cancer and thereby minimize the negative side effects. Once done, you get a catheter placed during the procedure. You go home that same day and generally that catheter comes out a few days later.
What is like a traditional treatment for someone in the same group, if they weren’t to have done this type of therapy?
WEIGHT: The two traditional therapies for intermediate risk prostate cancer are surgical therapy, where you remove the entire prostate or radiation therapy, where you deliver a form of radiation to the entire gland. The surgical therapy is still a standard treatment and we use it often. The prostate is usually removed with robotic assistance with a few poke holes in the belly. You stay in the hospital overnight and then a catheter stays in for approximately a week. The radiation therapies are often delivered either through a form called external beam, where there are external X-rays that are delivered to the prostate over the course of as few as two or three weeks to as many as eight weeks, giving small little doses every day. Or another form is called brachytherapy therapy, where you have small little radioactive seeds. They almost look like grains of rice – placed throughout the prostate in a one-time procedure.
And it’s my understanding that the Cleveland Clinic is only one of – there’s not many hospitals, I should say, doing this procedure, it sounds like.
WEIGHT: There are not very many. This was FDA approved several years ago for the destruction of prostate tissue. We still have some research to do on who is an appropriate patient to apply this to, what the long term outcomes will be. The early outcomes are promising in the appropriately selected person and that’s the key, is that this is not a treatment that’s intended for all men with prostate cancer. It’s only if you fall into a select category. But if you’re in that group, you can really get a good cancer treatment, we feel, and have minimal side effects.
What advice would you have for men as they go about screening? What symptoms should they look out for if they do feel like something’s wrong?
WEIGHT: Well, that’s one of the tricky things about prostate cancer is the symptoms are pretty inconsistent or even nonexistent. Many men, as they get older, will experience a decline in their urinary function. They have to urinate more often, they have to get up at night. That’s quite common. The good news is that usually doesn’t represent prostate cancer. It usually just represents aging of the prostate and the bladder that many men will experience. On the other hand, if they’re really progressing and becoming bothersome or if there’s blood in the urine, that merits an evaluation. The best way to catch prostate cancer is screening appropriately in the right patient, particularly patients that are at high risk or a little bit older or that have a family history or some of these other details. Screening really involves periodic exams, blood work and some newer tests like MRI, for example, and some other blood tests besides the PSA.
So once the procedure is done, I imagine it’s just follow up. How consistently does someone have to come in after that to see if everything’s progressing as it should?
WEIGHT: Yeah, so we usually will get a follow up PSA in the short time period after the procedure, somewhere around three months, to check in and see how that PSA is doing. There was a recent study published that shows the average reduction, if you ablate half of the prostate, is about a 50 to 75% reduction in the PSA. If you’re following that curve, then we’re reassured that we’re on the right target. Then follow up also includes some form of imaging off and down the road, like a repeat MRI and probably a repeat biopsy down the road as well to confirm adequate kill of the tissue and no recurrence or development of a new tumor, for example, outside of the zone of ablation.
It ultimately sounds like there’s a lot of benefits to this procedure. Can you kind of talk about the side effects you had mentioned prior?
WEIGHT: Well, similar to all prostate cancer treatments, there’s always a slight risk of effect on urinary function as well as on sexual function. These are the two domains that, unfortunately, all of our prostate cancer treatment has some effect. But the effect seems to be quite transient and minimal. And in fact, on urinary function, there’s often a slight improvement because the HIFU, it works by creating a really high intensity-focused beam of sound waves. And you can think of it somewhat like a magnifying glass. If you shine the light of the magnifying glass from the sun onto one defined spot, it can get really hot in that spot. And it’s a very similar concept to that, except for instead of light waves, its sound waves. So it destroys that tissue. And if you have bad urinary symptoms because your prostate is pressing in on your urethra, as that tissue is destroyed and as your body starts to heal, urinary symptoms actually improve. And most studies show that the risk of incontinence, which is one of the feared complications of the traditional treatments like surgery or radiation, are on the order of zero to one percent, which is really encouraging at five years. The risk on sexual function tends to be minimal, if at all, especially if the treatment is focused or a hemi-gland. And so, for example, just one half of the prostate. Historical series have reported HIFU treating the entire gland. And if you do that, the risks of these complications rise compared to kind of a focal or a half-gland treatment. And we have chosen to really focus on this group of patients that have kind of one or two defined areas to try to really optimize the risk-benefit ratio for these patients with prostate cancer.
Wow. This is really fascinating. Is there anything I didn’t touch on that you think the public should know about with this procedure and how it works? Any advice for patients who might be deliberating on whether or not to move forward with something like this?
WEIGHT: Yeah, I think it’s really important to have a discussion with a physician who does these. We are still in the early phases of understanding who the exact right person is for this. We know that failure rates are much higher in patients with high risk prostate cancer. And I think we need more clinical trials if you have high risk disease. We also know that we probably don’t need to treat a large amount of men with low risk disease. And so those men can be safely watched through active surveillance. If you’re wondering if this is an appropriate treatment for you, I think it’s a good idea to do some research online. There are some good resources if you stay on reputable sites that are .org or .edu rather than .com sites. And then make a visit with a provider who offers this treatment and ask questions to see if maybe this is an appropriate treatment for you.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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