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Increasingly, many surgical disciplines have come to grips with the significant complications associated with radical cancer surgery and have modified their approach to cancer excision. For example, surgery for breast cancer has moved away from a radical approach and adopted the lumpectomy or local excision instead of removing the whole organ. This modified approach preserves survival and is associated with significantly less complications and improved quality of life (QoL).
However, since urologists developed the radical surgical procedure as a treatment option for prostate cancer they have wrestled with how to deal with the very significant downsides and after effects associated with this treatment option.The urology hierarchy however, chose intentionally to stay the course with the radical approach. The common post operative complications associated with this radical surgical approach are impotence and incontinence (limp and leaking). As well, these complications result in a significant negative impact on QoL not only for the man, but his wife and their partnership (see prostate cancer treatment:the good, the bad and the ugly).
Eventually, recognizing this disposition for complications after surgical removal of the prostate, surgeons refined their radical approach to prostate cancer treatment and developed the “nerve sparing” technique in attempts to lessen this propensity for “limp and leaking”. However, this “nerve sparing” approach for prostate cancer excision did not realize the expected great improvement in results with better preservation of erectile function and urinary continence. This dilemma then led some surgeons to cheat by creating “new” definitions for impotence and incontinence so that their radical surgery was now associated with acceptable levels of these complications.
Subsequently, when the bio-tech industry found a use for their robotic machines in prostate cancer treatment, technology firms soon discovered that they could report even more impressive post operative results. These impressive treatment results for radical surgery/robotics were achieved through the coupling of these spurious definitions for limp and leaking with more misleading information. This so called data for the non FDA trialed treatment option was then spiced with unbridled and unabashed marketing and propelled into the forefront of prostate cancer treatment as some quasi gold standard. When financial rewards and lobbyists were added to this mix it was not hard to realize that some physicians had lost their soul and credibility. Furthermore, the endorsement of a surgical technique by a professional of stature under these circumstances does not necessarily equate with physician competence or honesty. In fact, some educated people are not above bending science with pseudoscience.
Certainly, there was a time when physicians, as true patient advocates, reported sincerely and honestly on cancer treatment options. However, these ideals have seemingly evaporated and the need for standardization of evaluation criteria and definitions of treatment complications are, apparently, no longer important. Indeed, Hippocrates affirmation: “As to diseases, make a habit of things to help or, at least do no harm” has been made redundant. More over, we have become comfortable with manufacturers speaking for the medical fraternity. In fact, now we do not even need rigorous blinded FDA trials scrutinizing the validity of localized prostate cancer treatment options (for hifu, cryoablation, radiation and surgery). This indolent approach by urologists is an injustice to patients that requires immediate attention and correction.
Important issues regarding negative aspects to prostate cancer treatment have been detailed before in several different media formats.
BOOKS
Gary Onik, Male Lumpectomy: focal therapy for prostate cancer
Several other books have underscored the concerns in prostate cancer treatment as well as the business side of the prostate cancer industry.
MAGAZINES
Men’s Health
L. Stains, I want my Prostate Back. March, 2010
WEB BASED

Fox News/Reuters
Life after Prostate surgery worse than expected. July 1, 2011
Hifurx.com
Bert Vorstman MD, Why should the after effects of some prostate cancer treatments be worse than the disease itself? August,2011
NEWSPAPER
Miami Herald
Prostate Cancer Treatment: the good the bad and the ugly. August 22, 2011
Sun Sentinel
Prostate Surgery is Booming, but at what cost? September 11, 2011

PROSTATE CANCER WITH A NORMAL PSA

Some 15-20 per cent of men with a normal total PSA (tPSA) of 4 ng/ml or less can have clinically significant prostate cancer.
These men have no symptoms and usually no findings on examination.
The only way these men can be identified is by calculating their per cent free PSA (%freePSA) which is determined from their tPSA and free PSA levels ( free PSA divided by tPSA X 100 = % free PSA).
The free PSA is so called as it is not bound to a carrier protein in the blood. However, the tPSA is bound to a protein called
alpha1 antichymotrypsin while the free PSA is unbound in the blood or, somewhat to alpha 2 macroglobulin.
Unfortunately, most physicians and screening studies do not make use of the %free PSA estimation so a good number of men have their prostate cancer undetected due to the MISTAKEN belief that all is well if the tPSA is 4 ng/ml or less.
The use of the %free PSA was approved initially only for men with a total PSA of between 4-10 ng/ml in the belief that if one could identify more accurately those men who could benefit from a prostate biopsy we could minimize the number of men having unnecessary biopsies.
However, the real value of the %free PSA is in identifying those men that have an increased probability of prostate cancer before the PSA is significantly elevated. Ideally, the %free PSA level should be greater than 25 and the lower the level of the %free PSA (converse of tPSA level where the higher levels suggest greater risk) the greater the probability of prostate cancer.
Some studies have shown that with tPSA’s of between 2.6-4 ng/ml and using the cutoff %free PSA of 19% that a prostate cancer detection rate of about 90% was achieved.
In my practice however, I advise men to consider a prostate biopsy who have a tPSA of 1.6 ng/ml or greater but with a
persistently abnormal %free PSA of 19 or less.
Early detection of prostate cancer by using the %free PSA is critical in identifying more men with organ confined disease.
Early detection,especially when the tPSA is under 4 ng/ml may increase the chance of a cure particularly with a minimally invasive option such as HIFU.
Importantly, one should not act on one abnormal laboratory value but have it repeated so as not to act on spurious lab results.
The tPSA blood test may be incorrect if the specimen has not been handled by the lab properly or has been assayed without proper calibration of the equipment. Also, the free PSA is affected by renal function leading to a false %free PSA estimation in those men with renal dysfunction. Furthermore, both tPSA and free PSA increase with age, after prostate examination, after biopsy, ejaculation and after a urinary tract infection but will normalize with time. Proscar and other medications reduce both tPSA and free PSA and can engender a false sense of security. Lowering the PSA in this way may not have a protective benefit.
Finally, nothing is absolute and no marker or MRI diagnoses prostate cancer. These studies may suggest a prostate cancer and having your %free PSA determined and repeated if necessary, can lead too an important prostate biopsy and an early jump on your prostate cancer if identified.

When prostates removed surgically for prostate cancer are examined, 50-75% of these specimens contain more than one area or focus of cancer and called multifocal prostate cancer. In other words, only about 25% of men may have a unifocal prostate cancer lesion that may be suitable for focal therapy. In these prostates with multifocal cancer, however, the gland has on average 3-5 tumors in various stages of evolution.

One of these cancerous areas is commonly bigger in volume than the others and called the index lesion.
In attempting to sort out when a focus of prostate cancer becomes significant and needing treatment, there is some acceptance that an index lesion with a Gleason score of 6 or more and with a volume of >0.5 cm3 is a size where treatment may become necessary.
Smaller index tumor volumes,or, smaller total tumor volumes as in those with multifocal disease can probably forgo treatment but diligently followed through active surveillance (AS).

During AS, PSA velocity (PSAV) monitoring can be valuable and a PSAV greater than 0.75ng/ml/year is associated significantly with prostate cancer and possibly progression. On the other hand, a PSA density of 0.08ng/ml/cc at first re-biopsy is a significant predictor of prostate cancer progression and probable need for treatment. However, no tumor marker is definitive and only a needle biopsy of the prostate can definitively diagnose prostate cancer, assess Gleason score and suggest progression of the cancer.

For the significant index lesion then, what is a tumor volume demanding treatment? Do we consider focal treatment of just that index lesion (focal ablation) with a minimally invasive treatment option such as HIFU, cryo or laser and disregard the other smaller satellite lesions in a multifocal prostate cancer?
Prostate cancer has a very varied biological potential and the clinical and prognostic significance of these smaller satellite lesions in men with multifocal prostate cancer is unknown.

Some have suggested that prostate cancer spread or metastasis, probably originates from a precursor cell and that the precursor cell may arise from the index lesion and therefore maybe treating only the index lesion is necessary. In this manner, by focusing treatment on only the index lesion, we may reduce the risk of collateral damage, a common byproduct of robotic prostatectomy and radiation and so preserve a man’s quality of life (QOL).
However, the desire for focal ablation or treatment of just the index lesion in those with multifocal disease needs to be tempered somewhat because of a number of concerns, least of which is the issue that men with higher tumor volumes have a greater risk for recurrence after treatment. Furthermore, prostate cancer located in the peripheral zone of the prostate (about 70% of prostate cancers are located in this zone) in contrast to those located in the transitional and central zones of the prostate, have a greater ability for prostate capsule,sphincter and seminal vesicle penetration and also lymph node spread. In addition, if the index lesion is substantial and or associated with a Gleason 7 or above and located in the base or apex of the prostate, infiltration of the sphincter or base of the prostate is likely. These margins should be biopsied to check if the prostate cancer is outside the prostate and no longer localized and therefore unsuitable for a minimally invasive treatment.

Also, in multifocal prostate cancer, there is a greater risk of higher grade prostate cancer and therefore a higher Gleason score, stage and recurrence rate when compared to unifocal prostate cancer.

With these issues in mind, most of my patients with significant localized prostate cancer prefer total prostate ablation with a minimally invasive option such as HIFU rather than just focusing only on the index lesion (focal treatment) and disregarding treatment of the satellite lesions.

Finally, much of the prostate cancer data needs to be viewed with caution as few if any studies include independent validations of the prostate pathology and, also, prostate cancer is still something to be reckoned with as it is the second leading cause of male cancer deaths after lung cancer.

Did you know that prostate cancer is the second leading cause of male cancer deaths after lung cancer? Most men have few if any symptoms of prostate cancer. How will you learn about your situation. Will it be too late?

One of the biggest misconceptions about needle biopsies is that they spread the cancer. This is simply false. Another misconception is that prostate cancer is best treated by cutting it out. This too is false

What else should you know about prostate cancer? You should know you have choices for treatment and we’ve dedicated a page on our main site that gives users a list of items on what the everyday person should know about prostate cancer.

Check it out today and give us a call if you’ve been diagnosed with prostate cancer to learn the facts and discuss your options.

There are four recognized definitive treatment options currently offered for localized prostate cancer,HIFU, cryoablation, radiation and robotic surgery. The best treatment outcomes after any one of these options is in men that have only truly localized prostate cancer, or cancer localized to the prostate and not outside the prostate. The survival benefits for localized prostate cancer after anyone of these treatment options are similar. However, the complication rates for these four options are quite different and warrant scrutiny.
The majority of prostate cancers are now found in men through screening with the finding of an abnormal total PSA (prostatic specific antigen) and/or %free PSA.
Other than this abnormal blood test, most men are relatively asymptomatic with no findings on digital rectal examination (DRE).
The diagnosis of prostate cancer can ONLY be made through a needle biopsy of the prostate and examining the tissue. The biopsy follows a sextant pattern whereby the prostate is divided into six zones,base, middle, apex of the prostate,right and left and each of those regions is randomly biopsied.
The results of the needle biopsy ( with particular attention to the volume of the prostate cancer in each of these needle biopsy cores and their Gleason score), in addition to the PSA and stage of the prostate cancer, are used in assessing a man’s risk for progression of his cancer. Also, the patient would do well to have the biopsy results validated through an independent reference laboratory to confirm not only the presence of the cancer but the volume and the Gleason score.
In addition to the forgoing, we would factor in a patients age and co-morbidities before suggesting treatment.
The following risk categories are considered:
LOW
PSA less or equal to 10ng/ml
Gleason score less or equal to 6
Stage T1,T1c,T2a
the risk is higher if greater than 50% of the cores are positive

INTERMEDIATE
PSA between 10 and 20ng/ml
Gleason score 7 (risk is greater for 4+3 compared to 3+4)
Stage T2b, T3a
the risk is higher if greater than 50% of the cores are positive

HIGH
PSA greater than 20ng/ml
Gleason score 8-10
Stage T3b

Of these three RISK CATEGORIES, the majority of LOCALIZED prostate cancers are found in the LOW to INTERMEDIATE RISK GROUPS.
How then can we assess the patients further (other than with imaging studies such as bone scans,CT and MRI scans) so we can prevent men from having treatment for presumed localized disease when the cancer may not be localized and already outside the prostate. The best method is to biopsy the MARGINS or the limits/edges of the prostate. If these margins are clear we can be fairly confidant that the prostate cancer is indeed localized and treatment would be ideal with a minimally invasive option such as HIFU.
MARGINS
After return of the validated biopsy report, I will look at where the cancer was found in the prostate, the tumor volume and the Gleason score. If there is significant cancer volume at the base (close to the bladder/seminal vesicles) or apex (close to the urinary sphincter) of the prostate or there is a Gleason score 7 or higher in these areas, I will have the patient undergo a biopsy of the MARGINS of his prostate. This may mean an additional biopsy but the importance of this step is outweighed by the possibility of preventing a man from having a treatment that may not be in his best interests. It is pointless subjecting a man to a treatment option that is ideal for LOCALIZED prostate cancer when the cancer is not really localized. For example, in addition to the considerable risks associated with debilitating surgery ( including robotic prostatectomy) with incontinence and impotence, 20-40% of the men treated in this manner will have positive margins (or cancer left behind) necessitating the need for additional treatments such as radiation.
Should biopsies of the prostatic margins show cancer infiltration and therefor a cancer no longer localized to the prostate, the patient is probably better served by radiation. Although radiation is associated with an increased risk for longterm bowel and bladder dysfunction, this treatment option may be a better choice for those men where there is infiltration of cancer at the margins (and particularly in the apical region ) of the prostate as, radiation, by being somewhat imprecise usually also directs treatment outside the confines of the prostate. However,for truly localized prostate cancer disease HIFU appears ideal as it is very precise as well as offering cure with a low risk for longterm complications and not at the expense of quality of life (QoL).