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Prostate Cancer Treatment Innovations: Next-Gen Focal HIFU

Alyne Ellis (Host): It's called HIFU high intensity focused ultrasound. And it's been around for a long time as a treatment for prostate cancer. And now the, Maimonides medical center in Brooklyn is the first center on the East coast to offer the latest generation of this amazing technology and it's a game changer. Here to tell us how this new HIFU machine works is Dr. David Silver, the director of the division of urology and the leader of the Maimonides prostate center. This is Maimo MedTalk. I'm your host Alyne Ellis. Welcome Dr. Silver. So glad you're here today.

David Silver, MD (Guest): Thanks so much for having me.

Host: So, let's start with talking about HIFU in general, high intensity focal ultrasound. And tell me, how does it work in general, before we get into this new iteration of it?

Dr. Silver: Well, I have to tell you, this is kind of an ingenious technology. It didn't start out being used for cancer or for soft tissue of any kind. It actually, as an outgrowth of an undesirable side effect of extracorporeal shockwave lithotripsy, which many people are familiar with because they've had it done for kidney stones.

And the engineers noticed when they were developing it, that it had the undesirable side effect of sometimes damaging the tissue of the kidney before it would get to destroy the stone. And so here’s the insight that got this started. Engineers looked at that and said, huh, what could we do to harness that? And that's how this developed. So, you know, this is not a technology that relies on a heat to destroy tissue. It doesn't rely on a cold to destroy it the way cryoablation does. It's really tissue tripsy, if you will, or destruction of tissue with ultrasound.

Host: And so this newest version of HIFU, how is that more innovative and how does it differ from the older versions?

Dr. Silver: So, these older versions were a whole gland treatment technology. You would line up the entire prostate gland into the field, and treat the entire thing, from top to bottom, both sides, from the base to the apex. Now, with this technology, it's possible to focus on a specific region of the prostate, which may be several millimeters in size, in order to destroy only that tissue and spare the surrounding tissue.

Host: So, in other words, the healthy tissue remains and the cancer is presumably destroyed. So, how does it do that? Does the patient have an IV with something that targets where the cancer is? How does the machine know where to target?

Dr. Silver: No, it's an image guided technology. The patients have imaging done beforehand, usually in the form of a magnetic resonance imaging, or an MRI study. And then the area of abnormality that's on the MRI study, is then outlined and transferred onto a treatment plan that's developed with a fusion of the MRI image to a real-time ultrasound obtained at the time of the treatment. And then that area of treatment is what's destroyed.

Host: And this has some real advantages for the patient in terms of living a more normal life. If you could go over some of them.

Dr. Silver: Well whole gland treatment can have some undesirable side effects. The tip of the prostate is right near the muscle that holds the urine in the sphincter. And that can be weakened by whole gland treatment and any of its forms, whether it's radiation or surgery or whole gland ablation. And it's right by the nerves and blood vessels that supply the penis and help to make the erections. And so by sparing as much of the normal tissue as possible, specifically in those two areas, we can limit the side effects or problems with the urinary control and problems with the sexual function that are much more common with whole gland treatment.

Host: And does the patient need to be sedated for this procedure?

Dr. Silver: Actually, it's done under general anesthesia. Now in Europe, some people are starting to use spinal anesthesia for it. But because it relies on the fusion technology where the imaging has to be precisely aligned with the real-time ultrasound, for the moment, I believe in the US, it's most common to be done under general anesthesia so that patient doesn't move at all in the course of the procedure.

Host: And what about staying overnight in the hospital? Is that necessary?

Dr. Silver: I don't take hostages unless I absolutely have to. Everybody goes home same day.

Host: That's great. So, can one presume that you only need one treatment for this for prostate cancer, or do you see people coming back again?

Dr. Silver: It doesn't necessarily have to be repeated, but it can be. We're trying to do as little destruction of normal tissue as possible. And sometimes that means that there may be an area just adjacent to a treatment area that requires retreatment, and that can easily, readily be accomplished.

Host: So is this procedure right for all patients with prostate cancer? Who is it not applicable to?

Dr. Silver: Well, it's really not applicable yet to patients with high-grade or poor risk disease. Those are patients who have grade group five prostate cancer or grade group four prostate cancer, or PSA's in excess of 20.

Host: Let's talk a little bit about what you offer at the Prostate Center about detection of prostate cancer in general, because in addition to monitoring PSA levels, I guess that's the first sign that something is wrong, there are other tests that you all have that are pretty advanced.

Dr. Silver: Well, we have a fairly advanced prostate MRI. Everybody thinks that MRI is like CAT scan. You go in one end to come out the other end and you get a picture and it's going to be the same, no matter where you do it. And it turns out that it's kind of not true for MRI. The magnet has to be the correct magnet to do prostate imaging. The patient has to be properly prepped, properly positioned. The technologist has to understand that the study has to be done in a certain way so that the images that are acquired are useful. The injection has to be done properly. And at the end of the day, even if the study is adequate, it has to be interpreted by somebody who really sees a lot of these. We have a single MRI radiologist who interprets all of these. I think that's probably the only thing she does. She does probably several hundred of these a year and the program has been very, very successful.

Host: And do you have any advice in general for how often a man should be screened for prostate cancer and anything else that we should know about this disease?

Dr. Silver: Yeah, there are guidelines for this and they keep changing a little bit. For a while, there was a recommendation by the US Preventative Task Force, not to do prostate screening because there was no study in their opinion, that really supported prostate cancer screening and reduce the death rate from prostate cancer.

But it turns out that it's almost impossible to do a screening study in the United States, because everybody's being screened anyway. It's PSA is very easy to order and everybody gets it. Whereas in Europe, where the screening studies have been more carefully done, there's clearly a survival benefit to what early detection and a population based benefit as well. So, while the guidelines are changing currently, my professional society recommends that people should be screened and that screening consists of a PSA. Everything else is in addition, an examination, an MRI, a biopsy and so forth, but the basic screen is supposed to be a PSA.

Alyne Ellis (Host): The PSA tests that Dr. Silver is talking about is a test that detects the level of prostate specific antigens or PSA in your blood. A high PSA level could indicate the presence of prostate cancer. Dr. Silver this sounds really exciting, this new HIFU machine. So, could you please tell us anything else we need to know about it?

Dr. Silver: This is a technology that attracts very, very smart people who are looking for something else. And it is a relatively new application of an older technology. It's been around in Europe as a whole gland therapy for over 13 years. And it's only recently been applied as a partial gland therapy. But this is a little different than the other "new treatments." We know that this works, because it's been around for years. How well it's going to work and who are the best candidates for partial gland treatment, is still being worked on.

Host: Well, thank you very much for joining us today. It sounds very encouraging.

Thank you so much, Dr. Silver for explaining this latest HIFU procedure to us and the quality of life it offers. Dr. David silver is the director of the division of urology and the head of the Maimonides prostate center. To find out more about HIFU and watch a video about it. And to learn more about the, Maimonides prostate center, go online to Maimo.org/ prostate. That's Maimo.org forward slash prostate. This has been Maimo MedTalk.

I'm your host Alyne Ellis, stay well, and thanks for listening.