Joey Wahler (Host): It's a minimally invasive treatment for prostate cancer, so we're discussing high-intensity focused ultrasound, also known as HIFU. Our guest, Dr. Patrick Springhart. He's a urologist with Prisma Health.

Host: This is Flourish, a podcast from Prisma Health. Thanks for joining us. I'm Joey Wahler. Hi, Dr. Springhart. Thanks so much for being with us.

Dr Patrick Springhart: Good afternoon.

Host: Good afternoon to you. So first, what therapies are typically used to treat prostate cancer and where would you say high-intensity focused ultrasound fits in there?

Dr Patrick Springhart: Well, currently, with prostate cancer, we have the traditional radical prostatectomy, which is often done using robotic assistance, but that treats the whole gland. We also have radiation, which has also been around for decades, that too treats the whole gland of the prostate. And then for those who unfortunately progress to metastatic disease, there's chemotherapy, oral and IV drugs. But what we haven't really addressed in urology is how do we treat those patients with small focal lesions inside of their prostate that don't necessarily need the whole gland treated by either surgery or radiation. That's where HIFU falls into the treatment armamentarium.

Host: Gotcha. And so when we talk about that issue of being more precise, why is that so useful for treating prostate cancer?

Dr Patrick Springhart: So if you think about, you know, I'm 52, soon to be 53 years of age, and unfortunately as I get older, things are starting to break down like many people my age and older. And when I go to my dermatologist, if I have a small lesion, let's say on my forehead, he doesn't need to take the scalpel out and cut it off, usually just uses that little freezing gun to help get rid of the pre-cancerous lesions because he's just treating one spot. And now with the use of multiparametric MRI, we're able to see prostate cancer in its infancy, if you will, where oftentimes it's just one spot. And therefore, instead of applying radiation, which is whole gland therapy or surgery, which is whole gland therapy, we needed something that could do something more precise.

Now, HIFU has been around for years, and it's been applied in a two-dimensional format. But as you know, we're all three-dimensional objects. So, the benefit of this type of therapy or three-dimensional HIFU is that it can localize that little spot, just like your dermatologist. And instead of cutting it out, we don't freeze it, we just use HIFU, and it eliminates the lesion so that you're not having to treat the entire gland.

Host: Sure. So, how long would you say HIFU has been around and what else has it been used for?

Dr Patrick Springhart: HIFU has been around for over 10 years. Mostly, it's been used outside of the United States and mostly in Europe. But it's been typically used for whole gland therapy because it was two-dimensional.

Host: And so having said what you already have, to kind of pick up on that, who would be a candidate for HIFU?

Dr Patrick Springhart: Well, really any man with prostate cancer that has either whole gland or a focal lesion is a candidate. There are some limitations to the treatment though. This is not a one-size-fits-all therapy. Nothing is. You always have to be seen by the doctor. The doctor has to take many things into consideration. Your age, your comorbidities, like diabetes, whether or not you've had a stroke, whether or not you're on blood thinners. So, it's not a one-size-fits-all, but it is generally applicable to all guys with prostate cancer.

Host: And so, what exactly does this procedure involve and what's the success rate?

Dr Patrick Springhart: What it involves is when a man has prostate cancer, more often than not because it's the standard, we get an MRI of the prostate. That helps localize the abnormalities. Then, we biopsy the prostate hopefully in a three-dimensional biopsy because it helps, again, even more precise biopsies. And from that biopsy, we then take that information, we sit down with the patient, review it. And if they choose to move forward with HIFU, what happens inside the HIFU machine is it recreates the prostate in three dimensions and it recreates the cancer actually inside the prostate in three dimensions. And using that computer-aided design, we can tell the computer we want to treat these areas around the cancer, allowing us to treat not only the cancer, but sometimes we'll actually create a margin around there, just in case the cancer has small little cells that maybe are not seen on the MRI that we can also destroy with the HIFU.

When the patient comes to the operating room, we localize it. And then, we tell the machine to treat it. The machine treats it, and the benefit is if the patient or when the patient follows up, if they have another lesion, just like when you go to your dermatologist, you can also get that treated in the future. So, HIFU does not eliminate the ability to, number one, be treated by HIFU again; number two, to have it surgically removed if you unfortunately would develop worse cancer or if it's now spread throughout the prostate; or number three, proceed with radiation, which again would be another whole gland therapy.

Host: So, you've obviously already addressed the preciseness of this procedure. That aside, how does this treatment compare to other focal therapies that remove cancer? Any other advantages?

Dr Patrick Springhart: So if you want to look at how it compares to first the traditional ways, which are the surgical approach where we cut the prostate out or radiation, there is new data coming out of Europe that shows that the oncologic or the cancer outcomes are similar, but the functional outcomes, those being incontinence and erectile dysfunction are superior with HIFU.

Now when you asked the question about how does this compare to other focal therapies, well, there's not a lot of other focal therapies on the market. There are things like cryotherapy. But the problem with cryotherapy is when you place the cryoprobe ultrasound, it creates an ice ball. And that ice ball limits your ability to see all the way through the prostate because the ice ball blocks the sound waves. Or there's laser therapies. But again, they don't have a lot of long-term data that would suggest it's either equivalent or superior to the traditional surgical or radiation therapies.

Host: So, how widely available is HIFU?

Dr Patrick Springhart: Well, it depends. You asked whether there's a focal machine that's available, or the normal two-dimensional machine. So if you look at two-dimensional machines, they're more available because they're older and more health systems have them in their treatment armamentarium. But recently with the advent of the Focal One machine, they are now starting to pick up, more health systems throughout the United States that are able to provide this therapy.

Host: Well, a moment ago you touched on some of the side effects that we hear a lot when it comes to prostate cancer, about the possibility of incontinence or sexual side effects. So, what exactly, as best as you can tell us, can patients typically expect when it comes to that?

Dr Patrick Springhart: So fortunately, with the focal therapies, you can conform or you can change the orientation of the sound waves so that you avoid things like the neurovascular bundles or the nerves that provide both continence and erections. You can also avoid critical structures like the rectal wall. You can avoid critical structures like the urethra. So, the difference with this type of focal therapy is that you can actually change the orientation of the sound wave with the machine. And therefore, as a result, you get less side effects in comparison to the alternative therapies.

Host: That's pretty amazing, no?

Dr Patrick Springhart: It is amazing. That's one of the reasons why I thought at the beginning I was like, "Oh yeah, HIFU. Yeah, it's been around for years. And no, thank you." But then, fortunately, I listened to what the representative had said, and I did my own research into the product because we've been waiting for this at Prisma Health for years. About 10 years ago, as our group, we always want to be at the cutting edge or at the tip of the spear when it comes to innovation and treatments for our patients in our community, we acquired the ability to do three-dimensional biopsies. And it increased the accuracy about 60%. And that in and of itself is amazing. And so going from a traditional two-dimensional biopsy just to diagnose the patient was not up to par or what we thought was the best for the patient. But now that we do three dimensional, just the biopsies has increased our ability to find the lesions and the prostate cancer so that we can actually counsel the patients. Because as patients will read, or as you may know, not everybody needs therapy. The majority of folks nowadays, we just watch. We do what's called active surveillance and make sure that it never does progress or affect them. So if you move on from a three-dimensional diagnostic technique to now a three-dimensional therapeutic option, you can imagine if we were two dimensionally imprecise, but now three dimensionally markedly more precise, what that's going to do for the outcomes of the patients in terms of not only their cancer outcomes, but also their incontinence and their sexual dysfunction.

Host: Absolutely. Couple of other things, is HIFU covered by insurance?

Dr Patrick Springhart: So if you look at when I was in training, robotics used to not even be covered by insurance. And eventually, people caught on and found how gracious the patients were, are admitted to the hospital less, they have less blood transfusions. And it's actually in the patient's best interest and it would be cheaper if they were not in the hospital as long. And so, insurance companies eventually came around. And now, we're starting to see that Medicare patients and patients with VA insurance, and now a lot of the private payers are starting to pay for HIFU because they're seeing the benefit as well.

Host: And then in summary, what results overall would you say patients can expect from HIFU? And to pick up on what you mentioned a moment ago, with the success that you've had using this at Prisma Health, what's been some of the feedback you've gotten from those patients where it's been a success?

Dr Patrick Springhart: It's funny that you asked that. Oftentimes, as I was explaining to some patients earlier today, they feel like they've had a sham operation, that I actually didn't do anything because they went home that day, they didn't feel any pain, they didn't require any pain medication. We do keep a catheter in the patient for a brief amount of time. Usually, it's about three days. because one of the biggest side effects is that they can't urinate as efficiently afterwards, so I want to make sure that they at least get a couple days to let that inflammation subside. But what they've said is they can't believe that they had a procedure because they didn't experience erectile dysfunction, they haven't experienced any incontinence. They do experience some urinary frequency and urgency a couple weeks later, but that typically resolves after a month. But if you look at the trade-off compared to the bigger procedures, it's well worth it.

Host: Well, folks, we trust you are now more familiar with HIFU as a therapy for prostate cancer. Dr. Patrick Springhart, thanks so much again.

Dr Patrick Springhart: Thank you. I appreciate your time.

Host: Same here. And for more information, please do visit prismahealth.org/flourish. Again, that's prismahealth.org/flourish. Now, if you found this podcast helpful, please share it on your social media, and thanks again for listening to Flourish, a podcast from Prisma Health. Hoping your health is good health. I'm Joey Wahler.