There is hope for a treatment known as "PGA" or, partial gland ablation.
The author and his association --Note the date--it is recent
"April 2, 2021
By Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases"
The article--copy all print between the lines to access the article. HU automatically shortened the link shortened and members opened the link to find, "404 Page Not Found". Certainly annoying to all.
There is a very recent trial published today about it. Of 107 intermediate risk patients receiving partial gland ablation (they used cryo or HIFU), 22% still had significant prostate cancer 2 years later. And after the therapy was redone, half of those still had significant prostate cancer.
This compares to SBRT on intermediate risk patients, which had 8% biochemical recurrence-free survival, with similar quality of life. Reported salvage cure rates are 82%.
Much depends on who does the ablation. The equipment is more advanced now. Ablation treatment of any type, whether it be FLA, focal laser ablation or cryo depends on the aggressiveness, extent and confinement to the prostate capsule. Focal ablation can be done again should it fail. Should other treatments be necessary, surgery and radiation are still on the table after failed ablation treatments. A high quality of life could be extended for years with ablation treatment. Focal ablation can be used to ablate biochemical recurrence for men that a radiation therapy has failed without immediately going an ADT regimen and the side effects associated these meds.
The Mayo Clinic has a doctor that specializes in HIFU ablation. Yes, HIFU does have limitations but also advantages. The Mayo Clinic sees a future for HIFU and other ablation treatments.
A link--copy the entire script between the lines to access the article.
"Derek J. Lomas, M.D., Pharm.D., a urologist and specialist in focal therapy for prostate cancer at Mayo Clinic in Rochester, Minnesota, discusses the addition of high-intensity focused ultrasound (HIFU) to the prostate cancer focal treatment armamentarium."
"How do you see HIFU playing a role in prostate cancer treatment over the next 10 years?
I see focal therapy in general becoming an option for more men in the next 10 years as more data supporting its use emerge and more providers become trained in the techniques. HIFU will definitely continue to be one of the main technologies used in prostate cancer focal therapy. There will continue to be ongoing research on other ablation technologies as well. To have a well-rounded focal therapy program, we must have multiple ablation technologies and techniques available to allow for focal therapy to be offered to a wide range of patients. There is still a role for radical prostatectomy and radiation therapy, and certainly they remain the standard of care at this point, but I think focal therapy should at least be part of the treatment discussion in men who are appropriate candidates and seeking a less invasive treatment option."
Note the last sentence by Dr. Lomas above that I placed in bold font.
Proton treatment is an attempt to limit the damage to cell's DNA from exposure to radiation. A kinder and gentler radiation.
Salvage High-Intensity Focused Ultrasound (HIFU) for Locally Recurrent Prostate Cancer After Failed Radiation Therapy: Multi-institutional Analysis of 418 Patients. S-HIFU for locally recurrent prostate cancer after failed EBRT is associated with 7-year CSS and MFS rates of >80% at a price of significant morbidity.
Author: Sebastien Crouzet, Andreas Blana, Francois J. Murat, Gilles Pasticier, Stephen C. W. Brown, Giario N...
So, just a question, NOT a disguised statement from me...... urologists trot out the use of salvage RT after surgery......does the use of salvage RT result in same, more or fewer SEs/morbidities compare to salvage HIFU, etc after initial RT??? Do the 2 salvage treatments have similar success rates?
Anyone thinking of HIFU should choose someone that knows what they are doing, has experience and a good track record. Don't pick the one that will always be the "B - student". Pick the one that the teacher keeps the gold stars to put on their tests!
This excerpt from the very article that you posted above--
thelancet.com/journals/lano...
"Interpretation
24-month biopsy outcomes show that MRI-guided focused ultrasound focal therapy is safe and effectively treats grade group 2 or 3 prostate cancer. These results support focal therapy for select patients and its use in comparative trials to determine if a tissue-preserving approach is effective in delaying or eliminating the need for radical whole-gland treatment in the long term.
Funding
Insightec and the National Cancer Institute."
T_A, all due respect, but it is well documented that ionizing radiation is a carcinogen.
A man grade group 2 or 3 as the study notes can be safely and effectively treated. Choosing the correct doctor for HIFU or another ablation treatment is just as important as choosing a skilled radiologist. Now why would a healthy, younger, man choose a treatment that is known for starting a countdown to the very real possibility of a secondary cancer(s) or urinary and fecal incontinence when focal ablation doesn't expose one to a carcinogen or the associated damage to other tissue? Should a focal ablation fail, ablation can still be a treatment option--as well as all the other treatments. Again, as the study noted, grade groups 2 and 3 should have good outcomes.
The man who is a candidate for ablation can extend the quality of his life! Think about this--a younger man, by choosing an ablation treatment, can avoid a more radical treatment with some nasty side effects including that ticking clock after radiation treatment of some sort.
Why go "nuclear" on a cancer that can be treated without radiation? I know how much you favor radiation treatments of different types and I understand that it is your comfort zone which is fine.
It was nice to see that Clare Tempany was involved in the study. I have friends in the Atlanta area that started a prostate cancer group. They also have interviewed some noted doctors who are internationally known and respected who treat prostate cancers. When speaking with one of them he told me that not far from me, there was a noted doctor, just in case I might ever need her--yes--the doctor he mentioned was Clare Tempany! Her fame precedes her.
Your fear of radiation is common but unfounded. The best data we have is that the rate of second primary cancers in men who have had SBRT is not significantly different from the rate of second primary cancers in men who have had prostatectomies:
The rates of patient-reported toxicities due to SBRT are minor and transient, After 2 years:
• Urinary and Bowel scores returned to baseline within 2 years of treatment
• They remained at those levels with 5 years of follow up
• Sexual scores were not significantly declined after 2 years, but most trials report a loss of about 30% in previously potent men
Whereas in the Behfar Ehdaie trial (I've met him and think he is an excellent doctor, especially for active surveillance), the toxicities due to HIFU were:
• Urinary and Bowel function scores were similar to baseline at 2 years (18% experienced transient urinary incontinence)
So we, see that HIFU toxicity was similar to SBRT. HIFU can be safely done, but since it is not effective, what is the point? Our best data show with the most modern equipment, 60% still had prostate cancer after HIFU.
I expected you to vigorously defend radiation procedures. That is fine. As studies have shown, for the correct candidate, ablation treatments are appropriate. Not me saying that either,
Copy everything between the lines and place in your search bar.
Befar Ehdaie, the doctor you noted above--quoting you comment about him in your reply,
"Whereas in the Behfar Ehdaie trial (I've met him and think he is an excellent doctor, especially for active surveillance), the toxicities due to HIFU were:"
An excerpt from the Memorial Sloan Kettering article:
Tuesday, June 14, 2022
MSK medical oncologist Behfar Ehdaie, who specializes in treating prostate cancer.
Behfar Ehdaie said the new treatment approach is like a “male lumpectomy.” Instead of removing all the tissue in a breast or prostate, doctors have learned “it is safe and effective to treat specific areas and greatly reduce the burden on patients.”
it seems Dr. Ehdaie has become much more optimistic about HIFU than when you spoke with him.
I spoke to him last week. I suggested he run a comparative trial where intermediate risk patients are randomized to SBRT or HIFU. The problem, after his HIFU trial, is in getting "equipoise" from doctors. Equipoise is an ethical consideration; it means that the doctor recommending the trial to the patient has to be indifferent between the two therapies the patients are randomised to. Because 60% of the HIFU-treated intermediate risk patients still had prostate cancer after treatment, vs 8% with SBRT, a doctor may have a hard time ethically randomizing patients.
Focal ablation isn't the way to go. I had full-gland HIFU ablation -- best to do a thorough job even if TURP, which I had already had, is a requirement. That was my HIFU surgeon's recommendation which made sense to me. My PSA dropped to undetectable after the surgery and six years later has leveled off at 1.8. No impact on erectile function. No incontinence. Yes, I dealt with transient hematuria. Interesting that Mayo is exploring HIFU as an option. Six years ago they weren't. I went out of state for HIFU surgery. Also interesting that one of the urologists in my local practice has also added HIFU to his bag of tricks. In my Erkel voice -- did I do that?
You were lucky. Full gland HIFU tested out almost as badly as focal HIFU. Over a third had residual cancer found at biopsy, and the toxicity was worse.
Do you think I wouldn't review the track records of the doctors I considered?
Luck doesn't like me and I don't like luck.
I fully understand the importance of experience. When I embalmed bodies at a busy funeral home, after I had embalmed 500 bodies, I then considered myself not an expert but entering the top level of my profession. The funeral home was averaging mid 180's numbers a year. In my last three years, there was only one body embalmed that I didn't embalm. Numbers also mean nothing if the practitioner is not talented.
When considering HIFU, I fully understood the importance of finding a doctor that had extensive experience and an excellent record of success.
I wrote this three days ago.
"Dr. Ehdaie's optimism about HIFU is on the record--again for the appropriate candidate.
As I said, why go nuclear when it isn't needed? I wouldn't use the shotgun if I saw a mouse in the house."
No clock concerning DNA damage to cells begins ticking either. Also, why was there cancer? Cellular changes had occurred either genetically, through lifestyle or exposure to a carcinogen. Adding doses of radiation to an area in which cells had already mutated resulting in a cancer if a focal ablation would suffice and add years of quality of life for a man may not be the most prudent of the choices of treatment. That is a decision that each of us who have been diagnosed have had to make.
My beliefs on this have not changed nor will they especially as Dr. Ehdaie supports my belief that yes, a focal ablation for the appropriate patient is a viable option.
I am not saying that radiation isn't a viable treatment when needed. Do what you have to do. Hold off using the 12 gauge loaded with double 00 buck when a 22 caliber works.
Dr. Ehdaie's optimism about HIFU is on the record--again for the appropriate candidate.
As I said, why go nuclear when it isn't needed? I wouldn't use the shotgun if I saw a mouse in the house.
I know how you worry a topic. Think this over and have a heart to heart with Dr. Ehdaie about his statement and his optimism for HIFU. HIFU isn't the only ablation treatment. As these doctors gain proficiency in ablation techniques it will add years of quality life to many men needing treatment. There are doctors that now are really good with ablation of different types. If and when necessary, these men can then choose a more SOC treatment with it's well documented side effects.
I like Dr, Ehdaie's bow tie! Dapper and doesn't interfere with his work.
After TURP I wasn't a candidate for RP and I considered that too invasive anyway. They steered me toward external beam radiation. I'll confess -- I was afraid of radiation. I've heard too many stories, on this site alone, about post radiation issues -- basically unintended tissue damage or inflammation, not secondary cancer due to the radiation. I chose full gland HIFU from an experienced practitioner and I am doing fine almost 6 years later.
Salvage High-Intensity Focused Ultrasound (HIFU) for Locally Recurrent Prostate Cancer After Failed Radiation Therapy: Multi-institutional Analysis of 418 Patients. S-HIFU for locally recurrent prostate cancer after failed EBRT is associated with 7-year CSS and MFS rates of >80% at a price of significant morbidity.
Author: Sebastien Crouzet, Andreas Blana, Francois J. Murat, Gilles Pasticier, Stephen C. W. Brown, Giario N...
Very important to choose an experienced HIFU practitioner since it was FDA approved only 6 or 7 years ago. Most experienced US HIFU surgeons used to perform operations in Mexico or the Caribbean prior to FDA approval here. HIFU surgery has been performed for quite a number of years in Europe before it was approved here.
Exactly Spyder! That is why I so strongly suggest that a mp 3.0T MRI done-- and read by one who is a noted expert-- with an in bore, biopsy ready should something be seen. The buckshot type of laying out a grid biopsy has caused much damage to men. As T_A has said, the trans perineal biopsy can access areas of the prostate that the TRUS can't and the chance of sepsis is greatly reduced or negligible. Any possibility of feces is no longer a factor. As I have said repeatedly, avoid fluoroquinolones. They are very dangerous drugs. Cefdinir and Rocephin can be substituted if needed.
A man that has the PGA, partial gland ablation, will usually have very few side effects and there is no ticking clock getting closer to a secondary cancer from a radiation treatment or the other side effects associated with that or surgery. A man's quality of life may be extended for years--if--he is an appropriate candidate--and someone experienced and competent in focal ablation does the procedure. Same as picking the wrong radiologist or surgeon.
I believe the Harvard article I posted the other day was dated this year. Thanks for posting this one.
It is time that the trans perineal prostate biopsy supplants the TRUS and PGA, partial gland ablation is viewed as a first line treatment for men who qualify for it. There is much resistance as PGA is relatively new in this country. How much do hospitals have invested in Davini units, radiation equipment and how many make earn their living by providing these treatments?
Follow the money.
What I have written should be a post rather than a reply. It all started with you. Nice!
I think the FDA was slow to approve HIFU prostate ablation because there were few champions in the US to start with and a whole lot of RP surgeons and radiation oncologists who were already trained and equipped to do their thing, not HIFU. Mayo mentioned HIFU -- the were silent on this technology 6 years ago.
Some say that "they research". I do not say that. I read data, information and other people's research and try to make a logical decision without bias--doing the "Spock thing"!
You are correct the robot has to pay for it's keep.
The initial cost of the robot, it's maintenance and the training of those who use it --wow! The robot has be kept busy to pay for itself. It has been successfully used for quite few types of surgery. A cousin had a kidney robotically removed. He didn't have cancer but a benign tumor that was beginning to obstruct the ureter from the kidney.
A little Davinci info from my time--note that the year 2012 is referenced.
Da Vinci Surgical Robot: Is it Worth the Cost? - Audet
The robotic surgical devices can cost as much as $2.6 million with add-on packages and technical support. There are concerns that widespread use of …
Estimated Reading Time: 4 mins
I also read an article that a "maintenance plan" HAD to be purchased along with the robot and that after 10 years it is taken out of service, no longer to be used. I do not know if that has changed.
I do know from my experience as an embalmer and speaking with my first uro who uses the robot that there is--or was-- no "tactile" sense quantified through --say a gauge, a readout or an alarm if a certain preset value of pressure or force is in some way exerted by the robot. I have decades of experience in the manufacture of specialty chemicals and pharmaceuticals. I have been closely involved in designing equipment trains, choosing equipment and contributing to the training of chemical technicians and engineers in running batches, cGMP practices and running batches myself to get FDA approval for the manufacture of drugs. You can't monitor your batch in process without sensors and readouts. With a batch one seeks consistency. The same temperatures at different points, pressures, rate of addition of API, active pharmaceutical ingredients, which can result in endotherm, or more likely an exotherm. Consistency is a large factor in yielding quality drugs. Batch making records are kept and are legal documents.
Is there consistency in the bodies which the robot will be used to perform a surgical procedure? When I was an embalmer, some bodies had arteries that could have been used for, as I have said to do pull ups from. Then there is the little old lady whose tissue is fragile one takes extra care. A good embalmer, an empathetic embalmer, realizes the importance of his profession and how the family's last moments with their loved one and how that one appears, is often the result of the embalmer's skill. A loved one that appears to have found peace at the end of life is very important for the family's memory.
With the Davinci in the 2012 and 2013 years, the patient, relied on the expertise of the operator, as there were no readouts of pressure or force at that time.
The "Rocco stitch" was the standard suture to connect the urethra again. Heat is used by the Davinci for surgery. The nerve bundles are separated by heat and like the steak you take off the grill continues to "cook" until the temperature lowers. It was found that spraying cold, sterile water on the nerve bundles immediately after they were each separated and held to the side, limited heat damage and improved regaining erectile function as well as speeding the recovery of erectile function.
Then of course, one of the interesting, unfortunate side effects of surgery, that I would not like to experience is "climacturia". it is said that climacturia "usually resolves itself". That is a common phrase used by uros and those who treat us.
Would I consider surgery if I needed to do --something--and wanted to? Yes I would and I would likely choose my first uro whose honesty I can't say enough about. He was a young man who was following in his father's profession. He has some numbers behind him now--experience. I hear he is doing well and is well respected.
Any treatment involving radiation would be my last choice. I don't need to start a clock ticking.
As "They" of knowledge gained through observations passed down through generations might say, "To each, their own".
Find info realizing that there are biases. Read. Talk with those who have had procedures. Make your own decision based on your comfort level and how you hope to live the rest of your life. Know that there are some procedures that do not interfere with other types of future procedures. It is your decision and you are the one that will live with it.
I asked a doctor why he didn't press me on --something--yet another did. He told me that it was obvious that I was what is known as "an informed patient". Should he have continued to press me, to try to influence me roll the dice, by submitting to --something--it could be construed as malpractice.
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Never delay seeking advice or dialling emergency services because of something that you have read on HealthUnlocked.
All of these ablation options instead of RP or RT ?
46M, diagnosed in April, approaching decision
