So, what is your opinion of treating prostate cancer with MRI-guided focal laser ablation?
I think it can be effective and it's on the table of options for men to consider.
The problem I have as a prostate cancer expert, I haven't really come across one maven,
one wonderful laser expert, that I have 100% confidence in. It is a skilled procedure like
any of the other prostate-related treatments. People have learned over the years that if
you're going to have surgery, go to one of the top centers, and don't just go to the right center,
go to the best doctor in that center and specify that surgeon by name. You don't just go to Johns
Hopkins to have surgery, you pick the best surgeon at Johns Hopkins, and the same sort of fastidious
care needs to be exercised when you think about any prostate treatment including a laser ablation,
but for men that are candidates for that—that means that they have a focal lesion that's visible
on a scan and it's an isolated lesion—then focal laser ablation is a reasonable option.
When people are researching these types of doctors, we know we talked about online reviews,
is there a number that you would give of say, you know, you're interviewing the doctor, he's
done this many operations that you would kind of feel it's better than others? Over 50? Over 100?
Yeah, but i don't think I'd bank my future on whether someone's done 50 or
5,000. I would be bank my future on some sort of quality assessment from
other physicians that have referred to that physician and have seen the outcomes,
subsequent outcomes, and watched the patients. Did they stay cured? Were they able to avoid
the impotence and incontinence that we worry about? That's what I would use.
Our next question comes from a viewer who's wondering if with PSMA PET. scans and
all the new radiotracers and everything coming out,
do you see random needle biopsies being eliminated in the future?
I don't know about eliminated, but certainly reduced. The scenario of maybe even a somewhat
elderly person who has an elevated PSA, gets an MRI, and they see a PI-RADs 4 PI-RADs 5 lesion
in the MRI, which, you know, 50 chance that it's a higher Gleason score cancer,
so then we're going to put that person through a needle biopsy. Seems like a logical alternative
that if a PSMA PET scan is done that doesn't light up that there's a low likelihood
that that person has cancer and therefore maybe they've been able to avoid a biopsy.
So, our next viewer is wondering have cure rates improved with the
advent of robotic surgery versus regular surgery?
No, robotic surgery came along I think around 2004-2006 and there were certainly hopes that the
technology would translate into better cure rates and into, you know, better or
lower rates of impotence and incontinence. Sadly, none of those things were achieved.
What has been achieved with robotic surgery? Shorter hospitalizations, quicker recovery,
so the scars are much smaller—old-fashioned surgery you'd have a zipper about this long on
your abdomen after standard radical prostatectomy and now they just have little tiny scars where the
robotic fingers go through and do their surgery. So certainly an improvement,
but in the things that men really care about, "Will I be able to get normal erections? Will
I leak any urine afterwards?" unfortunately it hasn't improved the results at all.
So, we have a patient who had 3+4 prostate cancer, so intermediate-risk; they sent their pathology
over to Johns Hopkins, and Dr. Epstein brought it down to a 3+3 and now their doctor wants them to
have a random needle biopsy after to confirm before they go on active surveillance. So,
do you agree that they should get a random needle biopsy or is there anything else that they can do?
Well, it's considered the standard of care to do a confirmatory biopsy, you know,
3 to 12 months after your initial diagnosis which has usually been done with a random biopsy,
and then it's oftentimes recommended to have a random biopsy every two to three years for
men that are on ongoing active surveillance. This policy is fairly universal throughout the world in
how to properly and safely monitor men with Gleason 3+3. My own personal bias
is quite different. I accept the information that was provided as long ago as 2015 where
random biopsy accuracy is compared to that of first-generation multi-parametric MRI
and found to be 20% less accurate than MRI. MRI, of course, is non-invasive;
biopsies are uncomfortable and one out of 50 men is hospitalized with life-threatening infections.
So, we now have third-generation MRIs which are more accurate than what was available when
those clinical trials were originally done, so the quality of the trials is impeccable, and I believe
the MRIs are more accurate than biopsies and certainly less uncomfortable and less dangerous.
So, we have started to use multiparametric MRIs at centers of excellence, places that know what
they're doing and you could trust, and we don't do any more random biopsies and our policy has
been to — that policy of doing random biopsies we abandoned that more than five years ago.
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