Alright, well we're gonna get deep into the topic that I'm excited about because I think
that this is a treatment that is being pushed very aggressively, and I don't think there's
a lot of people really being clear on whether or not this is really the best option for
patients. So, we're talking about HIFU, which is a huge topic. I see it all over the internet.
I see tons of ads. If you even Google the word "HIFU" it's like six ads on Google on
the first page. So, can you explain, is this really the hot new thing to do? I know it
got, I think, FDA approved about three years ago.
HIFU is another way to destroy prostate tissue, and if the prostate tissue is where the cancer
is, it's an effective way to get rid of that tumor and to cure it. The problem with all
prostate treatments—I mean, if you go back 15, 20 years, people were terrified of radiation
treatments. What changed? Targeting changed. So, the capacity to deliver the radiation
exactly where you want it and not spill over into the surrounding organs is what now makes
radiation probably the preeminent treatment.
So, HIFU is just getting started. We know that just like radiation or lasers or freezing,
you can destroy prostate tissue. The question is, are the HIFU doctors that are using this
technology fully experienced in targeting in the fashion that will get the job done
without destroying the surrounding tissue. So, it's an attractive thing to do for some
sort of focal treatment. Some of the doctors are using it to try and treat the whole prostate.
The treatments that are directed at the whole prostate are going to have problems with erectile
dysfunction just like surgery and radiation and the rest, so it's the patients that are
going to be having focal treatment that might be able to benefit and have fewer side effects,
but that requires even more accurate targeting. So, my problem with HIFU has nothing to do
with HIFU itself. My problem is that it's usually urologists who are using HIFU; not
radiation therapists who are trained in targeting; not interventional radiologists who are also
trained in targeting, but surgeons. And so, the surgeons get involved and there's going
to be a long learning curve. Some of them, I predict, will never learn how to do it really
well. So, that's always the big challenge in prostate cancer. It's not what you do;
it's who you have do it.
That kind of funny. From a patient perspective—like the first time that I heard "high intensity
focused ultrasound" I think like, "Oh, it's automatically going to be focused or it's
automatically going to be focal and targeted," but I think that almost is kind of a mislabel.
Like, I think that can lead people astray very easily. So, yeah, that's a really good
point.
Yeah, it does destroy the tissue where you point it, but it's not easy to see prostate
cancer in the prostate. We use MRIs, we use ultrasounds, we use template biopsies, targeted
biopsies, but knowing where the edge of the cancer is and exactly where it is located
is quite difficult. I've been doing color doppler ultrasounds for 12, 13 years, and
we can't always see precisely where the tumor is. When you can see it, then, of course,
you have the challenge of getting your targeted treatment right on the spot, and then setting
a good margin around it for safety (not going to far! because you're going to have more
side effects). So, it takes the most skillful experienced doctors to do targeted therapy.
So, if a patient has been offered this as an option from their doctor and they go and
talk to a urologist who is gonna do HIFU—Is there like—I know at the conference we've
mentioned questions like, ask them how many procedures that they've done. Is that something
that they should pay attention to and the patient can ask?
Yeah, that's relevant. It's never easy, but I think that the online reviews are pretty
good. If you have a long list of very happy patients that are putting five star reviews,
that's a hopeful sign.
Okay, and what type of side effects can we expect from a standard HIFU treatment?
Well, the main risk with most of these treatments is the development of erectile dysfunction,
but you can have other complications, and the worst-case scenario, they create connections
between the bladder and the prostate or the rectum and the prostate, which sometimes don't
heal well. So, those issues can occur in less skill doctors. They shouldn't occur with the
highly skilled doctors.
And you currently don't have anyone that you've seen that has been able to use HIFU very effectively
and treat patients without many side effects?
Yeah, so I haven't found a maven that I trust and routinely send patients to. Another discouraging
factor is many times this is not covered by insurance and it can be very expensive as
well.
And have you seen patients come into your office who have had HIFU and are now needing
subsequent treatment because it wasn't fully taken care of?
Definitely—Not just HIFU. Patients that have had cryo or laser where the doctors try
and do a focal treatment, but miss the target.
You know, it's interesting. It seems like we've done six or seven episodes of "Ask a
Prostate Oncologist" and every single time the point has been made that you have to really
research the doctor. You have to look at the reviews. You have to find somebody who's going
to treat you well, and it's amazing to me how much I can Google this information, and
I was talking to a patient on Monday and he's like, "Yeah, I didn't know that. Like, I didn't
know that until somebody finally wrote an article on Google and I went to a support
group and they said, 'It's all about the doctor!'" You know, it's not just these treatments and
not everybody's an expert and I think that we do have this overall sense of the medical
community, you know, Oh it's a doctor! We trust them, and they know way more than I
do. They've gone to medical school for 12, 16 years depending on their specialty, why
would I know anything? And, so I think that, you know...
The problem comes down to the very sensitive area that the prostate is located. If it was
a gallbladder or an appendix or something like that: go to Kaiser, go to an HMO. A routine
surgery done by a routine surgeon—an average surgeon—will almost certainly turn out fine.
But the prostate is probably closer to something like brain surgery. The nerves are really
complicated, there's not much space, there's a lot of blood vessels, and of course, when
things don't go well, men lose their capacity for normal sexual function and that's a huge
deal.
You've discussed radiation a little bit and the differences. So, would you—if you had
a patient, you wouldn't be suggesting HIFU to them currently with all the other types
of treatment that are out there?
Yeah, the people talk about using these things as salvage treatments for people that had
a radiation therapy that wasn't effective. Other things that are considered for salvage
are, like, laser, cryotherapy. So, I—we've used a cryosurgeon who we've mentioned before,
a guy named Dr. Duke Bahn in Ventura, California who has the skills. He's an interventional
radiologist, and I'm sure there are others, but it is important to find that special person
that has dedicated their whole life to doing this and then they're able to deliver and
to give results that are acceptable and without a lot of collateral damage.
If you would like to have me ask Dr. Scholz a question in the future, you can go ahead
and leave your questions in the comment below, and our team will pick them up. And, for more
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