Prostate Cancer Focal Therapy

Additional Info

• Audio File:uf_health_shands/ufhs055.mp3
• Doctors:Brisbane, Wayne
• Featured Speaker:Wayne Brisbane, M.D.
• Guest Bio:Wayne Brisbane, MD, is an assistant professor of medicine in the Department of Urology at the University of Florida College of Medicine. Dr. Brisbane received his undergraduate degree in Biology, cum laude, from Seattle Pacific University and his medical degree from Loma Linda University School of Medicine. 
  
  Learn more about Wayne Brisbane, M.D.
• Transcription:Melanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole and today we're talking about prostate cancer focal therapy. Joining me is Dr. Wayne Brisbane. He's an Assistant Professor in the Department of Urology at the University of Florida College of Medicine. Dr. Brisbane, it's a pleasure to have you join us today. Before we get into prostate cancer focal therapy, can you tell us a little bit about your background and expertise in focal therapy and how this hasppened?
  
  Wayne Brisbane, M.D. (Guest): I am a Prostate Cancer Specialist. That's pretty much all I do and see, and treat. I did my residency at the University of Washington and did a lot of surgery for prostate cancer. And then I went and did a fellowship, at UCLA and in the second year of that fellowship, found focal therapy through my mentor, who's Leonard Marks and does a lot of focal therapy out in California. And he showed me a lot about prostate cancer and focal therapy. And I really found it to be a very compelling treatment option for some men. And so, I did about 150 focal therapies with a variety of different energies, including cryotherapy, high intensity focused ultrasound or HIFU, and laser ablation of the prostate.
  
  We also published a bunch of papers on focal therapy. Who's a good candidate, how we do focal therapy better. And then when I was looking for positions was very interested in coming out to Florida under our chairman, Dr. Su, and he felt like this was an area that we could expand for our patients.
  
  Host: Well, thank you for sharing that with us. So, give us an overview of prostate cancer focal therapy, and really talk about its role as a middle ground, as it were, to the treatment of prostate cancer as a means of bridging the gap between a radical prostatectomy and active surveillance, all the different treatment modalities out there.
  
  Dr. Brisbane: Prostate cancer focal therapy, the main idea behind it is that you're treating just the cancer and you're trying to spare critical structures that surround the prostate. And the prostate's kind of in a confluence of many different organ systems. The prostate is responsible as far as mother nature is concerned, for reproduction. So it produces the thing like proteins and sugars that help the sperm survive. The urine, as it exits, the bladder goes through the prostate. It sits right next to the rectum. It also sits right on top of a couple of nerve bundles that are responsible kind of for the hydraulics of erections.
  
  So it's in the confluence of a lot of different things. And prostate cancer is really common. The prostate is working hard all the time, under the influence of testosterone and there's a bunch of brake pedals that kind of have the prostate stop its growth and start working on function. If any of those brake pedals malfunction, you can get cancer and over the course of a man's life, he has a 12.5% risk. And so that translates into about one in nine men getting prostate cancer at some point and it causes about a little over 33,000 deaths per year. So prostate cancer is very prevalent.
  
  So the really big, important thing for prostate cancer is you have to risk stratify it. There's basically three main buckets. Low risk, intermediate risk and high risk. And that's very important for prostate cancer because it tends to be in the family of all cancers, a slower growing cancer. So it's not like treating pancreas or brain or lung cancer. And so it's really important once somebody gets a diagnosis of prostate cancer to put it in one of those risk buckets. And so there's, the Gleason score is the grade. And so the Gleason score is how it looks under the microscope, obviously.
  
  And if it's in the 3+3 category and the PSA is less than 10 where the provider feels like they can't feel it, all those are going to be in the low risk bucket or category. Those patients are often able to be treated with nothing, just active surveillance.
  
  And that's been a paradigm shift as things have gone through the last 10 years. High risk cancers are kind of Gleason scores greater than 4+4, PSA is greater than 20, T3 disease, things that feel like they're kind of trying to extend into the neurovascular bundle or the seminal vesicles.
  
  And oftentimes those are best treated with surgery or radiation, but then you have this big family and which is going to be your Gleason 3+4 and 4+3, where they can probably be treated with a lot of different options. So, some men with low volume, 3+3 or 3+4 can be watched. There's some active surveillance going on there. Men with high volume 4+3, probably need some surgery or radiation, but there's an option to provide these men focal therapy and what we're doing with focal therapy is we are trying to identify the tumor. So that's the first step with focal therapy is some kind of imaging.
  
  And then second, ablate the tumor, which would be trying to ablate just the tumor and leave everything else around spared and then surveilling the patient, over years because these tumors can pop up other places or they can recur at the margins.
  
  Host: Well, then differentiate for us between this focal therapy and whole gland therapy and help us to understand the limitations to this type of focal therapy.
  
  Dr. Brisbane: When I was a kid, I was one of four kids and we were responsible for cleaning our bathrooms and so, we had this little spot of mold that kind of popped up in the corner of the bathroom. We scrubbed it and didn't pay attention to it for a while. And finally let my mom know about it. And she came down and it turned into a huge deal where we actually had to take out the dry wall and it was much more aggressive on the other side of the drywall than it initially had been presenting. If you were to equate this mold with prostate cancer, it's got a lot of similarities.
  
  And so if you have mold in your bathroom, and you want to take care of it, a whole gland therapy, as far as surgery would be just removing the entire bathroom. A whole gland therapy, as far as radiation would be kind of taking some kind of ablation, like a flame thrower or something silly, but basically ablating the entire bathroom.
  
  And the problem with that is it causes a lot of collateral damage. You have to find a new place to urinate or all the kinds of tissue is no longer functional. But with focal therapy, what you're trying to do is you're going in and you're just removing the mold and leaving everything else there.
  
  So the bathroom is still functional. What that equates to for patients is they're going to have many fewer side effects as far as erectile dysfunction, or leakage or urinary urgency. But they'll have treatment of their cancer. The careful thing is you have to monitor these patients. And so that's a really big differentiation between a full whole gland therapy and focal therapy. You're going to have to continue to monitor patients long-term because the mold can come back or the prostate cancer can come back at different locations. And you have to be able to monitor them continually in order to kind of mop up when that happens.
  
  Host: Well, then as you're telling us about some of the limitations and what a great educator you are, that was an excellent explanation; can you characterize for us the ideal patients? Speak about patient selection for this type of therapy?
  
  Dr. Brisbane: So, your ideal patient is going to be not your low risk and not your high risk, it's that big group in the middle. So, it's going to be intermediate risk patients. So Gleason 3+4 or 4+3 easy way to remember it is just Gleason 7 cancer. They're going to need to have some kind of imaging and MRI is the best kind of imaging.
  
  There's also PSMA PET scans and micro ultrasound, which we're doing at University of Florida, quite a bit. The imaging is all in effort to localize the tumor. So, we're really make sure that we're adequately treating, A, that we're establishing a good margin. So treating up to the extent of where the tumor is, and then also, you know, it doesn't really work to treat invisible disease because if I can't see it on an MRI, it's hard for me to go through and actually do a good job of putting needles in and ablating the tissue.
  
  So you're going to have intermediate risk disease. It has to be visible on an imaging modality, and then you don't want the tumors to be too big. So, at times people will say it needs to be less than T2C, which the technical term for that is just needs to be on one side of the prostate.
  
  There's some nuances there, but really big tumors are probably not the best candidates for this kind of treatment. And then you also, probably want patients who can benefit from this longterm. So prostate cancer treatment, you're not talking about benefiting patients within a year or two years. It's oftentimes over five to 10, even 15 years. And so you really need to look at the patients and say, are they healthy? Are we expecting them to live a ten-year lifespan?
  
  Host: So interesting. So then tell us a little bit about the outcomes that you've seen or the efficacy of focal therapy and really what you would like to see happen in the future with this technology.
  
  Dr. Brisbane: Yeah, so the outcomes are trally the carrot. That's what's really nice about this is so far, when patients get focal therapy, they tend to have very limited side effects. And that's where, you know, it's very appealing to patients. And so we will have a lot of your patients coming in to talk to you about focal therapy will say, oh, this is really what I want. What they're saying is I really don't want bad side effects. I really would like to get rid of my cancer and not have side effects, which is definitely the carrot. So, because we're trying to not damage any adjacent critical structures, mainly the nerves, and the bladder, the urethra to some extent and the external sphincters that control continence. Patients tend to do great as far as urinary side effects. They, you know, they oftentimes actually urinate better after these procedures than when they started. As far as erectile function, that's a little bit more complicated. I tell my patients that about 50% of patients are going to have the same erectile function after their procedure, as they came coming in, about 25% are going to be a little bit worse and unexplainably within our data about 25% get a little bit better. What I tell people is it's going to be kind of variable what your erectile function is coming out of the procedure, but it's a lot gentler than radiation or surgery.
  
  Host: Wow. What an informative episode this was. Dr. Brisbane, as we wrap up with your incredible expertise in this area, what projects are you working on or what will you be working on at UF Health Shands? And what would you like urologists and other providers to know about prostate cancer focal therapy?
  
  Dr. Brisbane: Yeah. So a lot of the things that we're doing within our research is really using the imaging to its fullest extent. So we're using, at least bi-modal imaging and occasionally trimodal imaging to inform exactly where the margins need to be and so we're using micro ultrasound, MRI, and occasionally PSMA PET scans to kind of really localize where the tumor is and get our margins, right. There's a lot of ways to kill the cancer. But there's only one margin. And so when you see patients coming in and saying, oh, you know, I want Tulsa Pro or I want HIFU, or I want a focal laser ablation or cryo or a photodynamic therapy, NanoKnife these are all technologies that kind of do a good job of treating the tumor, but really what we're working on is making sure that the margins for treatment are perfect. And then, the other thing is we're trying to figure out kind of a bunch of trials to see how should this be done correctly with neoadjuvant therapies? How can this be done in order to kind of do a nerve sparing focal therapy. So can we warm the nerves? Can we cool the nerves? What are the ways that we can really optimize our outcomes while still taking care of patient's tumors? And then, you know, we're also trying to run some trials where we compare outcomes in regular therapy versus focal therapy. So, there's a lot of work in this space that needs to be done. And it's really an exciting space to work in.
  
  Host: Certainly an exciting time to be in your field. Thank you so much, Dr. Brisbane for joining us today. To refer your patient or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital.
  
  Please also remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.
• Hosts:Melanie Cole, MS
• Post Test URL:https://cme.ufl.edu/mededcast/