An update on prostate cancer treatment [PODCAST]

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“Even though prostate cancer patients are anxious to receive treatment, they still want to minimize their exposure to anyone outside their COVID bubble. One procedure that is especially attractive to our patients is focal therapy high intensity focused ultrasound (HIFU).

Focal therapy HIFU is appropriate for patients whose prostate cancer is diagnosed at a higher grade and stage, but is still confined to the prostate. We use guided imagery to locate and destroy only the diseased portion of the prostate. It is done quickly (approximately two to three hours), in a single session. Patients like the ability to get in and out, with minimal exposure to the health care system. Focal therapy HIFU is ideal for this.”

David A. Silver is a urologist.

He shares his story and discusses his KevinMD article, “The ideal elective surgery during a pandemic.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have David Silver. He is a urologist, and he wrote the KevinMD article “The ideal elective surgery during a pandemic.” David, welcome to the show.

David A. Silver: Thanks for having me, Kevin.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

David A. Silver: I’m a urologic oncologist. I’ve trained all my life in New York, although I grew up in the Midwest. I did two years of surgery, four years of urology, and two additional years of fellowship training in urologic oncology. I’ve been practicing in Brooklyn since I returned here in 1997. My practice is exclusively oncology. It’s changed completely over the years. We have a tremendous draw area here, because we are the largest tertiary care hospital in Brooklyn, Maimonides Medical Center, with multiple residency and fellowship programs. We are 711 beds, which is by far and away the largest hospital in the area.

And the practice has gone from what was originally a pure surgical oncology practice to kind of a hybrid practice of surgical and non-surgical treatments, consistent with the way things have changed in the past years for almost every specialty. And so while I started my fellowship doing open surgery for everything, virtually nothing of what I do is open surgery anymore, except for the largest kidney cancer cases. Almost everything is laparoscopy now. And now we’ve even migrated to non-invasive treatments like high-intensity focused ultrasound ablation.

Kevin Pho: And during the last year, over the pandemic, what are some of the challenges that you faced through your lens as a urological oncologist?

David A. Silver: One of the challenges is a challenge that every oncologist has had, which is that patients are just not coming in, all right? And men are big deniers to begin with. Men will pee tomato juice for six months before mentioning anything to their primary. I’m sure you’ve had that experience as a primary care physician. And so the new cancer diagnoses, or even symptoms of cancer, have been pushed to kind of a back burner by the patient, because they’re terrified to come in because of COVID. During COVID, of course, we were almost exclusively an ICU hospital. We had 500-and-something beds of patients on oxygen, ventilators. And now that we’re back to normal operations, people are coming out of the woodwork to get their cancer screenings and their cancer care.

During the pandemic, New York State shut down everything, all elective procedures, all surgeries, including cancer-related cases. And what patients wanted afterwards was to ensure that they weren’t going to be exposed to COVID-19 patients. And so we developed really two streams of patients: the patients who were coming in through the emergency department with the symptoms of COVID-19, who got immediate testing and then admission to whatever level of care they needed, and everybody else who was looking for routine care. And so the patient streams remained separate, and people did not want to be in the hospital for any length of time if they didn’t have to.

And that circles back to the article, which was about how ablation, which is an outpatient procedure, is kind of the ideal scenario for patients who are eligible, because this way they get their pre-testing. Everybody needs pre-testing and medical evaluations. They will get their pre-testing at an outpatient facility remote from the hospital. They will come into an ambulatory area well away from the inpatient side of the hospital and leave the same day. And this is the kind of thing that people were really looking for after the pandemic.

Kevin Pho: Now, are you finding that you’re diagnosing cancer cases at a later stage because people are delaying their screening?

David A. Silver: It’s a really interesting question. In the breast cancer literature, and in the colon cancer literature, it appears that the wait has really resulted in a stage migration upward. With prostate cancer, since most of these are diagnosed based on PSA screening, and now with MRI screening, we really didn’t see that much of a change in stage. What we are finding is people with higher and higher PSAs, though. And PSA, interestingly, is not part of the staging system.

Kevin Pho: All right, so let’s talk about the KevinMD article that you wrote, “The ideal elective surgery during a pandemic.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

David A. Silver: High-intensity focused ultrasound ablation of prostate cancer is not a new treatment. It was invented in Europe many years ago, when it was an outgrowth of an undesirable side effect of another non-invasive procedure, which is extracorporeal shockwave lithotripsy for stones. Probably everybody who listens has heard of this. It used to be the stone bath, because it was water-based; now it’s the stone machine, because we no longer use a water bath. A shock wave generator generates a pulse, which is focused and goes through the skin, and at the focal point, where the stone is located, those pulses can be used to break up the stone. There are different types of lithotripters, different ways of generating the shock, but it works tremendously well.

However, some of the engineers noticed, when they were building this machine and developing it, which goes back over 20 years, that there were some undesirable side effects as well, which is that if you weren’t really focused directly on the stone, you could do a lot of damage to the kidney. And so that kind of took a back burner to getting the lithotripter up and running. But after a while, the engineers went back to the lab and said, “You know what? Maybe we could use this to deliberately destroy tissue.” And so an undesirable side effect got used for a desirable effect of non-invasively destroying tissue.

And because it’s delivered through a transrectal probe, which everyone is familiar with from diagnosing and monitoring prostate cancer, that seemed to be the most direct route to deliver it. And so it was packaged together with an intraoperative ultrasound that allows acquiring an image and then selecting where in the prostate you wanted to treat. And it originally started as a whole-gland treatment, to destroy the prostate tissue non-invasively. So this happened about 13 years ago in Europe, but it didn’t catch on here, because as a whole-gland treatment, we’ve already had whole-gland treatments like radiation and like surgery.

Now, however, because it’s possible to treat just a portion of the prostate with the latest generation of equipment, now everybody’s interested in treating just the part of the prostate that’s got the cancer, leaving the rest of it alone. Because, as you could expect, treating less tissue means having less side effects, the things that everyone is most afraid of, urinary control and problems with sexual function. That turns out to be true. If you treat less of the prostate, you will get less side effects.

And so it was approved for use in Canada, I think, about five years ago, and in the U.S. two years ago. And so we’ve been doing it for about two years, and it’s tremendous. It works very well. Patients love it because they don’t have to stay in the hospital, which has become, as I said, increasingly important during the pandemic. And it seems to be very effective, although I have to question, we have only short-term data on it.

Now, the interesting part of this, of course, is the biologic part. If you’re treating half the prostate, or a quarter of the prostate, or just a lesion in the prostate, what happens to the rest of the prostate? Nobody knows the answer to this. It’s going to be many years before we figure out what happens to it. And so there’s a lifetime of follow-up monitoring associated with treating just a portion of the prostate. But it’s an interesting shift in the way we conceptualize prostate cancer. When I was a resident, when I was a fellow, having a little cancer was like being a little pregnant; you either had it or you didn’t. And it turns out that’s not exactly true. We know that for the lowest-volume disease, doing nothing is a great treatment, and we also know that for higher-grade, higher-volume disease, treating the entire prostate is effective. And so this lies somewhere in between. It really is an evolution of the way we think about prostate cancer.

Kevin Pho: Now tell me, who are the right patients with prostate cancer that may be appropriate for high-intensity focused ultrasound?

David A. Silver: Well, Kevin, that’s a great question. The answer is we actually don’t know 100 percent yet. We know that patients with low-volume, non-high-grade disease will do well with surgery, with radiation, with observation, and they’ll do equally well with ablation. And so you haven’t gained anything by treating only those patients. I think it’s the patients who are not high-grade, because nobody wants to experiment with people with high-grade disease, to do something that may or may not work. So it’s really ending up as the people with intermediate-grade, intermediate-risk disease who have the most gain.

The other group of patients who really gain from an ablative approach are those people who initially started with observation but along the way decided, “You know what? I can’t live with the uncertainty of having a prostate cancer and not treating it.” And so treating them in a limited fashion solves both problems. It solves the cancer problem, which you would expect it to solve, and it solves the psychological problem, which is, “Oh, my God, I got the big C. I’m going to die. I must be crazy to not treat this.”

Kevin Pho: Now, let’s say I sent you a patient with newly diagnosed prostate cancer. Take me through your decision-making points in your conversation with the patient. And how much say does the patient have in terms of what treatment to select? Because, as you said, there are a variety of options when it comes to approaching prostate cancer.

David A. Silver: So my professional society says in a guideline recommendation that the conversation has to be a two-way conversation, that there’s no one-size-fits-all, and that the treatment is given within the context of the patient’s preferences regarding side effects and regarding outcomes. And so for a person with low-volume, non-high-grade disease, let’s say it’s Grade Group 1 or Grade Group 2, three or four cores positive, no more than half a core positive, PSA of less than 10, nothing you can feel on exam, I would usually ask those patients to do an MRI to ensure that we’re not missing something that might have been either not sampled or undersampled with the original biopsy. And then if it turns out that they either have no lesion or a small lesion, and it’s concordant with their prior biopsy, then they have any number of options: from doing nothing, which is a guideline recommendation for Grade Group 1 or Grade Group 2 non-high-volume disease, or whole-gland standard therapy, surgery in one of its forms, which today usually means robotic or laparoscopic prostatectomy, or radiation in any of its forms, whether it’s standard external, implant, proton beam, CyberKnife, any of the forms of radiation.

And really, the thing that drives patients’ decisions is side effects, because remember, these are patients you cannot make better. They’re already perfect. They have normal sexual function for their age, they have normal urinary control, and everything you do has the possibility of making them slightly worse. And so there’s a trade. You’re trading the side effects in the long term for the potential benefit of survival in the long term. And so this is very much a patient-driven decision, and there’s an enormous literature on decisional regret after treatment for prostate cancer.

What I tell everybody is that it’s not important to make a quick decision. Everybody has this idea that, “Oh, my God, I have cancer. I’ve got to decide immediately. It’s going to affect the rest of my life.” No, no. Stop, think about this, decide where you want to be 10 years from now, and then decide what side effects you’re willing to tolerate to get there. And that way, it minimizes decisional regret. I tell my residents this all the time: You can’t kiss on the first date. You don’t let a patient decide on the very first time you see them what to do. They have to get a sense for what’s important to them, what their lives are going to look like, and the best way to treat the cancer for them. It’s going to be different from the guy who came in before and from the patient who’s coming in after them.

Kevin Pho: Now, when I’m in the exam room talking about the pros and cons of prostate cancer screening, and we eventually come to a shared decision, more often than not, patients opt for the screening. You did mention some literature on decisional regret when it comes to potentially treating prostate cancers. Now, for those patients who may be listening to this podcast, what are some of the reasons that some patients may come to regret treating early-stage prostate cancer?

David A. Silver: Some of them are going to have side effects: problems with urinary control, two to three percent after radiation, about 10 percent after surgery; problems with sexual function, 40 percent after radiation, 50 percent after surgery. These are a Medicare sample of men age 65 and older. And the last thing you want is a guy sitting across the desk from you 10 years down the line saying, “Oh, man, I should have done the other one.” That’s just, I’ve seen this before, and it hurts to see that. And so it’s really critically important to make sure that patients understand what they’re getting into.

Go home, read about this, talk to your friends, talk to your buddies who may have had either one or the other. We have a support group here, actually, for patients who are interested to talk to other patients who’ve had it. Everybody knows somebody who’s had prostate cancer these days. There’s an increasing awareness of it, and it’s being increasingly diagnosed. And it’s less important to get a quick treatment than it is to get the right treatment that the patient is going to live with for the rest of their lives.

Kevin Pho: We’re talking to David Silver. He’s a urologist, and he wrote the KevinMD article “The ideal elective surgery during a pandemic.” I’m going to come at you from a primary care lens, because certainly that’s my world. So in terms of prostate cancer screening, obviously we have the PSA tests. But within the next three to five years, what do you envision coming along the horizon when it comes to prostate cancer screening?

David A. Silver: So there have been other forms of PSA and other markers that have been used as tentative screening tools. None of them have really panned out. PSA still remains our most useful tool. The interesting part now is imaging. So for years, the transrectal ultrasound has been used as a biopsy guide, and we know that a lesion on a standard six- or eight-megahertz transducer has about a 50-50 chance of being a prostate cancer or not. Prostate MRI has been terrific. It’s really good at finding higher-grade lesions, which correspond to high-grade tumors, the kind we actually want to discover and treat, and it’s really bad at diagnosing low-grade disease, which is the kind that we would probably try to ignore anyway. And so MRI went from being an experiment, which no insurance company paid for, to a staging tool, which some insurance companies paid for, and now it’s moving into the pre-biopsy realm, where almost everyone now is allowing us, after an abnormal PSA, to get MRIs, which help to guide the biopsies.

Because this is what used to happen: I would see a patient with an elevated PSA and tell them, “OK, you need a prostate biopsy, standard 12-core, six from one side, six from the other side.” But if that’s negative and your PSA is still high, well, maybe we missed something, because the biopsies are directed to the peripheral zone, where most of the prostate cancers are. But what about the other parts of the prostate? What about the transition zone? What about the anterior fibromuscular stroma? And so they would get a biopsy, and then they would do an MRI, and then the MRI would show an area of abnormality, and then they’d get another biopsy. So this doesn’t make any sense. It makes much more sense to do a PSA, do an MRI, and then biopsy whatever is there, 12 cores plus whatever is there on the MRI. So that turns out to be a biopsy strategy with higher yield, because this has been studied, than trying to do one or the other.

The next thing that’s coming is high-resolution ultrasound. If you jack up the resolution on transrectal ultrasound and use a 29-megahertz probe, now you’re able to find things that are a millimeter to three millimeters in size. And that’s the next thing that’s being researched, to try to figure out whether it’s better than MRI, the same as MRI, or better than or the same as PSA, whether there’s additive value to it or not. I’m expecting our next meeting in Las Vegas, which I think isn’t going to be in September, for the American Urological Association, is going to have a lot of information about high-res ultrasound. So those are the two things that are really in progress.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

David A. Silver: So the audience is mostly physicians, right? And I would say that you’ve got to expect and embrace change. You really have to. A million years ago, when I interviewed for fellowships, I went to the MD Anderson Cancer Center. I didn’t end up going there as a fellow; I went to Memorial. I interviewed there, and the chief of urology there said something to me that has stuck with me forever, because it was absolutely right. He said, “You know, the fellowship that you’re interviewing for right now, it’s not the fellowship you’re going to do, because three years from now, when you’re a fellow, life is going to be different. There are going to be changes in diagnostics. There are going to be changes in treatments.” That’s been absolutely true. That guy was Andy, and he ultimately worked for the NCI, and then he was director of the FDA for some time. And that has stayed with me.

I tell my residents this all the time: There is very little that I do today that I did as a fellow 20-something years ago. It used to be all open surgery, then it went to laparoscopy, then it was robotics, and now it’s ablation, it’s non-invasive treatment. And who knows what’s coming down? I don’t know what it’s going to look like 10 years from now, but I can promise you it’s going to be absolutely different than what I’m doing today.

Kevin Pho: Well, that’s well said. David, thank you so much for sharing your time and insight, and thanks again for being on the show.

David A. Silver: Thanks for having me.

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