Men who are diagnosed with prostate cancer are typically asked to choose between two alternatives, active surveillance and radical surgery.
Active Surveillance and Radical Prostatectomy Compared
Active surveillance, which is also known as expectant management, is an approach to prostate cancer that involves putting off therapy until there are signs the disease has progressed. This isn't quite the same thing as the older approach of watchful waiting. In active surveillance, there is a recognition that if the tumor is clearly defined, if is well "differentiated," then it is relatively easy to determine when it has begun to spread. Sometimes prostate cancer simply never spreads, so it is thought better not to put men through treatments (described below). "Watchful waiting" was more of a decision not to treat men who are so old that they are likely to die of something else before they would succumb to prostate cancer.
Radical surgery, or radical prostatectomy, means removing the prostate and surgically reconnecting the urethra to allow the flow of urine. Prostatectomy is usually followed by radiation. Sometimes it is possible to perform "nerve-sparing" surgery, but often the surgery itself results in the need to use sanitary pads or a catheter to urinate, and loss of erectile function. Men are often put on "chemical castration" to stop the secretion of testosterone, which accelerates the growth of prostate cancer cells the surgeon missed, or even actual surgical castration if the drugs used to suppress testosterone secretion or to block the release of testosterone are ineffective.
Prostate cancer patients are often given drugs to stop the spread of cancer to bone. These drugs work by stopping the normal processing of breaking down and remodeling bone in order to stop bone pain and fractures. However, they cause calcium to stay in the bones, and can cause dangerously low calcium levels in the bloodstream.
HIFU as an Intermediate Step in Prostate Cancer Treatment
High-intensity focused ultrasound was developed as an alternative for men whose cancer merits more than watchful waiting or active surveillance, but whose cancer is not so advanced that the doctor is forced to recommend radical prostate surgery.
What is high-intensity focused ultrasound, also known as HIFU?
In this method of prostate cancer, a probe generates ultrasound that heats just one lobe of the prostate gland to 195 degrees Fahrenheit (about 95 degrees Celsius) for two to three seconds, leaving surrounding tissue unaffected. The brief exposure to high heat kills cancer cells, but leaves the rest of the prostate intact. The entire procedure takes 20 to 90 minutes.
There are several advantages to HIFU for men who have prostate cancer. When HIFU is used for ablation of the entire prostate gland:
- 99 percent of men remain continent.
- 92 percent of men are cured of the cancer.
- 70 percent of men retain normal erectile function.
When HIFU is used for removal of just the cancerous part of the prostate gland:
- 95 percent retain erectile function, and
- 89 percent achieve the "trifecta," normal erectile function, no need for diapers or sanitary pads, and no cancer at 12 months.
Where Can Men Get HIFU?
It's not hard to understand why men who are diagnosed with prostate cancer want HIFU. "Many guys don't want their whole prostate out and they see this as a big win if it's reasonably effective in treating cancer," Michael Koch, MD, professor and chair of the Department of Urology at Indiana University in Indianapolis. It's also not hard to understand why many doctors are interested in the procedure. Many American doctors have been giving HIFU at clinics in Mexico and the Dominican Republic to men who are able to pay their fees in cash. Since the procedure was not covered by health insurance in the United States until May of 2016, most American men could not get it. However, recently the US Food and Drug Administration approved HIFU not for cancer treatment, but for "ablation of the prostate." The procedure is known to leave a small part of the cancerous tumor behind, but the expectation is that completely removing the tumor is not necessary for long and active life, and the lack of side effects outweighs the small danger of leaving a few cancer cells.
High-intensity focused ultrasound treatment of prostate cancer has been used in Germany for 20 years. German health authorities report very good success rates with the procedure. About 90 percent of men who get HIFU for prostate cancer in Germany are still cancer-free 20 years later. However, in Australia and Canada, where the treatment was approved about 10 years ago, there are relatively high rates of incontinence and erectile dysfunction among when who receive it as their primary means of treatment. Why should this be?
"HIFU requires a huge amount of back-up, sophistication, and expertise," says urologist Mark Emberton, MD, a high-intensity focused ultrasound expert from University College Hospital in London. "The current HIFU landscape in the United States is like being given a car with no instructions on how to drive it," said urologist Manoj Monga, MD, from the Cleveland Clinic, told Medscape Medical News.
So if you are a man who has been diagnosed with cancer treatment, and you don't trust active surveillance but you would like to keep your prostate if at all possible, or at least keep your continence and erectile function, what can you do?
- Ask about high-intensity focused ultrasound, but don't volunteer to be your doctor's learning experience. If at all possible, you want a doctor who has performed the procedure dozens of times over a period of months of years.
- Don't take no for an answer from your health insurance company. HIFU has been approved for ablation of the prostate. Your doctor will have to write the notes to reflect "ablation," rather than "cancer treatment," and almost certainly your doctor will, but the insurance company's medical examiner will no doubt attempt to misconstrue it. Don't accept a mischaracterization of the procedure as final. It is to be hoped your doctor's office has extensive experience in negotiating with insurance companies over these matters.
- Don't expect HIFU to be a pleasant procedure. You will still need to urinate through a catheter for 10 days to two weeks. You can have rectal bleeding and burning. You will need to treat constipation proactively to avoid aggravation of the ultrasound site. You may have to give up caffeine for a while so your bladder is not as active.
When performed by an experienced doctor, HIFU may be the option that gives you the greatest quality of life without compromising length of life. Not every man with prostate cancer will qualify for the procedure, but every man who has prostate cancer should ask about it.