HIFU vs. TULSA PRO vs. Other Focal Therapies for Prostate Cancer | Mark Scholz, MD | PCRI
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- เผยแพร่เมื่อ 10 มิ.ย. 2024
- Medical oncologist Mark Scholz, MD, fields questions all about TULSA-PRO, an image-guided form of high-intensity focused ultrasound that is becoming more popular as a form of focal therapy for prostate cancer. The hope is that this procedure can reduce the side effects of radical treatment via surgery or radiation while maintaining excellent cure rates.
0:09 What are HIFU and TULSA-PRO and how do they work?
2:13 What are the side effects of these treatments?
4:33 At what point would a prostate be too large for treatment with HIFU or TULSA-PRO?
5:40 Is HIFU more or less effective depending on the Gleason score?
6:41 If a patient with a high Gleason score has HIFU, should they also have a course of hormone therapy?
8:07 Are HIFU and TULSA-PRO considered curative therapies?
8:31 How do TULSA-PRO and HIFU compare to other forms of focal therapy?
10:03 Are these treatments covered by Medicare or other insurances?
10:31 Which factors would you take into consideration if deciding between HIFU or TULSA-PRO?
11:22 How many procedures would you expect a doctor to have performed to be considered competent in HI-FU or TULSA-PRO?
12:32 What should PSA look like after focal therapy with HI-FU or TULSA-PRO?
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I just had TULSA PRO whole gland treatment for my Gleason 8 Prostate Cancer. They actually went over the left side (cancer side) with the TULSA device three times during my procedure and the right side once. The PSMA PET scan showed the cancer was strictly limited to the inside of my prostate. I don't believe the doctor would have considered me without the PSMA PET scan showing the cancer was limited to my prostate gland.
My procedure took considerably longer than normal in part due to the three swipes of the aggressive cancerous side. I checked in at 7AM and left at about 3PM. I believe a normal whole gland treatment might have had me out of there before noon. I figured my prostate has shown a propensity to grow prostate cancer so I wanted the whole gland ablated.
I also found another doctor who would have performed focal laser ablation too. It was about the same price but I thought treating the whole gland offered the most opportunity for success.
Of the 12 core biopsy, 2 of my samples had Gleason 8; one with 8 percent and one with 16 percent. I also had a 3+4 and a 4+3 on the same side. My PSA density was .09 and my Free PSA was 23 to 28 pre biopsy. Considering the low PSA density and higher Free PSA levels, the numbers suggested the initial odds of high grade prostate cancer were pretty low. Some calculators stated 4 percent or less and other 6 percent or less. I also read a study stating that elevated creatinine levels in the blood can throw off the Free PSA levels. My creatinine levels have been at times outside the upper end of the normal box and I believe that study may be valid. If your creatinine levels are high, high levels of Free PSA may not be as useful. I am sure most of you know that Free PSA levels over 25 indicate you have a very low chance of having prostate cancer.
I personally requested my initial MRI since the PSA was up to about 5. Since, my free PSA was at levels that favor not having prostate cancer and the DRE was normal other than my urologist's estimate my prostate was about 60cc they weren't leaning toward doing a biopsy. I called my doctor to request the MRI. I merely wanted to verify the actual size of my prostate with the MRI. Unfortunately, it showed two PiRAD 4 lesions on the left side of my prostate. My prostate size ended up being about 57 cc. So, the doctor was very close on his guess. Considering, I had two Gleason 8 biopsy samples, I am glad I didn't wait another year to visit my urologist.
I still have the catheter in for about another week. I would consider adding hormone therapy if I could do it for 4 to 6 months just for insurance. I am sure that may sound over the top, but some people don't believe you should treat Gleason 8 with TULSA PRO. Although the PSMA PET Scan is a huge advance at detecting cancer, it isn't perfect and that is why it might be nice to supplement with hormone treatment.
A recent University of Michigan study showed that if you have two cores or less with less than 50% in your Gleason 8 samples and some other samples with Gleason 3s, a Gleason 8 is downgraded a high percentage (up to 82%) of the time following a prostate removal surgery. I guess I will never know the answer to that question.
I wonder how many radiation treatments it might take to ablate most of the tissue inside of the prostate? TULSA PRO is able to do this is one office visit. In the end, you maintain your functions at a much higher percentage than many of the other procedures. Sadly, insurance does not cover it.
I recognize the risk I am taking using a new procedure. I also recognize that I am looking at quality of life vs quantity of life. I read the stats of Gleason 8 returning at various points in time regardless of the procedure. Dr Scholz mentioned these newer therapies are capable of killing high grade cancer cells as well as the lower grade cancer cells that are often used in the trials. Dr. Scholz suggested you find an experienced professional to perform whatever procedure you might select. I am not saying this is for everyone. For me, it is a path I am willing to take. I turned 65 the day after my procedure and consider myself healthy other than the prostate cancer.
I hope to live many more years and wish everyone on this page the very best of health and happiness.
At a top London institute, although HIFU isn't the GOLD standard of care due to lack of long term data (5yrs vs 10year data), data so far indicates where appropriate it is as effective - they'll only offer HIFU if cancer is on one side of the prostate. (Talking about HIFU and not TULSA).
Thank you for sharing your experience with the Tulsa Pro and personal evaluations. It seem like you did an excellent job to find your personal best outcome.
To guard against recurrence, you might look into the Dean Ornish study that uses diet for protection. The results were positive. Thank you for sharing such comprehensive info.
@brettm7597 - how are you doing one year later?
@@dondgc2298 I am doing great. I just had my second MRI at the location that the doctor prefers in Florida. He mentioned the radiologist there is much more familiar with reading the 3.0 Tesla MRI post TULSA than might be available at other centers. I had MRI's at 6 months and again at just over 12 months. Thankfully, both came back clear. I recognize that MRI's can miss cancer. With that said, I am thankful that to this point things look great.
This is a cut and paste from my report that I received today -
There are no abnormal early
focal areas of enhancement on DCE to suggest residual or recurrent intraprostatic malignancy. No T2 signal mass
or abnormal diffusion restriction. No extraprostatic extension (EPE) of tumor. No seminal vesicle, bladder or rectal
tumor invasion. No pelvic enlarged lymph nodes or suspicious bony lesions.
It also mentioned I have some inflammation or Prostatitis. With that said, I didn't know it. Everything works just fine without medications. It is also nice not to have to get up multiple times a night to urinate. Prior to my procedure, I would get up 2 to 4 times a night...my prostate used to be just under 60cc.
My prostate density is under 1 on both MRI's. They still watch that number. I still have a prostate and it is larger than I imagined it might be...so, I still have PSA under 2. My prostate is now 20 cc. It was 23 cc on my MRI at 6 months. The area where the Gleason 8 and Gleason 7 was looks like a void on film. It is just not there.
With that said, I know Gleason 8 is something that tends to return and I will continue to be followed the rest of my life. I did have my original biopsy sent out for genomic testing and it basically confirmed that I have high grade cancer. My Decipher score was .71. That report said the Genomic risk is high. They don't have numbers associated odds for recurrence with TULSA. Their odds are based on prostate removal and radiation treatment. The report indicates that with either radiation or prostate removal the risk of metastatic spread with that number is 7.2% at 5 years and 13.9% by 10 years and 21.9% of those who have either radiation or prostate removal will lose their battle with prostate cancer with my genomic number prior to 15 years.
There is an ongoing study that is comparing prostate removal to TULSA. I would guess they might discover it is within 10 percent of being the same. Time will tell if I am guessing correctly. The big advantage is you don't have the barbaric side effects. Since I had my procedure, several enhancement have been made to TULSA that will improve the results. Specifically, they now have a "boost" feature to better obliterate the tumor zone. Considering they perform this procedure without opening up the prostate...perhaps there are some "containment" advantages to prevent the disease from spreading. Time will tell.
I recognize and respect that everyone's decision is personal and they must make their decisions based on their own research and perhaps degree of spread. I am sure people feel I was foolish for moving forward with TULSA. Regardless of what happens, I am not going to second guess my decision. I wish you success in the decision making process and a happy life.
Best Prostate Doctor on the planet..
I’ve had focal cryo treatment but I have read about many focal treatments like these. Your videos are invaluable for a quick snapshot of these treatments. I am watching this video six months after it was posted but just wanted to comment that I so appreciate that the PCRI maintains such a high level of passion and quality for the subject matter. Through my journey you guys have been my first source of info and I have full trust in you. I return to watch videos often to refresh my memory and guide my future decisions. I can’t thank you enough. I only wish I lived closer to you so I could visit in person. Blessings to you all.
Excellent information as always, much appreciated!
Excellent questions and answers. Thank you!
really honest discussion tks
Thanks for the informative talk.
Very informative, as usual. Dr. Scholz and Alex, please keep up your excellent service.
In comparing TULSA to HIFU Dr. Scholz missed the main advantage of TULSA i.e., that TULSA monitors tissue temperature voxel by voxel in real time, thereby minimizing the probability of side effects.
Another great informative video. Whats your opinion of HIFU v 4D Brachytherapy?
could you ask dr schols what his opinion on PHI (prostate health index) in determining the go ahead for prostate biopsy?
I got HIFU procedure done on 3/19/2019 by Dr Pugach, he treated the whole organ. That’s what Dr Pugach had it done to his prostate . Anyway, my psa is still stable, no incontinence, could still get it up.BTW I was 3+4.
I'm in the exact same boat, Grade 2, Gleason 3+4 w/ a 10mm lesion where the adenocarcinoma is isolated. I'm scheduled for HIFU on June 27, 2023
@@bdento59- Can i kindly know where is the doctor and whether insurance coverage?
@@bdento59Hello: I hope your treatment has gone well. I also have 3+4 (just on one side) and just three weeks ago had the one year follow up biopsy. There has been little change, so, I’ve decided to stay on active surveillance. I know, someday, some treatment will most likely be needed. I’m looking at HIFU at UCSF. If you get this, maybe you can let me know how things are going. Thank you.
Ditto as @MM-sf.3rl ?
@@bdento59 whole gland ablation?
My question is...if you have this same video in Spanish language, because it's very instructive and helpful, so I'll be so grateful if you answer my inquire. Thank you.
Whats the outlook of the current focal Lazer therapies on one or two small tumors in a single lobe?
What do you know about nanoknife ? There is a clinic in Germany that offers it. Looking for information please
i was given a PHI test after few minutes the uro gave me a DRE. that would increase the number of my PSA. am i right?
Can just the p prostrate bed be treated as my husband’s prostrate was taken away, but cancer is now in the bed
I reached HIFI after my biopsy last year and the success cure rate was not be very good. That and the fact my insurance won't cover it made my decision to have radiation easier.
What about nano knife IRE/
You mentioned that TULSA and HIFU are curative, neglecting any small specks elsewhere in the body that aren't addressed by these methods. But likewise, neither RP nor RT would address small specks elsewhere, correct?
Correct!!
I experienced both UTI and epididymitis after Tulsa Pro. Another difference is having to wear a Foley for up to 12 days. Does focal therapy work better than active surveillance? I haven't seen those studies. The INTACT study was limited to GL 3+4 or less.
Mark, how long after your procedure did you experience the UTI and epididymitis? I am 7 days past my TULSA procedure and at this point I am doing fine. The catheter is to come out in 3 more days. There are several centers performing Focal Laser Ablation. The center I visited still required a catheter after the procedure. I went with TULSA since it treated the whole gland and felt like my prostate tissue has demonstrated a propensity to grow cancer.
@@brettm7597 The UTI was a few days after the catheter came out. The epididymitis was a week after the UTI. It occurs on and off since then.
@@mperloe Thank you...I will try to stay ahead of it. They prescribed two antibiotics. I finished the fist one and just started the second one and I will still be on it after the catheter comes out. Hopefully, that helps prevent the UTI. I hope I do not experience the epididymitis.
Are these therapies effective for salvage treatment if prior radiation treatment has failed and the PET PSMA shows no metastasis outside of the prostate?
The reality is people often times have to reject even considering this treatment because they can't afford it but I will tell you one of the top Tulsa clinics in the country 40% of their patients are doctors so you tell me
Dr. Schoz could not have said it better when he said, "This procedure is totally operator dependent and how ambitious the operator is" Therefore, the outcomes of this procedure are based on the physician and their skillset. So always ask the doctor who performs this procedure how many have they performed over a timeframe of a year. Unfortunately, since this procedure is relatively new in the USA and only 3000+ procedures have been done worldwide, the amount of physicians doing this procedure is still limited. So you really need to weigh the risks and benefits and don't get drawn in on the marketing of this product.
While the video is good, it does NOT mention one critical limit. The reach of the Tulsa Pro is 30 mm (1 3/16") from the urethra, so if your cancer is outside of that radius, you are out of luck without further intervention. Interestingly NONE of the Tulsa Pro videos I have watched points that out. And don't ask me how do I know it.
I have had 3/4 biopsies and 2 nanoknife procedures
I was looking at Tulsa pro but concern has been expressed it might not work as the prostrate has scarring tissue and very fibrotic
Would I be better to give up on focal therapy
you mentioned you had 2 nanoknife procedures. Please tell me about that. I gave up looking for a place in the U.S. that does them. I don't think Dr. Scholz has discussed that procedure. I see that it's done extensively in other countries with a high price tag.
@@erindean3167 hi I went to Germany for an assessment as there were few places that offered the treatment. After further research I found professor Emberton in london did nanoknife and went with him.
His results seemed good
I had to pay for treatment at £12000 a time.
Unfortunately the cancer recurred after first treatment and also after the second attempt
What I did not fully appreciate was the scarring left by this procedure and biopsies ruled out other options like hifu and Tulsa
So if choosing focal treatment be aware of limitations it might bring in for other options
At least you tried to do the best thing you could for yourself. Dr. Emberton is one of the best in the business. You could’ve had a radical prostatectomy or chemo, and still have cancer. The upside hopefully is that you do not have incontinence and ED, and have had a better quality of life.
Dr. Sholz I need your advice urgently. I was diagnosed with 3+ 3 Gleason 6, PI-RADS 4 cancer on right side peripheral. Now my Doctor wants to do another biopsy this time it's targeted. I'm so scared for a repeat biopsy because it's so much to bear. Can't I be treated and not do a repeat biopsy targeted ? Need your help urgently because I'm scheduled in two weeks time.
Hello, we have a helpline with patient advocates that can discuss your case with you. You can find our contact information at pcri.org/helpline.
I believe the repeat biopsy is to confirm the mri pi-rad 4 score. My understanding is the Biopsy/pathology is the only way to confirm the cancer grade. Reply if you have other info.
I hope you got the biopsy. It’s far worse to miss cancer. My original diagnosis was 3+3 but the urologist was skeptical so I did a perineal and they found the 3+4. I had the nanoknife.
@@your_royal_highness what percent of the biospy cores had 3 and 4 cancers? How long ago did you have nanoknife? How are you doing now? Any other treatment(hormone, ect). Side effects?
@@marka9073 I had the nanoknife in May. The surgeon said I had the most immediate side effects, some bleeding (he said he had to get close to the urethra) and I had the catheter put in three times; the first and second times I could not urinate and had to rush to the ER. However, my PSA drop was easily the biggest. I do not know how they arrived at the 3+4. No other treatment before or of course, since. I know I will have to do PSA’s and maybe more MRI’s. I will likely do at least one more perineal biopsy in a year or so. Fingers crossed. Mine was localized in one spot at the bottom of the gland and was fairly large in size which is why the urologist thought he missed something after my second biopsy (which showed the Gleason 6). I did not want to wait to go for it as I knew I would have to do something eventually. In fact, the surgeon said he was doing active surveillance with 5 patients and by the time surgery was needed 4 of 5 say the cancer spread outside the prostate. From what I can tell, the electricity does not generate heat (or cold) and thus the damage to surrounding tissue is close to nil. I prefer executing the cancer cells vs boiling, freezing or irradiating. 😊
I am sooooo glad I did not do this therapy as it can really do damage. Medicare covered my nano-knife in May and all in all, I think it worked. My PSA was supposed to drop by 30% but mine dropped by 80% to where it was 15 years ago. Some side effects in recovery but mostly back to where I was before the treatment. Little harder to get an erection. I no longer ejaculate but can still orgasm.
I understand cryo is only suitable for anterior tumours. HIFU has less side effects than radical therapies.
Where did you have the nano-knife done? Thanks
Far less damage than surgery or radiation