RRH urologist discusses high-intensity focused ultrasound, a “game change” therapy for prostate cancer patients that preserves erectile, urinary function
By Chris Motola
Q: I understand there have been some new developments in prostate cancer treatments, particularly with regard to preserving erectile function.
A: There have been a lot of new developments in prostate cancer treatment over the last couple decades. One of the really game-changing ones has been the introduction of HIFU (high-intensity focused ultrasound) for use in prostate cancer. HIFU is not exactly a new technology. It’s about 25 years old. Its application for prostate cancer was initially used in Europe and then rapidly spread throughout the world. In America it only got FDA approval in 2016. It preserves, better than traditional therapies like radiation or surgery, erectile and urinary function in a much better fashion. There are certain patients it’s more ideal for than others, but it’s been a really nice extra tool in our belt. We actually have nearly 10 years of experience doing HIFU locally, and my partners and I at the Center for Urology at Rochester Regional Health were the first to offer HIFU in the area. In fact, we were the first to do HIFU anywhere in New York state outside of New York City back in 2016 when we started our program. This technology has spread across the country to become more mainstream over that past decade, whereas it was once considered more on the fringe. But like any new technology, it does have a learning curve, and we presented data on that learning curve at a recent international urology conference in September 2024. We are fortunate in the Rochester area to be able to offer this therapy which historically was out of reach for many patients either geographically or financially.
Q: How well are you able to preserve the prostate?
A: Traditionally the most common treatments were radiation, with or without hormonal treatments or surgery, where we just remove the prostate. Even with radiation you’re not really preserving the prostate, you’re irradiating the cells which then wither away and die even if it’s still technically there. The problem with both of these is that there’s a lot of collateral damage to the nerves and bladder, which we try to minimize. The best way to preserve the prostate is to use focal therapies like HIFU. There’s cryotherapy as well, which is an older therapy that injects a freezing gas into the prostate. But HIFU allows you to choose where you send the beam millimeter by millimeter and spare parts of the prostate. It’s almost like the evolution in breast cancer treatment where, instead of bilateral mastectomies, we’re doing more lumpectomies and sparing more of the healthy tissue.
Q: Can HIFU cure prostate cancer?
A: The goal is always to cure, if possible, but one of the risks of focal therapy is there’s a chance the spared tissue could develop cancer down the road. And there’s always a chance we could have missed a spot or that it survived the treatment. So this is kind of a new paradigm so people need to be surveilled to make sure it doesn’t return or spread. The great thing about HIFU is that it doesn’t close the door to further therapies, including more HIFU.
Q: Prostate cancer is one of the slower-moving cancers, right?
A: Yeah, it is. It’s the most common non-skin cancer in American men. The incidences of new prostate cancers per year are about 250,000 per year. But not all prostate cancers need to be treated because they are so slow-growing. One of the other nice changes we’ve seen during that same time period has been the advent of active surveillance where some people just need to be monitored instead of treated. So we only need to treat the aggressive ones or the ones that are causing problems. Of course, not all prostate cancers are slow-growing. The difficult part for urologists — and all doctors really — is figuring out which ones need to be treated and which ones don’t. And when you switch from monitoring to treating it’s a very complex decision.
Q: At what age does prostate cancer tend to emerge?
A: According to the current guidelines for the average man we recommend screening around age 55 and for once a year, terminating around age 69. The logic being that it hasn’t been proven that screening younger or older than that saves any lives. So there’s kind of that sweet spot for monitoring. Some people are at a higher risk and need to be screened earlier. People with a family history, have general genetic risks for prostate cancer and certain other risk groups like African-American men. Those people in a higher risk group we tend to suggest starting between age 45 and 50, depending on how high their risk is.
Q: Is the idea that, after age 69, it’s not going to emerge in a way where it will be a huge problem within a normal lifespan?
A: Basically after age 70 there are so many other competing health risks that, if it hasn’t been found by then, given the average American males lifespan which, if they made it to 70 would be between 80 and 85, something else is more likely to cause a problem during that window. But you bring up a good point. Just like some people need to be screened early, some people who are extremely healthy at 70 I might screen longer.
Q: What other factors contribute to your likelihood of prostate issues?
A: Diets that are pro-inflammatory, heavy in cholesterol and animal fats, smoking, alcohol do tend to promote a higher risk for cancer in general. Obesity increases the risk of cancer overall. With prostate cancer in particular there is a role of healthy living. What is unclear is whether those modifications decrease progression once it’s been diagnosed, but definitely there’s a role for diet and lifestyle. Beyond that there aren’t too many other clear risk factors. There’s an old adage that if any man lives long enough he’ll eventually get prostate cancer, even if that isn’t actually what gets him. Time and testosterone are risks. Those factors are there and can’t really be stopped. To be clearer, testosterone won’t plant the seed, but it will water it. This becomes more important as more men go on some kind of testosterone therapy. They need to be monitored more closely. Testosterone will feed and accelerate prostate cancer because the prostate is a hormone sensitive organ. Suppressing testosterone is one of the traditional treatments for prostate cancer. But nowadays we only tend to it with advanced disease.
Lifelines
Name: Anees Fazili, M.D.
Position: Chief of urology at United Memorial Medical Center
Hometown: Williamsville
Education: Northwestern University Medical School
Affiliations: Rochester Regional Health System
Organizations: American Urological Association, American Board of Urology
Family: Wife, three children
Hobbies: Running, reading