MARCH 2008
VOLUME 5 NO. 3

ADVANCES in MEDICINE

Prostate care

HIFU prostate Tx burns tumours
— and cash

Risks persist and longterm effects are
unknown, warn experts


Man's HIFU experience hasn't put him off the treatment

Firefighter and paramedic Eric Sondeen is one of those patients who chose HIFU. The Boulder, Colorado resident got the call a year ago, on Christmas Eve. His PSA levels were through the roof — he had prostate cancer. His urologist suggested HIFU, so Mr Sondeen did what most patients do these days: he went online.

"I did a lot of research and it looked like the best option," he recalls.

Since the treatment is not yet approved in the US, though clinical trials are underway, Mr Sondeen joined the ranks of medical tourists and headed to the Dominican Republic — with his urologist. All was well in the beginning, the cancer was flushed out and everything was in working order.

But at month four, trouble struck. Mr Sondeen developed urethral strictures — scar tissue was clogging up his urethra, making urinating difficult and downright painful. It's got to the point that he now has to self-catheterize on a regular basis to empty his bladder.

He now says he wishes he'd weighed his options a little more carefully — and not believed the hype. "The incidence of urethral strictures is actually closer to 20% according to one study," he says, "rather than the 2% presented to me and my doctor."

Mr Sondeen is now looking into repair treatments. But, despite his difficulties, he remains optimistic about the future of HIFU. "I think I was among the percentage of people to take a bullet for this so we could all learn about it," he says. "I wouldn't want to throw the technology out with the bathwater."

For more HIFU patient stories, see our blog exclusive at www.nationalreviewof medicine.com/blog.

"Is there anyone out there who has tried HIFU?" wonders a prostate cancer patient on cancercompass.com's message board. "I hear it's being done in Canada," replies a fellow sufferer.

He heard right.

Though not yet approved in the US, high-intensity focused ultrasound (HIFU), with its vaunted minimally-invasive technique and low risks of impotence and urinary incontinence, is gaining ground in Canada — despite its prohibitive $20,000 price tag.

"Men are being diagnosed earlier and earlier with prostate cancer," says urological surgeon William Oravan, medical director of Toronto's Maple Leaf HIFU Company. And while older patients with slow-growing cancers may be placed on watchful waiting protocols, the younger ones — those in their fifties with organ-confined tumours — will most certainly require some form of treatment. "There are a significant number who won't want radiation therapy or surgery, which are major, invasive techniques, so for them HIFU is a very attractive alternative," he adds.

FOCUS ON HIFU
The treatment is a one-time, outpatient procedure that takes two to three hours and if all goes well, leaves men free to resume their normal lives the same day — minus the cancer. It involves focusing a pulse of high-energy ultrasonic waves onto a single area of the prostate and cranking the temperatures to near-boiling (90° Celsius) until the cells die.

"It's like when kids use a magnifying glass to focus sunlight on a leaf and burn it," explains Dr Ian Brown, medical president of the Niagara HIFU clinic, in Niagara Falls, ON. "Only instead of sunlight, you're focusing energy on a target."

HIFU requires only some mild sedation and spinal anesthesia and the doctor then inserts the device through the rectum. The transducer comes equipped with ultrasound imaging so the physician can see the entire prostate on a monitor and avoid damaging surrounding structures like the nerves responsible for erectile function.

Post-op, the downside for the patient is that he has to wear a catheter for two to three weeks until he can urinate on his own. And there's the slew of potential side effects normally associated with any prostate cancer treatments, ranging from retrograde ejaculation to urethral fistula — though reports say the risks of any of those adverse events are minimized with HIFU. But not eliminated, as some patients have discovered (see "Man's HIFU experience hasn't put him off the treatment,").

"It's a new technology and longterm evidence is still evolving," concedes Dr Brown. His clinic has been in operation since June of last year, and so far only one patient has developed strictures, he says. "He was treated with dilation — a widening of the urethra — and so far, so good," he adds.

Keep in mind, it's not for all prostate cancer patients, Dr Brown points out. "The ideal candidate is someone with a lower risk cancer, or someone with intermediate risk, but older. For young intermediate risk patients, it's not the first choice."

GLAND SIZE and Tx COST
There are two types of machine used in Canada, the Ablatherm, the first to be developed, and the Sonablate 500.

"With Ablatherm, there are four safety measures prior to any discharge of energy," says Dr Oravan, who uses the machine in his clinic.

Dr Brown favours the newer Sonablate 500. "Both are similar in terms of safety, but we looked at limitation in terms of prostate size, when we chose to go for the Sonablate," he says. The Ablatherm can only treat patients whose prostate size is 20 to 30 grams, whereas Sonablate can take a prostate size that's 40 to 50 grams.

If size were no obstacle, cost probably will be. The procedure runs in the $20,000 range — and it isn't covered by any province in Canada. "Health Canada approved it back in 2004 based on European data, but to this date no province has chosen to pay for it through its insurance system," says Dr Orovan.

 

 

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