HIFU offers an eye-opening alternative to treating prostate cancer.
Claudio DeMarchi publisher of the Traveling Golfer is sharing this very personal experience with the hopes that as many fellow golfers get older, and may have to deal with such issues, are aware that there are alternatives to what the good Doctor may tell you!
By Ted McIntyre
It’s the sort of news that shakes you to your core: “You have cancer.”
DeMarchi has little problem recalling the details. The sound is like the “Whack” of a driver hitting you in the side of the head.
“I had a PSA (prostate-specific antigen) test as part of regular physical. The actual confirmation of prostate cancer was after a biopsy in March 2016, the day before my 60th birthday. Happy Birthday to me!
I received the results on April Fool’s day—no joke!”
No joke, indeed. According to the Canadian Cancer Society, about one-in-eight Canadian men is expected to develop prostate cancer during his lifetime; one in 27 will die from it. It’s estimated that 21,600 men will have been diagnosed with the disease—the leading cancer in Canadian males—by year’s end, representing 21% of all new cancer cases in men.
With that sobering information absorbed, the question for DeMarchi was how to proceed. But that query hardly receives a consistent response across the country. According to a study produced by the Canadian Partnership Against Cancer, even low-risk prostate cancer patients in Canada may be opting for treatment with major life-changing side effects without fully understanding other options, including the choice to forego treatment unless the disease progresses.
DeMarchi also encountered inconsistent advice in advance of his decision. At Royal Victoria Hospital in Barrie, near DeMarchi’s Collingwood home, “they were only offering the most invasive open procedure,” he notes. “My urologist said the type of cancer I had was aggressive—he put forward an urgent request for a procedure there, and didn’t forecast a very good life after the procedure.” DeMarchi questioned the urologist in Barrie,
“I asked, ‘What about radiation?’ and the Doctor said, ‘You are not a candidate for that, besides you would have to go to Toronto.’
I asked ‘What about Robotic surgery?’ Doctor, ‘You are not a candidate for that, and we don’t do that here. Do you know how much that machine costs?’ RED FLAG!
I asked, ‘What about HIFU?’
Doctor, ‘Do you know what HIFU means? (We are not going to tell you what the Dr. said) You are not a candidate for that either!’ RED FLAG #2! We knew better!
I asked, ‘What if I do nothing at all?’
Doctor, ‘You are not a candidate to do nothing.’ RED FLAG #3 and if you count the radiation seed questions we will make it a Par 4 on Red Flags!”
DeMarchi was now sure that he was in the wrong place! “I am a candidate to make my own decsions!” This particular hospital had only one thing to offer, the most invasive procedure but a good filler of valuable Operating Room time!
DeMarchi researched alternatives. A friend and fellow golf industry type, 2015 Canadian Men’s Senior Team Championship member Lars Melander, had undergone the da Vinci Surgical System’s robotic prostatectomy late last year, a procedure that uses finely controlled micro-surgical robotic instruments and high-resolution cameras.
While that option is considered minimally invasive, it would still have had detrimental effects on DeMarchi’s more ‘sensitive’ areas, so his online investigation continued. It was there that DeMarchi stumbled upon Ablatherm HIFU. Developed in Europe, the procedure was FDA-approved last November and has been administered in Canada since 2004.
While traditional surgery would require several days in the hospital and potentially radiation and/or chemotherapy, the HIFU treatment takes about 2 hours, depending upon the size of the prostate, and is performed on an outpatient basis. A 2010 report showed that 85% of the 803 patients reviewed had negative prostate biopsies and 83% had PSA levels after seven years indicating that they were disease-free. Only 7% have required further treatment for their prostate cancer.
That’s a similar success rate to radical prostatectomy, but with the major advantage of using non-invasive technology with fewer side effects. Unlike Melander’s robotic treatment, HIFU is not covered under OHIP, but it’s hard to put a price on the quality of life one he could comparatively expect in the aftermath of the treatment, DeMarchi figured—even if it did cost $22,000.
As fate would have it, the office of the surgeon Melander had initially recommended, Dr. Bobby Shayegan, is situated just 50 feet from that of Dr. William Orovan. A professor of Urology and Urological Oncology and Associate Dean of Clinical Services at the Faculty of Health Sciences at McMaster University in Hamilton, ON, Orovan also happens to be the Medical Director of the Maple Leaf HIFU clinic in Toronto.
Located at the Canadian headquarters of the renowned Cleveland Clinic, with whom they have a working relationship, Maple Leaf HIFU was the first in North America to offer HIFU to treat prostate cancer. They have since performed more procedures than any other facility in North America and average between 50 and 60 HIFU procedures a year, two-thirds of which are administered to American patients.
“In Western Europe, it’s very mainstream,” Orovan notes of the procedure’s birthplace. “People are just as likely to choose HIFU as any of the other option.
How does Maple Leaf HIFU qualify its patients? A biopsy comes first, says Orovan. “Some would like to substitute a multi-parametric MRI in place of a biopsy, but I believe that histological confirmation—that is, a tissue biopsy—is really important so that you know exactly what you’re dealing with. We also need any other staging studies that have been done, including an MRI, CT or bone scan.
“The other important factor is the prostate volume,” the doctor notes. “Prostate biopsies are done traditionally under trans-rectal ultrasound (TRUS) guidance, and prostate volume is calculated. That’s an important issue for us. We treat anything up to 40 cubic centimeters. We like it smaller than that and can, by drugs, reduce the size over a three-week period.
“I sent them my biopsy and they said the cancer was not that close to the nerves, and size was good, so I was a candidate,” explains DeMarchi, who underwent HIFU treatment on July 21. “They put you up overnight at a nearby hotel. I had the treatment the next morning and instead of being in the hospital for five days with the open procedure, or three days with the robotic treatment, I went out to dinner that night and came home the next day!
As for HIFU follow-ups, regular PSAs are scheduled every three months for two years, then every six months thereafter, although patients can obtain them from their own regional urologist if they so choose.
Five months after his HIFU procedure, DeMarchi says there are no unexpected lingering effects. “Life is pretty much back to normal,” he says. “I did have my first follow-up PSA, and the number was low, which I thought was good, although Dr. Orovan indicated that he would like to see it lower.”
HIFU APPROVAL PROCESS
Health Canada should take note: Given that the procedure would seem to involve far less financial strain on the Canadian medical system in terms of hospitalization and follow-up care than traditional surgery, why is it that HIFU is not yet covered by provincial health systems? “I took it forward at one point, and there was some interest, but it never proceeded,” says Orovan. “And to be honest, these things are often political and there are strong negative forces. We saw this in the U.S. when we sought FDA approval. The panel was made up of radiation oncologists, who want to deliver radiation, and urological surgeons, who want to operate. And sometimes, like other areas of endeavor, self-interest plays a factor.”
Whichever avenue is selected to treat prostate cancer, information is critical, Orovan notes.
Some of that data can be found in an upcoming new Maple Leaf HIFU publication that includes the firm’s first 750 primary treatment patients, with a minimum of one-year follow-up. “Our data shows that 9% (1 in 11) require some sort of second-line treatment at some time during their follow-up—the maximum follow-up being 12 years,” Orovan notes. “That’s not perfect, but it’s very good.”
Of course, that doesn’t factor into account patients’ improved quality of life in the interim, and the accompanying lack of dependence on friends and family for support.
“It really does come down to a patient preference, though.” Orovan says. “Part of it is how patients deal with risk. For some, once hearing the word cancer, nothing will do except to cut it out. They can’t stand the concept of living with risk. And even though surgery carries with it the risk of lack of cure or side effects like incontinence and erectile dysfunction, surgery is seen as a more aggressive way of dealing with it. Others, who have a more sanguine approach to risk and benefit, and wish to minimize the side effects and maintain good quality of life while still having a very high probability of cure, are drawn to ablation techniques like HIFU.
“I think people deserve the information and then they can make the decision that’s best for them,” Orovan adds. “And HIFU should be part of the lexicon of that decision making.”
DeMarchi, for one, is pleased with his decision. Recently returning from visits to the charming city of Birmingham, Alabama and the Mayan Riviera in Mexico.
As with all cancer patients, his life will march onward, with hopes that his prostate cancer will eventually become a distant memory.
For more information about Maple Leaf HIFU www.hifu.ca