Focal Therapy & PSA Screening: Minimally Invasive Options

Clare Delmar

Hello and welcome to On Focus, brought to you by the Focal Therapy Clinic, where we connect you with issues facing men diagnosed with prostate cancer that are little known, less understood, often avoided or even ignored. Prostate cancer is the most commonly diagnosed cancer amongst men in the UK, and with this somber fact comes a multitude of challenges and opportunities. I’m Clare Delmar. Joining me today is Alan Doherty, Clinical Director at the Birmingham Prostate Clinic, who was recently voted one of the UK’s top ten prostate cancer specialists in a national poll of consultant urologists published in the Daily Mail. Alan has been an innovator advocate and dedicated practitioner of precision treatments for prostate cancer and he joined the Focal Therapy Clinic last year to develop his expertise in delivering focal therapy. In addition to HIFU focal therapy, Alan has embraced IRE or NanoKnife focal treatments with great success for his patients, which has reinforced his views on early diagnosis and in particular, prostate cancer screening. He’s here today to speak with me about how advancements in and success with focal therapy change the discussion around screening. Alan, thanks for joining me today. I’m really looking forward to this conversation.

Alan Doherty

Hi, Clare, so am I.

Clare Delmar

Good. Okay, well then let’s jump right in. And one of the reasons I wanted to have this conversation this week is because there’s been in the last few weeks a real sort of acceleration of discussion around screening. Because I guess evidence is building on both advanced diagnostics and focal treatments and the whole argument about the harm of over or under diagnosis is actually being challenged quite significantly. What is your view on this?

Alan Doherty

I think screening has been controversial ever since I started in urology 30 years ago, and the population studies have been somewhat conflicting and they never really showed that the benefits were hugely better than the harms which came with the diagnostic process and the treatments. And that probably explains why there isn’t a government screening programme for prostate cancer. And the use of PSA is really driven by individuals or groups of maybe charities, but not really by the NHS or by any government policy. And I can understand why that is. It’s really important that we understand what screening is. And I think sometimes that helps to clarify the situation with prostate cancer in particular. Because when somebody doesn’t have any symptoms, which is virtually by definition what screening is because what you’re trying to do is to identify a problem in the future, a potential problem in the future, because it’s not a problem now because you haven’t got any symptoms. And the problem in the future could be ten years away, it could be 20 years away, it could be 30 years away, and the size of the problem could vary from death to just having to take a few tablets. The difficulty we have in prostate cancer is to decide when we make a diagnosis. Well, first of all, is whether we should be making a diagnosis. But when we do make a diagnosis is to say, well, what is the potential problem in the future? How big is it? How far away is it? And we use rather basic instruments to make that guess. So we look at the level of PSA, we look at the imaging, we look at the Gleason score, and increasingly, we’re starting to use genetics. And so what we are trying to do is to get this looking glass into the future, to make an accurate assessment of what is coming your way. And if we think that what’s coming your way is a big problem and it’s not far away, then we’re going to obviously want to treat that. And patients are prepared to take on some side effects if they think that the benefit is worth it. Now, the trouble with prostate cancer is that so many of these cancers, and this has been shown in a number of studies, in particular, the ProtecT study, is that the natural history of a PSA detected, organ confined prostate cancer is really good. And so you’re very unlikely to die of that sort of cancer in the next ten years. So why would you take on a potential problem that’s miles away with a treatment that gives you a problem now? In a way, you can see why patients well, they don’t really understand it. I think the media have made patients hyper concerned about an early prostate cancer, and that means that they’re prepared to take on treatments which give them potential life changing side effects. And they’re prepared to take that because they probably wrongly think that the type of cancer that they’re going to, the effects of the cancer that they’ve been diagnosed is going to be much worse than the side effects of the treatment. And that’s not necessarily the case. And that’s your point about over treatment, but equally, you don’t want to under treat. And it struck me that when these screening studies were published, that there were still quite a few deaths from prostate cancer. And you would have thought that if you were doing a screening programme, you wouldn’t have any deaths, you might get harm, you might get side effects of treatments. It struck me that the studies were badly designed because the fact that there weren’t deaths at all in the prostatectomy group. So if you treat someone by removing the prostate, well, how can you die of prostate cancer? Well, the answer is either you don’t do it properly or the cancer has already spread before you take it out.

Clare Delmar

Yeah.

Alan Doherty

In other words, you’re screening people too late. So there’s another problem, what age group do you start looking at these things? Because I suspect the people who are going to die of prostate cancer have quite aggressive cancers that present very early, probably before the age of 50. So screening studies that use PSA and by the way that’s another important point that the screening studies so far published were using PSA only as their criteria on who they would go on to biopsy and treat. Now we’re far more sophisticated because we use the MRI scan to decide who we’re going to biopsy and treat. At least that’s the major factor. You can see that the jury is still out as to whether screening is good and I think the answers to whether it’s good or not will depend on how accurate we are at diagnosing it without harm and then whether the treatments cause any harm or not.

Clare Delmar

So on that point, I want to pick up on something I said in in introducing you earlier, which was that, you know, you’ve become a recent adoptee of of the NanoKnife with patients, and we’ve spoken to some of your patients, and I’ve spoken to you about this, and both you and they have been extremely positive. And how has this influenced your thinking about screening?

Alan Doherty

I think enormously. I think the focal therapies, and of course NanoKnife is one of the focal therapies, has allowed us to offer a treatment to patients with minimal harm being done. It’s not without risk and in fact, the more I’ve been involved in focal therapy the more I realise just how powerful these tools are. But the fact you can precisely destroy the cancer where you see it in the prostate is just such an advance and potentially for a patient that reassurance. Patients don’t like to leave things once they know they’re there. They like to address it even if they know the problems a long way ahead. And so it makes sense to me that if you find something that is treatable with a focal therapy why would you just leave it and monitor it? It doesn’t make sense to me at all. I mean there are some situations where you would say that removing the prostate or using radiation therapy is needed because of the type of cancer you’ve got. So I don’t think focal therapy is the answer to all men with all prostate cancer but if you’re going to pick up early prostate cancers that are likely not to harm you for years, then why would you just leave it if you can just treat it with minimal side effects? So I think as an alternative to doing nothing, the ProtecT study showed that even if you’ve got Gleason seven or eight or even worse, leaving it until it was obvious you needed another treatment sometime in the future did not compromise your survival at ten or 15 years. That’s quite powerful stuff. So I think what screening does is it picks up lots of early prostate cancers, which you don’t necessarily want to go in and cause harm with prostatectomy or radiation therapy, but you can control it with a focal therapy. To be fair to surgery and radiation therapy, and we should give a balanced view, is that the techniques have improved and so the amount of harm is reducing. In the radiation field, you have things like MR linac which allows the minimisation of collateral damage from the radiation. And the same with surgery is the development of nerve sparing techniques. So the trend is very much going towards minimising collateral harm and the focal therapies are right up there in delivering that. An effective treatment with minimal collateral damage. So if we’re going to start adopting screening, you have to have the focal therapy weapon up your sleeve.

Clare Delmar

Yeah, I mean, I think one question would be do you think that just the very existence of focal and getting the message out to men that if it’s caught early, it can be treated in a less harmful way that you’ve described, do you think that would be enough of an impetus to actually bring men forward so that they’re not afraid? And maybe asking it in a different way do you think men are afraid to come forward and request a PSA test because they’re simply just terrified of all the implications of much more interventionist treatment?

Alan Doherty

I think some are definitely terrified, but others now are terrified of dying of prostate cancer because in the news and celebrities are being highlighted as having it. I think it goes both ways. Some people are over scared of prostate cancer and other people are over scared of an early diagnosis and potentially impact on particularly the erectile function. So it is a complex issue. One of the things that is always going to play a part in all this is cost. Focal therapies require high-quality MRI scanning, and they require surveillance with MRI scans after the treatment. These are cost implications which I suspect will influence any government decision on implementing a screening programme.

Clare Delmar

Except on the other side of that, the very existence of those MRI scans and the precision interpretation of those is that it reduces the biopsies and potentially ultimately the treatment.

Alan Doherty

Absolutely.

Clare Delmar

I think it does work both ways. On that point, I wanted to ask you one of the arguments now in the last few months, few weeks even, and I know Prostate Cancer UK has shifted its view of it and they’ve published this on PSA screening and they specifically mentioned that they’ve done so in light of advancements in the MRI diagnostic pathway. So given that that’s all happened, that’s now accepted and granted there is way to go still. But why do you think the views have been so rigid? Why do you think that even in the presence, multiparametric MRI, which reduces the amount of biopsies by what, 30%, sometimes even more, why has it remained unchanged?

Alan Doherty

I think that now that I’ve left the NHS and I’ve sort of not doing the group think, you open your mind to other ideas and other concepts and I think the group think is to achieve cure at all cost.

Clare Delmar

Okay.

Alan Doherty

There isn’t this concept of a trade off between perhaps a lower cure rate, but less morbidity. If you’re going to do a curative treatment, it’s got to be curative. And this radical approach is, I think, fine for some people, and I think that’s the discussion you have with people, with your patients, but it’s not fine for a lot of people. And so it’s not really up for the consultant to put his views, say, these are the only views that you can consider, because that’s clearly not the case. There are other approaches and I think consultants need a bit of humility here to say there are other ways which you may or may not agree with, but you shouldn’t exclude them at all. I think the other point on the diagnostic side is that there’s still a long wait before MRI scans are done reliably enough that consultants can sort of confidently say, well, I’m not going to biopsy you because I think perhaps in the future with artificial intelligence. It’s relatively new that people are using MRI scan in this diagnostic way, maybe on average three or four years or something like that. Whereas people who’ve been advocating it have probably been around for 15-20 years.

Clare Delmar

That’s a really important point. And you and I have talked in the past, I think, on another podcast about the MRI and the advancements, and we’ve talked about this issue of uniformity, or you would put it potentially non uniformity, and the variation of the imaging that you see. Could you put any kind of metric on that? Would you say that of all the MRI scans done for prostates in this country, there’s a variability of what percent?

Alan Doherty

Clare, you give me a challenge on that and I’ll rise to it. I would say as many as 50% of them are substandard, and I suppose that’s not a very fair percentage in a way, because I get a very small group of people coming in for a focal therapy and the quality that you need for a focal therapy needs to be very high.

Clare Delmar

Yes, indeed.

Alan Doherty

I’m immediately critical because of that bit. But if you’re using MRI scans for other purposes, maybe just the diagnosis or just the staging, it’s probably much better than that. But for what we need it for…

Clare Delmar

Absolutely. I mean, that’s probably another conversation in itself. But as the consensus emerges on whether it’s PSA testing or combined with MRI, once that consensus and a screening programme maybe is developed, how would you foresee takeup? So, say, next week, suddenly we all agreed and there was a programme, but I read somewhere recently that in breast cancer screening, for example, there’s huge variation in take-up of it, and that’s a study in itself, and women from various ethnic backgrounds or income groups or locations don’t take it up. I mean, I realise this is something long into the future and it’s a nice problem to have if you have a screening programme, but would you see take up because of the time it’s taken to arrive at a programme and that all the information that’s come together maybe has been dispelled. Or would you see this as something that has to be worked on in its own right?

Alan Doherty

It’s a great question and I’m sure there are precedents out there from previous studies. And my experience with a ProtecT study was that the pickup was actually quite high, remarkably high, and it was driven by GPs, who were sort of calling patients in to have it. It was higher than I thought it would be. I can’t remember the exact percentage, but it was pretty high.

Clare Delmar

Yeah, interesting.

Alan Doherty

I think there is an appetite out there in the public for this. You can tell by the way, if a charity is putting on a free PSA test, the queues go around the street. So clearly people do want to know if their prostates are healthy or not. And of course, a lot of patients have urinary symptoms when they get to a certain age and it’ll be playing on their minds, thinking, well, perhaps these symptoms are to do with cancer. And so the opportunity to go and get checked out would be very tempting, rather than to make an appointment and seem like they’re worried well, we don’t want to do that. So I think a PSA programme would be good and I think if we are going to do a trial on whether it’s beneficial or not, it’s got to include a focal therapy. It’s surely it’s got to include it.

Clare Delmar

Or at least the information that this range of treatments is available and to take the fear factor away, as you said.

Alan Doherty

Well, I mean a sort of a proper government study, but the trouble with these studies, they take years to do and I’ve not heard of any potential screening studies in the pipeline.

Clare Delmar

So, final question and another challenge to you. If you were to run a PSA based screening programme, what three things would you focus on? I mean, you’ve mentioned a couple, but maybe you could sum it up in three points.

Alan Doherty

Transparency of outcome has always been something which I think is not there, and it should be there because a lot of these treatments are skill based and it’s very hard to interpret outcomes and so not enough work has been done on that. So patients can be misled on what they are likely to get from treatments. That’s one thing. I think the other thing I’d be quite keen on is obviously people being counselled properly about the implications of what they’re doing and that would be quite important. And the last thing would be to make sure that the MRI quality is up to scratch. I think those things that would be the ones that I focused in on if I was setting up a screening programme.

Clare Delmar

Okay, we’ll hold you to it when this all happens. But really interesting, I mean, I can see a follow on interview coming up in the near future. But as always, Alan, wonderful to chat with you and very enlightening. And thanks very much for coming and speaking with me today.

Alan Doherty

Pleasure.

Clare Delmar

Further information on Alan Doherty and his clinical practise is available on our website, along with the transcript of this interview, as well as additional interviews and stories about living with prostate cancer. Follow us on Twitter and Facebook at The Focal Therapy Clinic. Thanks for listening and from me, Clare Delmar, see you next time.