Charlie LeBosquet, clinical application specialist for Prostate Care Limited joins the podcast to discuss his views from the frontline of prostate cancer diagnostics and treatment. Charlie has been a critical link in the theatres where men are biopsied and treated for prostate cancer for nearly two decades, supporting clinicians and operational staff alike, and he has a unique and valuable perspective on the advance and adoption of technology in the diagnosis and treatment of prostate cancer. Please find below a written transcript of the interview, and call The Focal Therapy Clinic today to discuss your prostate cancer treatment options: 020-7036-8870

Clare Delmar

Hello, and welcome to OnFocus, 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 sombre fact comes a multitude of challenges and opportunities. I'm Clare Delmar. Joining me today is Charlie LeBosquet, clinical application specialist for Prostate Care Limited. Charlie's been a critical link in the theatres where men are biopsied and treated for prostate cancer for nearly two decades, and he has supported clinicians and operational staff alike. He's got a unique and valuable perspective on the advance and adoption of technology in the diagnosis and treatment of prostate cancer. And he's here today to talk about his view from the front line. Charlie, thank you so much for joining me today.

Charlie LeBosquet

Hello, Clare. Thank you for asking me.

Clare Delmar

So you've been in this business for a long time, as we say, and hence why it's taken me with such persistence to get you here because I know you have a lot to share. I guess the first thing I just want to say is you've been, I love this term, clinical application specialist in the field of prostate cancer for well, I think I said almost two decades, but maybe you can clarify that and just tell us a little bit about what that role means. What is a clinical application specialist?

Charlie LeBosquet

So it's actually about 16 years, in fact. So what we do as clinical application specialists is the various companies that have work for provides the equipment and the technical expertise for the surgeons to use in their diagnosis and their treatment of prostate cancer. A good way of describing this as an analogy is in the same way that rock bands have roadies who set up all their equipment and manage their sound desk whilst they're playing their instruments and doing their stuff, we have a similar role within theatres. We set all the equipment up. We're very knowledgeable in how the equipment works and the best ways of getting it to suit what the surgeon wants to do. We set everything up for them. They carry out the procedure, and our role is to help them get into the best possible position to be able to do the procedure itself.

Clare Delmar

Okay. And I appreciate the analogy of roadies for rock bands, because I know that you actually are a rock musician yourself, so you're kind of operating on both sides, but that'll be for another interview, I guess.

Charlie LeBosquet

I'm not big enough of a musician to have roadies ourselves.

Clare Delmar

So basically you're there on the front line with the surgeon and the theatre team, and, of course, the patient. And you've been doing this for a very long time. So what has changed since then, since you began, in terms of both the technology that you're talking about, that you set up and the theatre operations themselves.

Charlie LeBosquet

When I first started, this is back in 2005, I was working with a company that provided HIFU equipment for treating prostate cancer using ultrasound. Now, at that time, the way I saw it from the technical point of view is the various technology companies were competing to come up with better ways of treating prostate cancer. I say the technology companies were coming up. Most of this, all of this is actually driven by the doctors and the technology companies are looking to find ways and ways of using the science to develop better ways of treating prostate cancer. That continued probably until about 2009. And then it seemed to me there was a certain shift in where the technology expertise was focused. Previously it had been all about finding better ways of treating prostate cancer to get a really good level of cure but to reduce the level of side effects. Around about 2009, the technology companies started coming up with better ways of diagnosing prostate cancer. I say the technology companies, it's not the technology companies that come up with the ideas, it's the clinicians that come up with the ideas and the technology companies go away and work on how they do that. So the emphasis shifted from different ways of treating prostate cancer to different ways of getting the best possible diagnosis that you could for prostate cancer.

Clare Delmar

And so is that where the multiparametric MRI made its debut?

Charlie LeBosquet

Not quite. From where I am, working in theatres, I see the technology when it actually is sufficiently developed to be able to be used in theatres. Whilst all this is going on a long time before you get to that stage, there's an awful lot of research going on in the background with technical companies, but mainly with the doctors and the first stage I think on that was to take biopsies from being a transrectal approach, i.e. putting a needle through the rectum into the prostate, which is a standard way of doing biopsies to using a transperineal approach, which is where the probe is still in the rectum, but the biopsy needles are actually put through the perineum and they're horizontal. And it's a much easier way of doing what they used to refer to as prostate mapping. Rather than doing fairly random biopsies, they could take very systematic biopsies covering the prostate to do the best they could to make sure they weren't missing anything. Now that kind of transperineal biopsy developed from brachytherapy and cryotherapy, where you had equipment that set up a grid on the perineum so you could put your needles through at specific intervals to be able to cover the whole of the prostate.

Clare Delmar

So in this case, the treatment informed the diagnostic approach?

Charlie LeBosquet

Yes, it's difficult to say as I wasn't involved in that part of it, but they were doing - I know when I first started - clinicians were doing cryotherapy and brachytherapy, which involves using these needle based setups. And then from there they began to use those, or they were using those in order to do transperineal mapping biopsies.

Clare Delmar

OK

Charlie LeBosquet

What happened after that, or again, this will have all been being developed at the same time as the technical and clinical teams were working on developing the MRIs to such an extent that the MRIs could give an indication before the pre-diagnostic as to where the suspicious areas may be within the prostate. And one of the things I specifically remember when we first started providing this equipment to do transperineal biopsies, the surgeons were coming into theatres with MRI reports of MRIs that have been taken prior to the biopsy, and they were looking at these MRI reports and saying, okay, I'm going to do a full mapping set up, but I want to focus on this area or these areas because the MRI reports were telling them that's where the suspicious areas were likely to be. So that helped to guide them. And they came up with this term or the term that I heard all the time was 'cognitive fusion'. And cognitive fusion was effectively where the surgeons had all the equipment, which gave them a live ultrasound image. And they had equipment to effectively be able to put the needles exactly where they wanted to.

Clare Delmar

OK.

Charlie LeBosquet

But they had to take the written report of the MRI and work out in their heads, which holes they needed to put the needles through in order to get into that area because there was nothing on the live ultrasound image that could mark out that area. You can't really see prostate cancer, you can't see prostate cancer on ultrasound. So they talked about cognitive fusion. And these guys are brilliant at doing this kind of thing. However often surgeons would say to me, what would be really great is if we could superimpose these diagrams that the radiologists are giving us as to where the likely areas of cancer are. If we could superimpose that on top of the live ultrasound image so we have the targets marked out.

Clare Delmar

Like a filter, like a tracing paper?

Charlie LeBosquet

Yeah, just like to be written over the top - now that would have been in probably 2010, 2011.

Clare Delmar

OK.

Charlie LeBosquet

When I think it probably started effectively in efficient systems, probably in my experience, in around 2014.

Clare Delmar

And so this is the actual MRI fusion you're referring to?

Charlie LeBosquet

That's right. That's right. So this is where companies came up with software in order to actually do this process where you can superimpose the target on top of the actual ultrasound image. So the way they manage that is by various different software methods, but effectively, in the nutshell, what happens is the MRI is taken in slices. The software package, enables the radiologist to outline the prostate at each slice and then to outline all of the suspicious areas at each slice. And if you imagine that creates almost like a framework, like if you imagine an egg in an egg slicer, you have all of those various slices. You end up with a sort of cartoon of the outside of the prostate and where the suspicious areas are. What then happens is you have that loaded into your software before you start the procedure. The live ultrasound is linked into the computer, into the software and effectively, the live ultrasound is broadcast and via a series of captures and manipulations, you can manipulate your cartoon as it were, to fit the actual live image of the prostate. And once you've got that live image overlaid, you can lock that down using software. And then as the surgeon moves the probe in order to get to the areas that they want you to take the biopsies, the fusion goes with it.

Clare Delmar

So I'm gonna pick up on your funny, popular cultural analogy from earlier on and say it sounds like a video game.

Charlie LeBosquet

A little more sophisticated than that.

Clare Delmar

In all seriousness, are there simulations for surgeons to actually learn how to actually superimpose this. I know the software does it, but then to actually practise exactly what you've just described.

Charlie LeBosquet

Well, there's different sorts of fusion. There's what is called elastic fusion. And there's what is called rigid fusion. Now, elastic fusion is where you have a software programme that you outline the prostate with your mouse at various levels. And then the little cartoon that we talked about earlier fits itself around that shape of the prostate. And the various mathematical algorithms adjust the shape in order to predict where the suspicious areas are.

Clare Delmar

OK.

Charlie LeBosquet

That's one method of doing it. You also have a method of rigid fusion, whereby the cartoon that you have is exactly the same shape as the MRI image of the prostate. Then it's more a question of making sure you're not squashing the prostate when you have the live ultrasound image and you overlay it. I mean, we talk about fusion. It isn't really fusion. It's overlay. You're overlaying one image over the top of the other.

Clare Delmar

Which are sort of using two technologies or two imaging technologies, I suppose?

Charlie LeBosquet

Exactly.

Clare Delmar

So I mean, what you're describing is it considered to be kind of the gold standard that everyone should have access to - this very sophisticated, very precise form of biopsy?

Charlie LeBosquet

That's not really for me to say, because we should perhaps have said this at the beginning: I'm not a doctor.

Clare Delmar

I guess where I was going with that is, do you actually see variations, do most hospitals do this procedure?

Charlie LeBosquet

Well, because I work for a private company and we take our equipment to hospitals who do these procedures, but don't do enough of them to necessarily warrant buying the equipment. I don't really see the areas where it's being used with people with hospitals that have already bought their equivalent. Bear in mind, this is cancer care. So the NHS hospitals will have the wherewithal to do these transperineal biopsies. Whether they're able to do fusion or not, I don't necessarily see, I'm afraid.

Clare Delmar

But I mean, given that you've seen this advance from paper or sort of physical MRI images and the cognitive process that you described earlier. You've seen that trend emerge into the fusion as you described. I'm not asking you to look into a crystal ball, but what do you think are the key technological trends that might be driving, you know, even more precision or more widespread adaptation and any thoughts on that?

Charlie LeBosquet

Well, again, it's difficult for me to say, because I don't see what the doctors are working on at the moment. If I put a patient hat on as it were and try to imagine what I would like to be able to see as a patient, what would be really fantastic is if the MRI could be definitive in its diagnosis of what is cancer and what isn't cancer. I have no idea whether that is ever going to be possible or not. But one of the things that all surgeons would feel that it gives them a better indication, a better understanding of what's going on in the prostate is if they have technology that can not only tell them where the cancer is, but can also tell them with some level of certainty that there isn't any cancer anywhere else. And that's still very difficult at the moment. There are lots of ways where it feels they can get close to that. But I don't think anybody could say I know that there is only cancer there and there's nothing anywhere else. But then, I suppose, go back many years, they probably wouldn't have been able to tell where anything was anyway. Things have developed quite significantly now, and if that carries on, then that may make life a lot easier for them. What I do know is once the surgeons that we've worked with have started using this technology, they don't want to stop. They don't want to go back to not using fusion.

Clare Delmar

Right. So that is an interesting observation and final point, I guess, is we've talked about technology and adaptation. How do you see that playing out in terms of the actual operation of the theatre? I mean, are the procedures quicker? Do you find them more efficient? Are there fewer people that are required to undertake these procedures because of this technology? What have you seen changing in the actual operation of the theatre itself in your time?

Charlie LeBosquet

That's a very good question. I'm not sure that much has changed because it revolves very much around the surgeon getting the needles into exactly those areas of the prostate that the surgeon wants to get the needles into. However much equipment you have, that process still needs to take place. So I don't think the theatre operation has changed a great deal other than the areas of targeting that are clearly marked out for the surgeon.

Clare Delmar

OK.

Charlie LeBosquet

But other than that, it's still the same process. I would say.

Clare Delmar

Charlie, I mean, you are somebody who's been incredibly devoted to the support of this incredible event of technology. You've seen so much and you know, I think it's important that all patients understand what the roadies are doing. Just as when you go and see the rock band, we know that all would not be possible without the roadies behind. So thanks so much for sharing all that with us. I think it's really important, and it's really fascinating and you've been so devoted to it. So I think you're a rarity. Thanks very much for joining us.

Charlie LeBosquet

Thank you very much, that's very kind of thank you. Clare.

Clare Delmar

A transcript of this interview is available on the programme notes on our website, along with further information on diagnostics and treatment for prostate cancer, along with additional interviews and stories about living and treating prostate cancer. Please visit the www.thefocaltherapyclinic.co.uk and follow us on Twitter and Facebook at The Focal Therapy Clinic. Thanks for listening and from me, Clare Delmar, see you next time.

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