Marc Laniado, Consultant Urologist at with The Focal Therapy Clinic and a leading innovator in imaging led diagnostics and targeted treatments for prostate cancer is today’s OnFocus guest. Marc has been a vocal advocate for the rights of patients to be informed about their treatment choices from his base at Frimley Health, where he is prostate cancer lead at Wexham Park Hospital. He’s also a dedicated practitioner in optimising treatment choices for patients, and has built a reputation in identifying and delivering the right treatment for each patient, based on precise diagnostics and comprehensive discussion about lifestyle, aspirations and relationships. He’s here today to speak with me about a relatively new treatment — IRE focal therapy, also known as the NanoKnife – that he’s been offering to patients and how he sees this developing in future
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 sombre fact comes a multitude of challenges and opportunities. I’m Clare Delmar. Joining me today is Marc Laniado, consultant urologist at The Focal Therapy Clinic and a leading innovator in imaging led diagnostics and targeted treatments for prostate cancer. Marc has been a vocal advocate for the rights of patients to be informed about their treatment choices from his base at Frimley Health, where he is prostate cancer lead at Wexham Park Hospital. He’s also a dedicated practitioner in optimising treatment choices for patients and has built a reputation in identifying and delivering the right treatment for each patient based on precise diagnostics and comprehensive discussion about lifestyle, aspirations and relationships. He’s here today to speak with me about a relatively new treatment, IRE focal therapy, also known as the NanoKnife, that he’s been offering to patients and how he sees this developing in the future. Marc, thanks so much for joining me today.
Marc Laniado
Hi Clare, it’s great to be back with you.
Clare Delmar
Good. I know we haven’t talked in a little while, so happy New Year and I guess I can still say that in February.
Marc Laniado
Yes.
Clare Delmar
So we’re all very excited about NanoKnife, and I’ve spoken to a number of your patients, so I’m really interested in hearing about it from you. And I guess the best way to start our conversation is to put it in the context of focal therapy, which you’ve been providing to patients for, I mean, I’m going to say a decade. Is that fair to say?
Marc Laniado
Well, probably more than that because I started in 2005 doing focal therapy.
Clare Delmar
Okay.
Marc Laniado
Using HIFU treatments anyway and I’ve been treating men for prostate cancer and diagnosing it for over 20 years. But HIFU began in 2005 and focal therapy shortly after that.
Clare Delmar
Indeed, indeed. So one of the things we’ve talked about before is how the sort of portfolio, if I can call it that, of modalities or various forms of focal therapy are really expanding and I mean, possibly even accelerating in the last few years. And there’s a lot of attention and a lot of excitement around NanoKnife, which you have embraced wholeheartedly. I mean, have you treated quite a number of patients with NanoKnife so far? Is it growing? How would you categorise the sort of state of play?
Marc Laniado
Well, as you identified, NanoKnife is a new treatment, so I’ve treated hundreds of people for focal therapy using HIFU, and in the last year I’ve adopted the NanoKnife procedure for men. So currently we’re treating about three or four men every month, possibly five men a month by NanoKnife to deal with prostate cancer, particularly in certain locations of the prostate. And to date, we’ve treated about eleven patients entirely by using this technology and as I said, we have patients coming through every month and actually an increasing number of patients are wanting it as it becomes known that we can offer this treatment as one of the ways of dealing with localised prostate cancer.
Clare Delmar
Yes, that’s one of the things I want to ask – what are the common features in terms of both the clinical disease and the lifestyle choices of the patients who are a) suitable for NanoKnife treatment and b) excited about undertaking it?
Marc Laniado
So most of the men who come to see us to talk about focal therapy are men who are still young at heart. They’re still active, vibrant, living life, perhaps to its full, hopefully to its full, exercising, cycling, playing golf. They have their relationships with partners and whom often they’re still sexually active. And these are men who have often been diagnosed with prostate cancer. And it’s been a big shock to them in many ways because they want to live their life to the best that they can. Yet they’ve now confronted with a disease that’s potentially life threatening. And so most of the men we see for this tend to have relatively smaller cancers perhaps than the large ones, which need, will definitely need radical treatment. So they’re men who have an area of the prostate that has prostate cancer so not the whole amount and they typically have intermediate grade cancers as well. So it’s what are called ISA grade group two or three or also known as Gleason score three plus four or four plus three equals seven. So that’s the intermediate group and sorry for using technical language, but they’re men who have, as I say, these small intermediate risk cancers which often, are said, perhaps suitable for treatment or perhaps for monitoring. And so now these men are also being told well, you have a cancer potentially we can treat it radically or we can monitor it and watch it and see what happens and intervene later. And they’re being offered the treatments or ways of managing the prostate by active surveillance because the active treatments themselves have quite significant side effects, as most of us well know. So radiotherapy can induce changes to the bladder and the bowel, giving rise to diarrhoea and having to pass urine very frequently and urgently, as well as quite significant fatigue. Often it’s combined with hormonal therapy too, which has significant sexual side effects. Surgery – even if you do surgery very well, which many of us do obviously, it can still have side effects with problems of erections commonly. And in some cases, it prolonged urinary incontinence. So if you’re a young man, 50s or 60s, with cancer that’s been told said to be intermediate in risk and you still want to enjoy a sexual relationship, it’s quite a difficult decision then to decide whether to take the risk of active surveillance or go ahead with treatment and take the risk of having that treatment
Clare Delmar
Indeed.
Marc Laniado
So it’s a difficult conflict.
Clare Delmar
Indeed, indeed. So how do you differentiate then, between the different focal therapy approaches? So, you’ve talked a lot about HIFU, which is you’ve been providing for decades, as you said. How does the NanoKnife differ both in terms of – this is a big question – but in terms of the energy source that’s actually ablating the cancer that you’ve just described on the patient’s prostate gland and secondly, are certain types of cancers of the prostate more amenable to NanoKnife treatment versus, say, HIFU?
Marc Laniado
So ablation means destruction or killing of cells, and we can achieve that by several means. So high intensity focused ultrasound, or HIFU, achieves that by a thermal effect. It heats the tissues to 55 degrees or more, and no carbon based life form can survive that temperature for more than a few seconds or more. It also creates shockwaves through the cells, which break them down. NanoKnife or irreversible electroporation kills cells a different way. A series of electrical currents, a direct current, are passed through the cells between electrodes, and the electricity breaks down the cell membranes of the cancer cells, which results in the cells dying. And the benefit of this technology is that it tends to spare the surrounding matrix, which supports the cells. So, for example, the tissue structure is important for continence, and the nerves and other structures around tend to be preserved more effectively than by, say, HIFU or cryotherapy, which is when you freeze the prostate. So they are different technologies. HIFU, high intensity focused ultrasound, is performed by placing a probe in the back passage to pass ultrasound energy through the rectum, whereas Nanonife is performed by putting probes or electrodes through the skin between the anus and scrotum called the perineum to surround the tumour. And so it’s a bit more similar to having prostate biopsies perhaps. Both are done under a genital anaesthetic so they’re completely painlessly. NanoKnife is particularly good for cancers at the front of the prostate. So about 20% of the cancers you have tend to be at the front of the prostate, one in five, whereas HIFU is probably best suited for cancers at the back of the prostate close to the rectum. So we can use the location of the cancer to help decide which might be the best treatment for the patient if he wants to have focal therapy. So those are the main considerations.
Clare Delmar
No, that’s a really good description. And what is the evidence base that IRE or NanoKnife is building on?
Marc Laniado
The evidence is judged on clinical trials, and the clinical trials are assessed by the National Institute for Clinical Excellence, NICE, in this country and various other bodies throughout the world. And they assess all the evidence that there is. And currently we have lots of evidence developing. They’ve been several systematic reviews and meta analysis which show that the treatment works in the sense that we know that we can ablate the tumours, we can destroy the tumours, and we know that the patients have a good PSA reduction and most people do not need additional treatment within about eight years. So we know that treatments work. What we don’t have, we don’t have traditional randomised controlled trials where one therapy is pitted against another, in which men are literally they’re randomised to, say, surgery or radiotherapy or NanoKnife or HIFU or cryotherapy. We don’t have those trials yet. But what data we have show that it does seem to be very effective. And what’s pretty clear is that the side effect profile of NanoKnife and HIFU compared to standard treatments is much better tolerated.
Clare Delmar
Yes.
Marc Laniado
Between NanoKnife and HIFU, it seems that the preservation of erections is better with NanoKnife. And there might be various reasons for that. It might be related to the energy, but it also could be related to the selection of patient men who have cancers at the front of the prostate. Because the nerves that give an erection run at the back of the prostate.
Clare Delmar
Back. Right.
Marc Laniado
I don’t think it’s entirely clear whether it’s just down to the technology, but certainly there’s no incontinence. Almost everyone is continent at one year. Most men preserve their erections, although there may be a dip immediately after treatment, most men preserve their erections at one year. And from that point of view, it’s extremely desirable. Most men are very attracted to that, to be able to deal with the cancer and yet preserve normal quality of life.
Clare Delmar
Yeah, understandably so. And do you expect NanoKnife to grow in your practise?
Marc Laniado
Yes, I do. Enormously. There’s several reasons for that. One is that, as I said, NanoKnife is really ideally suited for cancers at the front of the prostate. And since we’ve introduced MRI scans to diagnose or find prostate cancer, we’re finding many more men who have cancer at the front of the prostate. These men often weren’t diagnosed for many years.
Clare Delmar
That’s interesting. That’s very interesting.
Marc Laniado
Yes, they weren’t diagnosed because we did transrectal biopsies through the back passage, so only ever sampled the back of the prostate. But with the advent of MRI and transperineal biopsies, which enable us to sample the front of the prostate more effectively, we’re identifying more men with cancers at the front of the prostate. Hence the number of men potentially suitable for NanoKnife or similar technologies will increase. And furthermore, although there is no actual screening programme in this country, in the United Kingdom, for prostate cancer at this time, we’re certainly seeing that more and more men are keen to find out if prostate cancer is present. And so more men are presenting with early prostate cancer, cancers that are right at the very beginning and actually are most amenable to treatment. These are the men who have often been told to go on to active surveillance because they’re small tumours and the benefits from radical prostatectomy or radical radiotherapy relative to the side effects is not thought to be great. That’s because the side effects of the traditional radical treatments are so toxic or potentially so toxic. So when we have a new way of managing cancer or treating cancer which has much less side effects, more men are going to say actually yes, I have to have this treatment on the basis it’s less likely to cause problems. And the easiest time to treat the cancer is when it’s at its smallest. You have the least amount of open quote collateral damage, close quote, most likely to be a lower grade and so more sensitive to treatments that can kill it. If you wait until it’s advanced and it’s bigger then you have to treat larger areas. Then you may have to treat areas include the nerves also it may become inherently more resistant to the treatment you deliver or it could already have metastasized at that and we often we don’t find that out for many years. In conclusion to your question, yes, I absolutely do think that NanoKnife will increase as a treatment option for men for prostate cancer and I will be doing much more of that in my practise.
Clare Delmar
Yeah. I want to pick up on what you said just now about you mentioned about presenting early and you mentioned even coming forward for screening, knowing that there and I wanted to kind of connect this between focal therapy and screening because it’s interesting to note that while this so called supply of focal therapy treatments has been increasing, we’ve discussed that HIFU and we didn’t talk about cryotherapy, but that’s out there and now obviously NanoKnife. But the demand seems to be moving in possibly a slightly different direction, not because fewer men are developing prostate cancer, but more men are presenting with more advanced disease and maybe less likely to be suitable for focal therapy. And maybe that’s because of backlogs things we hear about in the media. And then what I’m wondering is if this raises the issue of cancer backlogs and better screening and do you see then a correlation between screening? Do you think this makes the case for more screening? Because then you get, as you said, early presentation and then as you also said, more suitability for treatments like focal therapy which as you said, are less toxic and very effective. So how do you see those things connecting?
Marc Laniado
So I think, yes, you’re right about the backlog. There are many people still waiting to be assessed with COVID and the problems associated with that. There are so many men who haven’t had the investigations they should have. We know in our local area that there’s a huge number of undiagnosed patients who eventually may come through but haven’t been found so far. So yes, absolutely that is true. But over time hopefully that will disappear and we will find we’re back to our normal way of doing things. Yes, I do hope that with better recognition of the potential for dealing with early prostate cancer in an easy way, that more people will come forward to have the test and more people will go into the treatment measurements that allow them to have these therapies and hopefully be free of cancer going forward.
Clare Delmar
Yeah. I mean, do you think that men are put off coming forward because they’re afraid of the outcome of not just obviously having cancer, but also because they have heard that the treatment itself is, as you say, so toxic?
Marc Laniado
I think even today in the news, I was reading an article about the young man in his 50s. He’d be recently diagnosed with prostate cancer and he was terrorised absolutely. He was terrorised at the thought of having the treatments and a test which might be painful and unpleasant. And he only came forth for tests because he had quite severe symptoms. But he was put off by the thought of urinary incontinence, loss of erections, bowel problems, all those issues which people have heard about when they look into the potential outcomes of what happens if you’re diagnosed with prostate cancer. So, yes, people bury their head in the sand and you can understand that. But I think if we recognise that actually it’s not quite so bad as it was and that, again, it’s much easier to deal with a problem when it’s small than when it’s large.
Clare Delmar
Of course
Marc Laniado
… more people become accepting that we should be moving forward with this.
Clare Delmar
So we have to emphasise the correct messaging to these people?
Marc Laniado
Absolutely. I mean, it beggars belief that we’re still very reticent about diagnosing and treating prostate cancer in the United Kingdom. We’re quite different to many other countries in the world where there is a much more proactive approach. It is true, and it’s absolutely right that the diagnosis has to be done correctly. You do need to have a properly performed MRI scan and then properly collected prostate biopsies and to be sure about the location and the type of cancer that’s present. Otherwise everything else that becomes we can’t manage prostate cancer with the least amount of side effects and the best benefit unless we have a good diagnostic pathway.
Clare Delmar
Absolutely.
Marc Laniado
And that has been lacking in much of this country, especially up north unfortunately, but it is improving. We are seeing more MRI scans and we’re seeing better biopsies, but there’s still a huge room for improvement. We’re still not seeing quite the benefit that we could by properly implemented MRI scans with the right protocols and radiologists to know how to interpret them, and then biopsies, which are actually definitely directed to the abnormality, which also leads on to treatment too. I mean, the other thing I didn’t perhaps talk about is about image fusion for focal therapy. We know that biopsies are much better if you can look at the MRI scan, see where the tumour is and direct the biopsies to there. Similarly with the tumours, if you use the MRI to direct your treatment to the abnormality on the MRI, you’re much more likely to get a good result. Historically, that was done by eyeballing it. A doctor would look at his screen with the MRI images and look at his ultrasound machine to his side and they think, right, I’m going to merge these two images in my brain and I’m going to direct the needles or the therapy into this right area. Actually, it makes logical sense that if you can use a computer system or an AI system to digitally fuse the MRI scans with what you’re looking at in real time, the ultrasound in real time, you’re much more likely to be able to direct your biopsy or your treatment into exactly the right area and hence also create a better safety margin. Because not only do you have to treat the cancer, plus you have to create a margin around it. And computers are much better able to draw those areas that need to be treated than the human brain can. So I think in time, as these additional technologies get embraced by urologists or other people delivering treatments or making diagnoses, we’ll see the precision of the treatment will be much better, the benefits will be higher and the side effects will be less.
Clare Delmar
Well, that’s what we want to see. But I have to say this has been fascinating and I really want to thank you for your time and we’ll be really excited to see as patients come forward, the ones that have, I know, have spoken to me about how extremely pleased they are with everything, the whole process from beginning to end. So we will look forward to hearing many more good stories. So Marc, thank you so much for speaking with me today. Really interesting stuff.
Marc Laniado
It’s a pleasure. It’s been lovely to talk to you.
Clare Delmar
Good. A transcript of this interview is available on our website, along with further information on diagnostics and treatment for prostate cancer, as well as additional interviews and stories about living with prostate cancer, please visit 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.