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Reasons to be Cheerful

A conversation with TFTC consultant, Alan Doherty

Joining the podcast today is Alan Doherty, Clinical Director at the Birmingham Prostate Clinic, and 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 joined the Focal Therapy Clinic last year to develop his expertise in delivering focal therapy. Having now treated a large cohort of patients with focal therapy following the Clinic’s rigorous MDT review , he’s even more positive now about the approach than he’s ever been, and joins Clare today to discuss how this experience makes him optimistic about the future of focal therapy and, most importantly, the future for men diagnosed with localised prostate cancer.

 

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 Alan Doherty, Clinical Director at the Birmingham Prostate Clinic and recently voted one of the UK’s top ten prostate cancer specialists in the 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. Having now treated a large cohort of patients with focal therapy following the clinic’s rigorous MDT review, he’s even more positive now about the approach than he’s ever been and he joins me today to discuss how this experience makes him optimistic about the future of focal therapy and most importantly, the future for men diagnosed with localised prostate cancer. Alan, thank you so much for joining me today.

Alan Doherty

Hello, Clare, thank you for inviting me.

Clare Delmar

And I’m always impressed whenever we chat how positive you are, which is why I thought this would be a great theme to sort of set the stage. We’re halfway through the year. It’d be really good way to get you talking about what you’ve observed from treating your patients. And I guess the first thing I want to ask you is what kind of cases have you seen, well, certainly in the last year since you’ve joined the clinic and even more recently, that gives you cause for optimism?

Alan Doherty

I suppose I’d answer that by saying I’ve been surprised by the enthusiasm of so many patients to have focal therapy and some, of course, are more suitable for it than others. And in a way, how often patients, even if you don’t think they’re particularly suited for focal HIFU, they often still want it. So it’s a difficult balancing act from our end to offer treatments which we think are perfect for them versus patients who have a strong view as to what they want and not necessarily listening to us as clinicians. I can understand why, because they’re getting so many different opinions from everywhere. So that’s the first thing I’d say. I think the second thing I’d say is that I’ve been so impressed by the way The Focal Therapy Clinic are able to assess a patient so that when we are recommending a focal therapy, you can really have confidence that this is the right thing to do. And the reason I say that is because a lot of focal therapy…and management of prostate cancer in general… early prostate cancer… Is very much dominated by good quality MRI scanning. Within our group we’re able to do that so well and that gives me confidence that when I recommend focal therapy that this is the right thing for me to be doing for a patient.

Clare Delmar

It’s interesting you say about the clinic bringing you patients that are so enthusiastic and I think that has to do with our approach to what we call patient advocacy, the first port of call for many patients is our wonderful patient advocacy team, so they actually begin to understand each prospective patient’s kind of hopes and dreams, as it were, and what their lifestyles are like. So I think that adds into the mix. But of course, the other thing, when you reference MRI is, we do an extremely rigorous MDT. How do you think that MDT has impacted your views on the future of focal therapy?

Alan Doherty

Again, probably two aspects. One is I share ideas with my clinical colleagues who are treating prostate cancer day in, day out and it’s always good to share an idea, to have it critically assessed. And then the second thing is the way that we can look at an MRI scan in a live setting and everyone sort of picks up slightly different things about the MRI scan and what it all means. And I think out of all the MDTs that I do, and you can imagine we do a lot of MDTs, this particular one is the most influential. It’s the one where I learn the most and it’s the one that I really don’t want to miss because it’s the one which I give feedback to patients with better information than I can from just myself thinking about the case.

Clare Delmar

And do you think that the quality is continually improving as well so that you can really deliver optimal care for your patients?

Alan Doherty

Most definitely. I think there’s something that I’d like to say about the focal therapy. What I’ve learnt about it in the last year. Is that it virtually transforms the reasons why for screening for prostate cancer is a good idea. In other words, if you’re going to find a cancer early, you have to have a treatment that is effective but also doesn’t cause many side effects. And it’s this concept of overtreatment which is inherent in the screening of any condition, because if you pick something up early, you don’t know whether it’s going to be a problem in the future. But if the treatments you’re offering for early treatments are associated with a lot of side effects, then the arguments for a screening programme don’t really stack up. But if you have a treatment with very low side effect profile, which can be delivered accurately like we can in our focal therapy clinic, it really does give a strong rationale for screening. And that’s the first time I think I’ve ever been able to stand up in front of a lot of doctors and say, well, I think it makes sense to find this early because we can treat it even if it doesn’t turn into a problem in the future without many side effects. So why wouldn’t you do that? The more you understand about how we’re treating these cases, the more you can see why there’s benefit and very little harm.

Clare Delmar

And of course, a lot of that is driven by the evidence base that’s continually being generated. I mean, even this year there have been a couple of studies that have been published about men undergoing focal therapy that have been really positive. Do you think those, given what you just said, will drive its adoption and availability more widely?

Alan Doherty

Most definitely. I think one of the troubles with any treatment is you’ve got to, I suppose, compare apples with apples and oranges with oranges. Because when you do something properly, as I think we are in the focal therapy clinic, because we’re doing it in this multidisciplinary meeting and we’re doing it with very high quality MRI scans. Our results are going to be a lot better than if you just do it in a sort of happy go lucky type of approach. So I think if a study is showing benefit when it’s not just done by one dedicated group, but it’s done by a whole heterogeneic group of people, you’ve got to say that the likely outcomes are even better than the studies are showing.

Clare Delmar

That’s an interesting way to look at it.

Alan Doherty

Yeah. And I think the other thing to realise, again, something else I’ve noticed in my last year is that often patients will be prepared to have the main lesion treated with focal therapy and just monitor a smaller lesion on the other side. Now, that’s an interesting situation to be in because if you define an outcome by the need for another treatment, well, that particular group are a high risk group because we know that we’re leaving a tiny amount of cancer there that’s possibly going to get worse in the future. But being prepared to do that because they’re confident that we’re going to monitor them closely and if necessary, treat them again with a minimal morbidity. I think when you’re doing studies, it’s really hard to compare apples to apples because you generally have groups of patients who are very diverse and clinicians that are diverse and you’re getting sort of quite a few varies. But the point I’m making is if you are showing benefit with that diverse group, then you can imagine how much better it’s going to be for the very select group when the treatment is done properly.

Clare Delmar

Yeah. Again, very interesting way of looking at it, because we’re always wondering how and when focal therapy will kind of go mainstream, so to speak. And I was going to ask you, do you see focal therapy playing a more significant role in educating men about their treatment options for prostate cancer? Or I guess. In other words. Do you think the urology community is developing more of a literacy around it and adding it to active surveillance, hormone therapy, radical prostate, radiotherapy in the treatment portfolio?

Alan Doherty

I think what focal therapy does is make you realise how important a good MRI scan is. Because a good MRI scan and good interpretation of that MRI scan by a very experienced radiologist. What that does is it allows you to do the focal therapy. But if you go one step back, it means that you’re not going to biopsy patients who have a normal MRI scan. In other words, if you’re confident in your MRI scan, you can really reduce the number of biopsies you ask for. So it will stop people being scared of having a PSA, because traditionally, if you had a PSA blood test and it was a little bit abnormal, you’d end up having a biopsy. So what I’m saying is, I suppose when you are offering focal therapy, you’re the type of clinician that’s not going to be biopsying people just because the PSA is slightly elevated. You’re going to be looking for early significant lesions that you can see. Focal therapy is all about seeing the lesion, hoping that it’s only in a focal area and then treating it accordingly, and you have to pick it up early so that you can get good outcomes from it. And I think that’s where it’s going. That the focal therapy is a natural consequence of a high quality MRI service. I agree that’s going to be hard to do because it’s a difficult one to do, that one. But with time, it’s relatively new that MRI scans become a dominant feature in prostate cancer management. And you can imagine, therefore, that if something is new, it’s going to take time to really develop. You’re going to have certain pockets of excellence and you’re going to have people catching up with that and then you’re going to have certain pockets where they need to pull their socks up a bit.

Clare Delmar

But I mean, picking up on your point about doing no harm and the benefit of early screening, I’ve heard you say in the past that now that you do have this highly precise MRI, which is only getting better and better. If you can see these cancers and you can define their severity, their location, their size, is it better to treat it than, for example, to do nothing? Is that the role of focal therapy? Is that how you see it?

Alan Doherty

That’s exactly how I see it. Because maybe you are over treating people, but that goes for all screening programmes and the trick is to over treat someone… sorry the trick is to try to avoid overtreating. But if you are going to, don’t give them side effects.

Alan Doherty

Yeah, no, absolutely. I guess on that point, that’s really good news. That often doesn’t translate down to the patient level because they often sort of undergo an MRI scan, for example, without fully understanding the significance. They might know that it’s obviously going to aid in their… well, as you say, whether or not they did a biopsy or not. But then later on some form of diagnosis. But I guess connecting that to they might be able to have less radical treatment because this new method allows that is probably something that needs to be educated.

Alan Doherty

And I think one of the last things to just mention is that people who do focal therapy probably are best as clinicians who don’t just do focal therapy do a number of different treatments because every treatment has its limitation.

Clare Delmar

Of course.

Alan Doherty

The more you do it, the more you understand those limitations and the better able you are to advise the patient as to what’s best for them because it’s not necessarily just the short term outcomes that matter, it’s also the long term outcome. So it’s quite a complex area, but a good clinician should be able to explain the issues. And every patient is different and has a different personality and has a different value system. So it’s quite fun being a clinician in this day and age because we’ve got so many different ways to treat people increasingly without making them miserable when just giving them benefit.

Clare Delmar

Yeah, and so much more information on which to make those decisions and have those conversations.

Alan Doherty

Exactly.

Clare Delmar

So I guess as a final question, what are the reasons to be cheerful if you’re a man over 50 and you’re faced with the fact that, oh, I’ve got to go get a PSA test, for some men, this actually makes them quite hesitant, even reticent about getting one. But from what you’re saying there’s, early screening can lead to, well, you tell me, what are the reasons to be cheerful if you’re a man over 50?

Alan Doherty

Well, I think that if somebody was to encourage a patient to have a PSA blood test, they should be confident that we’re only going to pick up a significant cancer that’s going to be seen. In other words, that the MRI scans normal, we don’t biopsy, and then if we do see something, we’re going to pick it up early enough that we can affect the natural history. In other words, that we can make a difference and stop you having to have treatment in the future that have a lot of side effects and even better than that, possibly even stop you dying from it. But it’s not just about living and dying. I often say to patients that it’s not just about being alive, you’ve got to live. It’s that combination of quality of life and quantity of life. I think the reason to be confident and positive about the future is that high quality MRI scan and a focal therapy just allows you to pick up and treat early tumours before they are really dangerous. And that’s got to be what screening is all about.

Clare Delmar

Well, on that note, I’m going to say thank you so much for sharing your optimism and giving us some really useful pieces of information about how some of this diagnostic information is really transforming what you can offer patients and how they’re going to recover.

Alan Doherty

Pleasure. I’m so glad you do these to share information with people because there is so much out there now and it’s confusing to patients.

Clare Delmar

Well, it’s great that you can actually help make it a lot more not simplistic, but a lot more easy to digest and, as you say, a reason to be cheerful. So thanks again for coming, Alan.

Alan Doherty

Thank you, Clare.

Clare Delmar

Further information on Alan and his clinical practise is available on our website, along with the transcript of this interview and 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. Bye.

 

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