How I talk to my patients about HIFU Michael Lazar MD, Medical Director

Overview of Diagnosis Begin with overview of definitions, staging, Gleason grading, etc., and orient the patient to the particulars of his own case. Must be speaking same language

Treatment Options Discuss the management options including: Surgery Radiation Cryotherapy HIFU Use information sheets the patient can reference at home.

Present the stats Presentation of the morbidity stats for each of the other therapy choices (especially incontinence and erectile dysfunction) provides a perfect segue to HIFU.

The Stats Virtually all morbidity stats are better with HIFU: the exception is 10-20% prostatic urethral stenosis with whole gland therapy. This does not occur with Focal/Hemi gland therapy where the urethra is typically spared. Whole gland therapy involves an incontinence rate of 1-2% (mild), and ED 10-20%. Both significantly lower than surgery or radiation, and 0% and <10% with Focal/Hemi

Who is a HIFU candidate?

Active Surveillance vs Focal HIFU Repeated biopsy sessions with attendant sepsis risk, bleeding, pain, etc. Focal HIFU: Cancer control efficacy and lower morbidity profile. Cancer Control Complication Management

Focal/Hemi Therapy Focal/Hemi therapy maximizes chances of maintaining normal physiologic functions (erections, continence, semen production, etc.) while providing good cancer control. All subtotal gland men should have mp-MRI

Explain the Procedure Go over the following: HIFU is exceptionally well tolerated. It is performed under anesthesia, but is painless and bloodless, as the energy seals the nerves and blood vessels. Patients are treated, recovered in PACU for an hour, then go home. HIFU is particularly beneficial for older men, or those not candidates for more aggressive treatment modalities, but whose tumors require definitive therapy. If the tumor ultimately proves not amenable to local therapy, at least the damage was minimized in the effort.

Burned Bridges Patients who require additional therapy (up to 30% of radical prostatectomies require salvage radiation) have burned no bridges. They are still candidates for salvage surgery, radiation, or repeat HIFU. Salvage radical prostatectomy after HIFU is not associated with the field fibrosis seen after radiation (common myth). Hence, the morbidity is little different from surgery on untreated glands.

Insurance Coverage While HIFU is only gradually being covered by insurance, it is still economical for employed men. When compared to being disabled after surgery, or having to be in radiation sessions 5 days per week for 7-8 weeks, the cost of HIFU becomes less than the lost income sustained with other therapies.

Important Lessons Don’t judge a book by its cover with consulting men. Impossible to know who will want it. HIFU consultation takes longer than other procedures Use the HPS nurses to save time

Important Lessons Remember, docs who do not offer HIFU will instinctively discredit it both to appear “cutting edge” and to appear to be offering full service options to their patients. They will cite the worst outcomes, out-of-date data, and Ablatherm studies (generally inferior). They will commonly state HIFU is only indicated for low grade cancers due to the original FDA study parameters. We have to be able to explain the differences between Sonablate and Ablatherm, as patients will assume they are equal in their own research.