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Learning more, cutting less

Non-surgical prostate cancer options improving
Latest technique uses ultrasound

By Paul Irish
Staff Reporter

September 19, 2005

There was a time when surgery was the only game in town.

The scalpel was an intrusive - but essential - instrument for ridding prostate cancer patients of malignant tumours.

But with the knowledge that most patients recover quicker with less-invasive procedures, researchers have been devoting time and money to developing new techniques that don't require radical surgery.

Physicians specializing in prostate cancer are now using two revolutionary procedures with excellent results.

Ablatherm High Intensity Focused Ultrasound (HIFU) - which has been used in Europe the past few years and is just being introduced to North America - is an extremely precise procedure using high-intensity, focused ultrasound to create heat within the prostate to destroy cancer cells.

Brachytherapy, which treats cancer by planting tiny radioactive pellets directly into the prostate, has been around since the early 1970s, but is just now gaining popularity as medical techniques become refined.

"The more we learn, the less we cut," says Dr. William Orovan, president of the Don Mills Surgical Unit whose private Toronto clinic is the only place in North America offering the HIFU procedure. "If you can get the same results without surgery, I'd strongly recommend it." About 30 men have opted for the HIFU operation at the Wynford Dr. clinic, which opened in April and is licensed by the province. (It also offers other unrelated medical procedures.)

HIFU is a targeted procedure, used to eliminate all cancerous prostate cells. It takes one to three hours, depending on the size of the prostate, and can be done with a spinal or epidural anaesthesia.

During the treatment, a probe is placed in the patient's rectum, which emits a beam of high-intensity, focused ultrasound that rapidly raises the temperature inside the prostate to 85C, thus destroying the prostate tissue and accompanying cancerous cells.

Dennis Robertson, 57, of Ingersoll, Ont., underwent the procedure in June and says he would recommend it to other men.

"There was no real down time, they didn't have to open me up," says Robertson, a salesman. "It was easy."

He was diagnosed in April and was about to get a radical prostatectomy, but his wife heard about the HIFU method on a news report and the couple started their research.

"I read about all the success they have had in Europe and I'm just too busy to be sitting in a bed recovering from an operation," he says. "If they can do the same thing without cutting me open, I'm all for it."

The procedure isn't covered by provincial medical insurance, but Robertson says it was worth the money he had to shell out of his own pocket. Orovan says that because HIFU is considered an equivalent to some forms of radiation therapy - already covered by health care - patients must pay for the procedure themselves.

"As more compelling results are produced, it will get closer to being covered," Orovan believes. "Right now, there's just not enough money to go around."

Robertson will have to wait until October for his first PSA test, but he "feels good" and is confident the cancer has been arrested.

A study of 137 patients in Europe showed that, five years after undergoing HIFU, 93 per cent had negative biopsies and 87 per cent had PSA levels of less than one. Rising PSA levels can be an indication of cancer.

Another study, from Lyon, France, reported similar results, and medical authorities have concurred that the treatment is an effective alternative to the more-invasive treatments commonly used.

The procedure also has fewer side effects than radical surgery. Orovan says incontinence is rarely a problem after HIFU, and impotence can eventually be overcome.

Dr. Gerard Morton, of the Toronto-Sunnybrook Regional Cancer Centre, who performs brachytherapy, agrees the less invasive the procedure, the better it is for the patient.

"The side effects are less and the guy is back on his feet sooner," he says. "We're getting away from the knife."

Brachytherapy is specifically for non-aggressive cancer that has been found early.

The seeds, small enough to be inserted into the cancer site through a hypodermic needle, give off radiation slowly over several months, with the treatment almost totally confined to the prostate, limiting damage to surrounding healthy tissue.

The amount of radiation decreases by half every 60 days, so that in half a year, about 85 per cent of the dose has been administered. It's gone from the body by one year.

With ultrasound and CT scans (computed tomography, which takes a series of thin-sliced x-ray images that are then fused to produce a three-dimensional image) the procedure has been refined, producing much better results and, ultimately, becoming more popular.

Morton says surgeons are beginning to see "quality results," with zero incontinence and cases of impotence responding well to drugs, such as Viagra.

The procedure is now performed at nine centres across the province, treating about 500 patients per year.

Aaron Bacher, 62, was diagnosed with prostate cancer when he was 56 and dealing with heart problems at the same time. On the same day he was told about the cancer, he was informed he needed a quadruple bypass.

"I was in a bit of a daze," says the retired Kodak worker, who is also president of Man to Man, the largest prostate cancer support group in Greater Toronto."It was a lot to deal with."

He was told to put the cancer on the back burner so he could concentrate on his heart issues.

Bacher underwent heart surgery in June 1999. When he started to focus on his cancer, he realized he didn't want another operation.

He started brachytherapy on Feb. 15, 2000 and believes he made a wise choice."It was simple ... it didn't knock me out of action," he says. "I did a lot of research before I made my decisions. Everything I read convinced me it was the way to go."

His PSA right before the procedure was 3.6, but it now sits at 0.35."I'd be lying if I said I had total peace of mind," he says. "Before each (PSA) test, I get a bit nervous. But it's something that has to be done. Every man should have it done at least twice a year."

© 2005, The Toronto Star