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BackTable / Urology / Podcast / Transcript #169
Podcast Transcript: Prostate Cancer: Navigating Focal Therapy Options
with Dr. Matthew Cooperberg and Dr. Arvin George
In this episode, Dr. Matthew Cooperberg (UC San Francisco) and Dr. Arvin George (Johns Hopkins) join host Dr. Aditya Bagrodia in a conversation about guidelines and treatment algorithms for focal therapy in prostate cancer treatment. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Clarifying Terminology and Standards in Focal Therapy for Prostate Cancer
(2) Navigating Guideline Changes & Regulatory Hurdles in Focal Therapy
(3) Focal Therapy Patient Selection
(4) Addressing Patient Expectations
(5) Genomic Considerations in Focal Therapy
(6) Post-Focal Therapy Management
(7) Comparing Focal Therapy Modalities: Advantages, Challenges & Practical Considerations
(8)Future Directions in Focal Therapy for Prostate Cancer
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[Dr. Aditya Bagrodia]:
Hello, everyone and welcome back to the BackTable Podcast, your source for all things urology. You can find all previous episodes of our podcast on iTunes, Spotify, and at backtable.com. This is Aditya Bagrodia as your host this week, and I'm very excited to introduce our guests today. We have Matt Cooperberg from UCSF, and we have Arvin George from Johns Hopkins. Matt, Arvin, how are you all doing today?
[Dr. Matt Cooperberg]:
Good. Pleasure to be here.
[Dr. Arvin George]:
Thanks for having us.
[Dr. Aditya Bagrodia]:
Perfect. We're going to get some different perspectives, an East Coast perspective, a West Coast perspective on focal therapy. I thought we'd kick off with-- so Matt, you're a UCSF lifer.
[Dr. Matt Cooperberg]:
You Can Stay Forever, UCSF.
[Dr. Aditya Bagrodia]:
You can stay forever. Perfect. Did you actually do focal therapy as a part of your training, or did this come into your attending hood?
[Dr. Matt Cooperberg]:
I would say minimally. We have been doing focal therapy at UCSF under Katsuro Shinohara for a long time, but very sparingly. When I was in training, it was mostly a question of focal cryotherapy. HIFU was a four-letter word at UCSF when I was in training based on the early generation machines and the early generation data, to be sure. We had some exposure to focal therapy. It was something like 100, 120 cases over about a decade so to an extent, but obviously, there's a lot more interest and a lot more exciting research and development going on now.
[Dr. Aditya Bagrodia]:
Got it. Arvin, so residency, LIJ, is that right?
[Dr. Arvin George]:
Yes, that's right. Now it's Northwell Health, but yes, LIJ.
[Dr. Aditya Bagrodia]:
During residency, did you do much focal? Where were things in that–
[Dr. Arvin George]:
No. It was still at that point, we weren’t doing much focal. I wrapped up residency around 2012. It was actually, early adoption of fusion at that time. I think fusion biopsy and image-directed biopsy really preceded the growth of focal.
[Dr. Aditya Bagrodia]:
How about in your fellowship at the NCI?
[Dr. Arvin George]:
Yes, the NCI was also sparing. We were starting with our initial focal laser ablation protocol. It was an in-bore laser ablation. There were a number of studies from other institutions, including the University of Chicago, which looked at that previously. Again, just a handful of cases at that time during fellowship.
[Dr. Aditya Bagrodia]:
Honestly, before starting here at UCSD, not only had I never done focal therapy, I'd never seen one. I would in no way, shape, or fashion put myself in the same category as you both in terms of really being thought leaders and pioneers in this field. I think it's nice that I always found it to be a little bit foreign, intimidating, that you can sink your teeth into it and learn it. Maybe we'll get to that. Let's just start with some basics, focal therapy definition. How do you define focal therapy? Or is it ablation? Is that the better term?
(1) Clarifying Terminology and Standards in Focal Therapy for Prostate Cancer
[Dr. Arvin George]:
There's some semantics that surround it and there have been some attempts at trying to clarify the terms but there's partial gland ablation, which is the overarching umbrella term, which is anything that's a subtotal ablation. Then focal therapy, in my mind, is really treatment of the index lesion plus a safety margin that I typically employ about 1 centimeter or more.
[Dr. Aditya Bagrodia]:
Matt, does that sound about right?
[Dr. Matt Cooperberg]:
Yes, I would totally agree, but to emphasize Arvin's point, the terminology is used highly variable across the literature. Samaritan Asia had a nice classification, which I'm sure many others have used as well, which is, truly focal being exactly what Arvin just described, a visible lesion with some margin around it. It could be hemi ablation. Others will do hemi plus, the other side. I've seen somewhere they do hemi plus almost the entire side, just sparing a little bit of tissue around the NVB and still call that focal.
You can see the term used and abused in lots of ways. It's one of the things that has made the literature a little bit difficult to track.
[Dr. Aditya Bagrodia]:
Yes, whole gland ablation, hockey stick ablation, hemi gland ablation.
[Dr. Arvin George]:
It's a spectrum. It's just a spectrum from A to Z. We feel compelled to call it different names to help clarify for comparing apples to apples, I guess.
(2) Navigating Guideline Changes & Regulatory Hurdles in Focal Therapy
[Dr. Aditya Bagrodia]:
Matt, I think you're-- I was chuckling when you said that hyphae was a four-letter word. For much of my training career, focal therapy was this gimmicky deal that people in Florida were doing for cash pay. Then they'd wind up at a normal center where everybody, high grade, low grade, surveillance candidates, high risk for getting ablation. I guess we just saw these catastrophes.
The state of the art seems to be improving imaging, all that. Of course, we'll talk about that. What about just guidelines? What do our US guidelines say? Is this experimental? Is this ready for prime time?
[Dr. Matt Cooperberg]:
The guidelines are, I think, appropriately pretty sparse in terms of what they say about focal. It is still experimental to an extent. The guidelines are pretty guarded in their endorsement of focal as an option. There are no explicit focal therapy guidelines that have been adopted by any national organizations. There are a variety of society guidelines and statements that have been put out.
We just had one out from the five University of California sites, which, of course, you were a part of, which does emphasize the point that patients should be told this is not a treatment with nearly the same duration of follow-up, with nearly the same validation data that the standard treatments, surgery, radiation therapy, active surveillance have. We don't call it experimental in the sense that this is first in human research, and it can be done outside of the setting of an academic institution.
That's I think a big part of the problem in the field is the way it's being done across the community practices. The guidelines do state we should be tracking these patients in a trial or a registry to collect better data about outcomes. It's a rapidly evolving space without a lot of hard guidance reflecting the state of the literature.
[Dr. Aditya Bagrodia]:
What do you think, Arvin? Do you think the guidelines are–
[Dr. Arvin George]:
Your two key guidelines are going to be the AUA and EAU guidelines, and either they say that it should be done within a well-designed prospective cohort or within a comparative study or clinical trial. In the salvage space, NCCN does include HIFU and cryo as a salvage treatment option, but I agree it should be exercised with caution. I'm not sure it's necessarily a community urology problem, it's just a lack of urology knowledge problem. Like you said, this is a field that we're taking a bite out of now and we're really starting to study it and understand it.
Things that may seem obvious to us maybe as academics 10 years from now, we're going to look back at it and say, what were we thinking at that time? I think it's a period of learning for all of us, and I think we have to accept that and be very brutally honest about it to ourselves and to our patients.
[Dr. Matt Cooperberg]:
One part of the problem, if we take a step back even from the guidelines, is that we're still in the regulatory environment here and it just reflects the fact that it continues to boggle my mind how difficult it is to get through the FDA with an injectable. To get a targeted fluorophore into the operating room, it's completely safe, not even a theoretical risk of harm, is this years-long process.
Whereas to get a device like an ablation machine or OR, you just have to show a lack of harm. It amazes me how difficult it is for drugs and how easy it is for devices. You just have to show that this will not cause direct harm to the patient. You don't have to show a single thing about efficacy. That's just the nature of our regulatory environment, which is different in other countries.
Once it is out there, well, it can be used for lots of different things without IRBs, without protocols, without being in a trial. If you look at how focal and ablation modalities have been rolled out over the last 20 years in the States and I should say across North America, if you look at the experience of folks taking their patients ex-US to Canada and Mexico to do HIFU in the 2000s, it's a history now that doesn't look great for us in terms of the way we have rolled this out.
I think there's a lot of horror stories out there, as you were just talking about. We're now getting just to the point where we actually have prospective studies. Some trials, and academics that are starting to take this seriously, but in a way, we're playing catch up with a field that really has been Wild West for quite some time.
(3) Focal Therapy Patient Selection
[Dr. Aditya Bagrodia]:
It does dovetail because without that disease-specific CPT code that's not going to get covered by insurance, that leads to cash pay and maybe makes it more or less appealing without going too far down that rabbit hole. All right. I think the guidelines are pretty reasonable, cautious but not quite as negative on focal, if you will, as they once upon a time were.
Grade group one, so let's stick to surveillance, high risk, let's stick to our standard options, intermediate risk, it's maybe a bit of the conversation. Let's talk about ideal patients and maybe we could talk about patient-specific factors, prostate and anatomy-specific factors, and then some cancer characteristics when you're thinking about focal. I'll just throw this out there, when I moved here to San Diego, they had recently purchased a machine to perform HIFU, and part of my charge was to help get that going.
I was waiting for a solitary MRI, visible peripheral posterior lesion, 3 + 4 = 7, one or two cores, fast forward a year and a half, and I'd done one focal therapy. I actually thought the patient would have done fine on surveillance. Maybe just with that context, ideal patients.
[Dr. Matt Cooperberg]:
I'd say you just described it. Like you say, there's not that many of them. I think the band is fairly narrow for the ideal focal patient because you need somebody who needs treatment, they're not a good surveillance candidate, but you need somebody who doesn't need whole gland treatment, where you're not worried about the field defect in the prostate genomics, you're not worried about the lymph nodes, the pelvis, and all the rest of it.
That's not a particularly wide band of the risk profile. I think it's, again, what you described. You want imaging visible, either an ultrasound or MRI, ideally on both. You want to find 3, 4, maybe limited 4, 3 in that lesion. We will accept 3, 3 in other parts of the prostate, but ideally no higher grade disease outside of the lesion, unless it's immediately adjacent. In the University of California protocol that's out there, and certainly at UCSF, we're trying.
We definitely strongly encourage confirmatory biopsy with MR guidance if the initial one was done without MR before committing to focal. We're trying to get genomics on everybody and encouraging folks with high-risk genomics, potentially to consider whole gland therapy. I would say one thing that the other selection criteria, the patients really need to understand that this is not an alternative to surgery or radiation therapy, if we're not talking about whole gland treatment.
I think about it as an augment to active surveillance for patients who are not otherwise great surveillance candidates. Everybody is committing or they should be committing to a biopsy one year later, no matter what happens with the PSA and imaging and we have to follow them for life. They can develop a recurrence, they can develop a brand new tumor. They really are on more of a surveillance path. Hopefully, with fewer biopsies and a lower chance of disease progression than if they were on pure AS.
In my mind, this is more active surveillance than it is alternative to prostatectomy or radiation.
[Dr. Aditya Bagrodia]:
I think that you covered a lot there, Matt. Arvin, maybe I'll ask you, it's both ends of the spectrum. You're the young, healthy patient who's quite functional that you really want to limit the potential adverse effects of surgery, radiation. The opposite end of the spectrum, you may have an older, sicker patient that merits treatment that you want to put them through whole gland treatment. What do you think about that spectrum?
[Dr. Arvin George]:
I think I'm probably a little bit less conservative than Matt in that I would apply to all intermediate risk, but I do believe there needs to be some guardrails up. Typically, either a PSA less than 15 or a PSA density less than 0.2 due to the recurrence rates do increase at that-- it's a bit of an arbitrary threshold. I don't treat low-grade disease and I'm also relatively aggressive in putting men who have favorable intermediate risk on surveillance if they're appropriate candidates.
There are all these disease characteristics which are really important but with any treatment, I believe that, the higher the risk, the diseases, the outcomes are going to be worse and that is the same for surgery or radiation. Mechanistically or procedurally, if there is a cancer that is isolated and I feel that I can destroy it and achieve a reasonable margin, there's no reason that prostatectomy would be superior.
I do think in the future that we will be able to treat high risk and there are some series that have already included high risk. I don't personally treat that in my practice right now, but I do think that as data accumulates and it will largely be out of a number of clinical trials that are already underway, that will really give us the signal as to where we can or we can't do it. Then one piece I think that Matt did not mention that of course is obviously at the top of all of our minds is the patient perspective.
A lot of times patients are coming to us asking about these treatments because of the limited morbidity. To a certain degree, we have to protect patients from themselves, but at the same time, we also have to be able to understand the patient's perspective and let them also take part in that decision between the trade-off between cancer outcomes and functional outcomes.
[Dr. Aditya Bagrodia]:
Totally, and I have here in my notes the patients insisting on focal and we can maybe talk about that. I don't know how it is at your institutions, but we get these new technologies, everybody gets excited. Then there's a press release that everybody and their brother come in wanting new treatment. We talked a little bit about the patient-specific factors. Significant BPH, is that potentially going to be benefited or is that going to cause problems?
[Dr. Arvin George]:
I don't think it makes a difference. It's going to be technology-specific and it also depends on the volume of tissue that you actually have to ablate. If you're going to have to do a hemi ablation in 120-gram gland, that's not going to be a great candidate versus if you have a very discrete image visible lesion target-only positive.
BPH actually gives you the ability to achieve a nice wide margin circumferentially and a lot of times improves some of those symptoms marginally, moderately, I would say, in terms of lower urinary tract symptoms on, four to five points on an IPSS and in some cases depending on the volume of tissue that you ablate.
[Dr. Matt Cooperberg]:
I think I worry more about their baseline IPSS than on the volume per se. Of course, I'm sure we'll get to this, but the anatomy beyond just the size of the prostate does matter. If the lesion is closer to the apex, closer to the urethra, more medial, et cetera, we're going to worry a little bit more about the urethral impact, especially in somebody who's got baseline obstruction.
[Dr. Aditya Bagrodia]:
Totally. We're going to get to the modalities and some of those specifics. Bilateral disease, bilateral intermediate risk disease, is that a deal breaker, not a big deal?
[Dr. Arvin George]:
I don't really treat bilateral disease. I think that if you're going to approach-- essentially what are you really achieving here in terms of what are you sparing? In those cases, I think that if it's the side effects of focal therapy specifically regarding continence and sexual function, then I would say that radiation is going to align best with their goals of care rather than radical prostatectomy. Those are my thoughts, yes.
[Dr. Aditya Bagrodia]:
I think we touched on grade, focality, bilaterality, location we'll talk about, PSAs, something reasonable, PSA densities.
[Dr. Arvin George]:
Aditya, I do think that whole gland ablation is probably underutilized. We have patients who aren't great surgical candidates, older patients who would otherwise deliver radiation to and maybe we don't need to achieve 10 years. Maybe we want to keep them not metastatic for a period of time and really if their life expectancy is greater than five years, it's really radiation that's recommended anyway.
I think that you have the opportunity for some people who don't have access to a radiation center or live closely within it. The skillset is not tremendously challenging. Again, in select patients.
[Dr. Matt Cooperberg]:
There was just that little bit of usual kerfuffle on Twitter. I'm sure, Scott Aigner just reported their phase two prospective series-- Yes, exactly. Of Tulsa. There were a couple of, usual suspects, radiation oncologists getting very aggravated about the data. This is experimental and I don't have to go, why are these patients just getting radiation therapy? You can imagine who said what. I will say we-- when I was in training, we're talking about training, we used to do Hoagland cryo to a very limited extent, I would say, in my early training.
The outcomes were consistently worse than what we would see with radiation or frankly, what we would see with prostatectomy done in a high-volume center. It really fell by the wayside and I worry a little bit about the variability of the outcomes. A lot of patients do great, but some of them clearly do not. I'm not sure that we have the tools to predict, especially with Hoagland.
It's the patient that is, "too sick for surgery." You wonder how many of them are really at risk of dying of prostate cancer in the near future. A five-year life expectancy, to me, that is incredibly narrow and that is what the NCCN says, I agree, but if your life expectancy is five years, you really should stop thinking about the word prostate and your list of life concerns as far as I'm concerned. 10 years, maybe, ya know.
[Dr. Aditya Bagrodia]:
I might've missed this MRI invisible. Is that a deal breaker? A big deal?
[Dr. Arvin George]:
I'm not a huge fan of treating MR visible disease. Now, I know there's different camps on this and I think that there's a little bit of cognitive dissonance in my thinking, but my concern is that if you're treating MR invisible disease, then how confident can you be that in the areas that you did not sample that were also negative on MR does not have disease? Now that can be true even if you see a visible lesion.
I think that the equation changes a little bit, at least in my mind, I'm a lot more comfortable treating somebody. The other thing is how do you follow those men apart from PSA? I think that imaging is a powerful tool in the surveillance setting as well. Having a target to treat I think is very helpful. I do think that it's a phenotype and it does speak to the biology of the disease to a certain extent as well.
MR visible disease is in my opinion, going to prove to be more clinically significant. Maybe it's a volume issue, maybe it's a grade issue, maybe it's a bit of both.
[Dr. Matt Cooperberg]:
I'd agree. I think there will be some exceptions if you have clearly unilateral disease, at least it's been well sampled. Again, confirmatory biopsy confirms unilateral and you're going to think about hemi ablation, I'm fine with that. In our protocol, the patients need at least that one-year biopsy, even if the imaging looks fine. I wouldn't say it's an absolute deal breaker, but it's a fairly uncommon scenario these days where the MR is truly negative and they have clinically meaningful disease that needs to be treated.
It does happen, but we're talking about a very select basis at this point.
[Dr. Arvin George]:
We do have the advantage of additional imaging like PSMA PET and unfavorable end-to-end at risk. I think it needs to be visible on any imaging modality. I think we have additional tools.
[Dr. Matt Cooperberg]:
Ideally, we see it on ultrasound as well, by the way.
[Dr. Aditya Bagrodia]:
Are you all using micro-ultrasound, just out of curiosity?
[Dr. Arvin George]:
Yes, we have it and we've been using it. I'm getting myself trained on it. I'd like to participate in the optimum trial. We have it up and running already, and I'm hoping to get more experience with it. I think that the optimum trial will give us a lot of insight as to its value in comparison to MRI. I think it's promising.
[Dr. Matt Cooperberg]:
I've done a few. I like it as a modality. It's definitely a learning curve. It's a very different picture than we're used to seeing with a conventional ultrasound, even the high-resolution ultrasounds that we've had, some 44 K high-resolution ultrasounds. There is that learning curve. I think it's got a lot of appeal in places where there's not easy access to high-quality MR. I think a urologist that's well-trained on this is going to do a much better job than a, let's say marginal quality or mid-quality community radiology center where they're doing mammograms in the morning and a couple of prostates a week in the afternoon.
There's a lot of validation work that has to be done. It is a learning curve to be sure.
[Dr. Aditya Bagrodia]:
Yes, we have it here as well. It's just right there next to our Uronav and, I'll complete my Uronav take a look and see if there's anything that I could've picked up or just trying to educate myself because the modules are great not to digress too far, but starry night, medium smudge, finger link potatoes. I'm like, oh my God, I can convince myself of just about anything. Okay so that does take us into–
[Dr. Matt Cooperberg]:
You do both. You do an ultrasound, you do your Uronav with the standard ultrasound and then do a–
[Dr. Aditya Bagrodia]:
Yes, and I just tell them, I'm going to take one more look, one more look and if there's anything else, I'll just mark it as additional–
[Dr. Matt Cooperberg]:
Uronav biopsy.
[Dr. Aditya Bagrodia]:
Yes, a micro-ultrasound target and then I'll look at that. Okay. We started talking some about the work up here, Matt, you mentioned a confirmatory biopsy. I think it's a foregone conclusion that everybody has an MRI. Are you guys in something that you're maybe thinking that this could be a focal candidate, halo biopsies, penumbra biopsies. Can you walk us through that? Yes.
(4) Addressing Patient Expectations
[Dr. Arvin George]:
I don't know who's going to be a focal candidate before. I don't routinely do that. What I do when I sample a target is I sample across the lesion. Whatever it is, whichever system that you're using, I'm not going to sample if it's Uronav the bullseye over and over again, because I'm just overrepresenting what I already know about. Rather, I'll actually map it across the lesion. Typically every 3 to 5 millimeters, depending on the size of the lesion, both of the anterior posterior and medial lateral directions.
[Dr. Aditya Bagrodia]:
What about you, Matt?
[Dr. Matt Cooperberg]:
I think this is an evolving concept. I think it has a lot of appeal to it. I think our institutional experience has guided us just to be putting wider margins on the lesions in general. I've seen a few studies recently on halo biopsies or a number of biopsies. It makes a lot of sense in terms of planning the size of the lesion. One concept, which I'm not sure how well validated, but it seems to be true is that the higher the grade of the lesion, the more the MR might be under-sampling it.
I don't know that that's a Gestalt developing. I'm not exactly sure that it's true, but I do worry more about under-sampling in higher-grade cancer. For pushing the envelope a little bit, maybe not that they have high-grade disease, but they've got three four with cribriform, they've got a marginal decipher. They've got biology that seems like it actually might become a problem as opposed to we are doing this to reassure the-- drop the patient-specific anxiety levels when we do PSA tests.
If we're worried about real cancer, I am more worried about the margin. I think, and I think this idea of halo biopsy makes a lot of sense.
[Dr. Aditya Bagrodia]:
The genomic classifiers in your hands, you mentioned that earlier, those are going to help deciding treatment, no treatment, if treatment what type still.
[Dr. Matt Cooperberg]:
Nothing decides treatment, okay? If anybody uses the Polaris test out there, I cannot stand this new report. This has, you do active surveillance, you do single modality, multimodality based on any single parameter, basically the genomic test. The genomic test is another piece of information that I think of as a tiebreaker or a decision helper. Somebody that has a high risk to cipher and I'm thinking, really high. In other words, the other 0.8 0.9 is not necessarily just into the red zone over 0.6. We just worry that this is one that's got the biological capacity to cause problems.
It doesn't mean they're likely to be metastatic, it doesn't mean, that they cannot do focal therapy, but I worry more about the background's genetic substrate in that prostate, how likely it is to grow another bad one in the relatively near future and what are the odds that we're missing something worse? I mentioned our focal cryo experience before we started doing, new generation HIFU and out of the 100 odd cases that were collected, I think we had three metastatic cases.
One was a patient of mine who had what looked like a perfect shot focal therapy tumor 3 + 4 MR visible, exactly what we were describing earlier. There's only two risk factors. Number one, he was himself a surgeon, which of course predicted something bad happening, and the other was he had an archetype score of 15. This was the very early days where we were doing genomic testing and an archetype of 50, in retrospect is not only high risk, it's really high.
This gentleman, got focal cryo, had negative lesion-directed biopsies a year later and then had metastatic disease four years after that. Now would surgery have made a difference? Probably not. He was probably micrometastatic already at the time of treatment, but it doesn't feel very good. It feels like undertreatment. I think it's a good example of one where when the biology is revved up in prostate cancer, it's got this capacity of getting out at the microscopic level very early, even though it's a slow-growing tumor, it can be an early metastasizing tumor, which makes it so tricky.
Figuring out which those are is really critical. That's where the genomics can help. They do not tell us what to do, but they help with these decisions.
[Dr. Arvin George]:
That also doesn't tell you that surgery would be better in that setting.
[Dr. Matt Cooperberg]:
No, that's what I said. No, I don't know that surgery would have made any difference or radiation. The only thing I would say for surgery or radiation is that we would've gotten lymph nodes either removed or radiated, which maybe when you catch the five cells in a node on the way to the button. Who knows? This is all hypothetical. Like I said, it feels like a [inaudible 00:28:06] mission retrospectively and it's rare. These are very uncommon.
[Dr. Aditya Bagrodia]:
There's some retrospective data out there that patients that have had previous bladder outlet procedures and subsequently go onto receive a diagnosis of prostate cancer, they may have worse outcomes, and this idea if you've got a prime prostate, do something that induces an inflammatory-- I mean, this is all super hypothetical, but I can see that mentality.
I mentioned this earlier and patients insisting on focal, not kind of this narrow candidate and then they'll very reasonably say, well, if you do the focal, and it doesn't work, no harm no foul. You're just to go back in and do something standard and I'm okay with that. How do you respond to that or how do you even just deal with that whole scenario? Let's just say a 56-year-old grade group for disease 4 + 4 = 8. Not 12 out of 12 cores, but two cores, one side and they're just like, "Doc, do the focal."
[Dr. Arvin George]:
I think it's like what I said before. We have a responsibility to protect patients from themselves. At the end of the day, we do have a degree of knowledge in terms of the outcomes of different treatments. There has to be some dividing line in which we put our boundaries and we simply refuse treatment. If the patient said, "I hate my left arm doc. It's driving me nuts." Are you going to take that arm off? You're not because that's not in the patient's best interest.
I tell patients that there will be somebody out there who will treat you. I said, that's not going to be me. These are the treatments that I think are going to be best for you because I think it's in your own best interest. If you were my own family member, if you were my own father, uncle, brother, whatever it is, this is what I would recommend to you. I think that in those cases, I think, it gives them some perspective and that this is my genuine opinion, that it's in their best interest.
[Dr. Matt Cooperberg]:
I thought you were going to go to the other end of the spectrum, the high-risk. I totally agree with Arvin on the low-risk patients. I think it's gotten easier over the years. It used to be this 45-minute conversation pulling somebody back from the cliff when they've got the C-word diagnosis. I think these days, most patients are familiar with the concept although I just had a patient in clinic yesterday whose local doc had set him-- setting him up for brachytherapy, had already given him ADT for a Gleason 3 + 3, which is just fine.
This is not even the hinterlands of California. It's still out there. I find it's easier than it used to be. A big part of our job is to pull them back from that cliff. I'm in this growing minority of folks that think we shouldn't even call the 3 + 3s cancer because patients still get led down this primrose path to things that they do not need to undergo. Again, I thought you were talking about the other end. What about the guy with a Gleason 8 who's insisting on–
[Dr. Aditya Bagrodia]:
Let's talk about the high-risk end because I actually think I see more high-risk patients that are like, "Do a focal treatment on me."
[Dr. Arvin George]:
I would apply that to both ends of the spectrum. I don't think it's unique to low-risk. I have patients who come and they're like, "Yes, Gleason, I'd rather, then I'm not going to do anything at all." Then I'm like, that's up to you. That's not going to force my hand in terms of offering it. Now, we all bend our rules in some cases. I'll have some, PI-RADS 5, only Gleason 6, but it doesn't make sense. PSA is, 8.
This patient has a strong family history and you're like, there's a Cobb pattern 4 in there and the patient's really worried about it. If I'm going to offer a prostatectomy or radiation in that setting, I think I have a reasonable argument to offer focal.
[Dr. Matt Cooperberg]:
It is an important point that there are exceptions to every rule. The PI-RADS 5 or the Gleason 6, especially somebody very young with a strong family history, you know if you're going to do another biopsy, you're going to find something. It's small, you can do focal, you're not burning bridges, and the guy is really on board with the ongoing surveillance, sure. 82-year-old with a small Gleason 8, MR visible, everything else negative, sure, accepting some risks.
There's going to be exceptions, but the point is they should be uncommon. We all know the folks that are offering focal to absolutely everybody, or radiation to absolutely everybody, or surgery. Any of these treatments can be abused.
[Dr. Aditya Bagrodia]:
Totally. I wholeheartedly agree with everything you guys said. I have nothing further to add other than just picking your brains on the post-focal prostate. Any experience, comments, issues, problems.
(5) Genomic Considerations in Focal Therapy
[Dr. Matt Cooperberg]:
I've done salvage prostatectomies after brachy, protons, IMRT, prostatectomy once, that was interesting and a number after. That's a different story, maybe for a different day. A growing number after focal therapy. I think it's a truism that it is easier after focal than after radiation therapy in general. I think it's also true that the fibrotic reactions can be very hard to predict after any of these modalities.
I've done more post-radiation than post-focal so far. Radiation, sometimes you go in and it seems like they forgot to turn the machine on, or they put expired palladium seeds in there. Other times it's like a bomb went off and there are no planes. Focal, likewise, you think you can make some assumptions based on how much of the gland was ablated, maybe based on the energy source, that sort of thing.
Sometimes the fibrosis is minimal, sometimes it's terrible. Generally speaking, it seems to be easier after ablative therapy, especially when it is hemi or less than with whole gland radiation therapy but that is a generalization. I think the data that are out there would support that outcomes are better with post-focal therapy surgery than with post-radiation surgery. Of course, radiation is still on the menu too, for patients that recur or progress after focal and I think there are a few issues there.
[Dr. Aditya Bagrodia]:
All right. Arvin, what do you think?
[Dr. Arvin George]:
I've done a handful, maybe about 10 to 15 cases post ablation, either laser ablation, antiparticle laser ablation, HIFU cryo. I would say in general, I think cryo probably has the most desmoplastic reaction post-ablation. I think that these cases are feasible. Actually, the cases that I've done, they have been deceptively less complex than I anticipated.
I was really dreading doing-- and maybe it's just the expectation that you set for the case, but you did the focal and you're responsible now. I'm not going to go send it to my partner and be like, hey guy, do you mind? Take another now? No, I'm going to take care-- This is my patient. I'm going to take care of this patient. And so you're really dreading this case, and then you go in and you're like, this is not that bad.
Then you can get too close to the prostate. My advice to anybody doing post-focal cases is that your local stage of that MRI post-ablation is not going to be great. You can run the risk of having extensive positive surgical margins, bladder neck invasion. When I do, and I corrected this through my anecdotal experience, but I go wide on the ipsilateral side of the prior ablation. If I can now spare on the contralateral side, I will.
I do not do bladder neck sparing of these patients anymore even if it's a-- unless it was an apical tumor and I can see clearly the bladder neck. I'm very cautious about being aggressive in the resection now.
[Dr. Matt Cooperberg]:
I agree. The MR is-- MR in general, I don't think is all that reliable post-ablation. I think it's an important point because there are cohorts out there that are using MR and MR alone to follow these patients without a subsequent biopsies, which is probably not yet a safe thing to do. That applies to exactly the situation we're talking about here. I have still done bladder neck sparing, I will say, but we use fairly liberal-- we make use of frozen sections fairly liberally in a person [unintelligible 00:35:49].
I would also say case selection is important. There was-- and I agree about the cryotherapy being probably the most fibrotic. We had one a few years ago now who had bilateral cryoablation, recurrence by MR, and one of my colleagues went in to do a biopsy and the biopsy needle was bending trying to get into the prostate, which tells you something about fibrosis and that patient never made it into anybody's OR for fear that a piece of rectum would come out with the prostate, I think.
[Dr. Aditya Bagrodia]:
Again, I think that captures it. I think some of the early HIFU technologies could be a little bit offensive too, but they've really improved, in my opinion. All right. I've glossed over it. First counseling, and maybe I'll just throw out my focal spiel at the high level. Recurrences in 20, 30% of patients in five years is the numbers I have in my head. Generally, we're obviously doing this for really prioritizing sexual function, preservation, urinary function wise, the first six, eight weeks, maybe a little bit rough. This is obviously very broad, but we don't expect to see the stressing constants or frequency urgency that are associated with surgery and radiation respectively. Does this sound about okay?
[Dr. Arvin George]:
Yes, that's about right. I do talk to them as well about-- I'm very clear and explicit at the beginning. I say, this is not a standard of care treatment option. I say, this is not a guideline concordant option. I tell them why. I say, we don't have long-term or comparative data to prove it's long-term data. The information that I can tell you is within these limitations. Then it's pretty close to what you say.
I also do talk to them about salvage afterwards, about what radiation would look like, what surgery would look like. I think that's really important and that I do also will plug their numbers into the Memorial Sloan Kettering Enogram or whatever it is and say, this is your risk of progression in five years if you had prostatectomy. Oftentimes, I surprise myself in that it may not be as far off as we think from focal treatments.
(6) Post-Focal Therapy Management
[Dr. Aditya Bagrodia]:
All right. Let's talk a little bit about modalities here. This is an ever-expanding list. Let's be honest, indication learning expand is big business, all that. Focal cryo back when we were youngsters, now there's a whole host of things. How do you think about this thermal, non-thermal, or maybe just run through the list. I think there's seven or eight that I can just fire off the top of my head.
Then we can run through a little bit of advantages, disadvantages of some of these. Maybe also a hypothetical. Actually, I'm curious, which all ones, which one do you have at your institutions? If you were starting today and you had to make a choice, which one would you go with?
[Dr. Matt Cooperberg]:
As I said, we're still doing very occasional focal cryo. We're doing a lot of focal HIFU, with the focal one, and Katsunori Shinohara and Howard Nguyen have really led that drive. We're starting to do IRE at UC and the Tulsa folks have been around, but we have not yet done any cases. That's our current menu. We've played with other things over the years. That's the current menu.
[Dr. Aditya Bagrodia]:
Oh, yes. One thing I forgot to mention during the workup is I really try to document in my biopsies if they have calcifications or not, which obviously can impact things for HIFU.
[Dr. Arvin George]:
I usually do a quick cine loop actually of the ultrasound because it gets archived into our packs because I'm not going to remember what it looked like. I do also have my own syntax in terms of like what I type in, rare calcifications, extensive, none. You know what that's going to look like, but that's really important because you don't want to have to go back.
[Dr. Aditya Bagrodia]:
Pelvic CTs, real quick.
[Dr. Arvin George]:
For Tulsa, you may need it, I think. We don't. What we have available to us is we have irreversible electroporation or IRE. That's also known as the nano knife. We have water vapor ablation on the VAPOR2 clinical trial, which is, for those who don't know, it's like the Resume technology. Yes, water vapor thermotherapy that has been redesigned to be able to reach the peripheral zone and treat cancer under image guidance.
We have high-intensity focus ultrasound or HIFU, of course, and cryoablation as well. I've previously used adipotico-directed laser ablation, focal laser ablation in the past.
[Dr. Aditya Bagrodia]:
I'll just throw this out. Calcifications, your ultrasound-based technology has become a little, the HIFU, Tulsa, a little less feasible, broad strokes here, anterior lesions. Anyone that you think may perform a little bit better?
[Dr. Arvin George]:
I'm not a huge fan for HIFU for anterior lesions only because one, I have the opportunity to-- with other technologies that I think that can overcome any of the potential limitations. The more tissue that the HIFU beam has to travel through, the more energy attenuation you're going to get. That's not to say that you can't get really good treatment. I've done heavy ablations in the salvage setting and then sometimes it's completely gone, that side.
It can treat anteriorly, but I think it's-- I have had some patients early on in the experience where I had anterior persistent disease and I transitioned to cryo for those IRE or any of these percutaneous procedures, even Tulsa now, because this transurethral can reach anteriorly.
[Dr. Aditya Bagrodia]:
I actually, confession, one of my early days, didn't realize that you couldn't skip the posterior part of the prostate with HIFU and just get anterior. I had a nice, perfect candidate just having to be anterior midline. We were able to do some gymnastics with the urethra back and forth but anterior midline is not going to be a good HIFU option. I think Tulsas maybe a little bit more attractive.
[Dr. Matt Cooperberg]:
For completeness of this whole discussion, by the way, we should acknowledge that focal radiation therapy is out there in the literature as well. Our radiation oncologists have done some of it. I wouldn't say we do a lot, but for that situation, focal SBRT is not other focal brachytherapy is on the list. Our crew have, like I said, have done a number of them. I actually don't know the numbers off the top of my head, but for lesions that are tough to get to with energy-directed treatments, and there's a major push to avoid radical therapy, it's on the menu too.
[Dr. Aditya Bagrodia]:
It's like you're in my head, Matt, the next one after the standard focal is focal radiation question mark. We'll absolutely talk about that and maybe flame a bit. Okay. The apex, nobody likes the apex. I don't like the apex. Is that an extended spectrum ablation candidate? Don't like it. If you're going to do it, go with X, Y, or Z.
[Dr. Arvin George]:
Apex is a challenge, not just for focal therapy, but for everything. We struggle with apical positive surgical patterns. There's a lot of things converging at that point in the apex, you have external sphincter, you have a weird shape of the apex that can be variable, you have your urethra right there, you have your neurovascular bundles coming close to the area.
There's a lot of things going on and you don't have too much give. I do think that there's a real opportunity for focal radiation in this bit. Dosimetry, I always say, dosimetry is a science. There are people who their entire careers are dedicated to dosimetry. They understand where to place lethal doses of radiation very precisely, really well. I think that in the future that will grow as it gains acceptance and there is more data that's generated within radiation oncology as well to show whether or not it can be effective.
For apex, I lean towards HIFU because the focal volumes that have been treated are much smaller. You can actually craft it to the prostate, the actual true shape of the prostate and capsule much better, but I do think that technologies like the vapor technology that really fills a space and is limited by capsule and anatomic boundaries will have a significant advantage in that space because you cannot force the vapor outside the capsule and it will fill it all the way down to the distal apex in theory.
We'll see whether or not that is true, but that's the way the technology is supposed to work.
[Dr. Aditya Bagrodia]:
TBD.
[Dr. Matt Cooperberg]:
I think the other thing that really comes into play again is baseline QOL in cases like that. Patients that already have a lot of obstruction once we start getting high doses of anything close to the urethra, I worry about the long-term retention risk. Also, I worry more, we talked about salvage treatment, I worry more about the prospect of salvage for somebody that has had significant work done next to the sphincter because when we talk about salvage prostatectomy versus a de novo prostatectomy, that's where the biggest delta is.
I think this is much more for post-radiation than post-focal therapy. It really is the continence outcomes. We-- I should find some wood to bang on here. I have not had a lot of rectal problems even in the post-radiation setting, but continence recovery, we can look people in the eyes today, most high volume surgeons, I think, and predict good continence recovery for the very large majority of men undergoing prostatectomy, whether it's a week or six months may vary, but they're going to get there.
If they've had prior whole gland treatment, it's a completely different story. I worry a lot. In the post-radiation setting of our continence, and I worry for folks that have had substantial ablation to the apex specifically.
[Dr. Arvin George]:
I 100% agree with that, yes.
[Dr. Aditya Bagrodia]:
I'm not an extended spectrum ablator by any stretch of the imagination. I pretty much tell patients, we're going to expose you to the risks of whole gland treatment without the benefits of whole gland treatment. Yes, we have Tulsa.
[Dr. Arvin George]:
What benefits of whole gland treatment? No, I'm just kidding.
[Dr. Aditya Bagrodia]:
Arvin and I are debating at the Indian AUA in San Antonio, so he's just getting. I'm in the con position. He's just getting his chip shots in. We have Tulsa, which is, I think, nice for anterior lesions. Of course, there are size limitations. When you get super peripheral, you may be a little bit limited. We have HIFU, which I think is nice for posterior lesions.
Cryo has largely gone to the salvage setting. One of my partners who got a lot of interest in this is bringing on IRE. I struggle a little bit. Do we pick one and get really good at it? Do we have a few that are going to be patient-specific? What do you guys think? Do you need a couple of tools in the toolkit or get one and keep that knife sharp?
[Dr. Arvin George]:
I don't think you can have just one. I think that, HIFU, if it's a really, anterior tumor-- If you're going to offer it to the full spectrum of patients, then one technology is going to be limiting because there are-- it's not just lesion, location, and volume, but there are other things like if you have a periurethral tumor, then maybe IRE is the best treatment because you have an athermal-- largely athermal, I'll say, ablative modality that is not going to succumb to a thermal sink from a warming catheter or something like that.
I think that there's no one-size-fits-all. There's also no perfect combination. I use actually-- you said it is gone to the wayside for you. I use Cryo as really like a workhorse as a treatment and get really good outcomes with it.
[Dr. Matt Cooperberg]:
I think being good at what you do is more important than being able to offer some modality to every patient that walks in the door personally. There's obviously a small number of centers that are really focused on this and have six options and they'll buy whatever is the latest and greatest. I think there's a place for that setup, but it also lends itself to treating the types of patients we were talking earlier about, who really should not be treated.
Inevitably, there's going to be some over-treatment and under-treatment and you get into selling modalities rather than selling good oncologic care. We worry a little bit about even the perception.
[Dr. Aditya Bagrodia]:
Yes, I think I appreciate both of those points. Absolutely. I think for people that really have a deep interest in this and can appreciate some of the nuances- location, size, et cetera, and have enough of a volume, maybe they've become a referral center, then having some different tools makes sense.
[Dr. Matt Cooperberg]:
For somebody who's contemplating getting into the space, if you're going to invest, I would say invest in imaging. Focal therapy-- the variation across these modalities that we're discussing, they're there, but they're reasonably subtle. We have a lot of different ways of destroying prostate tissue if we know what we're treating. That if is a big one and one thing we have not talked about, I think it's critical that the urologists who are doing focal have learned to read both the ultrasound and the MR themselves, that they've got a good working relationship with a high volume prostate focused radiologist, and that imaging piece is extremely rock solid before getting into image-based treatment.
That sounds obvious but when you look at the variability in even PI-RADS assignments around the country, and even within institutions, we have a long way to go in terms of standardizing imaging.
[Dr. Aditya Bagrodia]:
I actually think that one of the nice things about Tulsa, for instance, which is a bit unique as it stands today, is in-bore procedure, you've got your real-time sequences. There's no contouring, mis-contouring, registering, cognitive this, that, and the other. It's, there's your lesion. Every five seconds, you're getting a diagnostic quality MRI, and you get a little bit of comfort.
If you get an ADCC gland, let's call it a centimeter peripheral lesion in the mid-gland, you're really putting a lot of faith and confidence in your contouring, and in your co-registering, if you're going to do something true focal, for instance. None of us wants a swing and a miss. In a biopsy, okay, you can go back in and sort it out but treatment, it just seems extra nefarious. Maybe I'll just pause there to hear your thoughts on that. Or ablate the whole half of the gland and just say, you know what? Let's just put this one to rest.
[Dr. Arvin George]:
Yes, you described a little bit about my evolution of learning and focal treatment in that initially, I was super conservative and then I started to see some great outcomes and got a little bit more aggressive and tight with the margin, but I started to see recurrences and now, I will try to achieve the largest margin I can without resulting in any functional deficit. In an 80-gram gland, I have much more liberal margin to go towards the apex and go towards the base if it's a mid-gland lesion and if it's one and a half, two centimeters, that's great.
Especially if I'm doing cryo, it really doesn't add-- adds three minutes to my case. It's really not going to do anything. It's not going to result in any greater risk of incontinence or sexual dysfunction and I've gotten a wider margin with the potential for a better cancer outcome because largely your recurrences or persistent disease will be at the margin.
[Dr. Aditya Bagrodia]:
I was hoping that we could walk through the procedure and I just don't think that's going to be feasible because there's all kinds of considerations, regimens, and so on but I did want to touch base on follow-up. This has come up a couple of times and well, I don't want to put any notions out there. What is your typical follow-up regimen? Garden variety, of course, it's going to be nuance, age, patient-specific disease characteristics, but something standard, here's what you can expect.
(7) Comparing Focal Therapy Modalities: Advantages, Challenges & Practical Considerations
[Dr. Matt Cooperberg]:
We typically follow the PSA every three to four months for the first year. We do an MRI at six months and an MRI with a biopsy at one year, pretty much no matter what the MR looks like. Then beyond that, they shift back into an active surveillance-type mode. We do follow the PSA. We'll follow with MR after that. If the biopsy was negative at a year and the MR stays stable, we're probably not going to do any more programmed biopsies, assuming the PSA is relatively stable.
There is no good PSA definition of recurrence here, despite all these attempts in the literature to use the Phoenix definition, which is meant for radiation therapy, there's this Heidelberg definition. Given how variable that term focal is, as we talked about at the beginning, there's no way to use PSA consistently across all these different patients as an indicator of outcomes.
It's not safe on its own. I would argue neither is MR today. Maybe at some point, MR plus PSMA or next-generation MR with better AI, better experience with reading MR after focal therapy, we may get there but the biopsy to me is critical.
[Dr. Aditya Bagrodia]:
What do you think, Arvin?
[Dr. Arvin George]:
I actually have a question for Matt. Matt, what do you do in those patients with whom you have untreated Gleason 6, maybe on the contralateral side? You said you do allow for that. Now, do you feel compelled to do a protocol biopsy there with all other things being stable in those patients on surveillance?
[Dr. Aditya Bagrodia]:
No, because Matt doesn't think they have cancer so he doesn't need to do anything about that.
[Dr. Matt Cooperberg]:
All right. Since you're poking that bear, I'll take the bait there, which is to say that even if we don't call it cancer, we absolutely still have to follow it. Even those of us that are very pro in this rename it debate would say active surveillance does not change. You call it something other than cancer, it still absolutely needs active surveillance but that's surveillance we're starting to tailor. The UK, they don't even do biopsies on active surveillance. They're following it entirely with MRI, which I'm not sure we're there yet.
The more follow-up you have on the tumor or in a given lesion, the better we feel about the imaging. We had a study out a couple of years ago from Karissa Chu, who's just rejoined us as faculty, looking at exactly this question of what's the NPV for MRI for not missing high-grade disease. At the confirmatory biopsy, so they've had a diagnostic, now they come to us for the confirmatory, it's not that great.
MR missed about 25% of upgrading events so it's even higher if the PSA density is high. On the other hand, once you've had the confirmatory, the downstream biopsies, biopsies 3, 4, 5, and on down the road, the NPV is much higher, and if the PSA density is low, it's over 90%. For following that 3, 3 that we're intentionally not treating on the other side, they get the biopsy of the year.
If that biopsy shows that the lesion has been effectively ablated, and we just find the same scraps of 3, 3 on the other side that we found before, we're going to follow that primarily with imaging. The protocol biopsies, we're trying to do less and less of. Every once in a while these days, I'm seeing somebody who's six, eight years since their last biopsy, and I say, well, I feel like we should do a biopsy because it's been so long.
If the imaging is stable and the PSA has been stable, invariably we find nothing, or we find a little 3, 3 again. I'm getting more and more comfortable using imaging alone for these ones that have already declared themselves to be stable.
[Dr. Aditya Bagrodia]:
I think this is an area that's really exciting and ripe for further exploration. PSMA PET, it's popped up a couple of times. how nice would it be if you have something that's PSMA PET positive and then it goes cold? Some of the secondary cancer screening biomarkers, you can get a pre-ablation and a post-ablation if they seroconvert or uroconvert or exosome convert to negative, maybe feel good about it.
I do think that this is going to be a bit of a shared decision-making, like surveillance. I really had an aha moment on a previous podcast with Arvin, Minaj, and Kara about, really tailoring active surveillance for shared decision-making. I think we may head there and this isn't like a cop-out to never have to do a biopsy or something like that but if it's the genomic classifier, the PSMA PET, some other test that may decrease the pretest probability of finding anything meaningful, if we could safely avoid biopsies, why not?
I think we've covered a lot. The practical execution, maybe we'll save that for another day, but I would love to just maybe wrap up with some parting thoughts. Arvin, perhaps we can start with you, and then Matt, get some from your end. We'll be respectful of the time differences here, start from east to west.
(8)Future Directions in Focal Therapy for Prostate Cancer
[Dr. Arvin George]:
First, I'd like to thank you, Aditya, again, for the opportunity to be here. It's always fun to talk these things out and have other people hear our perspective on things. As final thoughts, I'd say that there is a huge promise for focal therapy, but I think that now that we are studying it much more closely, that we're seeing value in it as a potential option that will help guide us do it in the right patients.
I think that we can come dangerously close to being our own worst enemies and try to look for the short-term gain, which can ultimately really harm a treatment option that could have some real viability. The future is bright and I think it's really promising, and I think the indications will continue to expand, and I'm looking forward to the future.
[Dr. Aditya Bagrodia]:
I love that. What do you think, Matt?
[Dr. Matt Cooperberg]:
There's this old saying that in surgical oncology, biology is king, and all the surgeons, and here you can throw in radiation oncologists and focal therapists and everybody else are the princess trying to overthrow the king, often to no avail. I think ultimately, it comes down to understanding the cancer more and more at the biological level. I think that the role for focal therapy is clearly going to grow as we can identify those tumors that are actually confined to the prostate, and we can visualize them with imaging, increasingly with functional imaging, as our focal modalities get more and more guided by real-time feedback from imaging.
Clearly, it makes sense. You look at the history, everyone always draws the analogy to breast cancer and lumpectomy, taking over from mastectomy. Obviously, there's a lot of different considerations in prostate compared to breast but nonetheless, the idea of treating the tumor rather than the prostate makes a lot of sense for a certain band of cancers. As we're able to identify that band, figure out the ones that need treatment and yet need less than total treatment and pelvic treatment, as we can identify those and target them, of course, the role here will continue to grow.
The only way we're going to identify those tumors is to take this seriously, to as we've said at the beginning, put patients that are undergoing focal therapy in a registry, on a trial, collect the data, be honest about our outcomes, and constantly be striving to improve those outcomes with research and improvements in our treatments.
[Dr. Aditya Bagrodia]:
Perfect. I think the things that jumped out to me are, this is something that you can acquire as a part of your armamentarium and skillset, even if you weren't trained on it. There's a lot of, I think, amazing people out there. We had Hal come down here and proctor us for some of our first FocalOne cases, which is tremendous. In the same breath, it is incumbent upon us to be thoughtful, to develop expertise, identify the patient, the cancer, the imaging specific features that are going to really help us identify and help the right patients and make sure we're not hurting anybody along the way.
Arvin, Matt, it's been great. Thank you so much for your time. We look forward to seeing you in San Antonio, if not before. Arvin, gloves up. Let's see what we get.
[Dr. Arvin George]:
I'm ready for you.
[Dr. Aditya Bagrodia]:
Thank you so much for listening. If you haven't already, make sure to subscribe, rate the podcast Five Stars, and share with a friend.
Podcast Contributors
Dr. Matthew Cooperberg
Dr. Matthew Cooperberg is a professor at UCSF in San Francisco, California.
Dr. Arvin George
Dr. Arvin George is an associate professor of urology at the University of Michigan in Ann Arbor.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2024, May 28). Ep. 169 – Prostate Cancer: Navigating Focal Therapy Options [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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