November 24, 2024 • 27 mins
CredentialsPositions
Board Certifications
Education and Training
- Professor, Department of Biochemistry and Molecular Pharmacology at NYU Grossman School of Medicine
- Professor, Department of Urology at NYU Grossman School of Medicine
- Martin Spatz Chair, Department of Urology
- Chief, Urology
Board Certifications
- American Board of Urology - Urology, 1987
Education and Training
- Residency, Johns Hopkins Hospital, 1985
- Residency, Johns Hopkins Hospital, 1981
- MD from Johns Hopkins University, 1979
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
The following is a paid podcast. iHeartRadio's hosting of this
podcast constitutes neither an endorsement of the products offered or
the ideas expressed.
Speaker 2 (00:09):
The following program is brought to you by NYU Land
Going Health. It's Kats's Corner with doctor Aaron Katz. You're
trusted expert in men's health, providing straight talk on a
wide range of men's health topics and advice on how
to live your healthiest life. Now on seventy ten WOOR.
It's the Chairman of Urology at NYU Land Gone Hospital,
(00:32):
Long Island. Here is doctor Aaron Katz.
Speaker 3 (00:36):
Good morning everyone, and welcome again a Katz's Corner here
on war. I'm so glad you could join us here
in this very kind of ball me in November so far.
We have a wonderful show for you today and if
you've been listening to the show, we've talked in the
past about different types of treatments for prosty cancer, and
we've touched in the past as well on focal therapy
(01:00):
and this is certainly an area of emerging treatments and
something that is applicable to many men who have early
localized prostate cancer. To help in the discussion this morning,
I've asked a wonderful colleague and a dear friend of mine,
doctor Herb Lapour, who runs and is the chairman and
Professor of Urology at the NYU Lango and Health System
(01:23):
in the city and also in Brooklyn. He has been
a champion of vocal therapy and has also done lots
and lots of thousands actually of radical prostatectomies in the past,
and has recently switched his own practice I believe, over
to choosing vocal therapy for many men, not all men,
(01:43):
but for many men. He trained under the great doctor
Patrick Walsh of Johns Hopkins and was really instrumental in
bringing the nerves sparing radical prostatectomy to the forefront. And
now years later, as time goes on and things change,
we have new emerging technique for the detection of prostate
cancer using MRIs, and we're going to get into all
(02:04):
of that with my good friend Herbert Lapour. Thank you
for coming on the show this morning. Her really appreciate
it and look forward to our conversation. Thank you.
Speaker 4 (02:12):
Yeah, now listen erin pleasure, pleasure to join you. I
feel that you're my professional brother and a good friend.
And then again this is a feel you yourself have
made tremendous contributions as well well.
Speaker 3 (02:28):
Thank you, and you know in your practice over the
last years and especially at NYU, we have been using
the PSA as our standard screening test, but now we're
using MRI and imaging, and perhaps you can give us
your thoughts on how this has changed the landscape for
the screening and detection of prostate cancer.
Speaker 4 (02:48):
So you know as well as I that we both
sort of grew up in urology before we had MRI
and we had PSA, and it's a great screening tool,
but it's limited because it's specific and not prostate cancer specific.
So you had an elevated PSA. The next thing was
to do a biopsy, and at that time we only
(03:09):
had ultrasound, and the ultrasound didn't really tell us if
there was a cancer where it was most likely to
reside in the prospect. So what we did was sort
of a random biopsy of the gland, and really one
of three things would have occurred. One the patient had
a potentially life threatening cancer, we detected it, We treated
(03:31):
them with a radical protect your radiation and saved a
life two, we may have totally missed a lethal cancer
in the prostate by this random process. Or a third
we found these very low risk cancers, and I myself
as guilty as the rest of our specialty is. We
treated those cancers because you know, half of the time
(03:54):
there was a more aggressive cancer within the gland. So
that was sort of the state of the art. And
I'd say about fifteen or so years ago along came
MRI and multi parametric MRI. We won't get into the
weeds on that, but unlike ULTRASUND, this said, hey, you know,
if there is a prostate cancer in the glen, here's
(04:16):
where it is most likely to reside. And the radiologists
would give sort of a scoring system of pirads, and
it went from one, hey we don't see anything that
said all irregular, to hey, you know there's something that's
a little bit a shadow that, Hey, it's unlikely to
be cancer. Then there'd be a three. Hey you know,
(04:37):
if you biopsy that, it's about a twenty thirty percent.
That was equivocal. Now you started getting into a four.
The report would say clinically significant cancer likely. That was
about sixty percent likelihood of the biopscene and detecting a
significant cancer. It was a five. It was almost one
hundred percent. So, as you had mentioned, when we didn't
(04:59):
know the cancer was but we knew there was a
cancer in the prostate, we ended up taking out the
whole procetate. And like I said, I was very much
fortunate to be at the right place at the right
time at Hopkins when I trained and Pat Wallshoe was
my mentor and probably the most preeminent urologist in America.
(05:19):
He said, you know, when we do this surgery, almost
all men lose their erections. So I think it has
to do with the nerves controlling the erection. They must
get injured when the nerves course to the prostate. And
so he told me, you are going to help me
figure this out, which I dutifully did. And nerves that
do control the erections that come very close to the
(05:42):
prostate or microscopic and they were injured. So along comes
the nerve sparing a radical prosetectomy. Now, look, this didn't
solve all the problems, but at least there was a
possibility to preserve a rectile function after a radical prosetectomy.
But we still had issues with incontinence. But this really
(06:02):
was a big step forward. So now if you think
about other cancers, right a colon cancer, you don't take
out the entire colon, you take out the peace of
the colon. Breast cancer really started this whole paradigm of
organ sparing treatment for cancer. You just removed the lump
and did the radiation, and the same thing we have
(06:23):
now today with the kidney cancer. So, really what happened
with the MRI once we sort of knew where the
cancer was, how aggressive that cancer was, it really set
the stage to sort of consider focal therapy, and that
would be basically either putting a energy source into the
(06:48):
prostate like the cryotherapy, which really you pioneered, or using
high intensity focused ultrasound and you have like a probe
in the erectum and you sort of direct the energy
into the propect with the goal of destroying the cancer
bearing part of the prostate, sparing the rest of the prostate,
(07:09):
and therefore the possibility of controlling the cancer with much
fewer side effects of treatment.
Speaker 3 (07:18):
Yeah, I mean, that's a wonderful explanation. It gives you,
gives all of our listeners a sense of the history
and how amazing things really can change in a relatively
short period of time. You're only talking maybe in medicine
twenty or let's say twenty years where we only had
really radical surgery as you said, or full course radiation therapy. Now,
(07:41):
as you know, in our centered NYU, we have a
much shorter course of radiation therapy that we can use
for whole gland treatment. And we have what you're saying
that the focal ablation where we don't have to treat
the whole prostate. Maybe we have a person that has
a cancer located in one region of the prostate, maybe
on one side of the prostate, and spare the nerves
(08:01):
and spare urinary side effects. And also, as you've well
documented in your publications, have excellent I mean, you report
excellent controls of cancer in the patients that you select.
And we'll get into the maybe we can talk about
it now. So who do you think really is a
HERB a good candidate who has prostate cancer? If you're
(08:25):
listening out there, you've been diagnosed, and you're going to
get your gleas and score. You have your Pyrade score,
you have your PSA, you have your age and quality
of life. So many factors that go into it. How
do you select the patients that you feel because not
everyone right is a good candidate. But if you were
to say, what would be the best candidates, so the
(08:47):
optimal candidates for focal therapy, what would they be?
Speaker 4 (08:50):
So, Aaron, that's a great question, and I think we're
really developing an evidence based answer for that question. I
think the obvious patient would be someone who has the
cancer that still remains potentially life threatening. So I'll give
you two patients that I saw today. So they had
(09:12):
an elevated PSA, they had a Pirat's four, which says, hey,
there's a pretty good chances a cancer. We targeted the
biopsy right into that area and that came back as
an intermediate favorable cancer and only in that area where
the MRI was positive. Now, so let's take focal therapy
out of the discussion for a minute, so that gentleman
(09:35):
would have the option of surveillance, saying, hey, you know,
this cancer isn't eminently lethal, let's just follow it and
see if it if it grows in size. But many
would be very reluctant to offer surveillance for somebody who
already has some aggressive elements, which makes it an intermediate
(09:57):
cancer such as the Gleason score of seven, which would
then sort of qualify for that intermediate category. So now
you sit back and you say, but the other option,
if you're sort of you know, doing the surveillance would
be too little and you're already have the aggressive cancer.
(10:17):
Well how about taking out your prostate or doing the radiation.
But you said, well, wait a second. You know this
cancer isn't throughout the glen. It's pretty localized. So that
patient really has really two really tough choices where I
think many would say that removing the entire prostate that
it's just too many quality of life consequences for what
(10:38):
seems to be a pretty localized cancer versus surveillance. But
you already have significant disease, So what are you really
looking to demonstrate? So both of these guys, I said, look,
we can follow you, but you know you already have
you know, aggressive disease. Now if I do a radical
and listen as you you know, indicate I've done five
(11:01):
thousand of these procedures, and I can say, look, there's
a chance that you will have urinary and continence. Now,
fortunately that's relatively small numbers over time, and there's a
pretty good chance that you're still going to have some
sexual dysfunction. So the other option in what we've been
using is the freezing technology. And again I would say
(11:25):
maybe fifteen years or even longer than that, you really
pioneered the freezing of the gland for sort of an
alternative to removing the whole gland or doing the radiation.
But now we can target this one area. So you
sort of mentioned the data that we've recently published. So
you know, Aaron, when we started doing this, we were
(11:46):
really concerned, you know, who are we really controlling destroying
the cancer in the prostate area, and are we developing
new cancer in the areas that we did intrigue. So again,
remember all of these men when we started out had
intermediate risk cancers, which meant they really should have surgery
(12:07):
or radical surgery or radiation. And we biop see these
guys in ninety seven percent of the time we controlled
the disease. Then at two years we went ahead and
biopsied everybody and in that group we had ninety percent
of the men we had controlled the disease. Now we're
up to five years and this is what we just published.
(12:30):
So remember these are all men who if they didn't,
we didn't have focal therapy, would have done radical prostectomy
or radiation. And at five years, ninety percent of those
patients have not required a surgery or radiation. And of
(12:50):
the ninety percent that didn't, only ten percent did they
develop cancer in other areas and they required another oblation.
So when we look at cancer control at five years,
I have to say it's much better than I thought
we would have when we sort of started doing the
(13:12):
focal therapy about a decade ago. And you know what, Aaron,
what a lot of people forget at that patient that
I'm talking about with intermediate risk prostate cancer has their
prostate removed surgically the radical prosttect me and ten years
there's a twenty percent chance that they can recur this
strait having the prostate removed. And then you say, okay,
(13:34):
so how did we do on the quality of life
side of the equation, because, as you know, whenever we
treat prostate cancer, we're balancing quality of life and cancer control.
In over five hundred cases, Aaron, we have not had
a First of all, it's outpatient. Only one patient in
five hundred did we have to admit we haven't had
(13:57):
believe it or not a readmission after treatment of these
five hundred plus cases, never had incontinence, never had rectal issues,
and we do have some sexual issues, but nowhere to
the extent that you would with surgery and radiation. So
when when surveillance is too little and radical surgery and
(14:20):
radiation is just too much, the focal therapy is a
perfect solution at least for the patient to consider. That
doesn't mean they do it, but I believe that patient
should at least be informed about focal therapy. And I
think it's a cop out if we simply say, oh,
dismiss it because oh it's experimental. It's not experimental. We
(14:44):
have a lot of data to guide those decisions.
Speaker 3 (14:47):
If you just waken up in the morning. Here on
Kats's corner, we're talking with doctor Herb Lapour, the Professor
and Chairman of Urology at the NYU Land go On
Health System in New York at TISH and talking about
focal therapy is clearly if you listen to an expert
in this area. Is published quite extensively, and if you
are interested in seeing doctor Lapour for a consultation, you
(15:08):
can go to the NYU Land Gon Health website for
further information on this and certainly incredibly exciting data. And
I think one of the other things that patients always
ask me and they say, well, you know that to cats,
if we have this focal therapy and it were to return,
(15:28):
do I still have the options, let's say, of if
I needed let's say, if it did come back in
the rear case, could I have radiation, could I have surgery,
or could I have a focal therapy again? And how
do you answer that question?
Speaker 4 (15:43):
Herber?
Speaker 3 (15:44):
I'm sure that comes up quite a bit. Patients are
always want to know, well, your data looks terrific, but
nothing in medicine, as we both know, is ever one
hundred percent, although your data is extraordinarily incredible and with
very high success. But if it did come back and
it was still localized in the state, what do you
feel of the options for these patients.
Speaker 4 (16:04):
Yeah, so listen, that's a great question, and you're spot on.
I think when if there's any reluctance to do the
focal therapy, that's the question that is often the game changer.
So here's the answer. So let's say the prostate cancer
and then half of the time when it recurs. It
(16:25):
recurs out a field which is in a totally different
area from where you ablated initially. You can do a
second oblation without any greater risk as if it was
the primary treatment. You know what, I sorted jokingly say,
It's like whackamo And my daughter who now was senior
(16:46):
Dentil's student at NYU, she could beat anyone on the
boardwalk when she was about eight years old. At whackamole.
She had unbelievable reflect which means, you know, you hit
the target and something else comes up and you whack that.
So if it comes up in a different area, we
can simply re ablate it. Now there are times where
(17:06):
it may be in an area that is really inaccessible
to focal therapy or else. You know, Aaron, the recurrence
was just too fast and too proliferative that you say,
you know what, maybe focal therapy is just not the
right idea. And I believe you, and I we were
on a publication which shows that if you do radiation
(17:32):
after focal therapy, the risks of the radiation are no greater.
Now they say that about surgery, but I don't believe it. Now.
The good news, Aaron, we don't have that many recurrences.
Probably half of them decide to do the radiation. So
(17:53):
I believe that certainly the radical proptectomy after focal therapy
is certainly doable. I think that it is a bit
more challenging. I think the potential for let's say, complication
is greater than it is with them. You know, when
(18:15):
it's done as a primary treatment. But the complications aren't
so problematic that surgery is just not feasible. Now here's
the other thing I'll tell a patient. So let's say
they recur the first time. I say, look, you can
decide between surgery and radiation if it's not amenable to
(18:36):
another focal therapy. But I say, if you do a
second focal therapy, I will not do surgery. If it
recurs after that, I will tell you probably most people,
but not all, will choose the radiation because you know,
it doesn't really the prior focal therapy does not add
(19:01):
to the complications of the of the of the of
the radiation, and the good if you select your patients well,
and again those of us at NYU. You know Jim Weisock,
who shares the database with me. Uh Samir ten Asia,
(19:21):
Uh and doctor Tan. You know, we are cancer surgeons,
so we we're concerned about preserving contents and sexual function.
But when we do focal therapy, we are cancer surgeons
and going after that cancer. And I think that's some
degree why the recurrences are so few, because we select
(19:44):
well and we really treat with the intent to cure.
But we can really achieve very good functional outcomes continence potency,
even when we have we sort of focally but aggressively
a blake that cancer.
Speaker 3 (20:01):
Yeah, you know her about You know, you mentioned these
two patients, and I'm sure that they were really pleased
to hear that they had this option of focal therapy.
But time and time again, patients come in and say,
you know, doctor Katz, I didn't even know that this
focal therapy exists. No one even told me. And so
I wonder, you know, on two fronts, you know, A,
why is that? And B amongst your colleagues, and you've
(20:24):
been in the field for a while, and you mentioned
you've mar at Hopkins, you're at n YU for now,
and you've you know, you speak internationally and nationally and
well recognized, and when you speak now about this approach
focal of focal therapy. How do your colleagues take this?
Is this well accepted me? And it used to be
only with the AUA. I used to think of the
American Neurological Association as the Radical Prostetectomy Association. That was
(20:47):
all that there was. And now and you know, are
you seeing a difference in opinions and from your colleagues
in terms of accepting this type of modality.
Speaker 4 (20:59):
Yeah, I think we are. You know what if you
look at what sort of the hot topics of the
national meeting and you and I actually had the pleasure
together of moderating one of the many sessions on focal therapy.
So you know, you wouldn't have two or three major
sessions if there wasn't interest. You know what I hate
(21:20):
to say, but you know what I think is going
to make be the game changer when you go to
another institution and they don't offer focal therapy, and of
course in New York they come for many second opinions,
and you do. When those surgeons begin to lose patients
(21:41):
to focal therapy, that's when they're going to take it seriously.
And I think that is beginning to happen because you
know what I'll tell you something. You know, one of
the best judges of patients satisfaction. You'll get a kick
out of this. I had a medical student that followed
me as they follow you, and after the day of
(22:01):
seeing about twenty five patients, I said, so to this dear,
what did you observe? I said, doctor, you're a wonderful community here. No no,
I said, look, I'm not looking for a pat on
the back. Tell me it's almost what I'm thinking. Of course,
he did sort of observe it. I said, you saw
three people hug me today. What did I do for them?
(22:22):
Focal therapy? I said, you saw all these guys whose
process I took out? Did you see one of these
guys give me a hust on the way out? And
I'm sure you see that too. Eron. So if that's
an indication of patient satisfaction, I can think of none
none better.
Speaker 3 (22:41):
Yeah, it is certainly very gratifying. And the treatment, as
you mentioned, is outpatient, so there's less hospital exposure. The
risk of infection is exxceedingly low, it's way under one percent.
And it's a cancer treatment and a cure that can
be achieved literally in like an hour. You know, and
(23:02):
if you talk about some of the patients that undergo
radiation and then some of those patients that maybe even
need hormonal therapy, you're talking about sometimes months of therapy
and the effects of hormone therapy, which we both know
by lowering testosterone for men can have a profound effect.
So I think, you know, I just want to congratulate
(23:23):
you on the program that you have there and what
you have established and really setting the state of the art.
You participate as well as I do in the focal
therapy society. Now, do you think that something like this
will help to to filter down and educate not only physicians,
but also to allow patients to understand more about their
(23:45):
options for focal ablation.
Speaker 4 (23:47):
Yeah, I think what's going to happen. You know what
if something makes sense and the data follows, so does
the change in the treatment period. And you know, when
they started doing lumpeck to me right maybe forty fifty
years ago, everyone said, oh, these people are crazy. You know,
you've got to take out the whole breast, you got
(24:09):
to do this huge lymph no dissection, and everyone said, oh,
those people they're just it's quackery. But it made sense
and then if you fast forward, that's the change in
the paradigm. You know, I really do believe that. You know,
now that we're doing MRI, Aaron, we're finding a lot
(24:29):
of these cancers that are localized. And so if it
once did paradigm changed with MRI and targeted biopsy, you
began to say, as we did, isn't you know this
was eroding into my livelihood, which was taking out prostates?
But I said, you know what, when the robot came around,
(24:50):
and that's another conversation, but that trains left the station.
There really hasn't been a legitimate study showing that the
robot really has transformed outcomes or even changed them in
a meaningful way. And I said, the only way we're
gonna sort of change that calculus between you know, quality
(25:12):
of life and cancer control is not by doing a robot.
That's just a sidestep. We got to offer an entirely
different paradigm, you know, which focal therapy at least conceptually
sound reasonable. And ten years later that sort of conceptional
(25:32):
reason or or or optimism I think has been transformed
into data. And one thing is, you know, these patients
must be followed, but so should every patient. After radiation,
you need to be followed. After surgery, you need to
be followed. But I think even more importantly if you
do focal therapy, the intensity of your follow up has
(25:57):
to be a bit greater because we've left a part
of the prostate untreated with. Certainly can develop cancer, although
so far at five years that's a relatively small proportion
of met.
Speaker 3 (26:15):
Yeah, and certainly we can help so many men with
this mode of therapy and prevent them from needing the
aggressive treatment that they may not have needed, as you
well pointed out. And we could probably go on for
several hours, Herb Lapore, but unfortunately that's the end of
the show. I want to thank you so much. If
you've been listening, we've been talking with doctor Herber Lapour.
(26:36):
If you want more information or want to seek a
consultation with doctor Lapour, you certainly can get all of
his information at the NYU lenko On Health System on
a nette. Thank you very much, I really appreciate it.
Have a wonderful day. Tune in every Sunday here on
Kats's Corner. We'll be back next week with the great show.
This is doctor Aaron Katz.
Speaker 2 (26:54):
You've been listening to Katzer's Corner come back every week
to hear more straight talk on a wide range of
men's health topics and advice on how to live your
healthiest life.
Speaker 1 (27:05):
The proceeding was a paid podcast. iHeartRadio's hosting of this
podcast constitutes neither an endorsement of the products offered or
the ideas expressed.
The following is a paid podcast. iHeartRadio's hosting of this
podcast constitutes neither an endorsement of the products offered or
the ideas expressed.
Speaker 2 (00:09):
The following program is brought to you by NYU Land
Going Health. It's Kats's Corner with doctor Aaron Katz. You're
trusted expert in men's health, providing straight talk on a
wide range of men's health topics and advice on how
to live your healthiest life. Now on seventy ten WOOR.
It's the Chairman of Urology at NYU Land Gone Hospital,
(00:32):
Long Island. Here is doctor Aaron Katz.
Speaker 3 (00:36):
Good morning everyone, and welcome again a Katz's Corner here
on war. I'm so glad you could join us here
in this very kind of ball me in November so far.
We have a wonderful show for you today and if
you've been listening to the show, we've talked in the
past about different types of treatments for prosty cancer, and
we've touched in the past as well on focal therapy
(01:00):
and this is certainly an area of emerging treatments and
something that is applicable to many men who have early
localized prostate cancer. To help in the discussion this morning,
I've asked a wonderful colleague and a dear friend of mine,
doctor Herb Lapour, who runs and is the chairman and
Professor of Urology at the NYU Lango and Health System
(01:23):
in the city and also in Brooklyn. He has been
a champion of vocal therapy and has also done lots
and lots of thousands actually of radical prostatectomies in the past,
and has recently switched his own practice I believe, over
to choosing vocal therapy for many men, not all men,
(01:43):
but for many men. He trained under the great doctor
Patrick Walsh of Johns Hopkins and was really instrumental in
bringing the nerves sparing radical prostatectomy to the forefront. And
now years later, as time goes on and things change,
we have new emerging technique for the detection of prostate
cancer using MRIs, and we're going to get into all
(02:04):
of that with my good friend Herbert Lapour. Thank you
for coming on the show this morning. Her really appreciate
it and look forward to our conversation. Thank you.
Speaker 4 (02:12):
Yeah, now listen erin pleasure, pleasure to join you. I
feel that you're my professional brother and a good friend.
And then again this is a feel you yourself have
made tremendous contributions as well well.
Speaker 3 (02:28):
Thank you, and you know in your practice over the
last years and especially at NYU, we have been using
the PSA as our standard screening test, but now we're
using MRI and imaging, and perhaps you can give us
your thoughts on how this has changed the landscape for
the screening and detection of prostate cancer.
Speaker 4 (02:48):
So you know as well as I that we both
sort of grew up in urology before we had MRI
and we had PSA, and it's a great screening tool,
but it's limited because it's specific and not prostate cancer specific.
So you had an elevated PSA. The next thing was
to do a biopsy, and at that time we only
(03:09):
had ultrasound, and the ultrasound didn't really tell us if
there was a cancer where it was most likely to
reside in the prospect. So what we did was sort
of a random biopsy of the gland, and really one
of three things would have occurred. One the patient had
a potentially life threatening cancer, we detected it, We treated
(03:31):
them with a radical protect your radiation and saved a
life two, we may have totally missed a lethal cancer
in the prostate by this random process. Or a third
we found these very low risk cancers, and I myself
as guilty as the rest of our specialty is. We
treated those cancers because you know, half of the time
(03:54):
there was a more aggressive cancer within the gland. So
that was sort of the state of the art. And
I'd say about fifteen or so years ago along came
MRI and multi parametric MRI. We won't get into the
weeds on that, but unlike ULTRASUND, this said, hey, you know,
if there is a prostate cancer in the glen, here's
(04:16):
where it is most likely to reside. And the radiologists
would give sort of a scoring system of pirads, and
it went from one, hey we don't see anything that
said all irregular, to hey, you know there's something that's
a little bit a shadow that, Hey, it's unlikely to
be cancer. Then there'd be a three. Hey you know,
(04:37):
if you biopsy that, it's about a twenty thirty percent.
That was equivocal. Now you started getting into a four.
The report would say clinically significant cancer likely. That was
about sixty percent likelihood of the biopscene and detecting a
significant cancer. It was a five. It was almost one
hundred percent. So, as you had mentioned, when we didn't
(04:59):
know the cancer was but we knew there was a
cancer in the prostate, we ended up taking out the
whole procetate. And like I said, I was very much
fortunate to be at the right place at the right
time at Hopkins when I trained and Pat Wallshoe was
my mentor and probably the most preeminent urologist in America.
(05:19):
He said, you know, when we do this surgery, almost
all men lose their erections. So I think it has
to do with the nerves controlling the erection. They must
get injured when the nerves course to the prostate. And
so he told me, you are going to help me
figure this out, which I dutifully did. And nerves that
do control the erections that come very close to the
(05:42):
prostate or microscopic and they were injured. So along comes
the nerve sparing a radical prosetectomy. Now, look, this didn't
solve all the problems, but at least there was a
possibility to preserve a rectile function after a radical prosetectomy.
But we still had issues with incontinence. But this really
(06:02):
was a big step forward. So now if you think
about other cancers, right a colon cancer, you don't take
out the entire colon, you take out the peace of
the colon. Breast cancer really started this whole paradigm of
organ sparing treatment for cancer. You just removed the lump
and did the radiation, and the same thing we have
(06:23):
now today with the kidney cancer. So, really what happened
with the MRI once we sort of knew where the
cancer was, how aggressive that cancer was, it really set
the stage to sort of consider focal therapy, and that
would be basically either putting a energy source into the
(06:48):
prostate like the cryotherapy, which really you pioneered, or using
high intensity focused ultrasound and you have like a probe
in the erectum and you sort of direct the energy
into the propect with the goal of destroying the cancer
bearing part of the prostate, sparing the rest of the prostate,
(07:09):
and therefore the possibility of controlling the cancer with much
fewer side effects of treatment.
Speaker 3 (07:18):
Yeah, I mean, that's a wonderful explanation. It gives you,
gives all of our listeners a sense of the history
and how amazing things really can change in a relatively
short period of time. You're only talking maybe in medicine
twenty or let's say twenty years where we only had
really radical surgery as you said, or full course radiation therapy. Now,
(07:41):
as you know, in our centered NYU, we have a
much shorter course of radiation therapy that we can use
for whole gland treatment. And we have what you're saying
that the focal ablation where we don't have to treat
the whole prostate. Maybe we have a person that has
a cancer located in one region of the prostate, maybe
on one side of the prostate, and spare the nerves
(08:01):
and spare urinary side effects. And also, as you've well
documented in your publications, have excellent I mean, you report
excellent controls of cancer in the patients that you select.
And we'll get into the maybe we can talk about
it now. So who do you think really is a
HERB a good candidate who has prostate cancer? If you're
(08:25):
listening out there, you've been diagnosed, and you're going to
get your gleas and score. You have your Pyrade score,
you have your PSA, you have your age and quality
of life. So many factors that go into it. How
do you select the patients that you feel because not
everyone right is a good candidate. But if you were
to say, what would be the best candidates, so the
(08:47):
optimal candidates for focal therapy, what would they be?
Speaker 4 (08:50):
So, Aaron, that's a great question, and I think we're
really developing an evidence based answer for that question. I
think the obvious patient would be someone who has the
cancer that still remains potentially life threatening. So I'll give
you two patients that I saw today. So they had
(09:12):
an elevated PSA, they had a Pirat's four, which says, hey,
there's a pretty good chances a cancer. We targeted the
biopsy right into that area and that came back as
an intermediate favorable cancer and only in that area where
the MRI was positive. Now, so let's take focal therapy
out of the discussion for a minute, so that gentleman
(09:35):
would have the option of surveillance, saying, hey, you know,
this cancer isn't eminently lethal, let's just follow it and
see if it if it grows in size. But many
would be very reluctant to offer surveillance for somebody who
already has some aggressive elements, which makes it an intermediate
(09:57):
cancer such as the Gleason score of seven, which would
then sort of qualify for that intermediate category. So now
you sit back and you say, but the other option,
if you're sort of you know, doing the surveillance would
be too little and you're already have the aggressive cancer.
(10:17):
Well how about taking out your prostate or doing the radiation.
But you said, well, wait a second. You know this
cancer isn't throughout the glen. It's pretty localized. So that
patient really has really two really tough choices where I
think many would say that removing the entire prostate that
it's just too many quality of life consequences for what
(10:38):
seems to be a pretty localized cancer versus surveillance. But
you already have significant disease, So what are you really
looking to demonstrate? So both of these guys, I said, look,
we can follow you, but you know you already have
you know, aggressive disease. Now if I do a radical
and listen as you you know, indicate I've done five
(11:01):
thousand of these procedures, and I can say, look, there's
a chance that you will have urinary and continence. Now,
fortunately that's relatively small numbers over time, and there's a
pretty good chance that you're still going to have some
sexual dysfunction. So the other option in what we've been
using is the freezing technology. And again I would say
(11:25):
maybe fifteen years or even longer than that, you really
pioneered the freezing of the gland for sort of an
alternative to removing the whole gland or doing the radiation.
But now we can target this one area. So you
sort of mentioned the data that we've recently published. So
you know, Aaron, when we started doing this, we were
(11:46):
really concerned, you know, who are we really controlling destroying
the cancer in the prostate area, and are we developing
new cancer in the areas that we did intrigue. So again,
remember all of these men when we started out had
intermediate risk cancers, which meant they really should have surgery
(12:07):
or radical surgery or radiation. And we biop see these
guys in ninety seven percent of the time we controlled
the disease. Then at two years we went ahead and
biopsied everybody and in that group we had ninety percent
of the men we had controlled the disease. Now we're
up to five years and this is what we just published.
(12:30):
So remember these are all men who if they didn't,
we didn't have focal therapy, would have done radical prostectomy
or radiation. And at five years, ninety percent of those
patients have not required a surgery or radiation. And of
(12:50):
the ninety percent that didn't, only ten percent did they
develop cancer in other areas and they required another oblation.
So when we look at cancer control at five years,
I have to say it's much better than I thought
we would have when we sort of started doing the
(13:12):
focal therapy about a decade ago. And you know what, Aaron,
what a lot of people forget at that patient that
I'm talking about with intermediate risk prostate cancer has their
prostate removed surgically the radical prosttect me and ten years
there's a twenty percent chance that they can recur this
strait having the prostate removed. And then you say, okay,
(13:34):
so how did we do on the quality of life
side of the equation, because, as you know, whenever we
treat prostate cancer, we're balancing quality of life and cancer control.
In over five hundred cases, Aaron, we have not had
a First of all, it's outpatient. Only one patient in
five hundred did we have to admit we haven't had
(13:57):
believe it or not a readmission after treatment of these
five hundred plus cases, never had incontinence, never had rectal issues,
and we do have some sexual issues, but nowhere to
the extent that you would with surgery and radiation. So
when when surveillance is too little and radical surgery and
(14:20):
radiation is just too much, the focal therapy is a
perfect solution at least for the patient to consider. That
doesn't mean they do it, but I believe that patient
should at least be informed about focal therapy. And I
think it's a cop out if we simply say, oh,
dismiss it because oh it's experimental. It's not experimental. We
(14:44):
have a lot of data to guide those decisions.
Speaker 3 (14:47):
If you just waken up in the morning. Here on
Kats's corner, we're talking with doctor Herb Lapour, the Professor
and Chairman of Urology at the NYU Land go On
Health System in New York at TISH and talking about
focal therapy is clearly if you listen to an expert
in this area. Is published quite extensively, and if you
are interested in seeing doctor Lapour for a consultation, you
(15:08):
can go to the NYU Land Gon Health website for
further information on this and certainly incredibly exciting data. And
I think one of the other things that patients always
ask me and they say, well, you know that to cats,
if we have this focal therapy and it were to return,
(15:28):
do I still have the options, let's say, of if
I needed let's say, if it did come back in
the rear case, could I have radiation, could I have surgery,
or could I have a focal therapy again? And how
do you answer that question?
Speaker 4 (15:43):
Herber?
Speaker 3 (15:44):
I'm sure that comes up quite a bit. Patients are
always want to know, well, your data looks terrific, but
nothing in medicine, as we both know, is ever one
hundred percent, although your data is extraordinarily incredible and with
very high success. But if it did come back and
it was still localized in the state, what do you
feel of the options for these patients.
Speaker 4 (16:04):
Yeah, so listen, that's a great question, and you're spot on.
I think when if there's any reluctance to do the
focal therapy, that's the question that is often the game changer.
So here's the answer. So let's say the prostate cancer
and then half of the time when it recurs. It
(16:25):
recurs out a field which is in a totally different
area from where you ablated initially. You can do a
second oblation without any greater risk as if it was
the primary treatment. You know what, I sorted jokingly say,
It's like whackamo And my daughter who now was senior
(16:46):
Dentil's student at NYU, she could beat anyone on the
boardwalk when she was about eight years old. At whackamole.
She had unbelievable reflect which means, you know, you hit
the target and something else comes up and you whack that.
So if it comes up in a different area, we
can simply re ablate it. Now there are times where
(17:06):
it may be in an area that is really inaccessible
to focal therapy or else. You know, Aaron, the recurrence
was just too fast and too proliferative that you say,
you know what, maybe focal therapy is just not the
right idea. And I believe you, and I we were
on a publication which shows that if you do radiation
(17:32):
after focal therapy, the risks of the radiation are no greater.
Now they say that about surgery, but I don't believe it. Now.
The good news, Aaron, we don't have that many recurrences.
Probably half of them decide to do the radiation. So
(17:53):
I believe that certainly the radical proptectomy after focal therapy
is certainly doable. I think that it is a bit
more challenging. I think the potential for let's say, complication
is greater than it is with them. You know, when
(18:15):
it's done as a primary treatment. But the complications aren't
so problematic that surgery is just not feasible. Now here's
the other thing I'll tell a patient. So let's say
they recur the first time. I say, look, you can
decide between surgery and radiation if it's not amenable to
(18:36):
another focal therapy. But I say, if you do a
second focal therapy, I will not do surgery. If it
recurs after that, I will tell you probably most people,
but not all, will choose the radiation because you know,
it doesn't really the prior focal therapy does not add
(19:01):
to the complications of the of the of the of
the radiation, and the good if you select your patients well,
and again those of us at NYU. You know Jim Weisock,
who shares the database with me. Uh Samir ten Asia,
(19:21):
Uh and doctor Tan. You know, we are cancer surgeons,
so we we're concerned about preserving contents and sexual function.
But when we do focal therapy, we are cancer surgeons
and going after that cancer. And I think that's some
degree why the recurrences are so few, because we select
(19:44):
well and we really treat with the intent to cure.
But we can really achieve very good functional outcomes continence potency,
even when we have we sort of focally but aggressively
a blake that cancer.
Speaker 3 (20:01):
Yeah, you know her about You know, you mentioned these
two patients, and I'm sure that they were really pleased
to hear that they had this option of focal therapy.
But time and time again, patients come in and say,
you know, doctor Katz, I didn't even know that this
focal therapy exists. No one even told me. And so
I wonder, you know, on two fronts, you know, A,
why is that? And B amongst your colleagues, and you've
(20:24):
been in the field for a while, and you mentioned
you've mar at Hopkins, you're at n YU for now,
and you've you know, you speak internationally and nationally and
well recognized, and when you speak now about this approach
focal of focal therapy. How do your colleagues take this?
Is this well accepted me? And it used to be
only with the AUA. I used to think of the
American Neurological Association as the Radical Prostetectomy Association. That was
(20:47):
all that there was. And now and you know, are
you seeing a difference in opinions and from your colleagues
in terms of accepting this type of modality.
Speaker 4 (20:59):
Yeah, I think we are. You know what if you
look at what sort of the hot topics of the
national meeting and you and I actually had the pleasure
together of moderating one of the many sessions on focal therapy.
So you know, you wouldn't have two or three major
sessions if there wasn't interest. You know what I hate
(21:20):
to say, but you know what I think is going
to make be the game changer when you go to
another institution and they don't offer focal therapy, and of
course in New York they come for many second opinions,
and you do. When those surgeons begin to lose patients
(21:41):
to focal therapy, that's when they're going to take it seriously.
And I think that is beginning to happen because you
know what I'll tell you something. You know, one of
the best judges of patients satisfaction. You'll get a kick
out of this. I had a medical student that followed
me as they follow you, and after the day of
(22:01):
seeing about twenty five patients, I said, so to this dear,
what did you observe? I said, doctor, you're a wonderful community here. No no,
I said, look, I'm not looking for a pat on
the back. Tell me it's almost what I'm thinking. Of course,
he did sort of observe it. I said, you saw
three people hug me today. What did I do for them?
(22:22):
Focal therapy? I said, you saw all these guys whose
process I took out? Did you see one of these
guys give me a hust on the way out? And
I'm sure you see that too. Eron. So if that's
an indication of patient satisfaction, I can think of none
none better.
Speaker 3 (22:41):
Yeah, it is certainly very gratifying. And the treatment, as
you mentioned, is outpatient, so there's less hospital exposure. The
risk of infection is exxceedingly low, it's way under one percent.
And it's a cancer treatment and a cure that can
be achieved literally in like an hour. You know, and
(23:02):
if you talk about some of the patients that undergo
radiation and then some of those patients that maybe even
need hormonal therapy, you're talking about sometimes months of therapy
and the effects of hormone therapy, which we both know
by lowering testosterone for men can have a profound effect.
So I think, you know, I just want to congratulate
(23:23):
you on the program that you have there and what
you have established and really setting the state of the art.
You participate as well as I do in the focal
therapy society. Now, do you think that something like this
will help to to filter down and educate not only physicians,
but also to allow patients to understand more about their
(23:45):
options for focal ablation.
Speaker 4 (23:47):
Yeah, I think what's going to happen. You know what
if something makes sense and the data follows, so does
the change in the treatment period. And you know, when
they started doing lumpeck to me right maybe forty fifty
years ago, everyone said, oh, these people are crazy. You know,
you've got to take out the whole breast, you got
(24:09):
to do this huge lymph no dissection, and everyone said, oh,
those people they're just it's quackery. But it made sense
and then if you fast forward, that's the change in
the paradigm. You know, I really do believe that. You know,
now that we're doing MRI, Aaron, we're finding a lot
(24:29):
of these cancers that are localized. And so if it
once did paradigm changed with MRI and targeted biopsy, you
began to say, as we did, isn't you know this
was eroding into my livelihood, which was taking out prostates?
But I said, you know what, when the robot came around,
(24:50):
and that's another conversation, but that trains left the station.
There really hasn't been a legitimate study showing that the
robot really has transformed outcomes or even changed them in
a meaningful way. And I said, the only way we're
gonna sort of change that calculus between you know, quality
(25:12):
of life and cancer control is not by doing a robot.
That's just a sidestep. We got to offer an entirely
different paradigm, you know, which focal therapy at least conceptually
sound reasonable. And ten years later that sort of conceptional
(25:32):
reason or or or optimism I think has been transformed
into data. And one thing is, you know, these patients
must be followed, but so should every patient. After radiation,
you need to be followed. After surgery, you need to
be followed. But I think even more importantly if you
do focal therapy, the intensity of your follow up has
(25:57):
to be a bit greater because we've left a part
of the prostate untreated with. Certainly can develop cancer, although
so far at five years that's a relatively small proportion
of met.
Speaker 3 (26:15):
Yeah, and certainly we can help so many men with
this mode of therapy and prevent them from needing the
aggressive treatment that they may not have needed, as you
well pointed out. And we could probably go on for
several hours, Herb Lapore, but unfortunately that's the end of
the show. I want to thank you so much. If
you've been listening, we've been talking with doctor Herber Lapour.
(26:36):
If you want more information or want to seek a
consultation with doctor Lapour, you certainly can get all of
his information at the NYU lenko On Health System on
a nette. Thank you very much, I really appreciate it.
Have a wonderful day. Tune in every Sunday here on
Kats's Corner. We'll be back next week with the great show.
This is doctor Aaron Katz.
Speaker 2 (26:54):
You've been listening to Katzer's Corner come back every week
to hear more straight talk on a wide range of
men's health topics and advice on how to live your
healthiest life.
Speaker 1 (27:05):
The proceeding was a paid podcast. iHeartRadio's hosting of this
podcast constitutes neither an endorsement of the products offered or
the ideas expressed.
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