Comprehensive Prostate Cancer Focal Therapy Is Now Available at Fred Hutch

By Fred Hutch Staff · February 9, 2023

The Fred Hutchinson Cancer Center recently added irreversible electroporation (IRE) to its slate of focal therapy offerings and is the only cancer center in the region to offer IRE, high-intensity focal ultrasound (HIFU) and cryotherapy. This comprehensive approach ensures that all patients who are good candidates for focal therapy can access the most appropriate treatment.

Ultrasound A procedure that uses high-energy sound waves to look at tissues and organs inside the body. The sound waves make echoes that form pictures of the tissues and organs on a computer screen. A procedure that uses high-energy sound waves to look at tissues and organs inside the body. The sound waves make echoes that form pictures of the tissues and organs on a computer screen (sonogram). Ultrasound may be used to help diagnose diseases, such as cancer. It may also be used during pregnancy to check the fetus (unborn baby) and during medical procedures, such as biopsies. Also called ultrasonography.

Dr. George Schade smiles for a portrait in the Fred Hutch library.

“Patients are increasingly asking about focal therapies because they are less invasive and have fewer side effects than radiation and surgery,” says Fred Hutch urologic oncologist George Schade, MD. “We are working to meet this demand through our multidisciplinary prostate cancer clinic at Fred Hutch.”

Therapies at the leading edge of technology

HIFU and IRE use state-of-the-art technology to destroy cancer cells. Operating systems include:

Focal One® robotic HIFU system: Focal One uses a rectal probe to target the prostate with a high-intensity beam of sound energy. With robotic positioning, the transducer concentrates ultrasonic energy into a precise area of tissue and destroys it with heat. Outside of this “focal” area, energy levels are low, so surrounding healthy tissue is unharmed. The Focal One offers precision tumor mapping and post-treatment enhanced ultrasound to confirm complete ablation of the tumor.
NanoKnife® IRE: Under transrectal guidance, NanoKnife uses electrodes inserted through the perineum and into the prostate. An electrical current between the electrodes creates pores in the membranes of surrounding cells. This leads to controlled cell death. IRE causes a precise zone of ablation around the electrodes without using heat.

HIFU and IRE are options regardless of prostate shape or size. Patients rarely require hormone therapy or transurethral resection to shrink the prostate prior to treatment.

Dr. Schade performs HIFU and IRE as outpatient procedures under general anesthesia. HIFU takes about two hours, while IRE takes a little longer to place and test the electrodes.

Less invasive procedures lead to rapid recovery

Recovery time is usually just a few weeks with HIFU and IRE. “The most common short-term side effect is swelling of the prostate,” says Dr. Schade. “Patients go home with a catheter to help them urinate until the swelling subsides. Most often the catheter is removed and patients can urinate on their own after about one week. Because IRE is more invasive, it may cause some minor bruising or bleeding at the electrode insertion sites.”

Surveillance after HIFU and IRE includes PSA tests at 6 weeks, 12 weeks and 6 months. Patients also receive an MRI and biopsy at 6 to 12 months to look for residual cancer and confirm the effectiveness of the treatment.

No randomized clinical trials have compared HIFU or IRE to standard treatments.

“Based on prospective single-arm studies and registries, we think that cancer control using focal therapies is similar to what we would expect for surgery and radiation therapy,” says Dr. Schade.

HIFU and IRE Reduce Sexual and Urinary Side Effects

Patients who undergo HIFU or IRE have a lower risk of sexual, urinary and bowel side effects.

Among men who had normal sexual function before treatment, about 85% who received HIFU or IRE retained sexual function versus 40% to 80% after surgery. For radiation therapy, long-term sexual outcomes are similar to surgery. How quickly men lose function ranges widely based on whether they receive hormone deprivation therapy with their radiation.

Urinary side effects are also lower with HIFU and IRE compared with radiation therapy and surgery. Long-term urine leakage rates after treatment are:

HIFU: 1 to 2%
IRE: 1% to 2%
Radiation therapy: 2% to 3%
Surgery: 10% to 15%

Bowel side effects are rare with surgery, HIFU, and IRE. After radiation, 5% to 10% of men can develop long-term fecal leakage.

Eligibility criteria for prostate cancer focal therapy

Current research suggests that 25% to 40% of men with prostate cancer are potential candidates for focal therapy. Eligibility criteria for HIFU and IRE include:

Localized, unilateral prostate cancer
Gleason score of 6 or 7 (or Gleason 8 for select elderly men with a good life expectancy)
MRI-visible disease to aid in treatment planning (ideally)
No evidence of seminal vesical involvement on biopsy and/or MRI

HIFU and IRE may also be an option for men who have localized recurrent prostate cancer after radiation therapy.

Evaluating Patients for Focal Therapy with a Repeat MRI and Biopsy

Dr. Schade evaluates patients with an MRI (if they have not had one) and repeat biopsy to ensure they are good focal therapy candidates.

"I find that about one-third of men evaluated for focal therapy have a higher-grade cancer or more extensive involvement of the prostate than the original tests showed," he says. “If we need to treat a larger area of the prostate or if both sides of the gland are affected, I usually recommend surgery or radiation. We have more data supporting those treatments and side effects are more similar.”

Selecting HIFU vs. IRE vs. Cryotherapy

If a patient is a good candidate for focal therapy, Dr. Schade’s first choice for primary treatment is commonly HIFU because it is less invasive. After radiation therapy, IRE is typically a better option.

“Calcifications, which are common after radiation therapy, and brachytherapy seeds interfere with HIFU sound waves,” says Dr. Schade. “When calcifications are present, cryotherapy used to be our best option. Now, IRE is replacing cryotherapy and is our preferred choice for salvage therapy.”

Prostate cancer care at Fred Hutch

Fred Hutch offers complete, coordinated care for all types of prostate cancer at our dedicated Prostate Oncology Center, located at UW Medical Center — Montlake.

Dr. Schade is a key member of the prostate cancer multidisciplinary team at Fred Hutch. This team evaluates each patient and recommends a personalized treatment plan that may involve one or more treatment types, including focal therapy.

To consult with Dr. Schade or another prostate cancer specialist, call (800) 489-3627.

Anesthesia Drugs or other substances that cause a loss of feeling or awareness. This keeps patients from feeling pain during surgery or other procedures. A loss of feeling or awareness caused by drugs or other substances. Anesthesia keeps patients from feeling pain during surgery or other procedures. Local anesthesia is a loss of feeling in one small area of the body, such as the mouth. Regional anesthesia is a loss of feeling in a part of the body, such as an arm or leg. General anesthesia is a loss of feeling and a complete loss of awareness that feels like a very deep sleep. Biopsy The removal of a sample of tissue or fluid that is examined to see whether cancer is present. This may be done with a large needle or through surgical removal of tissue or fluids. Eligibility criteria In clinical trials, requirements that must be met for a person to be included in a trial. These requirements help make sure that participants in a trial are similar in terms of specific factors. In clinical trials, requirements that must be met for a person to be included in a trial. These requirements help make sure that participants in a trial are similar in terms of specific factors such as age, type and stage of cancer, general health and previous treatment. When all participants meet the same eligibility criteria, it is more likely that results of the study are caused by the intervention being tested and not by other factors or by chance. Hormone therapy Hormones can cause some cancers to grow. To slow or stop growth, synthetic hormones or other drugs can be used to block the body’s natural hormones, or surgery is used to remove a hormone-producing gland. Treatment that adds, blocks or removes hormones. For certain conditions (such as diabetes or menopause), hormones are given to adjust low hormone levels. Hormones can also cause certain cancers (such as prostate and breast cancer) to grow. To slow or stop the growth of cancer, synthetic hormones or other drugs can be used to block the body’s natural hormones, or surgery is used to remove the gland that makes a certain hormone. Also called endocrine therapy, hormonal therapy and hormone treatment. Magnetic resonance imaging A procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body. A procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body. These pictures can show the difference between normal and diseased tissue. MRI makes better images of organs and soft tissue than other scanning techniques, such as computed tomography (CT) or X-ray. MRI is especially useful for imaging the brain, the spine, the soft tissue of joints and the inside of bones. Oncologist A physician who has special training in diagnosing and treating cancer. Some oncologists specialize in a particular type of cancer treatment, such as treating cancer with radiation. A physician who has special training in diagnosing and treating cancer. Some oncologists specialize in a particular type of cancer treatment. For example, a radiation oncologist specializes in treating cancer with radiation. Radiation therapy The use of high-energy radiation from X-rays, gamma rays, neutrons, protons and other sources to kill cancer cells and shrink tumors. The use of high-energy radiation from x-rays, gamma rays, neutrons, protons and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy or brachytherapy). Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that travels in the blood to tissues throughout the body. Side effects A problem that occurs when treatment affects healthy tissues or organs. Some side effects of cancer treatment are nausea, vomiting, fatigue, pain, decreased blood cell counts, hair loss and mouth sores. Side effects A problem that occurs when treatment affects healthy tissues or organs. Some side effects of cancer treatment are nausea, vomiting, fatigue, pain, decreased blood cell counts, hair loss and mouth sores. Surveillance Closely watching a patient’s condition but not treating it unless there are changes in test results. Surveillance is also used to find early signs that a disease has come back. In medicine, surveillance means closely watching a patient’s condition but not treating it unless there are changes in test results. Surveillance is also used to find early signs that a disease has come back. It may also be used for a person who has an increased risk of a disease, such as cancer. During surveillance, certain exams and tests are done on a regular schedule. In public health, surveillance may also refer to the ongoing collection of information about a disease, such as cancer, in a certain group of people. The information collected may include where the disease occurs in a population and whether it affects people of a certain gender, age or ethnic group. Treatment plan A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A treatment plan may also include information about how much the treatment is likely to cost and about regular follow-up care after treatment ends. Ultrasound A procedure that uses high-energy sound waves to look at tissues and organs inside the body. The sound waves make echoes that form pictures of the tissues and organs on a computer screen. A procedure that uses high-energy sound waves to look at tissues and organs inside the body. The sound waves make echoes that form pictures of the tissues and organs on a computer screen (sonogram). Ultrasound may be used to help diagnose diseases, such as cancer. It may also be used during pregnancy to check the fetus (unborn baby) and during medical procedures, such as biopsies. Also called ultrasonography. Gleason score A way of describing prostate cancer based on how abnormal the cancer cells in a biopsy sample look under a microscope and how quickly they are likely to grow and spread.

A way of describing prostate cancer based on how abnormal the cancer cells in a biopsy sample look under a microscope and how quickly they are likely to grow and spread. Most prostate cancers contain cells that are different grades. The Gleason score is calculated by adding together the two grades of cancer cells that make up the largest areas of the biopsied tissue sample. The Gleason score usually ranges from 6 to 10. The lower the Gleason score, the more the cancer cells look like normal cells and are likely to grow and spread slowly. The Gleason score is used to help plan treatment and determine prognosis (outcome).

Ablation Treatment to remove or destroy all or part of a cancer; also used to remove or stop organ function. Besides surgery and drugs, other types of ablation include extreme heat, freezing and chemicals.

Treatment that removes or destroys all or part of a cancer; can also be used to remove or stop the function of an organ. For example, removing the ovaries or testicles or taking medicines that cause them to stop making their hormones would be called ablation. Besides surgery and drug treatment, other ways of ablating body tissues and tumors include extreme heat, freezing and chemicals.

Prostate-specific antigen A protein made by the prostate gland and found in the blood. Prostate-specific antigen blood levels may be higher than normal in men who have certain prostate diseases or conditions.

A protein made by the prostate gland and found in the blood. Prostate-specific antigen blood levels may be higher than normal in men who have prostate cancer, benign prostatic hyperplasia (BPH), or infection or inflammation of the prostate gland.

perineum The area of the body between the anus and the vulva in females, and between the anus and the scrotum in males.

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