Description
In this episode, we have the chance to interview Dr Arvin George, from Johns Hopkins School of Medicine in Baltimore, Maryland (USA).
What are the main differences between transrectal and transperineal approach? What are the benefits of MRI/US fusion images? What about therapies? How is the landscape in United States? Dr George will hilghlight us on these stunning topics!
Hosted on Ausha. See ausha.co/privacy-policy for more information.
Transcription
This podcast is created by Coelis.
I try to think about it. If this was my own family member, what would I want in that scenario? And it would certainly be to have an MRI up front so that we are not ultimately having to undergo a separate biopsy if we identify a lesion outside of the standard biopsy template later.
Dear Prostatalkers, welcome back for a new episode of our podcast. I'm your host, Thomas, and today we are embarking on a journey through time, from the early days of prostate cancer diagnosis to the cutting-edge realm of localized therapy. Joining us for this enlightening discussion is Dr. Ovin George, a trailblazer in the field of urology who has witnessed firsthand the evolution of prostate cancer management. From traditional diagnostic methods to the revolutionary advanced in focal therapies, Dr. George Hassinilor. In this episode, we'll trace the remarkable journey of prostate cancer care, exploring the pivotal moments, the groundbreaking innovations, and the future possibilities. Hi, Dr. George. We are really pleased to welcome you. We are live from the 2024 AUA Annual Meeting in San Antonio, Texas. place to be for urologists this time of year. How are you today and how is the new AUA edition?
Thank you so much, Thomas, for the invitation. I'm so pleased to be here. AUA has been great so far, enjoying the nice warm weather here in San Antonio and looking forward to chatting with you a little bit more about prostate cancer diagnosis and treatment.
We are really glad to have you for this podcast. Before we start this insightful interview... Could you please tell us more about yourself, your background and your urology practice, of course?
Yeah, I'm a urologic oncologist. Like all of us, I started with my residency, which was at, now it's called Northwell Health in Long Island. I stayed there for an endourology fellowship with focusing on minimally invasive surgery and robotics. And then completed a three-year urologic oncology fellowship at the National Cancer Institute, with really a focus on prostate, image-guided diagnosis, image-guided treatments. And then subsequently was a faculty at the University of Michigan for a number of years, and most recently have joined Johns Hopkins as a staff and helped lead the prostate cancer programs there.
Great. I'm a little bit curious. So can I ask you, why did you choose urology? You finished medical school with so many options. What was it that attracted you to this field of expertise?
Well, Tomas, I'm going to be honest with you. I was trying very hard to avoid urology. My father is a urologist, and I felt like I did not want to be compared to somebody who is a great doc. And however, that is what gave me my initial exposure to urology. As I learned more and more about the field, I really loved it. You know, the opportunity really for innovation, complex surgical procedures, simple procedures, longitudinal follow up with your patients, a really, really grateful patient population. And it just ended up being the right fit for me. And thankfully and fortunately, I was afforded the opportunity to do a residency and become a urologist.
Perfect. Very interesting. Dr. George, let's go to the heart of the matter and let's talk about prostates. First of all, are you a fan of transrectal or transparenal approach when doing biopsies?
That's a great question. I think that this year it's becoming a little bit more murky with the addition of some new randomized control data. I will say that I personally made the switch to transperineal biopsy in 2017. And transperineal biopsy is really my default biopsy, though I do believe you can get a good biopsy with a transrectal procedure. But I really think that the logistics and the risk of infection and a number of other things are significantly streamlined when we do the transperineal biopsy approach. So really, the reason that I prefer transperineal biopsy, of course, there's the reduced potential risk of infection, but is the antibiotic stewardship. So I don't give any antibiotics to any of my transperineal biopsy patients unless they've had a prior history of sepsis or there's a significant risk factor. I don't do any enemas prior to the procedure. They're allowed to remain on baby aspirin. So the logistics of the procedure is so much easier in terms of patient preparation. And I feel like I can do a better biopsy.
We can't agree with you more. Are you performing this under local or general anesthesia? Maybe both. And can you provide some insight in your preference?
Yeah, so the vast majority of patients that I do are going to be done under local anesthetic, I would say 90 plus percent. I think even with transrectal biopsy, there's always a number of men who may have significant anxiety, or we may really need them to be still to get an accurate biopsy if they've had multiple prior negative biopsies, or they just have a preference to be under sedation because they know they have a low pain threshold or tolerance and totally appropriate to do it under sedation or anesthesia. The vast majority of cases were able to complete very successfully under local anesthetic with a good patient satisfaction as well.
As we know, the transrectal approach has been the go-to for biopsies in the past. And now, like yourself, we are seeing many urologists make the transition over the transperineal, and some of them came to this podcast to share their experience. Can you tell us a bit about the clinical reasoning and your personal experiences?
Yeah. So the problem has been historically that we've had rising rates of infections. I remember sitting in residency through our mobility and mortality conference and almost... every conference, when you're in a practice with a high volume of biopsies, we would see an infection here, an infection there, and despite doing everything we can to help mitigate those risk of infection. And we've tried everything, needle disinfection techniques, augmented prophylaxis, culture-directed antibiotics. All of those things add additional layers of complexity to the biopsy procedure for both the provider and the patient. To be honest with you, Thomas, transpironeal biopsy was just the simplest solution. It's a simple technical modification to really transform those outcomes and go to a virtually 0% or 0.3% risk of infectious hospitalizations or sepsis following a prostate biopsy. Really transformative.
You are absolutely right. To take this biopsy topic a step further, it's my understanding that you are someone that believes in utilizing image fusion in performing prostate biopsy. Could you tell us about your perspective on MRI ultrasound fusion and why you find it beneficial in your practice?
Yeah, I think that every single thing that we do in medicine has benefited from image guidance. And we look at any solid organ malignancy, it is not sampled in a blind fashion. And so transrectal ultrasound alone just gives us guidance in terms of where we are in the prostate, understanding the anatomy. But it's very challenging to identify discrete areas of suspicion because the specificity of anything on ultrasound is really, really low. And so for me, I try to think about it. If this was my own family member, what would I want in that scenario? And it would certainly be to have an MRI up front so that we are not ultimately having to undergo a separate biopsy if we identify a lesion outside of the standard biopsy template later.
This is true. Precision really matters in prostate care, which brings me to my next question. I have heard that you are quite pioneers in focal treatment for prostate cancer. Could you please tell us more about that?
Yeah, I'm really bullish on the potential of focal therapy and the potential that it has. And so I think that we're not quite there yet in terms of saying, hey, this should definitely be a standard of care treatment. We don't have that long term randomized control trial comparative evidence data, but it's coming. And we are starting to accumulate more and more evidence and understanding a lot more in the space. Now, we know the limitations of radical therapy. We are not benefiting every person who undergoes radical therapy, and we are certainly exposing them to excessive morbidity. And that's where I think focal therapy has the potential to fill that treatment gap where there's a critical need. You may not be appropriate for surveillance. And really, there's unclear benefit in especially an intermediate risk where whether every single man who undergoes treatment is likely to live a longer life or prevent metastasis as a result of treatment. Focal therapy allows us to be able to treat that disease in carefully selected men and potentially avoid the morbidity while still providing excellent cancer control.
What is the current landscape in the United States when it comes to focal therapy treatment for prostate cancer? Is there a general consensus on this topic?
You know, there is not a consensus. I will say that there is cautious optimism from those of us who perform focal therapy, but there are also many people who appropriately are questioning its viability, its relevance, given what we do understand about prostate cancer today, being multifocal, and given the outcomes of different treatment modalities. That being said, I think that We are starting to learn more and more. And as our imaging techniques have gotten better, as we're able to more appropriately risk stratify men, as we're more appropriately be able to localize disease, that's what has really made focal therapy a viable option. We can see it. We can treat. We know where to go, exactly how to treat it, and we can get an accurate representation. Now, historic treatments, like you mentioned before, Tomas, like surgery and radiation, these are a one-size-fits-all approach. And we really do need a more precision approach to these treatments. And I do believe that focal treatment allows us to provide an individualized treatment to that patient and their prostate cancer, rather than putting a prostate in the bucket, regardless of what the pathology is.
And what kind of focal treatments do you offer to your patients? And what is your process for when to utilize various focal modalities?
Yeah, so I've really tried to understand and get experience with as many different focal therapy technologies as possible. So I have done conventional laser interstitial thermotherapy under MR guidance. I've done nanoparticle directed photothermal laser ablation. But what I currently use is high intensity focused ultrasound or HIFU cryoablation. I do water vapor thermal therapy on a clinical trial. Also, irreversible electroporation. Those are the main technologies that I personally have experience with. For me, I really prefer to use HIFU in smaller glands, in posterior zone, and percutaneous procedures such as cryo, IRE, in the anterior gland. I do have access to the Tulsa Pro machine. I'm looking forward to getting some experience with that technology as well.
And how do you choose which treatment for which patients?
That's a great question. We need to understand the patient's disease risk and understand the disease characteristics. Is this a large volume ablation? Is this a small volume ablation? Because that's going to impact which technology that you choose. We want to understand what is the location of the tumor and what are the characteristics? Is there suspicion for extracapsular extension? Is it close to the urethra, bladder neck, apex? And based on those factors, we can determine which is the best treatment. So for example, if I have an anterior periurethral tumor. That's a cancer that I would really favor irreversible electroporation, which is largely athermal and won't succumb to thermal sink that can happen if you have a warming catheter during cryoablation. Alternatively, if I have a lesion, let's say, at the apex of the prostate, that's where I think HIFU has the opportunity to shine because of the focal zones are so small, you can really sculpt that treatment according to the true shape of the prostate.
And if tomorrow a physician says, hey, I want to implement a focal program for my patients, what advice would you provide them?
The first thing is going to make sure that you feel that you're confident in your imaging. If you have good imaging and a good radiology partner, then that's going to be half the battle. The second step is going to be just doing it. There's a lot of inertia in terms of being able to get started. It can feel overwhelming to how do I choose the right patient? What's the technology that I start with? You know, you may not be able to treat everybody and everything with a single technology or a single approach, but you need to overcome that barrier. And so really, it's going to be identifying or I call it you pick your poison in terms of the technology that you're going to use. And you identify patients that will fit within that specific treatment and start your treatments. Once you gain some experience, you start to understand your outcomes, your patient experience. Then you can expand your portfolio to. other technologies to provide a comprehensive focal therapy solution to your patient population.
Thank you for this enlightening discussion. Before we wrap up, can you share with us what are some current projects you are working on and your plans for the future?
Absolutely. So the future is really bright in this space. Focal therapy technology space is exploding. Imaging is exploding. Artificial intelligence and MRI interpretation and prostate segmentation. So many exciting new things in the works that are going to improve our diagnostics and treatments. So me personally, I'm involved in water vapor thermotherapy on a clinical trial, and my focus has really been on clinical trials largely. I'm optimistic about new technologies in the space, microwave ablation, bipolar radiofrequency ablation, non-boiling histotripsy. All of these things are going to start to coalesce to define and find their role in this space. And I think everybody will have a role. And I don't think there's any single technology or solution that's going to fit every scenario. Given the volume of prostate cancer that we see, given the opportunity in terms of patients looking for treatments that are less invasive and that have a great focus on their quality of life, I think that this field is going to continue to grow and expand over the next few years.
Perfect. Thank you so much for your time. Before turning off this episode, I'd like to ask my guest a final question, unprepared, sorry, about their song of the moment. Which one is yours, Dr. George?
The song of the moment. That's a great question. I'm going to tell you what it is. Let me pull up my playlist here. All right. So a couple of songs. One is this is an oldie but a goodie. It's a groove theory. Tell me by now and latest. The other one that I'm liking right now is Real Love by Retrowaves. Wow. So check them out.
Perfect. Looking forward to hear that. So thank you so much. And I hope you will join us for another episode in the future with me. I'd love to. Thank you so much. Bye-bye. Have topics you'd love us to cover? Share your ideas in the comments or connect with us on social media. Your input guides the future of Pros.Talk. Thanks for being a crucial part of our community. For more urology insights, visit Kallis.com. Stay tuned and see you next time.
Description
In this episode, we have the chance to interview Dr Arvin George, from Johns Hopkins School of Medicine in Baltimore, Maryland (USA).
What are the main differences between transrectal and transperineal approach? What are the benefits of MRI/US fusion images? What about therapies? How is the landscape in United States? Dr George will hilghlight us on these stunning topics!
Hosted on Ausha. See ausha.co/privacy-policy for more information.
Transcription
This podcast is created by Coelis.
I try to think about it. If this was my own family member, what would I want in that scenario? And it would certainly be to have an MRI up front so that we are not ultimately having to undergo a separate biopsy if we identify a lesion outside of the standard biopsy template later.
Dear Prostatalkers, welcome back for a new episode of our podcast. I'm your host, Thomas, and today we are embarking on a journey through time, from the early days of prostate cancer diagnosis to the cutting-edge realm of localized therapy. Joining us for this enlightening discussion is Dr. Ovin George, a trailblazer in the field of urology who has witnessed firsthand the evolution of prostate cancer management. From traditional diagnostic methods to the revolutionary advanced in focal therapies, Dr. George Hassinilor. In this episode, we'll trace the remarkable journey of prostate cancer care, exploring the pivotal moments, the groundbreaking innovations, and the future possibilities. Hi, Dr. George. We are really pleased to welcome you. We are live from the 2024 AUA Annual Meeting in San Antonio, Texas. place to be for urologists this time of year. How are you today and how is the new AUA edition?
Thank you so much, Thomas, for the invitation. I'm so pleased to be here. AUA has been great so far, enjoying the nice warm weather here in San Antonio and looking forward to chatting with you a little bit more about prostate cancer diagnosis and treatment.
We are really glad to have you for this podcast. Before we start this insightful interview... Could you please tell us more about yourself, your background and your urology practice, of course?
Yeah, I'm a urologic oncologist. Like all of us, I started with my residency, which was at, now it's called Northwell Health in Long Island. I stayed there for an endourology fellowship with focusing on minimally invasive surgery and robotics. And then completed a three-year urologic oncology fellowship at the National Cancer Institute, with really a focus on prostate, image-guided diagnosis, image-guided treatments. And then subsequently was a faculty at the University of Michigan for a number of years, and most recently have joined Johns Hopkins as a staff and helped lead the prostate cancer programs there.
Great. I'm a little bit curious. So can I ask you, why did you choose urology? You finished medical school with so many options. What was it that attracted you to this field of expertise?
Well, Tomas, I'm going to be honest with you. I was trying very hard to avoid urology. My father is a urologist, and I felt like I did not want to be compared to somebody who is a great doc. And however, that is what gave me my initial exposure to urology. As I learned more and more about the field, I really loved it. You know, the opportunity really for innovation, complex surgical procedures, simple procedures, longitudinal follow up with your patients, a really, really grateful patient population. And it just ended up being the right fit for me. And thankfully and fortunately, I was afforded the opportunity to do a residency and become a urologist.
Perfect. Very interesting. Dr. George, let's go to the heart of the matter and let's talk about prostates. First of all, are you a fan of transrectal or transparenal approach when doing biopsies?
That's a great question. I think that this year it's becoming a little bit more murky with the addition of some new randomized control data. I will say that I personally made the switch to transperineal biopsy in 2017. And transperineal biopsy is really my default biopsy, though I do believe you can get a good biopsy with a transrectal procedure. But I really think that the logistics and the risk of infection and a number of other things are significantly streamlined when we do the transperineal biopsy approach. So really, the reason that I prefer transperineal biopsy, of course, there's the reduced potential risk of infection, but is the antibiotic stewardship. So I don't give any antibiotics to any of my transperineal biopsy patients unless they've had a prior history of sepsis or there's a significant risk factor. I don't do any enemas prior to the procedure. They're allowed to remain on baby aspirin. So the logistics of the procedure is so much easier in terms of patient preparation. And I feel like I can do a better biopsy.
We can't agree with you more. Are you performing this under local or general anesthesia? Maybe both. And can you provide some insight in your preference?
Yeah, so the vast majority of patients that I do are going to be done under local anesthetic, I would say 90 plus percent. I think even with transrectal biopsy, there's always a number of men who may have significant anxiety, or we may really need them to be still to get an accurate biopsy if they've had multiple prior negative biopsies, or they just have a preference to be under sedation because they know they have a low pain threshold or tolerance and totally appropriate to do it under sedation or anesthesia. The vast majority of cases were able to complete very successfully under local anesthetic with a good patient satisfaction as well.
As we know, the transrectal approach has been the go-to for biopsies in the past. And now, like yourself, we are seeing many urologists make the transition over the transperineal, and some of them came to this podcast to share their experience. Can you tell us a bit about the clinical reasoning and your personal experiences?
Yeah. So the problem has been historically that we've had rising rates of infections. I remember sitting in residency through our mobility and mortality conference and almost... every conference, when you're in a practice with a high volume of biopsies, we would see an infection here, an infection there, and despite doing everything we can to help mitigate those risk of infection. And we've tried everything, needle disinfection techniques, augmented prophylaxis, culture-directed antibiotics. All of those things add additional layers of complexity to the biopsy procedure for both the provider and the patient. To be honest with you, Thomas, transpironeal biopsy was just the simplest solution. It's a simple technical modification to really transform those outcomes and go to a virtually 0% or 0.3% risk of infectious hospitalizations or sepsis following a prostate biopsy. Really transformative.
You are absolutely right. To take this biopsy topic a step further, it's my understanding that you are someone that believes in utilizing image fusion in performing prostate biopsy. Could you tell us about your perspective on MRI ultrasound fusion and why you find it beneficial in your practice?
Yeah, I think that every single thing that we do in medicine has benefited from image guidance. And we look at any solid organ malignancy, it is not sampled in a blind fashion. And so transrectal ultrasound alone just gives us guidance in terms of where we are in the prostate, understanding the anatomy. But it's very challenging to identify discrete areas of suspicion because the specificity of anything on ultrasound is really, really low. And so for me, I try to think about it. If this was my own family member, what would I want in that scenario? And it would certainly be to have an MRI up front so that we are not ultimately having to undergo a separate biopsy if we identify a lesion outside of the standard biopsy template later.
This is true. Precision really matters in prostate care, which brings me to my next question. I have heard that you are quite pioneers in focal treatment for prostate cancer. Could you please tell us more about that?
Yeah, I'm really bullish on the potential of focal therapy and the potential that it has. And so I think that we're not quite there yet in terms of saying, hey, this should definitely be a standard of care treatment. We don't have that long term randomized control trial comparative evidence data, but it's coming. And we are starting to accumulate more and more evidence and understanding a lot more in the space. Now, we know the limitations of radical therapy. We are not benefiting every person who undergoes radical therapy, and we are certainly exposing them to excessive morbidity. And that's where I think focal therapy has the potential to fill that treatment gap where there's a critical need. You may not be appropriate for surveillance. And really, there's unclear benefit in especially an intermediate risk where whether every single man who undergoes treatment is likely to live a longer life or prevent metastasis as a result of treatment. Focal therapy allows us to be able to treat that disease in carefully selected men and potentially avoid the morbidity while still providing excellent cancer control.
What is the current landscape in the United States when it comes to focal therapy treatment for prostate cancer? Is there a general consensus on this topic?
You know, there is not a consensus. I will say that there is cautious optimism from those of us who perform focal therapy, but there are also many people who appropriately are questioning its viability, its relevance, given what we do understand about prostate cancer today, being multifocal, and given the outcomes of different treatment modalities. That being said, I think that We are starting to learn more and more. And as our imaging techniques have gotten better, as we're able to more appropriately risk stratify men, as we're more appropriately be able to localize disease, that's what has really made focal therapy a viable option. We can see it. We can treat. We know where to go, exactly how to treat it, and we can get an accurate representation. Now, historic treatments, like you mentioned before, Tomas, like surgery and radiation, these are a one-size-fits-all approach. And we really do need a more precision approach to these treatments. And I do believe that focal treatment allows us to provide an individualized treatment to that patient and their prostate cancer, rather than putting a prostate in the bucket, regardless of what the pathology is.
And what kind of focal treatments do you offer to your patients? And what is your process for when to utilize various focal modalities?
Yeah, so I've really tried to understand and get experience with as many different focal therapy technologies as possible. So I have done conventional laser interstitial thermotherapy under MR guidance. I've done nanoparticle directed photothermal laser ablation. But what I currently use is high intensity focused ultrasound or HIFU cryoablation. I do water vapor thermal therapy on a clinical trial. Also, irreversible electroporation. Those are the main technologies that I personally have experience with. For me, I really prefer to use HIFU in smaller glands, in posterior zone, and percutaneous procedures such as cryo, IRE, in the anterior gland. I do have access to the Tulsa Pro machine. I'm looking forward to getting some experience with that technology as well.
And how do you choose which treatment for which patients?
That's a great question. We need to understand the patient's disease risk and understand the disease characteristics. Is this a large volume ablation? Is this a small volume ablation? Because that's going to impact which technology that you choose. We want to understand what is the location of the tumor and what are the characteristics? Is there suspicion for extracapsular extension? Is it close to the urethra, bladder neck, apex? And based on those factors, we can determine which is the best treatment. So for example, if I have an anterior periurethral tumor. That's a cancer that I would really favor irreversible electroporation, which is largely athermal and won't succumb to thermal sink that can happen if you have a warming catheter during cryoablation. Alternatively, if I have a lesion, let's say, at the apex of the prostate, that's where I think HIFU has the opportunity to shine because of the focal zones are so small, you can really sculpt that treatment according to the true shape of the prostate.
And if tomorrow a physician says, hey, I want to implement a focal program for my patients, what advice would you provide them?
The first thing is going to make sure that you feel that you're confident in your imaging. If you have good imaging and a good radiology partner, then that's going to be half the battle. The second step is going to be just doing it. There's a lot of inertia in terms of being able to get started. It can feel overwhelming to how do I choose the right patient? What's the technology that I start with? You know, you may not be able to treat everybody and everything with a single technology or a single approach, but you need to overcome that barrier. And so really, it's going to be identifying or I call it you pick your poison in terms of the technology that you're going to use. And you identify patients that will fit within that specific treatment and start your treatments. Once you gain some experience, you start to understand your outcomes, your patient experience. Then you can expand your portfolio to. other technologies to provide a comprehensive focal therapy solution to your patient population.
Thank you for this enlightening discussion. Before we wrap up, can you share with us what are some current projects you are working on and your plans for the future?
Absolutely. So the future is really bright in this space. Focal therapy technology space is exploding. Imaging is exploding. Artificial intelligence and MRI interpretation and prostate segmentation. So many exciting new things in the works that are going to improve our diagnostics and treatments. So me personally, I'm involved in water vapor thermotherapy on a clinical trial, and my focus has really been on clinical trials largely. I'm optimistic about new technologies in the space, microwave ablation, bipolar radiofrequency ablation, non-boiling histotripsy. All of these things are going to start to coalesce to define and find their role in this space. And I think everybody will have a role. And I don't think there's any single technology or solution that's going to fit every scenario. Given the volume of prostate cancer that we see, given the opportunity in terms of patients looking for treatments that are less invasive and that have a great focus on their quality of life, I think that this field is going to continue to grow and expand over the next few years.
Perfect. Thank you so much for your time. Before turning off this episode, I'd like to ask my guest a final question, unprepared, sorry, about their song of the moment. Which one is yours, Dr. George?
The song of the moment. That's a great question. I'm going to tell you what it is. Let me pull up my playlist here. All right. So a couple of songs. One is this is an oldie but a goodie. It's a groove theory. Tell me by now and latest. The other one that I'm liking right now is Real Love by Retrowaves. Wow. So check them out.
Perfect. Looking forward to hear that. So thank you so much. And I hope you will join us for another episode in the future with me. I'd love to. Thank you so much. Bye-bye. Have topics you'd love us to cover? Share your ideas in the comments or connect with us on social media. Your input guides the future of Pros.Talk. Thanks for being a crucial part of our community. For more urology insights, visit Kallis.com. Stay tuned and see you next time.
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Description
In this episode, we have the chance to interview Dr Arvin George, from Johns Hopkins School of Medicine in Baltimore, Maryland (USA).
What are the main differences between transrectal and transperineal approach? What are the benefits of MRI/US fusion images? What about therapies? How is the landscape in United States? Dr George will hilghlight us on these stunning topics!
Hosted on Ausha. See ausha.co/privacy-policy for more information.
Transcription
This podcast is created by Coelis.
I try to think about it. If this was my own family member, what would I want in that scenario? And it would certainly be to have an MRI up front so that we are not ultimately having to undergo a separate biopsy if we identify a lesion outside of the standard biopsy template later.
Dear Prostatalkers, welcome back for a new episode of our podcast. I'm your host, Thomas, and today we are embarking on a journey through time, from the early days of prostate cancer diagnosis to the cutting-edge realm of localized therapy. Joining us for this enlightening discussion is Dr. Ovin George, a trailblazer in the field of urology who has witnessed firsthand the evolution of prostate cancer management. From traditional diagnostic methods to the revolutionary advanced in focal therapies, Dr. George Hassinilor. In this episode, we'll trace the remarkable journey of prostate cancer care, exploring the pivotal moments, the groundbreaking innovations, and the future possibilities. Hi, Dr. George. We are really pleased to welcome you. We are live from the 2024 AUA Annual Meeting in San Antonio, Texas. place to be for urologists this time of year. How are you today and how is the new AUA edition?
Thank you so much, Thomas, for the invitation. I'm so pleased to be here. AUA has been great so far, enjoying the nice warm weather here in San Antonio and looking forward to chatting with you a little bit more about prostate cancer diagnosis and treatment.
We are really glad to have you for this podcast. Before we start this insightful interview... Could you please tell us more about yourself, your background and your urology practice, of course?
Yeah, I'm a urologic oncologist. Like all of us, I started with my residency, which was at, now it's called Northwell Health in Long Island. I stayed there for an endourology fellowship with focusing on minimally invasive surgery and robotics. And then completed a three-year urologic oncology fellowship at the National Cancer Institute, with really a focus on prostate, image-guided diagnosis, image-guided treatments. And then subsequently was a faculty at the University of Michigan for a number of years, and most recently have joined Johns Hopkins as a staff and helped lead the prostate cancer programs there.
Great. I'm a little bit curious. So can I ask you, why did you choose urology? You finished medical school with so many options. What was it that attracted you to this field of expertise?
Well, Tomas, I'm going to be honest with you. I was trying very hard to avoid urology. My father is a urologist, and I felt like I did not want to be compared to somebody who is a great doc. And however, that is what gave me my initial exposure to urology. As I learned more and more about the field, I really loved it. You know, the opportunity really for innovation, complex surgical procedures, simple procedures, longitudinal follow up with your patients, a really, really grateful patient population. And it just ended up being the right fit for me. And thankfully and fortunately, I was afforded the opportunity to do a residency and become a urologist.
Perfect. Very interesting. Dr. George, let's go to the heart of the matter and let's talk about prostates. First of all, are you a fan of transrectal or transparenal approach when doing biopsies?
That's a great question. I think that this year it's becoming a little bit more murky with the addition of some new randomized control data. I will say that I personally made the switch to transperineal biopsy in 2017. And transperineal biopsy is really my default biopsy, though I do believe you can get a good biopsy with a transrectal procedure. But I really think that the logistics and the risk of infection and a number of other things are significantly streamlined when we do the transperineal biopsy approach. So really, the reason that I prefer transperineal biopsy, of course, there's the reduced potential risk of infection, but is the antibiotic stewardship. So I don't give any antibiotics to any of my transperineal biopsy patients unless they've had a prior history of sepsis or there's a significant risk factor. I don't do any enemas prior to the procedure. They're allowed to remain on baby aspirin. So the logistics of the procedure is so much easier in terms of patient preparation. And I feel like I can do a better biopsy.
We can't agree with you more. Are you performing this under local or general anesthesia? Maybe both. And can you provide some insight in your preference?
Yeah, so the vast majority of patients that I do are going to be done under local anesthetic, I would say 90 plus percent. I think even with transrectal biopsy, there's always a number of men who may have significant anxiety, or we may really need them to be still to get an accurate biopsy if they've had multiple prior negative biopsies, or they just have a preference to be under sedation because they know they have a low pain threshold or tolerance and totally appropriate to do it under sedation or anesthesia. The vast majority of cases were able to complete very successfully under local anesthetic with a good patient satisfaction as well.
As we know, the transrectal approach has been the go-to for biopsies in the past. And now, like yourself, we are seeing many urologists make the transition over the transperineal, and some of them came to this podcast to share their experience. Can you tell us a bit about the clinical reasoning and your personal experiences?
Yeah. So the problem has been historically that we've had rising rates of infections. I remember sitting in residency through our mobility and mortality conference and almost... every conference, when you're in a practice with a high volume of biopsies, we would see an infection here, an infection there, and despite doing everything we can to help mitigate those risk of infection. And we've tried everything, needle disinfection techniques, augmented prophylaxis, culture-directed antibiotics. All of those things add additional layers of complexity to the biopsy procedure for both the provider and the patient. To be honest with you, Thomas, transpironeal biopsy was just the simplest solution. It's a simple technical modification to really transform those outcomes and go to a virtually 0% or 0.3% risk of infectious hospitalizations or sepsis following a prostate biopsy. Really transformative.
You are absolutely right. To take this biopsy topic a step further, it's my understanding that you are someone that believes in utilizing image fusion in performing prostate biopsy. Could you tell us about your perspective on MRI ultrasound fusion and why you find it beneficial in your practice?
Yeah, I think that every single thing that we do in medicine has benefited from image guidance. And we look at any solid organ malignancy, it is not sampled in a blind fashion. And so transrectal ultrasound alone just gives us guidance in terms of where we are in the prostate, understanding the anatomy. But it's very challenging to identify discrete areas of suspicion because the specificity of anything on ultrasound is really, really low. And so for me, I try to think about it. If this was my own family member, what would I want in that scenario? And it would certainly be to have an MRI up front so that we are not ultimately having to undergo a separate biopsy if we identify a lesion outside of the standard biopsy template later.
This is true. Precision really matters in prostate care, which brings me to my next question. I have heard that you are quite pioneers in focal treatment for prostate cancer. Could you please tell us more about that?
Yeah, I'm really bullish on the potential of focal therapy and the potential that it has. And so I think that we're not quite there yet in terms of saying, hey, this should definitely be a standard of care treatment. We don't have that long term randomized control trial comparative evidence data, but it's coming. And we are starting to accumulate more and more evidence and understanding a lot more in the space. Now, we know the limitations of radical therapy. We are not benefiting every person who undergoes radical therapy, and we are certainly exposing them to excessive morbidity. And that's where I think focal therapy has the potential to fill that treatment gap where there's a critical need. You may not be appropriate for surveillance. And really, there's unclear benefit in especially an intermediate risk where whether every single man who undergoes treatment is likely to live a longer life or prevent metastasis as a result of treatment. Focal therapy allows us to be able to treat that disease in carefully selected men and potentially avoid the morbidity while still providing excellent cancer control.
What is the current landscape in the United States when it comes to focal therapy treatment for prostate cancer? Is there a general consensus on this topic?
You know, there is not a consensus. I will say that there is cautious optimism from those of us who perform focal therapy, but there are also many people who appropriately are questioning its viability, its relevance, given what we do understand about prostate cancer today, being multifocal, and given the outcomes of different treatment modalities. That being said, I think that We are starting to learn more and more. And as our imaging techniques have gotten better, as we're able to more appropriately risk stratify men, as we're more appropriately be able to localize disease, that's what has really made focal therapy a viable option. We can see it. We can treat. We know where to go, exactly how to treat it, and we can get an accurate representation. Now, historic treatments, like you mentioned before, Tomas, like surgery and radiation, these are a one-size-fits-all approach. And we really do need a more precision approach to these treatments. And I do believe that focal treatment allows us to provide an individualized treatment to that patient and their prostate cancer, rather than putting a prostate in the bucket, regardless of what the pathology is.
And what kind of focal treatments do you offer to your patients? And what is your process for when to utilize various focal modalities?
Yeah, so I've really tried to understand and get experience with as many different focal therapy technologies as possible. So I have done conventional laser interstitial thermotherapy under MR guidance. I've done nanoparticle directed photothermal laser ablation. But what I currently use is high intensity focused ultrasound or HIFU cryoablation. I do water vapor thermal therapy on a clinical trial. Also, irreversible electroporation. Those are the main technologies that I personally have experience with. For me, I really prefer to use HIFU in smaller glands, in posterior zone, and percutaneous procedures such as cryo, IRE, in the anterior gland. I do have access to the Tulsa Pro machine. I'm looking forward to getting some experience with that technology as well.
And how do you choose which treatment for which patients?
That's a great question. We need to understand the patient's disease risk and understand the disease characteristics. Is this a large volume ablation? Is this a small volume ablation? Because that's going to impact which technology that you choose. We want to understand what is the location of the tumor and what are the characteristics? Is there suspicion for extracapsular extension? Is it close to the urethra, bladder neck, apex? And based on those factors, we can determine which is the best treatment. So for example, if I have an anterior periurethral tumor. That's a cancer that I would really favor irreversible electroporation, which is largely athermal and won't succumb to thermal sink that can happen if you have a warming catheter during cryoablation. Alternatively, if I have a lesion, let's say, at the apex of the prostate, that's where I think HIFU has the opportunity to shine because of the focal zones are so small, you can really sculpt that treatment according to the true shape of the prostate.
And if tomorrow a physician says, hey, I want to implement a focal program for my patients, what advice would you provide them?
The first thing is going to make sure that you feel that you're confident in your imaging. If you have good imaging and a good radiology partner, then that's going to be half the battle. The second step is going to be just doing it. There's a lot of inertia in terms of being able to get started. It can feel overwhelming to how do I choose the right patient? What's the technology that I start with? You know, you may not be able to treat everybody and everything with a single technology or a single approach, but you need to overcome that barrier. And so really, it's going to be identifying or I call it you pick your poison in terms of the technology that you're going to use. And you identify patients that will fit within that specific treatment and start your treatments. Once you gain some experience, you start to understand your outcomes, your patient experience. Then you can expand your portfolio to. other technologies to provide a comprehensive focal therapy solution to your patient population.
Thank you for this enlightening discussion. Before we wrap up, can you share with us what are some current projects you are working on and your plans for the future?
Absolutely. So the future is really bright in this space. Focal therapy technology space is exploding. Imaging is exploding. Artificial intelligence and MRI interpretation and prostate segmentation. So many exciting new things in the works that are going to improve our diagnostics and treatments. So me personally, I'm involved in water vapor thermotherapy on a clinical trial, and my focus has really been on clinical trials largely. I'm optimistic about new technologies in the space, microwave ablation, bipolar radiofrequency ablation, non-boiling histotripsy. All of these things are going to start to coalesce to define and find their role in this space. And I think everybody will have a role. And I don't think there's any single technology or solution that's going to fit every scenario. Given the volume of prostate cancer that we see, given the opportunity in terms of patients looking for treatments that are less invasive and that have a great focus on their quality of life, I think that this field is going to continue to grow and expand over the next few years.
Perfect. Thank you so much for your time. Before turning off this episode, I'd like to ask my guest a final question, unprepared, sorry, about their song of the moment. Which one is yours, Dr. George?
The song of the moment. That's a great question. I'm going to tell you what it is. Let me pull up my playlist here. All right. So a couple of songs. One is this is an oldie but a goodie. It's a groove theory. Tell me by now and latest. The other one that I'm liking right now is Real Love by Retrowaves. Wow. So check them out.
Perfect. Looking forward to hear that. So thank you so much. And I hope you will join us for another episode in the future with me. I'd love to. Thank you so much. Bye-bye. Have topics you'd love us to cover? Share your ideas in the comments or connect with us on social media. Your input guides the future of Pros.Talk. Thanks for being a crucial part of our community. For more urology insights, visit Kallis.com. Stay tuned and see you next time.
Description
In this episode, we have the chance to interview Dr Arvin George, from Johns Hopkins School of Medicine in Baltimore, Maryland (USA).
What are the main differences between transrectal and transperineal approach? What are the benefits of MRI/US fusion images? What about therapies? How is the landscape in United States? Dr George will hilghlight us on these stunning topics!
Hosted on Ausha. See ausha.co/privacy-policy for more information.
Transcription
This podcast is created by Coelis.
I try to think about it. If this was my own family member, what would I want in that scenario? And it would certainly be to have an MRI up front so that we are not ultimately having to undergo a separate biopsy if we identify a lesion outside of the standard biopsy template later.
Dear Prostatalkers, welcome back for a new episode of our podcast. I'm your host, Thomas, and today we are embarking on a journey through time, from the early days of prostate cancer diagnosis to the cutting-edge realm of localized therapy. Joining us for this enlightening discussion is Dr. Ovin George, a trailblazer in the field of urology who has witnessed firsthand the evolution of prostate cancer management. From traditional diagnostic methods to the revolutionary advanced in focal therapies, Dr. George Hassinilor. In this episode, we'll trace the remarkable journey of prostate cancer care, exploring the pivotal moments, the groundbreaking innovations, and the future possibilities. Hi, Dr. George. We are really pleased to welcome you. We are live from the 2024 AUA Annual Meeting in San Antonio, Texas. place to be for urologists this time of year. How are you today and how is the new AUA edition?
Thank you so much, Thomas, for the invitation. I'm so pleased to be here. AUA has been great so far, enjoying the nice warm weather here in San Antonio and looking forward to chatting with you a little bit more about prostate cancer diagnosis and treatment.
We are really glad to have you for this podcast. Before we start this insightful interview... Could you please tell us more about yourself, your background and your urology practice, of course?
Yeah, I'm a urologic oncologist. Like all of us, I started with my residency, which was at, now it's called Northwell Health in Long Island. I stayed there for an endourology fellowship with focusing on minimally invasive surgery and robotics. And then completed a three-year urologic oncology fellowship at the National Cancer Institute, with really a focus on prostate, image-guided diagnosis, image-guided treatments. And then subsequently was a faculty at the University of Michigan for a number of years, and most recently have joined Johns Hopkins as a staff and helped lead the prostate cancer programs there.
Great. I'm a little bit curious. So can I ask you, why did you choose urology? You finished medical school with so many options. What was it that attracted you to this field of expertise?
Well, Tomas, I'm going to be honest with you. I was trying very hard to avoid urology. My father is a urologist, and I felt like I did not want to be compared to somebody who is a great doc. And however, that is what gave me my initial exposure to urology. As I learned more and more about the field, I really loved it. You know, the opportunity really for innovation, complex surgical procedures, simple procedures, longitudinal follow up with your patients, a really, really grateful patient population. And it just ended up being the right fit for me. And thankfully and fortunately, I was afforded the opportunity to do a residency and become a urologist.
Perfect. Very interesting. Dr. George, let's go to the heart of the matter and let's talk about prostates. First of all, are you a fan of transrectal or transparenal approach when doing biopsies?
That's a great question. I think that this year it's becoming a little bit more murky with the addition of some new randomized control data. I will say that I personally made the switch to transperineal biopsy in 2017. And transperineal biopsy is really my default biopsy, though I do believe you can get a good biopsy with a transrectal procedure. But I really think that the logistics and the risk of infection and a number of other things are significantly streamlined when we do the transperineal biopsy approach. So really, the reason that I prefer transperineal biopsy, of course, there's the reduced potential risk of infection, but is the antibiotic stewardship. So I don't give any antibiotics to any of my transperineal biopsy patients unless they've had a prior history of sepsis or there's a significant risk factor. I don't do any enemas prior to the procedure. They're allowed to remain on baby aspirin. So the logistics of the procedure is so much easier in terms of patient preparation. And I feel like I can do a better biopsy.
We can't agree with you more. Are you performing this under local or general anesthesia? Maybe both. And can you provide some insight in your preference?
Yeah, so the vast majority of patients that I do are going to be done under local anesthetic, I would say 90 plus percent. I think even with transrectal biopsy, there's always a number of men who may have significant anxiety, or we may really need them to be still to get an accurate biopsy if they've had multiple prior negative biopsies, or they just have a preference to be under sedation because they know they have a low pain threshold or tolerance and totally appropriate to do it under sedation or anesthesia. The vast majority of cases were able to complete very successfully under local anesthetic with a good patient satisfaction as well.
As we know, the transrectal approach has been the go-to for biopsies in the past. And now, like yourself, we are seeing many urologists make the transition over the transperineal, and some of them came to this podcast to share their experience. Can you tell us a bit about the clinical reasoning and your personal experiences?
Yeah. So the problem has been historically that we've had rising rates of infections. I remember sitting in residency through our mobility and mortality conference and almost... every conference, when you're in a practice with a high volume of biopsies, we would see an infection here, an infection there, and despite doing everything we can to help mitigate those risk of infection. And we've tried everything, needle disinfection techniques, augmented prophylaxis, culture-directed antibiotics. All of those things add additional layers of complexity to the biopsy procedure for both the provider and the patient. To be honest with you, Thomas, transpironeal biopsy was just the simplest solution. It's a simple technical modification to really transform those outcomes and go to a virtually 0% or 0.3% risk of infectious hospitalizations or sepsis following a prostate biopsy. Really transformative.
You are absolutely right. To take this biopsy topic a step further, it's my understanding that you are someone that believes in utilizing image fusion in performing prostate biopsy. Could you tell us about your perspective on MRI ultrasound fusion and why you find it beneficial in your practice?
Yeah, I think that every single thing that we do in medicine has benefited from image guidance. And we look at any solid organ malignancy, it is not sampled in a blind fashion. And so transrectal ultrasound alone just gives us guidance in terms of where we are in the prostate, understanding the anatomy. But it's very challenging to identify discrete areas of suspicion because the specificity of anything on ultrasound is really, really low. And so for me, I try to think about it. If this was my own family member, what would I want in that scenario? And it would certainly be to have an MRI up front so that we are not ultimately having to undergo a separate biopsy if we identify a lesion outside of the standard biopsy template later.
This is true. Precision really matters in prostate care, which brings me to my next question. I have heard that you are quite pioneers in focal treatment for prostate cancer. Could you please tell us more about that?
Yeah, I'm really bullish on the potential of focal therapy and the potential that it has. And so I think that we're not quite there yet in terms of saying, hey, this should definitely be a standard of care treatment. We don't have that long term randomized control trial comparative evidence data, but it's coming. And we are starting to accumulate more and more evidence and understanding a lot more in the space. Now, we know the limitations of radical therapy. We are not benefiting every person who undergoes radical therapy, and we are certainly exposing them to excessive morbidity. And that's where I think focal therapy has the potential to fill that treatment gap where there's a critical need. You may not be appropriate for surveillance. And really, there's unclear benefit in especially an intermediate risk where whether every single man who undergoes treatment is likely to live a longer life or prevent metastasis as a result of treatment. Focal therapy allows us to be able to treat that disease in carefully selected men and potentially avoid the morbidity while still providing excellent cancer control.
What is the current landscape in the United States when it comes to focal therapy treatment for prostate cancer? Is there a general consensus on this topic?
You know, there is not a consensus. I will say that there is cautious optimism from those of us who perform focal therapy, but there are also many people who appropriately are questioning its viability, its relevance, given what we do understand about prostate cancer today, being multifocal, and given the outcomes of different treatment modalities. That being said, I think that We are starting to learn more and more. And as our imaging techniques have gotten better, as we're able to more appropriately risk stratify men, as we're more appropriately be able to localize disease, that's what has really made focal therapy a viable option. We can see it. We can treat. We know where to go, exactly how to treat it, and we can get an accurate representation. Now, historic treatments, like you mentioned before, Tomas, like surgery and radiation, these are a one-size-fits-all approach. And we really do need a more precision approach to these treatments. And I do believe that focal treatment allows us to provide an individualized treatment to that patient and their prostate cancer, rather than putting a prostate in the bucket, regardless of what the pathology is.
And what kind of focal treatments do you offer to your patients? And what is your process for when to utilize various focal modalities?
Yeah, so I've really tried to understand and get experience with as many different focal therapy technologies as possible. So I have done conventional laser interstitial thermotherapy under MR guidance. I've done nanoparticle directed photothermal laser ablation. But what I currently use is high intensity focused ultrasound or HIFU cryoablation. I do water vapor thermal therapy on a clinical trial. Also, irreversible electroporation. Those are the main technologies that I personally have experience with. For me, I really prefer to use HIFU in smaller glands, in posterior zone, and percutaneous procedures such as cryo, IRE, in the anterior gland. I do have access to the Tulsa Pro machine. I'm looking forward to getting some experience with that technology as well.
And how do you choose which treatment for which patients?
That's a great question. We need to understand the patient's disease risk and understand the disease characteristics. Is this a large volume ablation? Is this a small volume ablation? Because that's going to impact which technology that you choose. We want to understand what is the location of the tumor and what are the characteristics? Is there suspicion for extracapsular extension? Is it close to the urethra, bladder neck, apex? And based on those factors, we can determine which is the best treatment. So for example, if I have an anterior periurethral tumor. That's a cancer that I would really favor irreversible electroporation, which is largely athermal and won't succumb to thermal sink that can happen if you have a warming catheter during cryoablation. Alternatively, if I have a lesion, let's say, at the apex of the prostate, that's where I think HIFU has the opportunity to shine because of the focal zones are so small, you can really sculpt that treatment according to the true shape of the prostate.
And if tomorrow a physician says, hey, I want to implement a focal program for my patients, what advice would you provide them?
The first thing is going to make sure that you feel that you're confident in your imaging. If you have good imaging and a good radiology partner, then that's going to be half the battle. The second step is going to be just doing it. There's a lot of inertia in terms of being able to get started. It can feel overwhelming to how do I choose the right patient? What's the technology that I start with? You know, you may not be able to treat everybody and everything with a single technology or a single approach, but you need to overcome that barrier. And so really, it's going to be identifying or I call it you pick your poison in terms of the technology that you're going to use. And you identify patients that will fit within that specific treatment and start your treatments. Once you gain some experience, you start to understand your outcomes, your patient experience. Then you can expand your portfolio to. other technologies to provide a comprehensive focal therapy solution to your patient population.
Thank you for this enlightening discussion. Before we wrap up, can you share with us what are some current projects you are working on and your plans for the future?
Absolutely. So the future is really bright in this space. Focal therapy technology space is exploding. Imaging is exploding. Artificial intelligence and MRI interpretation and prostate segmentation. So many exciting new things in the works that are going to improve our diagnostics and treatments. So me personally, I'm involved in water vapor thermotherapy on a clinical trial, and my focus has really been on clinical trials largely. I'm optimistic about new technologies in the space, microwave ablation, bipolar radiofrequency ablation, non-boiling histotripsy. All of these things are going to start to coalesce to define and find their role in this space. And I think everybody will have a role. And I don't think there's any single technology or solution that's going to fit every scenario. Given the volume of prostate cancer that we see, given the opportunity in terms of patients looking for treatments that are less invasive and that have a great focus on their quality of life, I think that this field is going to continue to grow and expand over the next few years.
Perfect. Thank you so much for your time. Before turning off this episode, I'd like to ask my guest a final question, unprepared, sorry, about their song of the moment. Which one is yours, Dr. George?
The song of the moment. That's a great question. I'm going to tell you what it is. Let me pull up my playlist here. All right. So a couple of songs. One is this is an oldie but a goodie. It's a groove theory. Tell me by now and latest. The other one that I'm liking right now is Real Love by Retrowaves. Wow. So check them out.
Perfect. Looking forward to hear that. So thank you so much. And I hope you will join us for another episode in the future with me. I'd love to. Thank you so much. Bye-bye. Have topics you'd love us to cover? Share your ideas in the comments or connect with us on social media. Your input guides the future of Pros.Talk. Thanks for being a crucial part of our community. For more urology insights, visit Kallis.com. Stay tuned and see you next time.
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