HIFU Brings Intensity to the Prostate Cancer Fight

Most of us associate ultrasounds with diagnostic purposes. Think of those first images of a developing fetus or pictures of internal organs, which allow doctors or surgeons to determine a course of action. But ultrasound waves—when focused at high-intensity levels—can actually be a form of cancer treatment.

High-intensity focused ultrasound (HIFU) therapy—which originated in Europe, South America, Mexico and Canada—is gaining acceptance in the United States as a treatment for prostate cancer and other diseases. The procedure is noninvasive, has minimal recovery time and carries minimal risks. Above all, it can eradicate cancer cells while preserving healthy tissue. While HIFU is not right for everyone, it could be the right prostate cancer treatment for you.

What is HIFU?

During an HIFU procedure, ultrasonic energy is used to focus ultrasonic waves to increase heat and destroy an area of cancer in the prostate, explained S. Adam Ramin, M.D., a urologist and the medical director of Urology Cancer Specialists in Los Angeles.

"The idea is that by applying heat to those areas, we can kill the cancer but preserve the prostate," Ramin said.

The ultrasound waves used in HIFU are not high energy, but they become high energy through the focused concentration on one point, said Jennifer Linehan, M.D., a urologist and an associate professor of urologic oncology at the Saint John's Cancer Institute at Providence Saint John's Health Center in Santa Monica, California.

Focusing the energy of the ultrasound waves on one area increases the temperature of the targeted tissue to 176º Fahrenheit (80º Celsius). As the tissue is heated, the water inside the tissue cells bubbles up and ruptures the walls of the cancer cells. The patient's body then creates an inflammatory response, causing those cells to die and, eventually, scar over.

Linehan added that focal therapy is used to treat many different types of cancer, from kidney to thyroid to breast, with the goal of preserving the good tissue while treating the cancer.

"With focal therapy, you also preserve function and quality of life. That was the theory behind the HIFU," Linehan noted.

Is HIFU right for you?

Ramin explained that although HIFU was approved by the Food and Drug Administration as a treatment for every type of prostate cancer, it's most appropriate for patients with low-grade prostate cancer, meaning small areas of cancer or a small overall amount of cancer in the prostate.

Linehan added HIFU might be right for patients who:

• Are worried about quality-of-life issues stemming from treatment, especially erectile dysfunction (ED) and incontinence 
• Aren't candidates for surgery
• Are older than age 75
• Have to be on blood thinners

According to Linehan, one of the primary reasons HIFU has been growing in popularity as a treatment option for prostate cancer is because data indicates there isn't a big difference in survival rates for people with low-grade prostate cancer who undergo surgery versus those who choose active monitoring. This approach involves closely watching a patient's condition but not giving any treatment unless the condition gets worse.

While surgery used to be the standard of care for prostate cancer, research shows a 99 percent survival rate for people who had surgery, while active surveillance cases had a 97 percent survival rate. Prostate cancer is a slow-growing cancer, so overall survival rates are higher than those for other types of cancers.

The procedure is noninvasive, has minimal recovery time and carries minimal risks.

"We realized that if prostate cancer is not killing people, why are we doing invasive things that cause poor quality of life?" Linehan said. "So it became about assessing treatment versus quality of life. With surgery, they risk things like becoming impotent or incontinent. With HIFU, those risks become much less."

In cases where the cancer has spread to multiple spots in the prostate or there is a large amount of cancer, men may need to explore other treatment options, such as a radical prostatectomy, or the removal of the prostate.

"HIFU can be a viable treatment, although, like anything else with prostate cancer, not every treatment is the right treatment for every patient," Ramin said.

Risks and benefits

Linehan explained that HIFU and surgery have different risks. While surgery carries a higher risk of incontinence and ED, the main potential negative outcomes of HIFU are: 

• Increased urinary tract infections (UTIs)
• Bladder obstruction, causing problems urinating
• Bladder contracture
• Fistula (a very rare complication)

Conducted under anesthesia at an outpatient surgical center, HIFU allows patients to go home the same day. The procedure causes injury to the tissue, resulting in swelling near the bladder, so patients can expect to go home with a urinary catheter for about seven days before returning to the office to have it removed.

HIFU is used only in low-grade prostate cancer cases, so the risk for complications is typically very low. However, if several areas of the prostate need to be treated, more tissue will be affected, which can increase the risks.

"It's rare for any urinary complications to be long term, but it also depends on how many areas of the prostate are treated," Ramin said. "If they do the whole prostate gland, there will be more inflammation."

In the end, choosing your prostate cancer treatment is an individual decision that should take many factors into account.

HIFU is highly effective at treating prostate cancer—Linehan cited a 76 percent to 80 percent cancer-free survival rate at eight years for low-grade cases. Additionally, one of the main benefits of HIFU is that if it fails, meaning the cancer wasn't eliminated or it returns, the patient is still a candidate for surgery or radiation. The opposite is not true: If a patient chooses surgery or radiation first, they are no longer eligible for HIFU.

Linehan said the technology used for HIFU has improved vastly since the initial research concerning risks. Formerly, the procedure was performed manually by a doctor directing the focal point of the treatment. Now, technology allows automatic targeting with precision focal points, greatly minimizing the chances for complications.

How to talk to your doctor about HIFU

HIFU is gaining acceptance as a treatment for prostate cancer, but not all urologists offer it, so talk with your doctor to decide whether it's an option for you and where to receive treatment.

More insurance plans, including Medicare, are covering some or all of the treatment, which has helped increase HIFU's popularity. If your insurance plan does not cover any portion of HIFU treatment, the costs can be steep. According to Ramin, one treatment can run anywhere from $20,000 to $30,000.

Ramin said some urologists offer molecular testing, which can be done from a prostate biopsy, to help narrow down treatment options. The testing looks at various genes to provide a better indication of how aggressive the cancer is and what would happen with different treatment paths. This can guide both the patient and the doctor in deciding the best treatment option. However, this is not a standard test and is not always covered by insurance, so you'll need to talk to your doctor to see if it's an option that might benefit you.

In the end, choosing your prostate cancer treatment is an individual decision that should take into account your age, the type of cancer you have, your goals for treatment outcomes and how the treatment will affect your quality of life.

"Prostate cancer is one of the 'lucky' cancers in that there are so many viable treatment options, but it can also make people very confused about what is the best thing for them," Linehan said. "Choosing what's right for you is all about balance."