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The challenge is,
first of all,
to get the right patient,
to make a patient selection as good as possible,
which is one of the main drawbacks in focal therapy,
that we have no option to really classify the patient as a patient with a unifocal clinically significant cancer patient.
Most of them are multifocal,
and the better the imaging is,
the better the fusion device is,
the better we will know if this is a patient for focal therapy or...
not but better for a radical treatment.
Welcome to today's episode of Prostatalk,
where we're diving into a topic that makes some folks scream in their seats.
The latest perspectives on prostate cancer treatment in Europe.
Now we know prostate health isn't always a comfortable conversation,
but trust us,
It's time to face it head on,
or should we say sit down for a while.
Today with Professor Ganser,
we will explore groundbreaking innovations that are making prostate cancer treatments less invasive.
Professor Ganser is a German neurologist with extensive experience in the treatment of prostate cancer and a particular interest in focal therapies.
From advanced therapies to the future of diagnosis,
we've got all the info to help keep...
things flowing smoothly.
So whether you're here to stay informed or just love a good Prostatpoon,
you're in the far right.
Hi DataGanzer,
welcome to our podcast Prostatalk.
We are currently attending the DGU Congress in Germany,
in Leipzig.
How are you today and how is the Congress going?
Morning,
I'm fine today and as every year the
DGU Congress is very interesting,
very busy,
very interesting.
topics running parallel,
so I'm quite happy to be here.
Perfect.
Before starting the interview,
could you please present yourself to our listeners?
Yes,
so my name is Roman Ganser.
I'm a urologist and started my training in 2003,
where I started my training at the
University Hospital in Regensburg,
where I was trained for about 10 years.
There I got...
experience and training in the fields of laparoscopy,
but also in Haifu.
These days,
we performed mainly whole gland Haifu and then later switched on to go to focal therapy.
Then I got the chance to switch to Leipzig in 2013 as the vice chair of Professor Stolzenburg,
where I got the chance to get training in robotic surgery,
mainly prostate cancer,
but also other entities.
And I was able to set up a focal therapy plan or fields,
including prostate fusion biopsy with a Coalesce device.
I was very lucky to conduct a multicenter focal therapy study with Haifu,
where we did hemiablation.
And in 2017,
I was able to set up a completely new department in Bad Tölz,
where I'm working right now,
south of Munich,
very nice region in the Alps.
I was very happy to get all the equipment that
I wished I had.
So a robot,
but also a fusion biopsy device.
And yeah,
for a percentage of patients,
we are offering focal therapy there.
Sounds fascinating how many topics like robotic surgery,
focal therapy.
Thanks for this nice presentation.
So let's now talk about prostate and especially focal therapy,
if you want.
First,
could you tell us more about your practice?
Okay,
so my daily practice is quite busy.
So my normal day is packed with four or five operations that I'm doing,
mostly two robotic surgeries,
but also endoscopic procedures.
But on two or three days,
we are doing a lot of fusion biopsies and by the selection of very good MRI.
Around 70% of these patients come back with prostate cancer.
So quite a lot of these patients are seen in our department and need treatment.
So we have the option to offer radical prostatectomy or other options like ectosurveillance.
But also we are trying to find good candidates for focal therapy among these patients.
What kind of therapy are you performing?
You mentioned IFU previously.
On the IFU,
do you perform also with the other energy and what are they?
The field of focal therapy has evolved tremendously during the last years.
We see many technologies,
but the only technology I'm experienced with is HIFU with the Focal One device,
which is a very good technology for mainly treating basal tumors,
tumors at the dorsolateral aspect of the prostate.
But if I had the chance,
I would always recommend somebody who is starting with focal therapy to have another option,
mainly a needle-based.
technology to treat anterior tumors because these are the ones I would not treat with HIFU because they have inferior results,
they have morbidity and so on.
So that's the only technology I'm experienced with that's HIFU.
That's very interesting and I have a practical question about that.
What would you advise to a colleague for example that would like to perform focal
If this colleague has the chance to have a list of devices he needs,
then first of all,
he needs to start with a good diagnostic device,
which is
MRI fusion biopsy device,
or maybe a high-resolution ultrasound device.
Then he needs one technology to perform the treatment.
It doesn't necessarily have to be bought at the beginning.
So there are rental models that are possible to get one of these devices.
If he has the chance to get a second technology,
then he should try to get a needle-based treatment device,
either cryotherapy or IRE or microwave.
One of these needle-based treatments that are performed perineally to treat anterior tumors.
So that's the complete package to perform focal therapy in a good setting.
And you mentioned good fusion biopsy systems.
The challenge is to guide precisely the needle of the energy,
right?
to make a good treatment?
Yes.
So the challenge is,
first of all,
to get the right patient,
to make a patient selection as good as possible,
which is one of the main drawbacks in focal therapy,
that we have no option to really classify the patient as a patient with a unifocal clinically significant cancer patient.
Most of them are multifocal.
And the better the imaging is,
the better the fusion device is,
the better we will know if this is a patient for focal therapy or not.
But...
better for a radical treatment such as prostatectomy or radiotherapy.
So everything starts with good diagnostic workup and for that we need a good radiologist performing good
MRIs that we use for
MRI fusion biopsy.
And do you work with your own radiologist in your hospital or sometimes patients can make their MRI outside of the hospital?
And do you have some issue with that when the patient arrives with this MRI?
Yeah,
so the radiologists,
especially in my department,
they are not experienced with a multi parametric MRI.
But in the neighbor hospital,
we have very experienced radiologists performing a multi parametric MRI since many,
many years.
And they always check with two colleagues for the final result.
And they make very clear reports.
So either it's pirates two or four or five.
So they very rarely classify a patient with a pirates three lesion,
which might be either
BPH or cancer.
So the more often you have a radiologist reporting pyro 3,
the unsafer he is.
So then you should change the radiologist.
So most of our patients are coming from this department,
but as I mentioned,
some come with their own results and they are of differing quality.
So in another way,
it's like a teamwork with the radiologist,
the patients,
and you are urologist,
right?
It is.
And they need feedback.
feedback.
So everybody who wants to start a focal therapy program,
he needs to be in a very good team with the radiologists and everybody needs to learn from the other parts.
And they're very happy if they get the prostatectomy results back to see if their classifications are right or if they have to improve.
So that is very important for the beginning.
And according to you,
why should urologist offer focal therapy option to their patients?
Because not every patient is either an active surveillance candidate or a candidate for a radical treatment.
Patients get older and the older they get,
the worse the side effects might be following radical treatment.
No matter how good you're doing the surgery,
continence will decrease with rising age because of decreasing muscle strength of the pelvic floor and so on.
So younger patients definitely run better,
run very good today if you're doing the
the da Vinci prostatectomy in a high quality,
but older patients will have some leak,
no matter how good you are at the surgeon.
And these are the patients,
in my opinion,
that might prefer from a treatment which either cures the patient or which turns the clock back.
which reduces the aggressiveness of the tumor and either cures him or gets him into an active surveillance patient.
And these are the candidates that should offer such a treatment.
It's not a treatment as an alternative to active surveillance,
but it's an alternative to any radical treatment.
So it's no psychotherapy,
it's a cancer treatment,
what we have to do with focal therapy.
You put the patient before your practice,
I mean it depends on the patient and the stage of his disease that you will choose active surveillance or radical prostatectomy or focal therapy.
So it's all matters about patient,
right?
Yes.
Okay.
What is the situation in Germany or in Europe in general?
I mean today,
do you have any special program for focal therapy like reimbursement for example,
or was it missing to make this type of program available in Germany?
We have different situations in European countries.
We have a reimbursement for
HIFU treatment in Germany.
There is a recommendation in France for reimbursement,
which was spoken in 2023,
but there's no decision yet.
There's a reimbursement since last year in Switzerland for
HIFU and focal treatment,
which is about half the reimbursement compared to a radical prostatectomy treatment,
but which is...
enough to cover all the costs and i'm not sure about the situation in in the uk with the nhs but they are doing a lot of haifu and focal treatments there but in germany it's only what
i'm what i'm saying it's only for haifu so i'm not sure about all the other new technologies such as ire such as laser such as microwave there's as far as i know there's no reimbursement situation for that
So these patients should go into any study protocol,
mainly at university departments,
hospital departments.
But I think in the normal setting,
it's difficult to get these patients reimbursed.
And are you part of some research program on your side?
Do you work with other physicians on this subject?
We finished a multicenter study in 2017.
All these results are published,
but our intention is to make a new follow up.
investigation on these patients to see what happens after seven and eight years of these patients.
Our patients are included in the registry right now,
but there's no prospective study that we are doing right now.
Okay,
perfect.
And Professor Ganza,
how do you see the treatment of cancer in the future?
How will technology help physicians?
Will patients be more educated about it?
Will focal therapy become a standard of care?
What is your vision of that?
Yes,
I think many aspects will change and improve in the future and maybe in the near future.
So first of all,
starting with screening and classification and imaging.
So let's start with imaging.
I think that multi-parametric MRI will be added by other imaging modalities like PSMA PET
CT scan and by artificial intelligence.
Especially MRI has a very high...
inter-observer variability.
If you look at the results,
there are studies showing that the same tumor is classified completely different among experienced radiologists.
And we have AI platforms that really show better results than the radiologists.
So I think that this will be the future of imaging.
When we perform better biopsies,
there will be probably help for the pathologists to
to classify the tumor,
probably also by artificial intelligence to classify the tumor as aggressive or not.
And there will be genetic testing for the patients to see like the BRCA mutation,
BRCA1 or 2,
to classify the patient having an aggressive or less aggressive cancer.
And this will probably improve classifying patients for either being candidates for active surveillance,
focal therapy.
or radical treatment.
So I think there will be a lot of improvement.
I'm not quite sure if technology of focal treatment devices will improve a lot.
That's my great wish.
But if we look at HIFU,
the devices are like 10 years or older.
I don't see too much technical improvement.
And a lot of other technologies coming on the market like microwave or IRE,
they have the potential,
but let's see what the future brings.
So I'm not quite sure if...
focal therapy will become standard.
So it's my great wish to have focal therapy somewhere in between radical treatment and for some patients also at this point,
but I'm not quite sure if this will become a clear standard.
Okay,
thanks a lot for your time and for your answer,
Prosegenza.
What are your next plans now and new studies in the pipeline?
Yes,
so what I told you,
we had our meeting with the German working group on focal therapy yesterday,
our session,
and we were discussing about these projects.
We want to follow up these,
it was 51 patients being treated in the HEMI study.
which was the largest prospective multicenter study on focal therapy in Germany with a very clear follow-up.
So we had about 95% of these patients having re-biopsies.
And I'm very interested in the question,
what happened to these patients seven or eight years or even longer,
who received radical treatment,
who is fine with focal treatment?
Because a limitation of most of the studies and technologies that we see in the literature is that the follow-up is not beyond 12 months.
So these are mostly feasibility studies,
but to know where the place of focal therapy is,
we need to know what is 10 years after a treatment.
Is it really turning the clock back,
or is it just some treatment which fails after a certain time?
So I think that's a very important step,
even if the results will be disappointing.
I'm not quite sure about that.
But what we know,
these patients had
much worse inclusion criteria and imaging and biopsy compared to what we have now as a standard.
I think these data will be important and might serve as a reference for upcoming studies,
which have much better results.
So we can't wait to follow these projects.
And I hope we will see you back here for presenting these projects.
Before ending this interview,
I like to ask my guest a surprise question,
Professor Genza.
Thank you.
What is your song of the moment?
I'm a fan of classical music because I play the cello.
So especially here in Leipzig,
I was working here for four years and as a student,
and I was joining a lot of the concerts in the Gewandhaus.
I was a fan of the Gewandhaus Orchestra,
but that's like a hobby for me.
So I'm also interested in jazz music.
And when I'm cycling,
I also listen to trance and motivating music.
But I can't give you a question on that final special favorite song right now.
Thank you so much.
Thanks again for your time.
And I hope you like the exercise and feel free to visit us again in this podcast.
So thank you very much for inviting me.
It was a pleasure.
Thank you.
Huge thanks to our dedicated listeners.
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