WEBVTT

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This podcast is created by Coelis.

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I try to think about it.

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If this was my own family member,

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what would I want in that scenario?

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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.

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Dear Prostatalkers,

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welcome back for a new episode of our podcast.

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I'm your host,

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Thomas,

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and today we are embarking on a journey through time,

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from the early days of prostate cancer diagnosis to the cutting-edge realm of localized therapy.

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Joining us for this enlightening discussion is Dr.

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Ovin George,

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a trailblazer in the field of urology who has witnessed firsthand the evolution of prostate cancer management.

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From traditional diagnostic methods to the revolutionary advanced in focal therapies,

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Dr.

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George Hassinilor.

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In this episode,

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we'll trace the remarkable journey of prostate cancer care,

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exploring the pivotal moments,

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the groundbreaking innovations,

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and the future possibilities.

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Hi,

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Dr.

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George.

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We are really pleased to welcome you.

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We are live from the 2024 AUA Annual Meeting in San Antonio,

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Texas.

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place to be for urologists this time of year.

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How are you today and how is the new AUA edition?

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Thank you so much,

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Thomas,

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for the invitation.

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I'm so pleased to be here.

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AUA has been great so far,

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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.

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We are really glad to have you for this podcast.

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Before we start this insightful interview...

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Could you please tell us more about yourself,

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your background and your urology practice,

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of course?

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Yeah,

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I'm a urologic oncologist.

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Like all of us,

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I started with my residency,

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which was at,

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now it's called Northwell Health in Long Island.

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I stayed there for an endourology fellowship with focusing on minimally invasive surgery and robotics.

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And then completed a three-year urologic oncology fellowship at the National Cancer Institute,

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with really a focus on prostate,

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image-guided diagnosis,

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image-guided treatments.

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And then subsequently was a faculty at the University of Michigan for a number of years,

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and most recently have joined

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Johns Hopkins as a staff and helped lead the prostate cancer programs there.

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Great.

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I'm a little bit curious.

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So can I ask you,

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why did you choose urology?

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You finished medical school with so many options.

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What was it that attracted you to this field of expertise?

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Well,

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Tomas,

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I'm going to be honest with you.

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I was trying very hard to avoid urology.

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My father is a urologist,

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and I felt like I did not want to be compared to somebody who is a great doc.

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And however,

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that is what gave me my initial exposure to urology.

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As I learned more and more about the field,

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I really loved it.

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You know,

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the opportunity really for innovation,

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complex surgical procedures,

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simple procedures,

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longitudinal follow up with your patients,

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a really,

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really grateful patient population.

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And it just ended up being the right fit for me.

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And thankfully and fortunately,

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I was afforded the opportunity to do a residency and become a urologist.

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Perfect.

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Very interesting.

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Dr.

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George,

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let's go to the heart of the matter and let's talk about prostates.

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First of all,

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are you a fan of transrectal or transparenal approach when doing biopsies?

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That's a great question.

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I think that this year it's becoming a little bit more murky with the addition of some new randomized control data.

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I will say that I personally made the switch to transperineal biopsy in 2017.

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And transperineal biopsy is really my default biopsy,

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though I do believe you can get a good biopsy with a transrectal procedure.

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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.

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So really,

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the reason that I prefer transperineal biopsy,

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of course,

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there's the reduced potential risk of infection,

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but is the antibiotic stewardship.

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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.

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I don't do any enemas prior to the procedure.

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They're allowed to remain on baby aspirin.

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So the logistics of the procedure is so much easier in terms of patient preparation.

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And I feel like I can do a better biopsy.

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We can't agree with you more.

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Are you performing this under local or general anesthesia?

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Maybe both.

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And can you provide some insight in your preference?

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Yeah,

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so the vast majority of patients that I do are going to be done under local anesthetic,

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I would say 90 plus percent.

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I think even with transrectal biopsy,

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there's always a number of men who may have significant anxiety,

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or we may really need them to be still to get an accurate biopsy if they've had multiple prior negative biopsies,

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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.

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The vast majority of cases were able to complete very successfully under local anesthetic with a good patient satisfaction as well.

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As we know,

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the transrectal approach has been the go-to for biopsies in the past.

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And now,

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like yourself,

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we are seeing many urologists make the transition over the transperineal,

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and some of them came to this podcast to share their experience.

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Can you tell us a bit about the clinical reasoning and your personal experiences?

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Yeah.

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So the problem has been historically that we've had rising rates of infections.

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I remember sitting in residency through our mobility and mortality conference and almost...

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every conference,

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when you're in a practice with a high volume of biopsies,

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we would see an infection here,

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an infection there,

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and despite doing everything we can to help mitigate those risk of infection.

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And we've tried everything,

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needle disinfection techniques,

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augmented prophylaxis,

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culture-directed antibiotics.

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All of those things add additional layers of complexity to the biopsy procedure for both the provider and the patient.

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To be honest with you,

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Thomas,

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transpironeal biopsy was just the simplest solution.

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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.

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Really transformative.

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You are absolutely right.

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To take this biopsy topic a step further,

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it's my understanding that you are someone that believes in utilizing image fusion in performing prostate biopsy.

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Could you tell us about your perspective on MRI ultrasound fusion and why you find it beneficial in your practice?

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Yeah,

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I think that every single thing that we do in medicine has benefited from image guidance.

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And we look at any solid organ malignancy,

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it is not sampled in a blind fashion.

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And so transrectal ultrasound alone just gives us guidance in terms of where we are in the prostate,

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understanding the anatomy.

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But

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it's very challenging to identify discrete areas of suspicion because the specificity of anything on ultrasound is really,

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really low.

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And so for me,

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I try to think about it.

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If this was my own family member,

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what would I want in that scenario?

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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.

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This is true.

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Precision really matters in prostate care,

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which brings me to my next question.

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I have heard that you are quite pioneers in focal treatment for prostate cancer.

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Could you please tell us more about that?

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Yeah,

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I'm really bullish on the potential of focal therapy and the potential that it has.

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And so I think that we're not quite there yet in terms of saying,

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hey,

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this should definitely be a standard of care treatment.

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We don't have that long term randomized control trial comparative evidence data,

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but it's coming.

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And we are starting to accumulate more and more evidence and understanding a lot more in the space.

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Now,

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we know the limitations of radical therapy.

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We are not benefiting every person who undergoes radical therapy,

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and we are certainly exposing them to excessive morbidity.

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And that's where I think focal therapy has the potential to fill that treatment gap where there's a critical need.

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You may not be appropriate for surveillance.

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And really,

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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.

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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.

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What is the current landscape in the

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United States when it comes to focal therapy treatment for prostate cancer?

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Is there a general consensus on this topic?

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You know,

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there is not a consensus.

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I will say that there is cautious optimism from those of us who perform focal therapy,

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but there are also many people who appropriately are questioning its viability,

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its relevance,

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given what we do understand about prostate cancer today,

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being multifocal,

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and given the outcomes of different treatment modalities.

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That being said,

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I think that

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We are starting to learn more and more.

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And as our imaging techniques have gotten better,

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as we're able to more appropriately risk stratify men,

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as we're more appropriately be able to localize disease,

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that's what has really made focal therapy a viable option.

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We can see it.

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We can treat.

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We know where to go,

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exactly how to treat it,

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and we can get an accurate representation.

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Now,

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historic treatments,

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like you mentioned before,

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Tomas,

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like surgery and radiation,

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these are a one-size-fits-all approach.

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And we really do need a more precision approach to these treatments.

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And I do believe that focal treatment allows us to provide an individualized treatment to that patient and their prostate cancer,

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rather than putting a prostate in the bucket,

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regardless of what the pathology is.

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And what kind of focal treatments do you offer to your patients?

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And what is your process for when to utilize various focal modalities?

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Yeah,

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so I've really tried to understand and get experience with as many different focal therapy technologies as possible.

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So I have done conventional laser interstitial thermotherapy under MR guidance.

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I've done nanoparticle directed photothermal laser ablation.

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But what I currently use is high intensity focused ultrasound or HIFU cryoablation.

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I do water vapor thermal therapy on a clinical trial.

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Also,

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irreversible electroporation.

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Those are the main technologies that I personally have experience with.

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For me,

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I really prefer to use HIFU in smaller glands,

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in posterior zone,

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and percutaneous procedures such as cryo,

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IRE,

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in the anterior gland.

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I do have access to the Tulsa Pro machine.

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I'm looking forward to getting some experience with that technology as well.

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And how do you choose which treatment for which patients?

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That's a great question.

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We need to understand the patient's disease risk and understand the disease characteristics.

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Is this a large volume ablation?

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Is this a small volume ablation?

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Because that's going to impact which technology that you choose.

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We want to understand what is the location of the tumor and what are the characteristics?

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Is there suspicion for extracapsular extension?

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Is it close to the urethra,

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bladder neck,

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apex?

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And based on those factors,

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we can determine which is the best treatment.

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So for example,

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if I have an

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anterior periurethral tumor.

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That's a cancer that I would really favor irreversible electroporation,

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which is largely athermal and won't succumb to thermal sink that can happen if you have a warming catheter during cryoablation.

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Alternatively,

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if I have a lesion,

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let's say,

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at the apex of the prostate,

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that's where I think HIFU has the opportunity to shine because of the focal zones are so small,

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you can really sculpt that treatment according to the true shape of the prostate.

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And if tomorrow a physician says,

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hey,

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I want to implement a focal program for my patients,

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what advice would you provide them?

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The first thing is going to make sure that you feel that you're confident in your imaging.

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If you have good imaging and a good radiology partner,

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then that's going to be half the battle.

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The second step is going to be just doing it.

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There's a lot of inertia in terms of being able to get started.

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It can feel overwhelming to how do I choose the right patient?

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What's the technology that I start with?

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You know,

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you may not be able to treat everybody and everything with a single technology or a single approach,

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but you need to overcome that barrier.

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And so really,

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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.

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And you identify patients that will fit within that specific treatment and start your treatments.

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Once you gain some experience,

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you start to understand your outcomes,

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your patient experience.

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Then you can expand your portfolio to.

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other technologies to provide a comprehensive focal therapy solution to your patient population.

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Thank you for this enlightening discussion.

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Before we wrap up,

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can you share with us what are some current projects you are working on and your plans for the future?

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Absolutely.

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So the future is really bright in this space.

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Focal therapy technology space is exploding.

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Imaging is exploding.

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Artificial intelligence and MRI interpretation and prostate segmentation.

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So many exciting new things in the works that are going to improve our

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diagnostics and treatments.

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So me personally,

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I'm involved in water vapor thermotherapy on a clinical trial,

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and my focus has really been on clinical trials largely.

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I'm optimistic about new technologies in the space,

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microwave ablation,

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bipolar radiofrequency ablation,

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non-boiling histotripsy.

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All of these things are going to start to coalesce to define and find their role in this space.

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And I think everybody will have a role.

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And I don't think there's any single technology or solution that's going to fit every scenario.

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Given the volume of prostate cancer that we see,

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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,

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I think that this field is going to continue to grow and expand over the next few years.

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Perfect.

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Thank you so much for your time.

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Before turning off this episode,

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I'd like to ask my guest a final question,

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unprepared,

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sorry,

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about their song of the moment.

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Which one is yours,

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Dr.

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George?

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The song of the moment.

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That's a great question.

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I'm going to tell you what it is.

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Let me pull up my playlist here.

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All right.

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So a couple of songs.

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One is this is an oldie but a goodie.

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It's a groove theory.

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Tell me by now and latest.

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The other one that I'm liking right now is Real Love by Retrowaves.

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Wow.

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So check them out.

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Perfect.

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Looking forward to hear that.

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So thank you so much.

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And

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I hope you will join us for another episode in the future with me.

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I'd love to.

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Thank you so much.

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Bye-bye.

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Have topics you'd love us to cover?

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Share your ideas in the comments or connect with us on social media.

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Your input guides the future of Pros.Talk.

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Thanks for being a crucial part of our community.

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For more urology insights,

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visit Kallis.com.

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Stay tuned and see you next time.