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HIFU prostate cancer treatment stirs debate

When Robert Abelson was told he had prostate cancer and needed surgery, he dreaded the possible side effects, which include impotence and urinary incontinence. So the 59-year-old Toronto home designer went looking for alternatives.

At the Man to Man prostate cancer support group, he heard about a procedure called HIFU - high-intensity focused ultrasound - and decided to discuss it with his urologist.

"He told me HIFU was expensive and it wasn't for everyone," Mr. Abelson said. But after considering the pros and cons, he opted for the approach.

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"Call me a coward but I was looking for a way to avoid surgery or radiation and I especially wanted to avoid the side effects everybody talks about," he said.

Early on Dec. 8, 2007, Mr. Abelson drove to a clinic in downtown Toronto. He was given a spinal anesthetic (an epidural) at 7:30 a.m., underwent the ultrasound treatment, rested a bit, ate lunch with his wife, then walked out at 2:30 p.m. without a prostate.

"Instead of cutting out the prostate, or destroying it with radiation, we kill the tissue by cooking it with ultrasound," said Jack Barkin, a urologist and partner at Can-Am HIFU. (The ultrasound is similar to the one used to break up kidney stones.) "HIFU has the same cure rate as other procedures but without the side effects," he said. "And the great thing is that patients walk in and literally walk out a few hours later."

Dr. Barkin stressed, however, that HIFU is not for every man with prostate cancer.

It is best for those whose cancer is located strictly in the prostate gland, whose prostate has swollen to the 35- to 50-gram range and who have a low to moderate Gleason score (a scale used to judge severity).

And, currently, it's only for men who can afford it. The procedure costs about $22,000, which must be paid out-of-pocket because HIFU is not covered by any provincial insurance plan in Canada.

Martin Gleave, director of the Vancouver Prostate Centre and a professor of urology at the University of British Columbia, said the lack of coverage is appropriate because HIFU doesn't make the grade.

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"I understand why it's attractive: People want a cure with no side effects. But I don't believe HIFU really offers that at this time," he said.

"I don't believe the public system should pay for a technology that is more expensive and with no efficacy data or clear benefit."

Dr. Gleave said the patients for which the ultrasound treatment is deemed appropriate often don't need treatment at all.

Rather, they are ideal candidates for watchful waiting - waiting to see whether symptoms of a slow-growing cancer progress before deciding on medical or surgical treatment, he said.

Dr. Gleave is also concerned that by undergoing HIFU, patients will have much more limited treatment options if their cancer returns.

Dr. Barkin, who is also an assistant professor of urology at the University of Toronto, said he practises watchful waiting, as well as a full range of surgical procedures, but he believes that HIFU is a viable option for some men with prostate cancer. (He also refers patients for radiation and brachytherapy, a procedure during which radioactive pellets are placed on the prostate to destroy cancer.) "The reality today is that 75 per cent of prostate cancer patients present at a point where they can undergo curative treatment and I believe we should be trying to cure them," he said.

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Dr. Barkin said that, if treatment fails, the HIFU can be done again. (The goal is to totally destroy the prostate but spare the nerves - so there can be residual tissue in which cancer may reoccur.) The same is not true of surgery or radiation. In fact, HIFU is often used as salvage therapy for those who fail radiation treatment.

He concedes that "there is not yet solid 10-year data" but the research published to date has demonstrated good results, with side effects comparable or lesser than those of standard surgery or radiation.

The cost, Dr. Barkin said, is also comparable to other treatments. Radiation treatment is about $18,000, robotic surgery $12,000 and standard surgery roughly $7,000, and hospital overhead costs are often not factored in for procedures done in the public system.

"The cost will come down if more people choose HIFU," Dr. Barkin said.

Currently, there are two HIFU machines in Toronto, and one each in Edmonton, Montreal and Niagara Falls, Windsor and London, Ont.

The aggregation of centres near the border is due to the fact that many Americans come to Canada for the treatment because HIFU has not yet been approved by the U.S. Food and Drug Administration (which is awaiting more long-term data). Some provinces, such as British Columbia, have also refused to approve the procedure, saying the data are not strong enough to allow the procedure to be done, even in the private sector. But it is approved and funded in some European countries such as England and Germany.

For his part, Mr. Abelson has followed the debate about the appropriateness and effectiveness of HIFU closely, but has no regrets.

"I'm a lucky guy: I have no cancer and I've had no side effects, major or minor. The only thing that bothered me was the catheter after the operation, but that was temporary," he said.

"I picked up my life where it left off a few weeks after cancer surgery," Mr. Abelson said. "I'm not one of those men who's looking back and disappointed he didn't examine all the options."

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About the Author
Public health reporter

André Picard is a health reporter and columnist at The Globe and Mail, where he has been a staff writer since 1987. He is also the author of three bestselling books.André has received much acclaim for his writing. More

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