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September is Prostate Cancer Awareness Month – the most common cancer among Canadian men.
In fact, as many as one in seven will face prostate cancer in their lifetime. The good news is mortality from the disease has been declining since the 1990s, with current five-year survival rates standing at 95 per cent.
As treatments continue to improve, Dr. Sangeet Ghai is striving to offer less invasive options to patients. The watchword is “appropriateness.”
“Surgery and radiation are important therapies, but they present their own risks,” says Dr. Ghai, Vice Chief of Research and Abdominal Radiologist with the Toronto Joint Department of Medical Imaging (JDMI). JDMI spans UHN, Women’s College Hospital and Sinai Health System.
“After a radical prostatectomy or radiation, 50 to 60 per cent of patients will have erectile dysfunction or incontinence, and that possibility creates a lot of anxiety. But for patients with less aggressive disease, a less aggressive approach may be more appropriate and have a significant impact on quality of life.
"We are working now to offer more alternatives, both in diagnosis and in intervention.”
On the diagnosis side, Dr. Ghai and his team recently participated in a 2,000-patient prospective randomized clinical trial of a new high-resolution micro-ultrasound system for prostate.
The micro-ultrasound system delivers images with three times the resolution of conventional ultrasounds. It is hoped that the new system will provide a more precise initial biopsy and limit the need for an expensive MRI (magnetic resonance imaging) for the earlier detection of high-risk disease.
When it comes to treatment, he is in the midst of clinical trials assessing the effectiveness of MRI-guided high-intensity focused ultrasound (MRgFUS) and MRI-guided focal laser ablation (MRgFLA) for localised intermediate-risk disease.
These trials were enabled by Dr. John Trachtenberg’s vision and supported by Dr. Walter Kucharczyk’s Canadian Foundation for Innovation (CFI) grant to purchase and operate a high field MRI. Although focused ultrasound has been used for treatment of prostate cancer since the 1990s, the novelty of Dr. Ghai’s research is the addition of MRI and MRI-thermography to guide and measure the direction and intensity of the ultrasound beams.
With the aid of MRI, Dr. Ghai can guide the focused ultrasound beam or the laser fibers with absolute precision to the cancer, thereby avoiding damage to normal tissue, while receiving real-time thermal feedback that the cancerous tissue has been destroyed. Contrast scans done immediately after the treatment also helps confirm complete coverage of the cancerous area.
The Toronto JDMI was the first site in North America to use both of these technologies, which direct intense heat at the tumour under MRI guidance. Dr. Ghai gets instant feedback on the temperature during treatment, which means he can minimize the risk of damage to surrounding tissues.
“This is an outpatient procedure that treats just 10 per cent of the prostate gland, with about 90 per cent left intact,” Dr. Ghai says. “This means there is minimal risk of incontinence or erectile dysfunction.”
Dr. Ghai points to collaboration with Dr. Nathan Perlis and Dr. Antonio Finelli among other urologists at Princess Margaret Cancer Centre as an essential piece in moving treatment forward.
“It’s a true partnership,” Dr. Ghai says. “The urology team sees patients in the clinic and we review the cases at our multidisciplinary meeting to assess candidacy for image-guided focal therapy. Nathan is present for treatments in many cases too.”
Dr. Ghai believes the increased confidence that comes with real-time visualisation and feedback could encourage physicians to manage more of their intermediate-risk patients in this manner.
“We are always seeking the least invasive and most effective means of treating this cancer.”
about the Joint Department of Medical Imaging.