Treating Prostate Tumors in 5 Sessions

 | MedStar Georgetown University Hospital was the first hospital on the East Coast to offer CyberKnife technology. Our team is among the world’s most experienced CyberKnife sites having treated more than 2,400 patients with prostate cancer and performed more than 35,000 treatments in total. Unlike traditional radiation that’s given in 40 sessions over eight to nine weeks, CyberKnife can treat prostate cancer in just five visits. Dr. Jonathan Lischalk, a radiation oncologist at MedStar Georgetown, discusses CyberKnife radiation therapy for treating prostate, and the advantages of CyberKnife over conventional radiation. For an interview with Dr. Jonathan Lischalk, or for more information about this podcast, contact MedStar Georgetown University Hospital Manager Media Relations, Ryan.M.Miller2@Medstar.net. Learn more about Dr. Lischalk.
| Learn more at MedStarHealth.org/CyberKnifeNow, or call 202-444-4255.

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Transcript

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Comprehensive, relevant and insightful conversations about health and medicine happen here on MedStar Health DocTalk. Real conversations with physician experts from the largest healthcare system in the Maryland DC region. MedStar Georgetown University Hospital was the first hospital on the East coast to offer CyberKnife technology. Our team is among the world's most experienced CyberKnife sites, having treated more than 2,400 patients with prostate cancer and have performed more than 35,000 treatments in total. You can count on our board certified specialists to provide the comprehensive and personalized care necessary to determine the Through our research engine, Georgetown Lombardi Comprehensive Cancer Center, we offer access to clinical trials and the latest breakthrough in cancer care. Welcome to MedStar Health DocTalk. I'm Ryan Miller and I'll be your host for today's episode. Today we're discussing CyberKnife radiation therapy and the advantages of CyberKnife over conventional radiation. We are here with Dr. Jonathan Shock, our specialty service director for the Geno Urinary Cancer Program. Dr. Lischalk specializes in CyberKnife treatment for men with prostate cancer. In addition, he is the MedStar Health Radiation Oncology Vice Chief of Clinical Research. Thank you so much for joining us on MedStar Health DocTalk. Thanks for having me, Ryan. So to start, I listed a number of titles for you. Can you walk us through these different roles that you have here? So to start off, Ryan, I am a radiation oncologist, which basically means that I treat cancers with radiation. I joined MedStar Georgetown to lead the genital urinary cancer program within radiation oncology as well as our radiation surgery program, which we use to treat a variety of malignancies, including in the prostate, CNS brain, spine, thoracic malignancies, things like that where we use very precise and high dose radiation to treat and cure these malignancies. Another aspect to my role here at Georgetown is to lead the research program within our radiation oncology department, and that includes being part of the Lombardi Cancer Center clinical Trials operation. So it's been an exciting leadership opportunity and research opportunity to really take some of the latest and greatest in radiation oncology and bring it to our patient population here in the Washington DC area to really move the field forward and optimize outcomes for patients We're so excited to have you on our team. Thanks again for walking us through that. Can you tell us about the CyberKnife prostate program here at MedStar Georgetown? So this is one of the most legendary programs. CyberKnife has been around for a couple decades now, and it was really kicked off here at Georgetown and a couple of other big time institutions, Stanford at NYU. So these are places that spearheaded and kind of pioneered this form of technology, and essentially what it is is taking a linear accelerator, which is essentially a machine that creates x-rays, placing it on this very advanced, almost futuristic robot and moving around a patient's body to deliver radiation, a very precise and conformal approach. This type of radiation was originally developed to treat brain and spine tumors by a neurosurgeon at Stanford. And over the subsequent years, we realized at the sites that I mentioned that we could really treat a lot of different cancers throughout the body using this technology. The ability of the machine to identify where a tumor is and deliver radiation to that area and from a variety of different angles and creating this very conformal, very precise radiation dose distribution around the tumor allows us to optimize curative radiation doses to the tumor and minimize radiation to surrounding structures. So it's one of these really fancy radiation machines that we have available to treat a variety of cancers. And what's really neat about this machine is that as time has gone on, we've realized all of the various types of cancers, stages of cancers that we can use to both cure and sometimes palliate patients that have variety of different malignancies. It sounds like we have a rich history with the CyberKnife. For those who are unaware, what is CyberKnife and how does it deliver the radiation? Ryan, unlike traditional radiation that's given in 40 sessions over eight to nine weeks, CyberKnife can treat prostate cancer in just five visits with radiation. It's a process that is minimally invasive. So term CyberKnife is a bit of a misnomer. There's no knife, there's no cutting, there's no pain, there's no anesthesia. Essentially, there's a bit of a lead up to a patient coming in for treatment, but once the patient comes in for their actual treatment, they will meet myself and my team, which is a really big team. This type of treatment cannot happen just on my own. I have a team of nurses and radiation therapists and physicists that all help create and develop a radiation plan for a patient that's personalized and unique to treat their specific cancer. And so when they come in for their first day of treatment, they'll meet this team. They will then go into a room where the CyberKnife machine is, they will lie down on a table and they will essentially have this machine move over their body. They won't see anything. They won't feel anything. Like I said, there's no cutting, there's no pain, there's no anesthesia. Sometimes the radiation machine will operate for as little as 10 or 15 minutes. Patient will get off the table and go home, and so it's almost like getting an x-ray. It's almost like going in to get a CT scan. It's a little bit longer than that, but you don't see anything. There's no pain immediately afterwards, and the patient can get off the table and go right back to work if they want or go home. It's great because it has a very limited impact on patients and quality of life and their day-to-day activities. Wow, it sounds like an incredible machine for sure. What are some of the benefits of CyberKnife compared and surgery? CyberKnife allows fewer treatments rather than conventional radiation therapy, which typically can be up to nine weeks of treatment Monday through Friday. So this is really minimizing the amount of time that this type of treatment takes up in a patient's daily life. The entire treatment takes at max 30 minutes, and because the treatment is non-surgical, there's no anesthesia, there's no incision, there's no blood loss. The recovery time is basically non-existent. In reality, we actually have decent data showing that radiation side effects are really no different than this nine week of treatment course that we used to do over the last five to 10, 20 years, and in fact might be a little bit less than using other types of machines. We are able to avoid the organs that are nearby, like the adjacent bladder and rectum and really protect these normal structures while maximizing radiation dose of the prostate and ultimately having this technology that's ultra precise that monitors where the target organ the prostate is in real time during the treatment and between the treatments, allows our precision delivery to minimize radiation exposure to these surrounding organs and maximize exposure to the target tissue, which is the prostate cancer. That's amazing that the treatment can take about 30 minutes, then people can go on with their day. Who would you say is a good candidate for prostate cancer with CyberKnife? What's interesting is that we've realized almost all stages of prostate cancer, a patient may benefit from CyberKnife. Early on, we focused CyberKnife SBRT on patients with low to intermediate risk prostate cancer, treating all those patients in five treatments. As time has gone on, we've realized that unfavorable intermediate risk could benefit from this type of treatment in a totally separate category of patients. Oftentimes, you might see a patient that has cancer that's spread out from where it started. For example, if the prostate cancer spreads into the lymph nodes or into the bones, there are situations where we can still use CyberKnife to treat these areas either in the prostate or outside of the prostate. So what's been very exciting over the last five to 10 years is our ability to expand the role of CyberKnife SPRT to treat patients of almost any stage. Obviously, this is something that we have to discuss with the patient in detail and evaluate based on their scans and their medical history, but I think we've really seen an expansion in the role of CyberKnife SPRT for a variety of stages in prostate cancer. How precise can the CyberKnife be? Like we talking down to the millimeter? Yeah, we can really get down there. There's some very interesting physics data that's been published originally out in California showing that only a couple of millimeters accuracy, precision that we're seeing here with CyberKnife. And this is happening not just when a patient's set up. It's happening between the treatments and happening throughout the treatment. So as you can imagine, the patient is under anesthesia, there's still some movement, even a patient is trying to lie perfectly still on a table. We have motion inside of our body that we don't even realize our bladder is filling, our bowels are changing. There's gas. There's really a change in anatomy that can occur even during treatment, even those 15 minutes. And so that's why the CyberKnife platform pioneered motion management more so than a lot of other types of radiation modalities very early on so that if there is motion, whether a patient has to itch, if they cough or if there's lying still and there's just internal motion you can't even control. The machine will see that, it'll see it, it'll stop, it'll reset, and that's how you get that level of precision. That's down to the millimeter. Wow. When it comes to pain, they might experience any discomfort after the treatment. There's nothing that the patient will notice during or shortly after treatment. When we think about side effects from radiation, what we're thinking about is cumulative effects. So it may be that towards the end of treatment, a patient might notice something. This is why our team of nurses and radiation therapists is so proactive in making sure that patients are assessed every single treatment that they are evaluated for any potential side effects, even minimal changes in their quality of life. We keep close track on, and that can occur shortly after treatment or towards the end of treatment, but oftentimes it's very minor. Now, this is something that we're not talking about hospitalizations. We're not talking about any types of procedures or surgeries that we have to do to manage these side effects. These are really usually minor. These are things that can be managed with adjusting somebody's diet or fluid intake to over the counter medications like NSAIDs, ibuprofen, to sometimes prescription medications that I can give a patient. And so we try to tailor the approach to managing side effects that most often are minor to what the patient is experiencing. I've and for the most part, people get through treatment quite well with minimal side effects. They may experience some things that have them want to be closer to the bathroom shortly after treatment, but beyond that, this isn't something where you're coming into the hospital and you have to get monitored in the ICU. This is something that doesn't have a massive impact on patient's quality of life. That's wonderful to hear, and they can drive themselves home afterwards, so it doesn't get much more convenient than that. Does CyberKnife treatment result in positive outcomes for prostate cancer? What we've seen over the last five to 10 years is really spectacular outcomes from a cancer cure rate. When we think about curing prostate cancer, we're not talking about 1, 2, 3 years down the line. We're talking about a decade later. And so as the data has accumulated using CyberKnife for SBRT to treat these types of prostate cancers, we've seen outstanding outcomes. And so when we think about outcomes, of course, the outcome for a given patient is going to be directly tied to the type of cancer that they're diagnosed with at the beginning. So if they're screened early and they have a low to intermediate risk prostate cancer, oftentimes we're seeing cure rates in the 90 95 percentile, sometimes even higher. Now, that doesn't mean patients don't need a follow up. I am very serious about patients coming back to see us making sure that we have any side effects or impact on their quality of life managed. And then at the time of followup, we'll be checking PSAs, and that's how we monitor the response to treatment. This is really the canary in the coal mine to identify if any cancer has come back. So we will get PSAs routinely as we see patients and follow up and making sure that their PSAs stay quite low. What's interesting is this is actually the same way that we monitor the response after surgery. And so when we look at radiation versus surgery, with the long-term randomized data that we've seen now published a couple of times, we're seeing the same outcome. So cancer can really be cured effectively with either radiation or surgery at equal rates. So again, it's going to be tied to the type of cancer you get diagnosed with at the beginning. As things get a little bit more aggressive, the cure rates go slightly lower. But one thing I'm excited about for Ryan is that we're trying to implement clinical trials here at MedStar Georgetown that take the next step for some of those more aggressive cases. And at the Lombardi Cancer Center, what we've been doing, and I've been working with a really amazing team of together some programs, some research and some clinical trials that can improve outcomes for patients to have more aggressive prostate cancer. And so that's what I'm really excited for in the future here in the next six to 12 months, I think we're going to be seeing some of these clinical trials open up so that folks that have more aggressive prostate cancer can really be optimized from a treatment standpoint and while paying close attention to minimization of side effects and maximization of quality of life. That's great to know that if you come here, you'll be receiving the latest advancements when it the CyberKnife treatment. Hearing. You talk about the research, your passion is very evident. What gets you most excited about this type of treatment with CyberKnife? Being a radiation oncologist is such a gift. It's such a great field to be in, and I've been passionate about it since I first discovered the field. One of the things that I'm so thrilled about being an oncology is the team that I work with. I mentioned the team within radiation oncology, which is an amazing group of residents and medical students and nurses and radiation oncologists, physicists, radiation therapists. It's just this incredible team of folks from top to bottom that you get to work with and take care of a given patient. And beyond that, we work with other departments. There is a lot involved in treating cancer, and so we have a lot of specialists that come to bear on a diagnosis like this, and that includes not only radiation oncologists, but urologists, medical oncologists, radiologists, pathologists. So these are the folks that read the biopsies after they're obtained or look at the MRIs once they're obtained to see where the cancer is in the prostate. And then the treating oncologist, including the medical oncologist and the urologist, all of us really come into play for a given patient's diagnosis. A lot of folks don't realize is that there's so much once a patient gets diagnosed with prostate cancer, a lot of the times there's a lot of communication that will happen before a patient even comes into the hospital to see us. We have a conference called a tumor board where all of these physicians sit down and one by one, we look at cases for a given patient to figure out what the best way to treat them is. For example, a patient might come in and they might be a candidate for both surgery, so a radical prostatectomy that's performed by urologist or they might be a candidate for radiation. So then how do you decide? Well, that's a tough question, and that's really where we start looking at the whole patient, the whole picture, what is this patient's medical history, what is the patient's current side effects? How is their urination pattern? What's the patient's preference? What would they prefer? All of this is taken into account, and so when we're in this conference, we're thinking about all that. And when we're seeing a patient in consultation, these are the questions that we're asking. So everybody's different. Everybody's cancer is different, everybody's medical history is different. And so the key here is personalization of care, and we do that with a multidisciplinary group of folks that are all experts in their field. And really the goal here is to optimize patient outcomes. Well said. Definitely not a cookie cutter approach here. Can you tell us about some of the research that you're involved with and something you really think will be beneficial down the road to patients? Yeah, great question. When I was before coming to MedStar Georgetown, I was up in New York City and one of the really exciting avenues of research that we were doing there was optimizing radiation, targeting it to the patient's specific area within the prostate. So when we talk about this, let's put it in the context of history, we used to just treat the entire prostate just like it was all the same in there with radiation one dose. But as time has gone on, we've developed newer imaging scans and different ways to target radiation with radiation planning and radiation equipment that can be, like I said earlier, very precise. So how are we trying to move the field forward? Well, we're taking, for example, MRIs and an MRI is where you really can see the inside of a prostate. You can see where in the prostate, the prostate cancer is really the most aggressive part of the prostate cancer is developing. And actually urologists already do this. When they're doing the biopsy, they take a biopsy of the whole prostate, but then if they see something in the MRI that looks fishy, they will biopsy that area a little bit more specifically. And once we get that information back, we take a look and we say, okay, so this is where the most aggressive prostate cancer is. So what we're trying to do in radiation oncology and what I was doing up in New York City is taking that radiological information, which is that the target within the prostate, and pairing that with the pathological information, which is historically we've used the term Gleason score or grade grouping, but also looking beyond just what we see in the microscope. Looking beyond that at the actual cancer genetics and epigenetics, we have some incredible tests now that you can send out and take a look at the genomic signatures that a cancer has. So we're looking at the DNA of the cancer, not the patient's D-N-A-D-N-A of the cancer, and seeing if there's any changes in that DNA, both the DNA itself and some of the epigenetic changes if this is a cancer that's more or less aggressive than some of the historical patterns that we've seen. But what we did is look at the genetic characteristics. We've paired that with the radiographic characteristics, and we've created a radiation plan that focuses some of that radiation, like a higher dose of radiation. The area that we see on the MR, I tie that to the genomic signatures and kind of figure out what the dose is actually. So rather than treating the entire prostate with one cookie cutter recipe, we're taking that information that's really personalizing cancer care for a patient, optimizing radiation dose to the area we see within the MRI and kind of doing that based on the genetic signatures. So there's so much in medicine that's moving so rapidly, we didn't even touch on some of the stuff within AI that we're using now. We have different characteristics that we can see on pathologic specimens that a lot of stuff that's been just FDA approved, that we can look at characteristics within the path sample and make decisions based on some of these valuations by ai. We're not trying to rest on our laurels here. We're trying to move things forward so that we can optimize treatment for patients. Now, I talked a lot about escalating radiation dose to the area within the prostate that we see that harbors the most aggressive disease. But what that also means is that if we can really escalate radiation to just that spot, maybe we can deescalate radiation to the rest of the area that may not be as problematic. How can that help a patient? Well, that could potentially lower radiation doses to other organs. Maybe the urethra could get a lower dose of radiation, the bladder, the rectum, every time we you're talking about making even more precise, even more precise, but also making sure that most of the radiation is going to the area that needs it, and minimizing the surrendering area. This is one of the terms that's been used historically was focal treatment, and that basically means radiation to a certain part of the prostate. What we're doing here is kind of creating gradations of radiation, heightening the radiation of the area within the prostate that harbors that most aggressive disease, and kind of lowering the radiation of the rest of the prostate that can really limit it and minimize some of the toxicity that you can see with CyberKnife. That's incredibly fascinating. And I never thought about cancer as having its own DNA, what a novel concept that is for an average show like myself, Dr. Ock, what is the latest research shown regarding long forms of radiation, roughly eight to nine weeks worth. In comparison to CyberKnife? Yeah, well, that's a great point. It's another history question almost. When we think about delivering radiation over nine weeks, what we're doing there is going Monday through Friday for nine weeks in delivering radiation to the prostate, but kind of this radiation cloud that's a little bit larger and less precise and almost more ambiguous. And the reason why we did that is that we just didn't have the imaging. We didn't have MRIs, we didn't have advanced machines like CyberKnife. We didn't have ways to track radiation treatment during the delivery of it. And so as a result, the cloud of radiation was a lot larger. And so when you're getting that nine weeks of treatment, that's a larger radiation cloud. And because of that, that's why you have to separate it out in those 40 plus treatments. What's interesting with CyberKnife is that, as we talked about, the precision, the monitoring of motion, the treatment planning that's advanced, the use of MRIs, all these things that take the most advanced equipment tight in that radiation cloud. It's really just surrounding the prostate with about a millimeter, a couple of millimeters there, and that allows us to deliver radiation and a larger dose of radiation a very quick way. So five treatments over about a week and a half, and we've known here at Georgetown that the outcomes have been outstanding. But what's interesting more broadly is that now we have randomized data as an oncologist and a researcher. The gold standard is randomizing data to figure out which is better. It's going head to head. This is head to head comparing longer courses of radiation with short course radiation. And what's really exciting in the last couple of years is that we have that now. It's been done. It's been done a couple times now, and what we see is that CyberKnife is a winner. We're seeing cancer outcomes that are basically the same long term. We're talking about five to 10 years here. We're seeing side effect profiles that are basically the same. We're seeing quality of life profiles that are very similar. The most recent publication that was in the New England Journal of Medicine, which is really the best journal that we have in medicine. It shows exactly what I just said. And this was an amazing trial published out of the UK by a friend of mine and showed that CyberKnife is an outstanding way to treat localized prostate cancer. And so we now have the data to say, well, we don't need the nine weeks. We can really go forward with the five days of treatment. And what's even more interesting and provocative is that that trial initially mandated people to use CyberKnife. It was actually an expectation in England for them to use it because they felt that that was the technology that might be an optimal way to treat. And there is some indication that patients that got CyberKnife on that trial might've done a little bit better from a toxicity standpoint, side effects standpoint. So that's why we're really excited about being able to offer it here at MedStar Georgetown. Why should a patient choose the radiation oncology department at MedStar, Georgetown University Hospital? Ryan? We talked a lot about technology and history and experience, and I think that is really, really important. But maybe the most important thing in my opinion that we have here at MedStar Georgetown and the Lombardi Comprehensive Cancer Center, really the only NCI cancer center in the region is a group of people, a group of specialists, a multidisciplinary group of folks who are here to treat and cure cancer and optimize the quality of life for patients. And so every day when I go in, it's a team of people from within our department and between departments that looks at a given patient and tries to figure out the best way to treat them, which regardless of whether I treat them with radiation or a medical oncologist that gives them targeted therapy or drug therapy or a urologist performs a prostatectomy, we're really not trying to offer a cookie cutter approach here. We are trying to take the best minds that we have and come up with a personalized and optimized treatment plan for every patient. And I think that's probably the most exciting and most important aspect to our MedStar Georgetown philosophy. No matter what is ailing you, we've got you covered at MedStar Georgetown University Hospital. I've learned a lot in our conversation today. So thank you so much, Dr. Lischalk, for your time. I've been talking with Dr. Jonathan Lischalk at MedStar Georgetown University Hospital in Washington, DC Thanks again for sharing your expertise with us on MedStar Health Doc Doc. Thanks for having me, Ryan. Learn more at MedStar health.org/cyberknife or call 2 0 2 4 4 4 4 2 5 5.