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Leading physician and Cyberknife pioneer, Jonathan Haas, MD, is the Chair of the Department of Radiation Oncology at NYU Long Island School of Medicine. In a recent conversation, Dr. Haas eloquently talked through the many treatment options for prostate cancer – and how bringing a holistic approach to treating the disease provides patients with more options for their care.
Program Notes
- Jonathan Haas, MD on the NYU Langone website
- Cyberknife company website
- NYU Langone: Prostate cancer treatment overview
- VIDEO: Dr. Jonathan Haas Explains How CyberKnife® Radiosurgery Is Used for Cancer Treatment
The Stay in the Game podcast is sponsored by MRIdian by ViewRay, unique in delivering MRI-guided stereotactic body radiation therapy (SBRT) for localized prostate cancer. As reported in JAMA Oncology earlier this year, MRI-guided radiation therapy – delivered with MRIdian – was found in a phase III randomized controlled MIRAGE trial to be superior in reducing the toxic GI and GU side effects of treatment, as well as significantly increasing patient-reported quality-of-life metrics.
For more information about MRIdian MRI-guided radiation therapy, or to see a list of participating healthcare institutions, please visit to viewray.com.
Episode Transcript
Announcer: Welcome to Stay in the Game, conversations about prostate cancer with Ed Randall. Here we’ll chat with doctors, researchers, medical professionals, survivors, and others to share and connect. This show was produced and shared by Fans for the Cure, a nonprofit dedicated to serving men on their journeys through prostate cancer.
The Stay in the Game podcast is sponsored by MRIdian, MRI-guided radiation therapy by ViewRay. MRIdian is used to treat a variety of cancers, including localized prostate cancer. As reported in JAMA Oncology, the phase three randomized control MIRAGE trial showed treatment with MRIdian to be superior to standard CT-guided treatment in reducing the toxic side effects. With MRIdian, over 80% of patients can complete treatment in as few as five outpatient sessions with few side effects. Talk to your doctor or to find hospitals where MRIdian is available, visit viewray.com.
Ed Randall: How are you doing, everybody? I’m Ed Randall, the founder and chief advocacy officer of Fans for the Cure. Welcome once again to our Stay in the Game Podcast.
My guest on this month’s podcast is a clinical professor and chair of the Department of Radiation Oncology at the NYU Long Island School of Medicine. And although he was not the first radiation oncologist to perform CyberKnife stereotactic radiosurgery, he is internationally recognized as one of the pioneers of researching and understanding the potential of CyberKnife technology, as well as teaching best practices and techniques to hundreds of oncologists around the world.
As though this were not enough, he and his close colleague at NYU, Dr. Aaron Katz, teamed up with Fans for the Cure for a successful free Community Screening and Prostate Cancer seminar at the NYU Long Island School of Medicine last December.
It is my great pleasure to welcome to the Stay in the Game podcast, Dr. Jonathan Haas. Dr. Haas, thanks so much for joining us and for many years of supporting our charity’s work in the prostate cancer community.
Dr. Jonathan Haas: Wow, what a nice introduction! My goodness! Thank you so much. I’m honored to be with you, my friend. You must have spoken to my dad about getting that introduction to me.
Well, thank you for having me. This really is an honor on every level. You know, I’m a huge fan of yours for many years, predating my having the honor of joining this wonderful organization on your medical advisory board you have. Both through your baseball, through your advocacy for men’s health, you’ve given us the honor to help do PSA screenings with you. So on every level, this is really an honor for me. So thank you.
Ed Randall: Well, it’s ours as well. John, despite a stellar and well-rounded career as a radiation oncologist, any current bio of you will surely include the word CyberKnife in the first or second sentence. Probably the first. But before we get into specifics about CyberKnife as a prostate cancer treatment option, here’s a question we constantly get at health events. Why is the word “knife” part of the famous brand name of a machine that provides radiation?
Dr. Jonathan Haas: Right. It’s a great question. So CyberKnife, just to take a half step back, what it is, it’s a regular radiation machine or linear accelerator that’s been miniaturized and placed on a robotic arm. And it has imagers built in to the floor of the machine, which are intelligent.
So to answer your question, CyberKnife was invented by a really brilliant, charismatic neurosurgeon named John Adler, who is a friend of mine from Stanford, California, from Stanford University back in the 1990s. His wife actually, believe it or not, was the one that named it. We had him at our course several years back. We got the history of the name.
The theory behind CyberKnife, which was initially invented for brain tumors, was to provide equivalent outcome for brain tumors that surgery would do with a knife. So that’s how the named “knife” got into CyberKnife. So you’re providing, hopefully the equivalent outcome of doing a surgical procedure, ie, with a knife, a scalpel, a [Bovie? 00:04:17] with an external beam, linear accelerate. So that’s how the name came about, through John Adler’s wife, believe it or not.
Ed Randall: Before we get into more detail about how the CyberKnife delivers radiation, would it be possible to back up for a moment? Can you describe for the 19 philosophy majors who have signed up for a podcast how radiation works?
Dr. Jonathan Haas: Radiation could be done one of several ways. The most common way is with external beam radiation. So you have a machine called a linear accelerator. And it’s called that because it accelerates particles of energy toward a tumor. The theory behind it was something called Bremsstrahlung. So if you’re driving a car like 100 miles an hour and you make a sharp left and all your momentum goes to the right, Bremsstrahlung is the Greek word for braking radiation.
So you have a particle of energy that’s accelerated super-fast and you have something called a bending magnet, which takes the beam of energy and bends it 90 degrees toward the patient. And that energy, that braking energy, no different from when you make your car go left is now focused toward the patient or toward the tumor.
So radiation works on the cellular level, those particles of energy damage the DNA of cancer cells. And the majority of it’s through something called the indirect action. So human beings are made predominantly water and the particle of energy breaks apart the water molecule and form something called a hydroxyl free radical. That free radical damages the DNA of cancer cell and prevents it from dividing.
The other way to give radiation is with internal radiation, something called brachytherapy. I used to be a proctor for doing the radioactive seeds. And that’s a different way to give radiation where you plant radioactive seeds, in this case into the prostate. And again, those particles of energy that are implanted will damage the DNA.
So that’s the way that radiation works on the cellular level. High particles of energy are directed toward the tumor, the energy damages the DNA and where a cancer cell would otherwise divide because of the damage to the DNA, it no longer does and it dies off.
Ed Randall: So when you and other radiation oncologists describe yourselves as marksmen, the balancing act of eradicating cancer while striving to spare healthy cells is what you’re talking about?
Dr. Jonathan Haas: Exactly. I’ve given a talk and you may have heard about this. I used the analogy that the prostate is like Grand Central Terminal. And there’s lots of tracks, there’s lots of things walking around there. And you want to give high doses of radiation to that target but minimize all the anatomy that’s going on around like a train trip.
So you have the prostate in the center, you have the bladder… I have a model, but I know it’s a podcast. So this is the prostate. You have a prostate here, you have the bladder sitting on top, you have the urethra going through the center and you have the rectum sitting right behind that prostate. So there’s really critical anatomy there and you’re trying to give super precise doses of radiation to the prostate, minimizing radiation to the bladder, minimizing radiation to the rectum, which is behind it.
So I always tell patients if I could give a gazillion units of radiation to the cancer, I’d cure everyone. Problem is you put a hole in the bladder, you’d put a hole in the rectum. So our job is to give very high doses, but safe doses of radiation to the prostate, minimize radiation to the normal surrounding anatomy.
Ed Randall: John, I recall from one of our earliest conversations that you began treating prostate cancer with CyberKnife in about 2005 or so. Was there an aha moment for you upon seeing the machine in action where you recognized it would be a game-changer, not only for future diagnosment but also for the direction of your career?
Dr. Jonathan Haas: You did your homework so well. So yes. So we bought the CyberKnife in like 2004, 2005 correctly. And we were initially going to get it for brain tumors because that’s what it was invented for. And there was a super charismatic radiation oncologist named Jay Friedland, who is from Tampa, Naples, Florida. Ironically, unfortunately, he actually died of cancer. But he was in his 40s, 50s, and he was doing CyberKnife for prostate cancer, and he was using a newer agent called [Amifos? 00:08:30] that was designed to protect the rectum.
He actually came up to give us a lecture on Emma Fosston for rectal protection. And his flight got canceled. It was a horrible day. LaGuardia’s flight got canceled so he had three hours to kill. So he gave us a talk on CyberKnife for prostate cancer, which is something newer that he was doing. So we had bought the CyberKnife for brain. Jay had given us this great talk on CyberKnife for prostate cancer. We went down to one of the Hopkins affiliate hospitals where they had a CyberKnife, and I thought I stepped out to the Starship Enterprise. I saw this robot moving and I saw this console on, I saw a therapist, and I’m like, “This is the coolest thing I’ve ever seen.” I was a young radiation oncologist.
We had just had a lecture on it for prostate cancer. We had a lecture on how to do rectal protection, and we kind of saw a need or an edge because the biology of this, and we can talk about that in much more depth, you know, the biology of prostate cancer supports giving larger fractions of radiation over a shorter period of time.
So it checked every box medically, it checked every box from patient’s convenience standpoint. But it was new. I mean, I was kind of terrified at the beginning. I went out for my training in one of the Hopkins Hospitals, and again, a gentleman who’s now a friend of mine named Mark Brenner was our proctor. We had hands-on for a week on how to use CyberKnife on patients.
And I remember we talked about the doses that we were given per fraction. And historically, radiation and prostate cancer, as you well know, was a seven, eight, nine-week course of everyday radiation. And Mark said, “Well, we’re giving this dose over five days.” And I guess my face went white. And he goes, “Yeah, I wore diapers my first week also.” That was his response to me. But that was the aha moment.
And then we started our program, as you correctly say, in 2005. We initially did it under the auspices of an IRB-approved protocol. So, you know, any time you do a newer treatment, and we can talk about some of the newest up there we have going on now at Perlmutter Cancer Center at NYU, Long Island.
But we did it under a trial because it wasn’t standard care back then. We were considered pariahs. Yeah, we were going from nine weeks down to five days. And the first 20, 30 patients that were done on study did fantastic. We opened it up to the world, we advertised, you know, because a lot of the doctors didn’t know about this. So we went directly to market. And for those of you in the New York area, you know we’re pretty aggressive with getting the word out about what we do. And we never really looked back.
So it was really, you know, to be honest, had Jay Friedland not had his flight canceled, you know, I think we probably would have done it. But that was the aha moment.
Ed Randall: Can you please go over the differences between the SBRT administered via the CyberKnife in five fractions and the nine weeks of conventional IMRT? And what are examples of the body parts and cancer types that do not work well with CyberKnife and would require the full nine weeks?
Dr. Jonathan Haas: Right. You know, we’re a full-service radiation oncology department. So while a big portion of my career is CyberKnife and specifically for prostate cancer, you know, I’m the chairman of a seven-person radiation oncology department. So we do IMRT all the time.
So prostate cancer, to take a step back, has something called a low alpha beta. What that means in English is it responds better to larger fractions of radiation given over a shorter period of time. And that’s unlike most of the cancers that we treat. So, for example, if you have a head, a neck cancer or a larynx cancer, it’s the opposite. It has a high alpha beta. So that’s going to respond better to smaller fractions of radiation given over a larger period of time.
Since the alpha-beta for prostate cancer is lower than the alpha-beta for the normal surrounding anatomy, in this case, the bladder and the rectum, you want to give larger fractions over a shorter period of time. If you have a cancer that is a high alpha beta using head and neck cancer, for example, your larynx cancer, tonsil cancer, you want to do the exact opposite.
Sometimes we’ll combine both treatments. Let’s you have a Gleason score ten, and we can have a whole discussion on Gleason score, when you have a more aggressive prostate cancer, we’re worried about treating you like a metastatic disease to the lymph nodes. Sometimes will combine both treatments where we’ll give IMRT to the prostate and the lymph nodes, and then we’ll finish up with an SBRT boost, the larger fractions at the end to the prostate. So we really kind of tailor the radiation to the individual.
Ed Randall: So let’s split hairs, no pun intended. How does CyberKnife differ from other available options that are out there, such as TrueBeam that also deliver hypo-fractionated radiotherapy with 1 to 2 millimeter precision?
Dr. Jonathan Haas: Great question. So we have a TrueBeam. I love true TrueBeams. These are our standard workhorse IMRT machine or IGRT machine. So most LINACs or most linear accelerator are something called the gantry, which means it moves in a circle like a record player as the beam arcs around. You can’t move out of the way when it sees the rectum. It doesn’t have that geometric ability where the CyberKnife is on an arm. It has an arm, shoulder and elbow, wrist and fingers.
So when it see the rectum, it’s going to move its shoulder, bend its elbow, flex its wrist, and come in a different angle. A CyberKnife is the only machine out there that can both track and correct in real-time. So a TrueBeam, you can put in a traditional marker, you can take a picture of the marker right before the beam goes on. But in that 2 to 5 minutes while the beam is parking around you, those machines can’t track and correct in real time. So if you’re off, you’re going to reposition the patient and then turn the beam back on or are you going to go fast enough that it doesn’t really make a difference. You do it rapidly.
That being said, I mean, there are fantastic radiation oncologists, colleagues of mine that only use a TrueBeam, that only use a MRIdian, and only use Elekta. I would let them treat. So it’s not necessarily only about the technology, it’s about the team using the technology.
So use the example. If you’re on an airplane, right, you want Sully to be your pilot regardless of what plane he’s flying. So, you know, the technology is important, but I think it’s as or more important as to the team using that technology. But I have colleagues that are at Memorial that use different machines, that are at UCLA that use different machines, that are at Georgetown that use different machines. And I would let them treat a family member of mine on a non-cyber because I trust that team and I trust their judgment.
Ed Randall: Let’s step back from the CyberKnife for a moment and talk about other issues in the prostate cancer world about which you might feel strongly, namely, the bunker mentality in approaching prostate cancer. You and Aaron, both in-person and on Doctor radio have eloquently made the case for a multidisciplinary approach. Describe this process for patients between you and Aaron and among other urologists and radiologists at NYU.
Dr. Jonathan Haas: Right. Thank you for that and thank you for noticing that. I first met Aaron, Dr. Katz, who is now chair of our urology about 11, 12 years ago when he was at another institution. He invited me on his radio show to talk about CyberKnife. And we just became really close friends right out of the gate. We just hit it off.
And Winthrop at the time, that sweat NYU Long Island, the name of it before we merged with NYU, didn’t have a chair of their urology department. So I went to our then CEO, I said, “I met this fantastic urologist who would be a great chair. He’s got ideas. He’s got electricity coming out of them. Could we try to recruit him?” And we did. An Aaron, to this day, when we meet for monthly chair meeting, which is tomorrow, he always slaps me in the head, he goes, “It’s your fault that I’m here.” That’s always the greeting 11 years later.
But we decided on the serious note that we were going to build a destination men’s health center. So you’re correct, many places if you go to the surgeon, you will be having surgery. If you go to the radiation oncologist, you will be adding radiation. If you go to the cryo surgeon, you will be having cryosurgery. We decided right out of the gate to have three three-person team for every patient. That team is the radiation oncologist, the neurologist, and the patient as an equal and third member of that team.
And we come up with what we think is the best treatment, which sometimes may be no treatment. Aaron’s opened my eyes to active holistic surveillance for watching it. And this is one of the few treatments that if you go to five different doctors, you will get five different opinions and they’re all valid.
So we decided to kind of take the silos down to make sure that every patient is seen both by the urologist and the radiation oncologists. Actually, interestingly, before we went to our electronic medical record 70 years ago, we used to have handwritten prescriptions for the radiation. And we made the urologist sign the radiation prescription with us because they had to agree. And if we didn’t agree, we didn’t treat the patient.
What really happened, it was actually interesting. When there were disagreements, not that there were many, it was usually the opposite of what you thought it would be. So as the radiation oncologists, I might think that the patient was better for CyberKnife. The urologist might think the patient was better for CyberKnife. So it was really kind of healthy kind of back and forth.
And we explained the issue to the patients. The other thing we did also, which I implemented, we started something called a Patient Mentoring program, where I’ve treated 6,000, 7,000 patients on CyberKnife in my career. This is my 26th year here and now my 16th, 17th year doing CyberKnife. So we keep the list of patients that wants to pay it forward that were all treated by us. And we have it stratified by their name, their date of birth, and when they finished.
So we try to match a patient with a mentor, or many mentors, and you can call these guys. They volunteered to be on the list. Are they happy? Are they unhappy? Would they do it again? So we really kind of open the hood for everything here. And we think that’s the best way to practice medicine.
You know, in New York, as you know, and probably many places, you know, we have a very educated patient population. They can go to fantastic medical centers within blocks of each other, which is great. I think it’s great. So we want patients to note that transparency in our department. Everything’s open. We publish our own data. We have our patients speak to our own patients. We encourage and mandate that the patient see both the radiation oncologist and the urologist. And you know, it’s part of our treatment. I think it’s the best way to practice medicine. Patients can kind of see through the BS in this area. They know when they’re being steered or push towards something. We never do that.
Ed Randall: We’ll pause for a moment for a brief word from our sponsor.
Announcer: The Stay in the Game podcast is sponsored by MRIdian, MRI-guided radiation therapy by ViewRay. MRIdian is used to treat a variety of cancers, including localized prostate cancer. As reported in JAMA Oncology, the phase three randomized control MIRAGE trial showed treatment with MRIdian to be superior to standard CT-guided treatment in reducing the toxic side effects. With MRIdian, over 80% of patients can complete treatment in as few as five outpatient sessions with few side effects. Talk to your doctor or to find hospitals where MRIdian is available, visit viewray.com.
Ed Randall: Another issue worth discussing is the US Preventive Services Task Force recommendations, both the initial Blockbuster in 2012 and when they walked it back slightly to a C that read more like a B in May 2018. If the task force’s main issue is to determine appropriate and proportionate treatment, then why is the metrics of recommendations solely related to testing PSA?
Dr. Jonathan Haas: That’s a great question. So, the initial guidelines were based on a flawed interpretation of several randomized trials. And on the task force was an OBGYN, a pediatrician, and a nurse. There was not a radiation oncologist, there was not a urologist, there was not a medical oncologist. So they incorrectly and I will say that with my neck out, made the recommendation that PSA screening should essentially be omitted. They did walk it back slightly.
So I accept the premise that not every patient needs to be treated. Quite the opposite, we have a very robust active surveillance program here. What I don’t accept, that if you’re going to get rid of what I consider to be the most effective cancer screening tool that we have incentive all of oncology, meaning a PSA, we’ll be back in the 1970s where we will be catching, you know, much fewer prostate cancer patients, but we’ll see the old time ones, the ones that present with bleeding, with bone metastasis, that won’t be curable.
So I do believe that patients should be screened, men should be screened. You can make the argument over 70. But even then you have a 70-year-old, you know, in this day and age you have 75-year-olds that are running marathon. So patients have a right to be screened, but they should know the treatment options. They don’t necessarily need to be treated.
Ed Randall: Just one more question about the task force. I think there was a study by Dr. Chen out in North Carolina in 2019 that demonstrated the increase in advanced-stage prostate cancer following the 2012 recommendation was already measurably significant a couple of years later due to reduced PSA testing. My question, do you believe primary care doctors have finally caught up and have begun ordering PSA tests based on the updated recommendations, at least for men ages 50 to 66?
Dr. Jonathan Haas: I think they’re catching up. I actually gave a presentation. We looked at our own data. I presented this at ESTRO in Singapore several years back and we did see stage migration because of that. Stage migration means you’re catching these patients later instead of being, you know, low risk or intermediate risk that are now high intermediate risk or high risk.
I think it’s catching up. It’s a great question. You’ve just prompted me to relook at our own data. My sense is that we are starting to, and it’s going back. And we do outreach all the time. You know, we had an event for Perlmutter Cancer Center on Long Island directed toward primary care. And we were still getting the questions about PSA. So I think the pendulum is swinging back. I don’t think it’s fully swung back.
Ed Randall: In a world where 95% of cases of prostate cancer are initially detected absent symptoms and via a blood test, should we be scheduling a ticker-tape parade for the PSA test? And that’s a rhetorical question. My actual question is this, for the three or four guys who have joined our men support group over the past month, what advice would you give to a man a week or two into a prostate cancer diagnosis?
Dr. Jonathan Haas: So I would tell them, take a breath. You know, prostate cancer is one of the few cancers that you have the luxury of time to do your homework. Make sure you seek multiple opinions, you know, from places that have respectable reputations. I think the finest ones are the ones that have an NCI-designated cancer center because they’ve gone through the rigor of getting that designation.
Most major cities have one or more. Speak to a surgeon, speak to a radiation oncologist. Speak to someone that does cryotherapy. Ask if you can speak to the patients treated there. If you find that you’re being pushed towards something, that’s not healthy, in my opinion. This is one of the diseases where you will have the luxury of time to seek 2, 3, 4 opinions.
Also, I always tell patients when they get this diagnosis, this is like a baseball bat—you’re gonna need a couple swings at this. And whatever you choose, don’t look back because the odds are you’re gonna be cured with your first therapy. And if you’re not, this is one of the few answers in oncology that there’s a second and third choice as a backup.
Dr. Katz and I have published multiple papers where he may have had a handful of patients that recurred after cryotherapy and we salvaged them with CyberKnife. Or I may have had patients that have the cancers come back after CyberKnife and he has salvaged them with cryotherapy and they’ve done fine. So you know, getting back to our team approach, you get a couple swings at this thing. The odds are, you know, nothing’s perfect obviously, but the odds are… my goal is to make sure that hopefully patients have a long life and something, not their prostate cancer, gets them a long time from now.
Ed Randall: We often see prostate cancer stratified as low, medium, and high-risk diseases. What are the PSA and Gleason score metrics for these three categories?
Dr. Jonathan Haas: It’s based on the D’Amico stratification. And Anthony D’Amico is a friend of mine. We both trained in Pennsylvania. He was about three years ahead of me. Anthony devised what’s called the D’Amico stratification, low-risk, intermediate and high-risk. So low risk, to answer your question, is a PSA less than ten and a Gleason score six. Intermediate risk is either a PSA between 10 and 20 or a Gleason score seven. And high risk is a PSA above 20 or a Gleason score eight and above. Intermediate risk can be broken up at the high intermediate and low intermediate based on whether it’s a Gleason three plus four or four plus three.
And to further drill into that, so when the pathologist, and now we’re moving toward Gleason grade, you know, 1, 2, 3, 4, 5, but when the pathologist looks under the microscope, they give two numbers to the cancer. The first is what’s called the major histology. What do most of the cancer cells look like? We give that a number from three to five. The second is the minor histology. What do the rest of the cancer cells look like? And we give that a number from three to five.
So a four plus three would mean most of the cells are more aggressive and the rest are less aggressive. That would be high intermediate risk. If it was a three plus four, that means most of the cells are less aggressive and the rest are more aggressive. That would be low intermediate risk.
Ed Randall: So that we know more about the categories of prostate cancer risk, which risk groups represent the best candidates to be treated by the CyberKnife?
Dr. Jonathan Haas: Well, now for many of our low-risk patients, we’re not treating at all. We’re putting them on active surveillance or active holistic surveillance. It means we’re modifying their diet, we’re modifying their lifestyle. The low intermediate risk I still think that the majority of those patients should be treated. High intermediate also, those patients sometimes will acquire hormones with the radiation. And the most recent NCCN guidelines have now been updated that you can consider SBRT, which is what CyberKnife is, Stereotactic Body Radiotherapy, even for high risk. So really all risk stratifications are becoming appropriate for SBRT, you know, be it CyberKnife or one of the other tools that’s out there.
Ed Randall: To be clear, CyberKnife works best for individuals with low and intermediate-risk prostate cancer. Then what are the ideal circumstances for what your NYU colleague, Aaron Katz, calls holistic active surveillance? And is it a worthwhile approach to consider confirming that particular treatment plan by adding a genomic testing component?
Dr. Jonathan Haas: Yeah. I love genomics. So there’s two major out there. One is Decipher, one is Oncotype. So genomics looks at the RNA of cancer cells. Active holistic surveillance has been felt and I believe to be an appropriate treatment for patients with low-risk prostate cancer. You know, Gleason score six, low volume PSA, and the low single digits. And most people do active surveillance. They put their head in the sand and hope nothing happens. We believe in something called active holistic surveillance. And Aaron’s kind of opened my eyes to this. With diet change, with lifestyle change, with supplements, minimizing external stressors, minimizing internal stressors, you may be able to push off treatment for months, years, or maybe even forever.
Genomics I love and I think it actually is great for patients that may be low risk by the book, but you look at the RNA, you know, the test goes out to California, it takes about three weeks to come back. If something you think is low-risk Gleason six, you know, PSA 5.5 or something like that, and you send their pathology off for genomics and it comes back high intermediate risk, meaning a decipher score, you know, maybe 0.5 or an Oncotype score, you know, higher, you know, those patients may not be appropriate for active surveillance.
Conversely, let’s say you have a patient has a Gleason seven, low volume three plus four and they’re interested in surveillance. This is where I think genomics are incredibly helpful. So let’s say I send the genomics off for the Decipher test, comes back three weeks later, and it comes back low risk. I’d be comfortable watching that patient, you know, because his genomics confirm what the patient wants to do.
So it goes both ways. I love genomics. You know, we’re using it now in our protocols to intensify or de-intensify therapy. So it’s been yet another game changer for us. You know, I feel like I’m Batman with my utility belt and it’s just one more thing I can put in there.
Ed Randall: Here is one we have heard from our men’s support group. Since it is problematic to go from radiation of the prostate to a prostatectomy and because so many diagnosed like the idea of the disease prostate in the garbage can, isn’t surgery the way to go when treatment is called for or are there real side effect gaps and other factors to consider when the choices come down to either CyberKnife or a prostatectomy?
Dr. Jonathan Haas: Great question. So most important thing is that the oncologic outcomes are equivalent. So we want to make sure whatever you choose, surgery, SBRT, cryo that the outcomes are equivalent. So there’ve been several randomized trials both looking at surgery versus radiation. There was the ProTech trial, which we can talk about, that came out of the UK. There was the PACE trial with randomized patients to SBRT versus surgery.
So I think pretty much everyone will agree that oncologic outcomes are the same, meaning your chance of being cured on a stage-by-stage basis are equivalent between surgery and radiation. So I’m a radiation oncologist. I don’t pretend that CyberKnife is better than surgery. And I also don’t think that surgery’s better than CyberKnife or SBRT. I think they’re equivalent.
To answer what you brought up earlier, that if you have radiation that’s difficult to do surgery afterwards, that is correct. However, in my opinion, you have as many or more salvage options if radiation doesn’t work and if surgery doesn’t work. So let’s say you have surgery to take it out. Let’s say you’re a Gleason score three plus four, you decide to have a prostatectomy by many of the world-class surgeons in our community, 90% of the time it’s gonna stay away. That still means 10% of the time it’s gonna come back if you flip the numbers, right? So where does it come back? Usually in the prostate bed where the prostate used to be. When one cell is left behind, one becomes two, two becomes four, four becomes eight, and so on. Then you have a rising PSA after prostatectomy.
In general, you only have one option. You can have regular radiation. You can’t have SBRT or CyberKnife because your prostate is in a garbage can somewhere on the fourth floor of my hospital or somewhere on 34th Street. Regular radiation will work about half the time. If that doesn’t work, you go on hormones. If it comes back after CyberKnife or any radiation for that matter, same 90% cure rate, right? So it still means 10% of the time it can come back. It’s difficult but not impossible to do surgery, but it is a more difficult surgery because things scar down.
However, you can have cryotherapy, which is freezing the prostate. Aaron is the world’s expert on that. In his hands, he can cure two-thirds of those patients that fail radiation. And cryotherapy can be done several times. So you actually have more options in the unlikely event that CyberKnife doesn’t work than you do in the unlikely event that surgery doesn’t work. Not that either one of us is planning on it not working.
Ed Randall: You’ve just addressed my follow-up, which is what is the biochemical recurrence rate of men following a radical prostatectomy for localized prostate cancer?
Dr. Jonathan Haas: Well again, it’s stage by stage. So if you have a Gleason six, you know, or low-risk prostate cancer, you’re looking at a 95% cure rate. So 5%. If you’re a three plus four, it goes to that 90% cure rate. So about 10%. If you’re a four plus three, drop to like 80%. And if you’re high-risk long term, it goes to the 60% to 70%. And stage by stage radiation’s equivalent.
Ed Randall: And one last question from the support group. Do CyberKnife and hypo-fractionization therapy allow for a re-radiation should follow-up monitoring indicate additional treatment? And does cryotherapy then also become an option?
Dr. Jonathan Haas: That’s a great question. So I had the privilege of moderating that very session at the Radiosurgery Society meeting several months back in Orlando and we had an entire session on re-radiation. So it is possible. The one area where re-radiation seems to be a little bit tougher is patients that have had prior prostate seeds or prior brachytherapy, those patients have a higher risk of side effects. So it’s theoretically doable.
I’ve never been an enormous fan of that. And the reason for that is that I have Aaron Katz as my wingman. So if you’ve given your best dose of radiation, which you’re gonna give the first time and it comes back, your hands are a little bit tied doing it again. It’s doable. But if I have Aaron Katz as my wingman and vice versa, who has a modality that the cancer has not seen in cryotherapy, we refer those patients for cryotherapy, so we can back each other up. But yes, it is possible to reradiate on a case-by-case basis.
Ed Randall: John, we’ve discussed improvements in diagnostics and significant advances in the treatment of prostate cancer. Still almost 35,000 men in the US will die of prostate cancer in 2023. Only lung cancer causes more cancer deaths among men in this country. Sure, a percentage of that number has to do with a percentage of population increase among men 60 and over. But still, what can we all do, doctors, charities, and the men in our communities to bring these numbers down?
Dr. Jonathan Haas: I mean, again, I’m still a fan of screening. Don’t put your head in the sand. I know you’ve been visionary on PSA screening. You know, we’ve had the privilege of helping you at Minor League ballparks. I drew blood at the duck’s game a couple years back. We’ve gone to Staten Island, we’ve gone to Brooklyn. Get screened appropriately. But get screened.
You know, I think that with research that’s being done with the genomics now, you know, making sure that what we think is low risk, intermediate, high risk really is that, and treating appropriately. I think there’s newer studies that are going on. You know, we have multiple studies going on at Perlmutter Cancer Center, you know, to intensify or de-intensify therapy.
So we’re doing a study now called the Intrepid Protocol, where we’re testing a novel hormonal agent called Darolutamide, which has less sexual side effects. And we’re integrating genomics into the radiation dosing to kind of change the doses based on how aggressive or not aggressive it is based on the genomic test, the Decipher test.
We’re doing things called simultaneous integrated boosts where we may treat the prostate to a certain dose and then use a more ablative dose to where will be something called the DIL, the dominant intra-prostatic lesion. So what that means in English, let’s you have a prostate looks like a chestnut or a walnut, but you have a big spot of cancer that PI-RADS 5 lead at the right base. So we’ll give the entire prostate some dose of radiation, but boost that area much higher.
And there’s data both in conventionally fractionated radiation and SBRT to do a boost to that area. So we’re doing that. So for me, again, I’m 56 years old, I’ve been doing this for 26 years and I’m as excited as I’ve ever been because all these new studies, all these new biomarkers, all these new genomics are coming out. So I have so many more tools than I had when I started in ’97. It’s really exciting.
Ed Randall: And I want to pick up on that, what you just said. It never gets old for me to be at the ballpark as you know, covering a game I’ve loved since there were three teams in New York City. Well, not quite that far. But I can hear it in the passion you have brought to this conversation. What is it that you love most about your job?
Dr. Jonathan Haas: I love everything. I always joke, you know, I kind of feel like I’m a low-level superhero. So my favorite patient is firefighters and the police officers, right? I mean, I love everyone, but I really connect with them. I’m a New York State police surgeon, so firefighters fight fires, police fight crime, and we fight illness. And my favorite part of the job, you know, at this point in my career, I love the medicine, but I love when patients come back. You know, I have a really robust follow-up clinic and I love when they come back, you know, 2, 3, 5 years later and we will beyond the cancer… who got married, you know, who had a christening, who had a breast, who had a bar mitzvah, who had a marriage, where your kids going to college.
That’s what’s keeps me young. And on top of that, being part of NYU now, having access to trials and the finest doctors, and the finest resources. I mean, we’re exploding. You know, we’re adding doctors. Again, we’ve just hired our seventh doctor in my department of Long Island. You know, we’re expanding to Suffolk, we’re expanding to Queens. So it’s really for me to kind of see what was a small mom-and-pop type of organization in the basement of a small hospital, Mineola, that’s where I am now, to grow to this… you know, multinationally. I get to travel the world. I give courses. We have our annual SBRT course.
I was in Tokyo three months ago and we had a standing remotely course at Tokyo. I was in Orlando. We have a course in Scottsdale most years. You know, I may be going to the Middle East next year. So to take what we’ve done and share it with the world, you know, you become like a doctor to the world. You know, I’m a music fan. Last year I saw the Foo Fighters, my favorite band, in London.
And I got to go to Tokyo, not quite on the same order of magnitude as Dave Grohl, but you know, to be in a lecture hall in Tokyo and have the room full and a trai… It was just really cool to kind of spread the word of what we do yet still be a local Long Island, New York City doctor and catching up with my patients afterwards. So it checks every box for me, and I am passionate about it. You know, if I won the $250 Mega Millions tonight, I would still do this. I might change the pace a little bit, but I would still do it. But sure, I would do it.
Ed Randall: I want to thank Dr. Jonathan Haas of NYU Langone Health for joining us in the first installment of what we hope will be an ongoing conversation about supporting men and families who are journeying with prostate cancer. Thank you for your patience with a C-E, by the way, and for making us all a little smarter. Thank you again, John. An honor to be with you and honor to know you.
Dr. Jonathan Haas: Oh, Ed, the honor is mine. You’ve become a friend now. You’re part of my family. So thank you for allowing me to do PSA screenings, to speak at your events, and thank you for coming to ours. You know, you were at that great event in December with John Starks. And what a blast that was. So you’re one of my favorite people on the planet. So thank you.
Announcer: The Stay in the Game Podcast media partner is Cancer Health, online at cancerhealth.com. Cancer Health empowers people living with prostate cancer and other cancers to actively manage and advocate for their care and improve their overall health. Cancerhealth.com provides accessible information about treatment and quality of life for people with cancer and their loved ones, along with information about cancer prevention, and health policy.
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Cancer Health empowers people living with prostate cancer and other cancers to actively manage and advocate for their care and improve their overall health. Launched in 2017, cancerhealth.com provides accessible information about treatment and quality of life for people with cancer and their loved ones, along with information about cancer prevention and health policy.
