Bill Taylor went to see his GP for what he thought was a minor problem, his sleep was being disturbed by the need to go the loo several times a night.
‘I was also finding that however hard I tried to empty my bladder, I invariably needed to go again a short time later,’ says Bill, 65, a retired police officer who lives with his wife, Jane, 60, in Farnborough, Hampshire.
‘I thought it was probably just a part of getting old.’
But it turned out to be something much more serious and a few months later, in November 2011, he was diagnosed with prostate cancer.
Bill Taylor went to see his GP for what he thought was a minor problem, but which turned out to be something much more serious
The prostate is a walnut-sized gland below the bladder and in front of the rectum that produces semen for carrying sperm from the testicles.
He underwent a physical examination, which revealed that the gland felt ‘slightly rough’ – if the prostate feels hard, enlarged or uneven rather than smooth it can be an indication of cancer so Bill was given a prostate specific antigen (PSA) test.
Raised levels of this protein can indicate cancer: Bill’s reading, 5.5, was slightly higher than the normal range for his age.
Using his work health insurance, Bill then saw a private urologist. ‘I wasn’t particularly concerned at first as I didn’t know what we were dealing with,’ says Bill, a father of five grown up children and nine grandchildren.
‘But I have a fairly pragmatic attitude to life so didn’t worry too much until I had an actual diagnosis.’
The consultant arranged for an MRI scan and a biopsy, as well as a bone scan to check if it had spread – a week later Bill was told he had prostate cancer.
The tumour was pressing against Bill’s urethra – the tube through which urine is removed from the body – which was causing his constant urges to urinate.
‘It wasn’t the news I wanted to hear of course, but I tried to remain positive,’ he says.
As the cancer had not spread outside his prostate and was slow growing, doctors decided Bill was low risk and would not require any immediate treatment.
Instead, he would have PSA tests every six months to monitor the cancer’s progression.
‘I was told that if the tumour did start growing – which would be indicated by the PSA levels rising – I may have to have surgery to remove my prostate or other treatments such as radiotherapy or hormone therapy to try to shrink the tumour.’
In September 2015, Bill was told the cancer had in fact grown and his PSA had risen to 6.4.
But rather than undergoing one of the standard treatments, Bill had a newer procedure which has a more targeted approach using ultrasound.
Image of a high intensity focused ultrasound scan. Treating the whole prostate with radiotherapy and surgery can lead to collateral damage in surrounding nerves
This has been demonstrated in several studies to be less harmful to nearby healthy tissue with lower risks of impotence and incontinence.
High intensity focused ultrasound (HIFU), is largely designed for treating cancer that’s localised inside the prostate, and works by sending a powerful beam of sound waves directly onto the tumour through a probe that is inserted through the back passage.
The three-second pulses of energy heat the tissue to 70C and effectively kills the tumour, avoiding damaging healthy tissue and structures surrounding it.
Usually half or even less of the prostate is destroyed during a treatment which takes about 90 minutes.
HIFU is still a relatively new treatment – it has been used in the UK for more than ten years, but was used initially to destroy all of the prostate which was until recently the conventional approach.
In September 2015, Bill was told the cancer had in fact grown and his PSA had risen to 6.4
But over the last seven years increasing numbers of men have undergone a more focal approach using this technology.
‘This treatment was less invasive and looked if it might work for me,’ says Bill.
In fact his consultant urologist, Richard Hindley, who works at the Basingstoke and North Hampshire Hospital has participated in collaborative research with University College Hospital investigating the role of focal HIFU.
In the last two years another development has been the introduction of fusion software.
Bill was the first patient in the country to undergo fusion assisted focal HIFU. It was done privately in March this year at Nuada Urology in London.
The most recent guidance from NICE is that focal HIFU therapy should be offered only to selected patients fitting certain criteria; all the data from their treatment should be fully recorded and kept on a central registry for other medics to access.
Fusion treatment can be offered on the NHS if patients are on a clinical trial. Patients more often have it privately.
‘This we hope will represent another incremental step forwards for those men eligible for focal therapy,’ says Mr Hindley.
Currently men undergoing HIFU treatment will have had an MRI initially and then some targeted biopsies of the prostate are undertaken to establish the diagnosis.
The MRI scan images which were performed a few weeks earlier can assist the surgeon during the HIFU procedure, enabling some parts of the prostate to be left untreated.
Using the fusion software, the area to be targeted is highlighted directly on the screen in front of the patient during treatment.
Mr Hindley explains that with Fusion, the MRI image is ‘fused’ with a live ultrasound image from the probe to create a 3D image of the prostate and the area to be destroyed, so the surgeon can provide more targeted treatment.
Mr Hindley currently treats the majority of his patients without the latest additional software as it is not yet widely available.
But he says all patients who are eligible for HIFU could one day have the new Fusion technology.
‘The image you get using the HIFU probe during the procedure is not of the same quality as the MRI images – indeed the picture is not much better than you used to get on an old black and white TV set.’
‘From the ultrasound, you can see the outline of the prostate but not really any level of detail of where the cancer may be.
‘But with the new fused image I have an exact target to aim for during the treatment so I am more confidence all the cancer will be removed.’
Bill had his treatment privately in London at a cost to his insurers of about £15,000. The treatment lasted about two hours and he returned home the following day.
‘I experienced a dull pain in my prostate area for a couple of days, but he didn’t have to rely on painkillers to ease it,’ he says.
Bill turned out to be a good candidate for a new procedure called HIFU, or high intensity focused ultrasound. He returned home the following day, and has had no problems since
‘But I didn’t have any side-effects such as incontinence and after two months was back to my old self. I can go to the toilet as normal. I could go back to playing golf and doing everything I did before.’
Commenting on the new technology, Simon Bott, a consultant urologist at Frimley Park Hospital, Surrey, says HIFU has meant patients can be cured with less risk of suffering side-effects because of improved accuracy of the treatment.
‘Both the diagnosis and treatment of prostate cancer has moved forward really dramatically in the last few years.
Largely this is because we can now see the cancers using MRI scanning. This enables us to treat just the cancer by targeting only the abnormal areas within the prostate rather than treat the whole prostate.
‘The muscle that keeps you dry, the back passage and the nerves that enable a man to get an erection, all sit right next to the prostate.
Treating the whole prostate with radiotherapy and surgery can lead to collateral damage in these areas, but only treating small areas inside the prostate gland using HIFU, these areas can be avoided, drastically reducing the side-effects of the treatment.’
In terms of downsides of Focal HIFU, the prostate gland will swell and can make passing urine more difficult, but this only occurs in less than 5 per cent of cases, says Mr Bott.
‘There’s a less than 1 per cent chance of incontinence – which is much higher when the whole prostate is removed,’ says Mr Bott.
‘And in 90 per cent of cases, men said they had a satisfactory erection, again a much higher percentage than if they had a prostatectomy or radiotherapy.
High intensity focused ultrasound (HIFU), is largely designed for treating cancer that’s localised inside the prostate
In terms of erections almost all men will lose their erection during radiotherapy as they receive hormone blocking treatments, meaning some will later regain their erections but most will not.
After surgery about 50 per cent permanently lose their erections.
‘After radiotherapy treatments, bowel symptoms are common and there is a small, but significant, risk of developing a secondary tumour in the bladder or rectum, whereas there is no increased risk after HIFU’.
‘I always make patients aware it’s a relatively new treatment, so we don’t know yet how it compares to conventional options as we don’t have years of data available to us yet.’
Mr Hindley says that 15 per cent of all men treated for prostate cancer do require a second treatment
‘We need to keep an eye on the remaining gland after treatment,’ says Mr Hindley. ‘But with HIFU, it can be repeated if necessary. And a prostatectomy or radiotherapy is still available if the cancer returns.
‘Studies currently underway will eventually give us the answers as to how the long term cure rates compare to whole gland treatments.’
Fusion HIFU is currently only available at Nuada Urology.