Dr. Josephson
The following interview with Dr. David Josephson is from HelloMD. For more articles please visit:
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The Q and A Interview with Dr. David Josephson:
Q: Dr. Josephson, it is a pleasure to speak to you about your pioneering work in both prostate cancer and robotic surgery. Could you take a few moments to sum up where we stand today in the treatment of prostate cancer?
A: The treatment of prostate cancer increasingly advanced over the past ten years. Both surgical and non-surgical treatments have gone through tremendous evolution. Non-surgical treatments, such as radiation have become far more focused in treating prostate cancer and less associated with side effects. Surgical treatments also became focused, far more precise and better at avoiding adverse side effects.
We have been able to adopt non-treatment strategies for men diagnosed with prostate cancer. Many now are not required for treatment. A decade ago if you were diagnosed with prostate cancer, it would have been crazy to say you would not get treated!
I would say about 20% of men in my practice get enrolled in what is called an active surveillance program. When a man enters active surveillance, we acknowledge that they have cancer but recognize that it may not be an aggressive form or not terribly harmful down the line. Observation is monitored carefully to intervene only when necessary.
We have access to a lot of tools that were non-existent years ago, including one aiding in the pre-diagnosis stage of prostate cancer. In past we depended on digital rectal exam and PSA levels (Prostate-Specific Antigen) to highlight who may have cancer. Afterwards we would go on to perform a biopsy.
Today we use Prostate-Specific Antigen in different complex forms. One includes the urine based markers, such as PCA3. We also look at alterations in certain genomic profiles including TMPR-ERG-22 associated with highly aggressive forms of prostate cancer. The tools used highlight who is at risk for an underlying clinically significant prostate cancer allowing for earlier detection to made.
Our arsenal is genomic analysis, a genomic test that highlights (once someone is diagnosed with prostate cancer) if the patient might have clinically significant or higher-grade prostate cancer. So today, rather than operating on everyone who gets diagnosed, as we did ten years ago, we can use these pre-diagnosis markers to separate our population of patients into pools; those that warrant definitive treatment upfront or those that warrant surveillance.
The use of MRI guided biopsy is an interesting development. Before, patients with an elevated PSA would receive a biopsy with negative results. Another PSA test made commonly showed PSA levels with increased elevation. With heads tilting, the question always arose, “why were tumor(s) never found”?
New MRI technology has 90%-95% accuracy in detecting cancer outside the normal biopsy template area. They’re fused onto ultrasound images allowing lesions in real-time. The MRI technology is used to not only diagnose the prostate cancer but to potentially offer focal treatment of the cancer lesion later.
Patients that have metastatic disease (the spread of cancer from one organ to another), now have drug treatments that were not available 4 or 5 years ago. The drugs target metastatic disease and give patients a longer, more hopeful chance of survival.
Immunotherapy is a new treatment that uses the patients own blood to harvest a vaccine against cancer. Other types of medications work on the hormonal pathways. We now know of different hormonal pathways that can be target to give a higher chance of controlling metastatic disease in patients.
Q: You can create a vaccine from your own blood? That sounds incredible.
A: Yes, that is called PROVENGE immunotherapy. The patient’s own blood is drawn and sent to an outside lab. Lab’s will make a vaccine targeting specific prostate cancer cells and use the blood to transfuse back to the patient. You are essentially using the patient’s own immune system to target the cancer cells.
Q: You are a board certified urologist, urologic oncologist and a pioneer in the area of robotic surgery. There are very few surgeons in the world that have had as much experience with robotic surgery as you. In your opinion, how has working with robotic surgery made a positive impact on your patients?
A: As humans we evolve and adapt. We adopt new technology into our daily lives; smart phones, GPS to get around, and complex computers. This is similar to the art of surgery. We have moved from the primitive and simple instruments used in open surgery. From using hands with a scalpel to effectively high advanced pieces of technology like the da Vinci Surgical System.
Robotics have a history and minimally invasive surgery has been in place for 20-30 years. Gynecology and General Surgery basically stated it all. At the time, the spaces being operated on were not generally tight and there was little complexity in the surgery itself. Reconstructive procedures were uncommon as well.
The Robotic Surgery was developed to address more complex specialties like cardiac surgery and urology. Robotics offer the same advantages of laparoscopic surgery; smaller incisions, shorter hospital stays, less risk of infection, less pain, less blood loss, and better visualization. The key difference is that robotics does the reconstructive aspects surgery extremely well and ensure better functional outcomes. The best possible outcome is of course what a patient is most concerned with. We really focus on the return of urinary control and the return of sexual function as soon as possible.
Q: Are you saying that in the past, with surgeries that were not robot-assisted, the outcomes for urinary control and sexual potency have been far worse statistically?
A: Certainly with open techniques we are able to get urinary control and sexual potency back, but never 100%. By no means with robotics is it 100% either. That said, in terms of the time period to achieve the best, most positive outcome, robotics achieves it in a faster time period.
Q: So let’s talk best-case scenario. How long would it take for a patient to return to full urological control and sexual potency?
A: This is dependent on a patient’s baseline status. Many patients are continent as soon as the catheter comes out. Depending on age and status some patients are potent. In my practice some patients were potent prior to the catheter coming out. This is definitely not the norm with open surgery. So essentially, there are a lot more patients getting these positive outcomes when robotic surgery is performed.
When people think of minimally invasive surgery, the first thing they think of is laparoscopic or arthroscopic surgery. In those types of surgical situations, the surgeon has direct contact with the instruments that are touching the body. Laparoscopic surgery uses chopstick like instruments with different maneuvers such as opening or closing jaws and cautery. Surgeons are able to grasp and move things in this manner.
The problem with laparoscopic instrumentation is that you cannot achieve the same kind of movement as your hand, specifically the movement and the angles of hands at the wrist. Robotics can achieve multiple degrees of movement that laparoscopy cannot.
The robot is a system with instruments controlled by the robot on top of the patient. Surgeons also known as the masters control the robot from a central console to reach and penetrate inside the cavity of the patient. Robots are surgeons slaves replicating moves in real-time, in a scaled fashion. Any maneuver the surgeon makes with the calipers, within the console, is directly translated into the same movements within the patient’s’ body. We can think of robotic surgery as the new generation with updated software. Think of laparoscopy as your first generation Apple 2E and Robotic assisted surgery as the MAC Book Pro.
Q: Is open surgery in some ways analogous to a landline phone?
A: Correct. Robotics is an upgraded software system-new technology with ergonomics for the surgeon and comfort for the patient. The best outcomes can be reached, unlike with laparoscopy. Surgeons standing and leaning awkwardly during laparoscopy can even cause pain for surgeons.
Robotics, from a surgeon perspective, is far more comfortable. It even has binocular vision. The da Vinci Surgical System has two lenses looking into the body, so you essentially have stereovision. You basically have a new sense of depth perception to create a 3 dimensional visualization of the operating field.
Q: So in some ways you almost achieve a type of bionic vision with the robot?
A: Yes, that is correct.
Q: You mentioned that 20%-30% of all prostate cancer surgeries are done with open surgery. I assume that means people are being opened by surgeons with their hands and cutting the cancer out with scalpels. It seems archaic after what you have just told me.
A: It is not archaic. People are just use to it. At this point, I think that the number is probably close to 20%.
Q: Is there accuracy with open surgery?
A: Some open surgeons have great results. The average board certified urologist in the 90% volume of prostate cancer surgery may only do 10-12 prostatectomies a year. So, in order to become proficient at laparoscopic surgery you need to perform at least 150-250 surgeries. If you do the math, it would take about 15 years to become proficient at the technique, during which time you are subjecting your patients to a surgical learning curve.
The learning curve of robotics is about half, allowing the surgeon about 80-100 surgeries to become proficient. It is by no means something you pick up after a weekend course! That’s what separates fellowship trained surgeons from people who try to learn after they are in practice. In a fellowship program you perform surgery after surgery amassing a large number of surgeries in a short time. A surgeon in private practice, learning a new skill, most likely does not have as many opportunities.
When you think of open surgery being done in the community, there is not enough volume to be able to learn these new techniques. I really believe that when it comes to prostate cancer surgery the surgeons need to be well-qualified with enough experience. Ideally you’d want someone who has done a fellowship with hundreds of surgeries under their belt. You absolutely do not want someone who is only doing one surgery a month.
Q: You have been at the forefront of robotic surgery for some time. More people are aware of this technology and more surgeons are gaining access to robotic surgical systems, especially in regards to clinically localized prostate cancer. How do you see robotics evolving and how will you continue to be a leader in this field?
A: The robot and system will continue to evolve. I hope new systems will come into play too. This is what sparks true innovation; when competitors aim at the same marketplace. Within the last 15 years the system itself even went through four different upgrades. There are also advancements not clinically used but have received approval from the FDA for studies.
The software has add-ons like fluorescence imaging to inject a dye, filter on the camera and visualize where the dye goes into the patient. It helps us visualize the cancerous tumor, assess margins and find segmental vessels that may feed a tumor. We can also examine the margin of the tumor so we don’t leave anything behind.
Q: Have you talked about the use in combination with conjugated antibodies?
A: Correct. These are used in conjunction to visualize the cancer. Essentially, it is like a heat seeking missile targeting areas of cancer within the body to see them more clearly.
Q: Wrapping up, can you tell me what you think the bright lining is for prostate cancer today?
A: Innovation, innovation, innovation! I believe this to be the case in both surgical and non-surgical arenas. In the past ten years we have seen a number of new drugs available for clinical use, the rise of surgical tools like the robotics surgery offering far better outcomes and new radiation technology offering a pinpointed delivery of radiation. All of them have an incredibly positive outcome. We even seen prostate cancer go from being the #2 killer of men to #3 following colon cancer.
Unfortunately, the negative is that patients are still dying of prostate cancer and further advancements in tools need to be made. I believe we need to constantly refine our tools and continue to pick up cancers at an even earlier stage for less death risks down the line.
Dr. David Josephson, is a Urologist with a sub specialty in Urologic Oncology. He is fellowship trained in both minimally invasive and robotic surgery as well as Urologic Oncology, which differentiates him from others in his field. Dr. Josephson is considered a leading innovator within his field based on his application of robotic surgery. Having performed over 1,200 robotic procedures, many are among the world’s firsts in robotic assisted surgery.
