Our physician spotlight today focuses on west coast urologist, Robert Pugach, MD. He is a specialist in minimally invasive procedures, including prostate cancer, and has been working with Sonablate HIFU for more than 10 years. He speaks regularly about HIFU and has been involved with close to 400 HIFU treatments.
What was your main motivation for becoming a doctor? When did you decide on this path?
I did volunteer work in the Emergency Department of my local hospital in Englewood, New Jersey when I was a young teenager. I was fascinated by what doctors were able to do for very sick patients. That led to summer jobs as an orderly in the operating room. I established the hospital’s first mentoring program where we were allowed to make rounds with surgeons, watch OR cases and see patients with them in their offices. I was hooked!
How did you decide on your particular specialty? Why urology?
I had the opportunity to do several “externships” at Englewood Hospital. This meant several weeks with doctors in a variety of medical fields. My mentor for urology was Dr. Alexander Bonacarti. We hit it off from the second we met. He was an inspiration. He was bit gruff on the outside but he was a deeply caring physician who loved helping people. Maybe that was the real inspiration – I learned how much urology could improve the quality of people’s lives. I loved the science of urology, the surgery that we could do and the encouragement of “Dr. B.” There was never another consideration – I knew I would be a urologist.
What is your favorite thing about being a physician?
Meeting and interacting with people from every walk of life and being able to help them no matter where they are from or what they do for a living. While I used to enjoy the wide variety of diseases I treated as a urologist, my career and area of focus has evolved into treating prostate cancer and that is what I want to for the rest of my career. I truly have a passion for this.
When did you first learn about HIFU as a treatment for prostate cancer? In the early 2000s. I was one of the first urologists in the world to focus my practice exclusively on “minimally invasive” techniques. That meant performing procedures that could achieve excellent clinical outcomes while minimizing the pain, bleeding and other potential side effects of older surgical methods.
When did you become involved in treating patients using HIFU technology? In 2005. I had developed a large practice performing cryoablation, which is freezing prostate tissue to eradicate cancer. I was able to provide excellent cancer treatment for many patients while minimizing many of the side effects of radical surgery. But, I was still looking for a method that was more effective and HIFU seemed to have that potential. One day in my office, a 76 year old woman who was the wife of a patient scheduled for cryoablation, asked if I could arrange for him to have HIFU. That was the impetus for me to start traveling out of the country to learn more about this remarkable technology.
Why did you initially become interested in HIFU as a treatment for prostate cancer?
As good as cryoablation was, I had two concerns about it. The first was that it was difficult to treat cancer adequately in the apex, or front, of the prostate. The second was that the rate of erectile dysfunction (ED) was just as high as what my radical prostatectomy patients experienced. HIFU was different. Not only could I treat cancers in the apex more effectively, but I learned that the incidence of ED was dramatically lower. I learned, early on, that HIFU had the potential to treat prostate cancer with dramatically decreased side effects like permanent urine leakage (incontinence) and erectile issues. In short, HIFU could treat cancer and allow a man to remain “whole.”
What do you typically tell a patient when they are first diagnosed with prostate cancer?
That it is CANCER. I can’t emphasize that enough. There is a false impression held by many that prostate cancer is never serious, rarely needs treatment and can be ignored in most cases. That is incorrect so I find my first challenge is to carefully explain to a patient that prostate cancer has the same potential as any other cancer in our body – it can grow, destroy nearby structures and spread to bones and soft tissue areas far away from the prostate. Once outside the prostate, it is incurable and may require the use of cancer controlling drugs that can be life altering. What I do next is to explain all of the treatment options available for the stage of a patient’s cancer and educated them about the potential benefits and side effects.
What different types of treatment do you offer men with localized prostate cancer?
I believe I have the largest private practice for minimally invasive treatment of prostate conditions in the United States. For prostate cancer, I perform HIFU and cryoablation. In fact, I do more of those procedures than anyone else east of the Mississippi. For patients who choose to have radical robotic surgery or radiation, I refer them to doctors whom I feel have the most expertise and experience in these areas.
In your professional opinion, what are the benefits of HIFU as a treatment for prostate cancer?
The best was to answer this is to use the example of a very close family member of mine. He was diagnosed with prostate cancer just before his 60th After extensively researching treatment options of radical robotic surgery, radiation of different types, HIFU and cryoablation, he concluded that HIFU was the best answer for him. More than 8 years later, he is cancer free, dry (continent) and potent (no ED). What more could a patient ask for? There is no other treatment for prostate cancer, in my opinion, that can consistently achieve such excellent results.
How do you decide if HIFU is right for the patient?
After 11 years of performing HIFU, I have come to the belief that HIFU can be performed on any patient for whom any other treatment is a consideration. So, if a patient is a candidate for radical robotic surgery, HIFU can be used instead. The same is true if a patient is contemplating radiation or cryoablation. Obviously, results are best when cancers are caught at an early stage and are confined to the prostate. That is why annual prostate screening and early diagnosis is so important for men.
In general, how quickly do your patients recover after HIFU? What do you tell men to expect?
Patients can actually resume limited activities within a couple of days after treatment. That means patients may travel, work in an office, do errands, etc. There is minimal discomfort after a procedure. Depending upon the extent of a HIFU procedure, a bladder catheter will be required for a period ranging from a few days to a few weeks. That’s the most annoying feeling a patient will typically experience. I also tell patients that they may feel like they have a bladder infection for a few weeks with the possibility of more frequent urination and strong urges to urinate.
There are obviously a lot of different treatments for prostate cancer, where do you think HIFU best fits in the prostate cancer landscape?
As I said earlier, I believe HIFU is appropriate for any patient considering any other prostate cancer treatment. What is fascinating about HIFU is that we are now formulating different types of HIFU treatment for different types of prostate cancer. So, for example, if most of a man’s prostate shows significant cancer growth, the entire prostate should be treated. If only one half is involved, we can perform “hemiablation” so only the diseased half of the prostate is eradicated. And, if the cancer is only in a few small areas, focal HIFU can be used to precisely target those areas while leaving healthy prostate tissue alone. There is no other prostate cancer treatment available that has such a wide range of treatment options.
In recent years there has been some discussion about over treating prostate cancer and even changing guidelines on when men should start getting regular screening for prostate cancer. What do you tell men?
I think everyone needs to say this simple phrase: “Prostate cancer is cancer.” For too long, there have been efforts from people in government and some people in the academic community to have people believe that prostate cancer is not a serious disease. That’s flat out wrong. It is the most commonly diagnosed soft tissue cancer in men; we diagnose about 225,000 new cases every year. It is the second leading cause of cancer death in men – only lung cancer kills more.
As for not treating patients, the evidence now points to the fallacy of this idea. At its peak, prostate cancer killed almost 50,000 men per year in the U.S. That decreased to 25,000 due to PSA screening and early treatment. Now, the death rate is rising again. Last year, it was up to 26,120 and some projections for 2016 estimate up to 28,000 deaths. Screening at an early age is, in my opinion, crucial for all men. It’s even more important for men at higher risk for prostate cancer – men with a family history of prostate cancer and men of African American or Scandinavian descent. While many men think prostate cancer screening isn’t necessary until much later in life (the average age at diagnosis is 66), the youngest recorded age at which prostate cancer was diagnosed is 33!
Many men fear diagnosis because they fear that treatment, if diagnosed with prostate cancer, will leave them with serious, life altering side effects. What I love about HIFU is that we now have a treatment in the U.S. that can treat prostate cancer without the side effects of other treatments like radical robotic surgery and radiation. As with any other health issue, the sooner a condition is diagnosed the easier it is to treat.
When you aren’t practicing medicine what do you like to do?
My wife and I love to travel. We have a large bucket list of places we want to visit. Europe is one of our favorite destinations. We’ve been to several other continents, too. We also enjoy travel in the U.S., including national parks and seeing the fall colors in New England. My main hobbies at home include studying and building models of old ocean liners (that may help to explain why we enjoy cruising so much!) and cooking. My wife and I love creating cuisines from all over the world and have enjoyed cooking classes in places as diverse as Tuscany and Bali.