Jonathan Haas, MD, is a radiation oncologist who specializes in the use of stereotactic body radiotherapy (SBRT), a procedure that delivers precise, high-dose radiation, to treat people with prostate and breast cancer. Dr. Haas, a member of NYU Langone Health’s Perlmutter Cancer Center, clinical associate professor in the Department of Radiation Oncology at NYU Long Island School of Medicine and chair of the Department of Radiation Oncology at NYU Langone Hospital—Long Island, was one of the first radiation oncologists to deliver SBRT using CyberKnife®, which targets the tumor from hundreds of angles and is able to compensate and correct for tumor movement in real time. This procedure decreases treatment time, which allows patients to recover more quickly and return to their normal lives. NYU Langone Hospital—Long Island is one of the largest CyberKnife® practices in the United States and is a recognized training site for this advanced technology.
Dr. Haas discusses SBRT for prostate and breast cancer, the outlook for people with prostate cancer, and more.
What can you tell us about CyberKnife and SBRT for treating cancer?
The Department of Radiation Oncology at NYU Langone Hospital—Long Island began using CyberKnife® to deliver SBRT in 2005. We were one of the early adopters, started the first institutional review board (IRB)–approved protocols, and have published and presented extensively on our experience here.
Both the National Comprehensive Cancer Network (NCCN) and the American Society for Radiation Oncology (ASTRO), which is our governing body, list SBRT as standard of care for low- and intermediate-risk prostate cancer, which is about 70 percent of all prostate cancer cases that we see. SBRT using CyberKnife® comprises about 50 percent of our departmental volume, and prostate cancer treatment represents the lion’s share of that.
The utility of CyberKnife® has continued to grow. We recently added a third CyberKnife® machine in the Department of Radiation Oncology at NYU Langone Hospital—Long Island, the S7 model, which is the newest available. We also have upgraded to that model in our Manhattan practice at 150 Amsterdam Avenue as well. The S7 is faster than any of the previous models, which in the past could take up to 45 minutes to deliver treatment. With S7, we are now treating most patients in under a half hour, with an average of around 20 minutes. So, from a patient perspective, a five-day treatment is now under a half hour per day with most patients done in less than a week. The new S7 also has a multileaf collimator, which enables us to treat certain conventionally fractionated cases as well.
CyberKnife® was initially designed for brain and spine tumors, and we continue to treat those patients as well. Dr. Jonathan W. Lischalk (clinical assistant professor of radiation oncology at NYU Long Island School of Medicine) recently joined us as the new medical director of our NYCyberKnife at Perlmutter Cancer Center—Manhattan, and he is also going to be our new director of medical research in the Department of Radiation Oncology at NYU Langone Hospital—Long Island. He is going to treat all types of tumors, with his first case being a rare spinal tumor case coming on in a few weeks. Again, we have always done brain and spine tumors, but we’re getting back to basics a little bit with that, too.
Dr. Todd J. Carpenter (clinical assistant professor radiation oncology at NYU Long Island School of Medicine) uses CyberKnife® to treat thoracic and central nervous system malignancies. Dr. Michael C. Repka (clinical assistant professor of radiation oncology at NYU Long Island School of Medicine) uses CyberKnife® for hepatobiliary malignancies, and Dr. David Ebling (clinical assistant professor of radiation oncology at NYU Long Island School of Medicine) has expanded CyberKnife® to treat certain gynecologic malignancies.
What do you tell people with prostate cancer who have concerns about the disease?
I tell patients that the vast overwhelming majority of prostate cancer cases are curable. And we’re not looking to just cure them, we’re looking to get them back to their normal life as quickly as possible. For example, providing 5-fraction radiation, as opposed to 45-fraction radiation, right off the bat is a home run. We have narrowed or tightened the margins of radiation around the prostate, so we’re radiating less of the bladder and rectum, which is a safer form of radiation in my opinion.
I would tell them my goal is to not only cure the cancer but to minimize their side effects, hopefully keep their sexuality, and get them away from us and back to their lives as quickly as possible. I try not to let them be concerned because as I said, the overwhelming majority of prostate cancer cases are curative.
What kinds of clinical trials are you conducting with CyberKnife to treat other cancers?
For breast cancer, there was pioneering work out of NYU Langone’s Department of Radiation Oncology doing five-fraction radiation for breast cancer. In 2011, we opened up a five-fraction CyberKnife® protocol on Long Island. We were the first ones to do a CyberKnife® five-fraction protocol for breast cancer.
At the ASTRO annual meeting in October, we presented the first longer-term data from a multi-institutional trial we conducted with Dr. Sandy Vermuelen at Swedish Medical Center in Seattle. We looked at 71 consecutive patients with breast cancer who we treated at both institutions, with a median follow-up of 80 months, which is considered long-term follow-up. We found that 94.3 percent of patients remained locally controlled with no evidence of disease. This compares favorably with standard 6-week radiation treatment, which provides 86 percent local control. To be fair, I think the outcomes are equal, but if a patient can be treated in five days safely as opposed to four to six weeks—and we have shown that with our longer-term data—that’s a home run for the patients.
The University of Texas Southwestern in Dallas, which has one of the preeminent radiation oncology departments in the world, invited us to join them on a one-fraction protocol for breast cancer using CyberKnife®, meaning the radiation is given over one day. Imagine, as a patient, that you can get all your radiation in one day. That’s really pushing the envelope. NYU Langone Hospital—Long Island was the only subsite selected to participate with them, and we enrolled four patients in the study and closed accrual this month. The fourth patient has yet to be treated, but that protocol has worked out beautifully as well.
What is on the horizon for CyberKnife?
Patients with intermediate- or high-risk prostate cancer also often receive hormone therapy called Lupron Depot®, which, unfortunately, has a number of sexual side effects, including the male equivalent of menopause. In conjunction with Dr. Aaron E. Katz (professor in the Department of Urology at NYU Long Island School of Medicine), the chair of the Department of Urology here at NYU Langone Hospital—Long Island, and Dr. David R. Wise (assistant professor in the Departments of Medicine and Urology at NYU Langone), who is one of the fantastic genitourinary medical oncologists at Perlmutter Cancer Center, we are going to be opening a protocol with a newer drug called darolutamide for our patients with prostate cancer. Darolutamide doesn’t cross the blood–brain barrier, so it presumably should have fewer systemic and sexual side effects. If we can treat these patients with a drug that has less toxicity, that’s a benefit. We’re doing that study in partnership with The Dana Farber Cancer Institute and Harvard Medical School. We’re excited about this trial, which should be opening in early 2021.
There’s also a growing volume of literature looking at using SBRT to treat oligometastatic disease, or low-volume metastatic cancer. Previously, if patients had metastases they would receive chemotherapy, or for prostate cancer, they would get hormones, and we would only provide radiation for pain management, really just for palliative care. We are now looking to expand the utility of radiation to include low-volume metastatic cancers. There are excellent data from phase 3 trials showing that by using SBRT, you can improve survival and outcomes. So, we are now offering this option to many of our patients, which we had not done often in the past.
We also continue to grow our patient database. Because we have such a large database with thousands of our patients with prostate cancer treated and followed, we can really get into the nuances of treatment to see what portends for better outcomes. With the database, we can look at projects such as treating younger patients or patients with bigger glands. Not every radiation oncologist would be comfortable treating a younger patient or a patient with a larger prostate size. We are very comfortable doing that, and we’re really pushing the boundaries of what we can do with CyberKnife®.
Finally, on a personal and departmental level, I can say that being a part of Perlmutter Cancer Center has provided us with even more resources than we’ve had in the past. Having access to new protocols and world-class colleagues both on Long Island and in Manhattan will enable our department to elevate our care even further. This is the most excited I’ve been in my 23-year career!