HIFU (high-intensity focused ultrasound) is one of the most talked-about focal therapies in prostate cancer—but who is it really right for? In this conversation, Dr. Matthew Cooperberg (UCSF)—a leading voice in urology, epidemiology, and integrative prostate cancer care—breaks down patient selection vs. energy modality, how modern imaging (MRI, fusion, RSI) drives precision, what genomics (e.g., Decipher) can and can’t tell us, and how salvage options compare after focal therapy vs. radiation. We also tackle lifestyle factors, trial design, and why midlife PSA screening (ideally <1 between ages 45–55) remains crucial.

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00:00 – Welcome + episode setup (HIFU overview, aims of focal therapy)

04:10 – The real first question: Who is a candidate? (selection > modality)

05:10 – What “focal therapy” means (lesion-only, margin, hemi-ablation) + imaging progress

06:25 – Recurrence after focal therapy: targeting, dose, or biology? Follow-up biopsies

07:40 – Genomics (Decipher): predicting recurrence; how results change counseling

09:30 – Lifestyle & microenvironment: can diet/exercise influence outcomes?

11:00 – Salvage after focal vs. radiation: fibrosis, feasibility, quality of life

14:00 – Cryotherapy vs. HIFU: image guidance, control, and why HIFU advanced

16:00 – Imaging upgrades (MRI fusion, RSI, C-13 spectroscopy) and treatment constraints

17:00 – IRE (irreversible electroporation): role for apical tumors, early results

18:00 – TULSA, water/thermal concepts, focal radiation, partial prostatectomy: what’s known

20:00 – Smarter trials: active surveillance ± focal therapy for borderline cases

22:00 – The counseling hierarchy: decision first, technology second

24:30 – Proton vs. photon incentives; why advertising confuses choices

26:30 – UCSF’s program: mostly HIFU; where IRE fits; adding new machines prudently

28:30 – The real bottleneck: sub-millimeter targeting; AI-guided ablation future

33:00 – HIFU mechanics: probe size, apex/anterior reach, distance constraints

35:00 – “I want HIFU for Gleason 8”: agency, nuance, and when we advise against it

38:00 – A cautionary case: negative biopsy → later mets—what it teaches us

40:30 – Millennials, risk tolerance, and why PSA at 45–55 (<1 is ideal) matters

44:00 – Growth vs. spread: which high-grade tumors can we treat focally?

46:00 – How low vs. high genomic scores tilt decisions (and their limits)

47:30 – Where to find Dr. Cooperberg + parting PSA advice

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___________________________________⚠️ Disclaimer

This podcast is for educational purposes only and not medical advice. The views expressed are Dr. Geo’s and not those of his employer(s) or affiliated organizations. Use of this content is at your own risk. Geovanni Espinosa, N.D., assumes no liability for direct or indirect consequences, including economic loss, injury, illness, or death.