Is focal therapy the future of treatment for localized PCa?

May 31, 2017

"For low-grade disease, it’s certainly worth a try because nothing is really lost. For high-grade disease, I don’t know that it’s appropriate-we don’t have the data," says one urologist.

Urology Times reached out to three urologists (selected randomly) and asked them each the following question: Is focal therapy the future of treatment for localized PCa?

 

“We’re starting to do some investigative studies on this, but it’s still premature to say whether it’s going to be the future.

For low-grade disease, it’s certainly worth a try because nothing is really lost. For high-grade disease, I don’t know that it’s appropriate-we don’t have the data.

It used to be that all grades of cancer were treated either by radiation or surgery. Now surveillance is preferred for low-grade cancer with close follow-up, including repeated prostate biopsies. Rather than having to do that, why not just do focal therapy-HIFU or cryosurgery? I’d rather follow up with PSAs than biopsies.

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For the study, we’re doing MRI of the prostate and seeing which lesions are suspicious. If we see five suspicious lesions, we do biopsies, and for any that are positive, we can insert a probe and freeze that area of the prostate. If the biopsy of another lesion is negative, we don’t freeze it. Based on the biopsies, you know exactly where to put the probes to treat locally.

The problem is the data is still premature. I think there is a future to it. Perhaps it will be used to eliminate radiation therapy where you radiate the entire prostate. Why radiate the whole prostate if you can do focal therapy with cryosurgery?

Urologists and radiologists are going to get more proficient reading the MRIs and the MRIs are going to get better, so we can be more specific in finding prostate cancer. The first thing we have to determine is if prostate cancer, as a multifocal disease, exists in one part of the prostate, will it exist everywhere else in the prostate? We just don’t know about it because it hasn’t grown. That’s why we don’t know the long-term outcome.”

Boris Klopukh, MD

Miami

Next: "I would like focal therapy to work for local prostate cancer because it would help us do a few things."

 

“I would like focal therapy to work for local prostate cancer because it would help us do a few things. We could spare nerves for sexual function and treat just one side of the prostate with cryo or HIFU or laser interstitial therapy.

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But the natural history of the tumor biology isn’t well known because prostate cancer is multifocal. If we knew how to identify the part of the prostate that had the tumor and whether it would be lethal, then I would say let’s do focal cryotherapy.

In terms of HIFU and interstitial laser therapy, I don’t know if the data exists yet on whether they can treat tumors effectively. I know cryosurgery can. But focal treatment is going to be an academic question. Private practitioners won’t answer that. It will be done in an academic center where a doctor does prostate MRI imaging, identifies various lesions, then takes samples of each lesion and does focal therapy-probably cryo-and then we look at outcomes. It’s got to be studied at an academic center.

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I do know there’s a higher chance you’ll be able to continue to be active sexually if focal cryotherapy is done versus whole-gland cryotherapy. That’s a big deal for men who are interested in sexual intercourse. Obviously, cryo will not affect continence, as surgery might. If they were able to prove that, I would offer it to my patients. But I don’t see that happening until studies are done. It would be better if patients didn’t risk incontinence from surgery, or erectile dysfunction from either surgery or radiation.”

Kurt Strom, MD

Loveland, CO

Next: "The jury is still out."

 

“People have been looking into focal therapy for a long time now. If you look at the old studies and radical prostatectomy specimens, 85% of prostate cancers are multifocal. That’s why treatment is always the treatment of the total gland, not just the focal area. It even happens with a multiparametric MRI. The MRI may miss a spot. A biopsy can test positive even though nothing was seen on the MRI. So, you run the danger of under-treating patients with focal therapy. That’s been my training and my experience in practice.

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Studies comparing conventional biopsies detected high incidence of high-grade cancer, but actually detected fewer cancers than the biopsies. We don’t have the technology to visualize all the cancers yet, otherwise that should not have happened. The multiparametric MRIs should have had a higher incidence of detection of cancer. There seems to be a potential for higher recurrence by using focal therapies. So the jury is still out.

I don’t think replacing active surveillance with focal therapy is a real option. When patients choose focal therapy, I think their expectation is to be cured.”

Young Kang, MD

Pleasanton, CA

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