Focal Therapy for Prostate Cancer: Possibilities and Limitations (original) (raw)
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Focal Therapy for Prostate Cancer: Rationale and Treatment Opportunities
Clinical Oncology, 2013
Focal therapy is an emerging treatment modality for localised prostate cancer that aims to reduce the morbidity seen with radical therapy, while maintaining cancer control. Focal therapy treatment strategies minimise damage to non-cancerous tissue, with priority given to the sparing of key structures such as the neurovascular bundles, external sphincter, bladder neck and rectum. There are a number of ablative technologies that can deliver energy to destroy cancer cells as part of a focal therapy strategy. The most widely investigated are cryotherapy and high-intensity focussed ultrasound. Existing radical therapies, such as brachytherapy and external beam radiotherapy, also have the potential to be applied in a focal manner. The functional outcomes of focal therapy from several phase I and II trials have been encouraging, with low rates of urinary incontinence and erectile dysfunction. Robust medium-and long-term cancer control outcomes are currently lacking. Controversies in focal therapy remain, notably treatment paradigms based on the index lesion hypothesis, appropriate patient selection for focal therapy and how the efficacy of focal therapy should be assessed. This review articles discusses the current status of focal therapy, highlighting controversies and emerging strategies that can influence treatment outcomes for the future.
Focal therapy for prostate cancer 1996: Maximizing outcome
Urology, 1997
Objectives. To summarize improvements in patient selection and the results of focal therapy for the management of localized prostate cancer. Methods. A contemporary series of patients managed with wide surgical excision, radiation therapy (threedimensional conformal radiation, interstitial radiation, and charged-particle or proton therapy), and cryotherapy were reviewed. Results. We used preoperative cancer grade, transrectal ultrasound, and serum prostate-specific antigen (PSA) in all patients, and cross-sectional imaging and bone scans in selected patients to allow for reasonably accurate cancer staging and selection of patients most likely to be cured by radical prostatectomy or radiation. In patients with extracapsular extension of prostate cancer, wide surgical excision and achievement of a clear surgical margin had therapeutic value. Newer radiation techniques resulted in a higher likelihood of prostate cancer control than previous techniques. Cryotherapy for patients with stages Tl through 3 prostate cancer was associated with a posttreatment undetectable PSA rate of 48% and a positive biopsy rate of 23%. Conclusions. Patients with organ-confined and, therefore, curable prostate cancer can be identified. Well-performed radical prostatectomy, radiation, and cryotherapy are alternative treatments for the management of localized prostate cancer.
Journal of Men's Health, 2014
Background: Following the lead of lumpectomy for breast cancer, focal therapy for prostate cancer was introduced in order to limit morbidity while providing good cancer control. Focal therapy is now an established trend in prostate cancer management, but long-term data have not been available. This report presents results on 70 patients treated with focal cryoablation, followed for an average of 10 years. Methods: Between May 7, 1996, and December 28, 2005, seventy patients were treated with focal cryoablation. All patients were pre-staged using an additional prostate biopsy-either transrectal ultrasound (TRUS) biopsy or transperineal three-dimensional prostate mapping biopsy (3D-PMB). All patients were treated with focal cryoablation of the known tumor(s). Biochemical disease-free status was determined by the Phoenix criteria. Results: Disease-specific survival was 66/66 (100%). Overall biochemical disease-free survival (BDFS) was 62/70 (89%). BDFS results stratified according to the D'Amico criteria were: 8/9 (89%) high risk; 28/32 (88%) medium risk; and 26/29 (90%) low risk. There was no statistically significant difference between the risk levels. Of those patients staged by TRUS biopsy, 8 of 24 patients had a documented local recurrence (33%). Of those staged by (3D-PMB), 2 of 46 (4%) patients had a local recurrence. Nine out of ten retreated local recurrences (90%) remain BDF. Continence after the first treatment was 100% (no pads). Potency after the first treatment was 94%, including retreatments it was 74%. Conclusions: The long-term cancer control results of focal cryoablation appear superior in medium-and highrisk patients to radical whole gland treatments. Focal therapy is associated with extremely low morbidity. If confirmed and applied widely, focal cryoablation could result in a substantial decrease in prostate cancer related mortality while offering a better post treatment quality of life.
The Role of Focal Therapy in the Management of Localised Prostate Cancer: A Systematic Review
European Urology, 2013
Context: The incidence of localised prostate cancer is increasing worldwide. In light of recent evidence, current, radical, whole-gland treatments for organ-confined disease have being questioned with respect to their side effects, cancer control, and cost. Focal therapy may be an effective alternative strategy. Objective: To systematically review the existing literature on baseline characteristics of the target population; preoperative evaluation to localise disease; and perioperative, functional, and disease control outcomes following focal therapy. Evidence acquisition: Medline (through PubMed), Embase, Web of Science, and Cochrane Review databases were searched from inception to 31 October 2012. In addition, registered but not yet published trials were retrieved. Studies evaluating tissue-preserving therapies in men with biopsy-proven prostate cancer in the primary or salvage setting were included. Evidence synthesis: A total of 2350 cases were treated to date across 30 studies. Most studies were retrospective with variable standards of reporting, although there was an increasing number of prospective registered trials. Focal therapy was mainly delivered to men with low and intermediate disease, although some high-risk cases were treated that had known, unilateral, significant cancer. In most of the cases, biopsy findings were correlated to specific preoperative imaging, such as multiparametric magnetic resonance imaging or Doppler ultrasound to determine eligibility. Follow-up varied between 0 and 11.1 yr. In treatmentnaïve prostates, pad-free continence ranged from 95% to 100%, erectile function ranged from 54% to 100%, and absence of clinically significant cancer ranged from 83% to 100%. In focal salvage cases for radiotherapy failure, the same outcomes were achieved in 87.2-100%, 29-40%, and 92% of cases, respectively. Biochemical disease-free survival was reported using a number of definitions that were not validated in the focal-therapy setting. Conclusions: Our systematic review highlights that, when focal therapy is delivered with intention to treat, the perioperative, functional, and disease control outcomes are encouraging within a short-to medium-term follow-up. Focal therapy is a strategy by which the overtreatment burden of the current prostate cancer pathway could be reduced, but robust comparative effectiveness studies are now required.
Focal therapy in prostate cancer: modalities, findings and future considerations
Nature Reviews Urology, 2010
| Focal therapy is emerging as an alternative to active surveillance for the management of low-risk prostate cancer in carefully selected patients. The aim of focal therapy is long-term cancer control without the associated morbidity that plagues all radical therapies. Different energy modalities have been used to focally ablate cancer tissue, and available techniques include cryotherapy, laser ablation, high-intensity focused ultrasound and photodynamic therapy. The majority of evidence for focal therapy has come from case series and small phase I trials, and larger cohort studies with longer follow-up are only now being commenced. More data from large trials on the safety and efficacy of focal therapy are therefore required before this approach can be recommended in men with prostate cancer; in particular, studies must confirm that no viable cells remain in the region of ablation. Focal therapy might eventually prove to be a 'middle ground' between active surveillance and radical treatment, combining minimal morbidity with cancer control and the potential for re-treatment.
Focal therapy for prostate cancer: revolution or evolution?
BMC Urology, 2009
The face of prostate cancer has been dramatically changed since the late 1980s when PSA was introduced as a clinical screening tool. More men are diagnosed with small foci of cancers instead of the advanced disease evident prior to PSA screening. Treatment options for these smaller tumors consist of expectant management, radiation therapy (brachytherapy and external beam radiotherapy) and surgery (cryosurgical ablation and radical prostatectomy). In the highly select patient, cancer specific survival employing any of these treatment options is excellent, however morbidity from these interventions are significant. Thus, the idea of treating only the cancer within the prostate and sparing the non-cancerous tissue in the prostate is quite appealing, yet controversial. Moving forward if we are to embrace the focal treatment of prostate cancer we must: be able to accurately identify index lesions within the prostate, image cancers within the prostate and methodically study the litany of focal therapeutic options available.
Focal Therapy in Prostate Cancer—Report from a Consensus Panel
Journal of Endourology, 2010
Purpose: To establish a consensus in relation to case selection, conduct of therapy, and outcomes that are associated with focal therapy for men with localized prostate cancer. Material and Methods: Urologic surgeons, radiation oncologists, radiologists, and histopathologists from North America and Europe participated in a consensus workshop on focal therapy for prostate cancer. The consensus process was face to face within a structured meeting, in which pertinent clinical issues were raised, discussed, and agreement sought. Where no agreement was possible, this was acknowledged, and the nature of the disagreement noted. Results: Candidates for focal treatment should have unilateral low-to intermediate-risk disease with clinical stage cT 2a . Prostate size and both tumor volume and tumor topography are important case selection criteria that depend on the ablative technology used. Currently, the best method to ascertain the key characteristics for men who are considering focal therapy is exposure to transperineal template mapping biopsies. MRI of the prostate using novel techniques such as dynamic contrast enhancement and diffusion weighed imaging are increasingly being used to diagnose and stage primary prostate cancer with excellent results. For general use, however, these new techniques require validation in prospective clinical trials. Until such are performed, MRI will, in most centers, continue to be an investigative tool in assessing eligibility of patients for focal therapy. Conclusions: Consensus was derived for most of the key aspects of case selection, conduct of treatment, and outcome measures for men who are undergoing focal therapy for localized prostate cancer. The level of agreement achieved will pave the way for future collaborative trials.
Focal Therapy for Localized Prostate Cancer: A Phase I/II Trial
Journal of Urology, 2011
Purpose: Men with localized prostate cancer currently face a number of treatment options that treat the entire prostate. These can cause significant sexual and urinary side effects. Focal therapy offers a novel strategy that targets the cancer rather than the prostate in an attempt to preserve tissue and function. Materials and Methods: A prospective, ethics committee approved trial was conducted to determine the side effects of focal therapy using high intensity focused ultrasound. Multiparametric magnetic resonance imaging (T2-weighted, dynamic contrast enhanced, diffusion-weighted) and template transperineal prostate mapping biopsies were used to identify unilateral disease. Genitourinary side effects and quality of life outcomes were assessed using validated questionnaires. Posttreatment biopsies were performed at 6 months and followup was completed to 12 months. Results: A total of 20 men underwent high intensity focused ultrasound hemiablation. Mean age was 60.4 years (SD 5.4, range 50 to 70) with mean prostate specific antigen 7.3 ng/ml (SD 2.8, range 3.4 to 11.8). Of the men 25% had low risk and 75% had intermediate risk cancer. Return of erections sufficient for penetrative sex occurred in 95% of men (19 of 20). In addition, 90% of men (18 of 20) were pad-free, leak-free continent while 95% were pad-free. Mean prostate specific antigen decreased 80% to 1.5 ng/ml (SD 1.3) at 12 months. Of the men 89% (17 of 19, 1 refused biopsy) had no histological evidence of any cancer, and none had histological evidence of high volume or Gleason 7 or greater cancer in the treated lobe. In addition, 89% of men achieved the trifecta status of pad-free, leak-free continence, erections sufficient for intercourse and cancer control at 12 months. Conclusions: Our results appear sufficiently promising to support the further evaluation of focal therapy as a strategy to decrease some of the harms and costs associated with standard whole gland treatments.
Focal Treatment on Prostate Cancer: The 3 Dilemmas Debating Focal Therapy for Prostate Cancer
Experimental Techniques in Urology & Nephrology, 2018
The new technologies development and their application as alternatives in the therapeutic approach of Prostate Cancer, is still under discussion. We face an scenario that is more frequent day by day. However, it is required more time and more medicine based evidence, to understand if this concepts will turn off or turn on the lights on those impetuous affirmations with "truths" intentions.