Focal therapy compared to radical prostatectomy for non-metastatic prostate cancer: a propensity score matched study (original) (raw)
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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.
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.
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.
Urologic Oncology: Seminars and Original Investigations, 2012
Because of the improvements on detection of early stage prostate cancer over the last decade, focal therapy for localized prostate cancer (PC) has been proposed for patients with low-risk disease. Such treatment would allow the control of cancer, thereby diminishing side effects, such as urinary incontinence and sexual dysfunction, which have an enormous impact on quality of life. The critical issue is whether it is possible to preoperatively predict clinically significant unifocal or unilateral prostate cancer with sufficient accuracy. Our aim is to determine whether there is any preoperative feature that can help select the ideal patient for focal therapy.
2022
Objectives.-To determine the proportion of patients who would have been eligible for focal therapy (FT) in a population of patients who underwent prostatectomies; additionally, to assess the risk of having underestimated disease on the surgical specimen by using consensus selection criteria. Method.-We retrospectively analyzed data from 446 patients who underwent radical prostatectomy between 2016 and 2018. Patients suitable for FT had unifocal significant prostate cancer on MRI, as well as on pathological data from targeted and systematic biopsies. Inclusion criteria were defined by the 2014 consensus conference, PSA < 15 ng/mL, tumor stage T1c-T2a and Gleason score 3 + 3 or 3 + 4 on biopsies. Disease was considered to be underestimated on postoperative data in the presence of extraprostatic invasion, a high Gleason score (≥ 4 + 4) and significant multifocality defined by secondary foci of Gleason 6 (3 + 3) > 5 mm or Gleason 7 (3 + 4). Results.-In our cohort of 446 patients, 97 patients met the inclusion criteria, and 27 patients (27.8%) were eligible for focal therapy. Among the eligible patients, 4 patients (14.8%) had pT3, and no patient had significant multifocality or a Gleason score of 8 (4 + 4) on the surgical specimen.
Journal of Personalized Medicine, 2022
To compare oncological and functional outcomes of high-intensity focused-ultrasound (HIFU) focal therapy (FT) versus laparoscopic radical prostatectomy (LRP) in patients treated for low- or intermediate-risk prostate cancer (PCa), we retrospectively analyzed data of consecutive patients comprising 30 men, who underwent HIFU-FT, and 96 men who underwent LRP, in an academic center. Oncological outcomes were assessed based on the follow-up prostate-specific antigen values. We used the International Index of Erectile Function short form score to assess erectile function (EF). Urinary continence status was defined based on the number of pads used per day. Median follow-up was 12.5 and 19.1 months in the LRP and HIFU-FT groups, respectively. The effects were computed after propensity score matching and expressed as average treatment effect (ATE). Compared to LRP, HIFU-FT was associated with increased risk of treatment failure (ATE 0.103–0.164, depending on definition, p < 0.01) and low...
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.
Prostate Cancer and Prostatic Diseases, 2021
Background For localised prostate cancer, focal therapy offers an organ-sparing alternative to radical treatments (radiotherapy or prostatectomy). Currently, there is no randomised comparative effectiveness data evaluating cancer control of both strategies. Methods Following the eligibility criteria PSA < 20 ng/mL, Gleason score ≤ 7 and T-stage ≤ T2c, we included 830 radical (440 radiotherapy, 390 prostatectomy) and 530 focal therapy (cryotherapy, high-intensity focused ultrasound or high-doserate brachytherapy) patients treated between 2005 and 2018 from multicentre registries in the Netherlands and the UK. A propensity score weighted (PSW) analysis was performed to compare failure-free survival (FFS), with failure defined as salvage treatment, metastatic disease, systemic treatment (androgen deprivation therapy or chemotherapy), or progression to watchful waiting. The secondary outcome was overall survival (OS). Median (IQR) follow-up in each cohort was 55 (28-83) and 62 (42-83) months, respectively. Results At baseline, radical patients had higher PSA (10.3 versus 7.9) and higher-grade disease (31% ISUP 3 versus 11%) compared to focal patients. After PSW, all covariates were balanced (SMD < 0.1). 6-year weighted FFS was higher after radical therapy (80.3%, 95% CI 73.9-87.3) than after focal therapy (72.8%, 95% CI 66.8-79.8) although not statistically significant (p = 0.1). 6-year weighted OS was significantly lower after radical therapy (93.4%, 95% CI 90.1-95.2 versus 97.5%, 95% CI 94-99.9; p = 0.02). When compared in a three-way analysis, focal and LRP patients had a higher risk of treatment failure than EBRT patients (p < 0.001), but EBRT patients had a higher risk of mortality than focal patients (p = 0.008). Conclusions Within the limitations of a cohort-based analysis in which residual confounders are likely to exist, we found no clinically relevant difference in cancer control conferred by focal therapy compared to radical therapy at 6 years.
Urologic oncology, 2018
The urological community's opinion over focal therapy (FT) for prostate cancer (PCa) has never been assessed. Our aim was to investigate the current opinion on FT in the European urological community. A 25-item questionnaire was devised according to the Cherries checklist and distributed through SurveyMonkey using a web link from November 2016 to October 2017. After a pilot validation (n = 40 urologists), the survey was sent through EAU and 9 other national European urological societies mailing list. Twitter was also used. We received 484 replies from 51 countries. Almost half (44.8%, n = 217) stated FT would represent a step forward, and 52.0% (n = 252) would suggest FT to a patient. Almost three-quarters (70.8%, n = 343) agreed FT will become a standard option after improvements in patient selection (n = 66) or when its effectiveness will be proven (n = 78), or both (n = 199). Most frequently used definition of FT was treatment of all significant (life-threatening) cancer foci...