BERKELEY, CA (UroToday.com) - More patients with localized prostate cancer elect to undergo active surveillance (AS) in order to postpone active treatment until disease progression. Because of the anxiety caused by AS and the toxicity carried by radical treatments, an increasing number of patients prefer focal therapy (FT). FT for prostate cancer seems to be part of a natural evolution in the quest to improve the management of early organ-confined disease. It’s a non-invasive, reproducible, tissue-preserving technique with a short learning curve. Our aim was to assess the morbidity of the initial experience of FT in a tertiary referral center for prostate cancer management.
From 2009 to 2011, 1 213 patients with clinically localized prostate cancer were treated at our institution. Of these, 547 were considered to have indolent disease according to the D’Amico criteria for low-risk disease, plus unilateral disease with a maximum of three positive biopsies. Exclusion criteria included clinically bilateral cancer, Gleason score ≥ 7, extracapsular extension proven on biopsy or suspected on multiparametric MRI, and patients who had been given androgen deprivation therapy by referring physicians. One-hundred-six patients underwent FT using high-intensity focused ultrasound (HIFU), brachytherapy, cryotherapy, or vascular-targeted photodynamic therapy (VTP). Ninety-seven per cent of the FT patients had transperineal volume-adjusted saturation biopsy. Complications were prospectively recorded and graded according to the Dindo-Clavien scale. Data was prospectively collected and retrospectively analyzed.
This study included 106 patients, median (interquartile range [IQR]) age 66.5 (61–73) years of age, who had prostate hemi-ablation: 50 patients (47%) had cryotherapy, 23 (22%) had VTP, 21 (20%) received HIFU, and 12 (11%) brachytherapy. The median (IQR) PSA was 6.1 (5–8.1) ng/mL, all the patients had a biopsy Gleason score of 6, and median (IQR) prostate weight was 43 (33–55) g. Median (IQR) IPSS was 6 (3–10) and median (IQR) IIEF5 was 20 (15–23). After treatment, the median (IQR) PSA at 3, 6 and 12 months was 3.1 (2–5.1) ng/mL, 2.9 (1.1–4.7) ng/mL and 2.7 (1–4.4) ng/mL, respectively. Overall, 13% experienced treatment-related complications. There were 11 minor medical complications (10 grade 1 and 1 grade 2), two grade 3 complications and there were no grade 4 or higher complications.
Several limitations in our study should be acknowledged. First, this study is a retrospective observation of a series of patients with short follow up. It was performed as a quality-of-care control to assess whether we should continue offering FT to our patients. While longer follow up is necessary before more definite conclusions can be made, these data show that FT is feasible, featuring acceptable early morbidity. Moreover, the major concern with FT could be the insufficient cancer control leading to inferior oncological outcomes compared with radical treatment. Indeed, inappropriate patient selection, inaccurate mapping of the cancer, partial cancer ablation, and the potential for missed curative opportunities make many urologists skeptical in trusting FT.
FT for a highly selected population with prostate cancer is feasible and had an acceptable morbidity with less than 2% experiencing major complications. We believe that focal therapy is a logical intermediate option to target solely the area where positive biopsies are located, aiming at attaining solid cancer control while maintaining quality of life. Focal therapy may represent a viable option for low-risk prostate cancer, and due to our results, we think that this kind of treatment could potentially be extended to intermediate-risk patients. The idea of a FT working group represents, perhaps, the path to follow in order to standardize and expand the deployment of the technique. As we have already mentioned, the learning curve does not represent a difficult task for these techniques. Therefore, the groups holding today’s expertise should be responsible for providing effective training and counseling for institutions aiming to embrace FT.
Youness Ahallal, Rafael Sanchez-Salas, and Eric Barret as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Urology Service, Department of Surgery
Institut Mutualiste Montsouris
42, Boulevard Jourdan
75014, Paris, France