Gleason Pattern 4: Active Surveillance or Focal Laser Ablation?

The strategy of using active surveillance (AS) is increasingly recommended to low-risk prostate cancer (PCa) patients as a way to avoid or delay overtreatment. This is a new way of thinking; before the New Millennium, PCa was assumed to be multi-focal and most men with more than 10 years of life expectancy were hurried into surgery or radiation. Today’s terminology includes words that might have been meaningless a decade ago, e.g. indolent cancer, very low risk disease, and focal disease are all consistent with the growing movement toward AS.

The American Urological Association states that

A program of active surveillance has two goals: (1) to provide definitive treatment for men with localized cancers that are likely to progress and (2) to reduce the risk of treatment-related complications for men with cancers that are not likely to progress.[i]

The AUA guidelines for PCa treatment suggest that AS is a good management strategy for patients with lower risk patients (low PSA, Gleason score and tumor stage). However, many patients with Gleason 3 + 4 or 4 + 3, considered to be intermediate risk, are choosing to go on AS. One study found that almost 9% of them start on AS despite questions about the safety and wisdom of this choice.[ii] According to the article, “the majority of AS protocols worldwide exclude men with GS4 cancers [Gleason score with at least one pattern 4] unless their life expectancy is limited.”

At the Sperling Prostate Center, we respect the right of each patient to make his own treatment decision. We also recognize that international guidelines strongly favor AS for low-risk patients, so for those with intermediate-risk PCa who are leaning toward AS we highly recommend having a baseline 3G multiparametric MRI (mpMRI) with results interpreted by an expert radiologist such as we do, and subsequently being monitored by more frequent (every 6-9 months) 3T mpMRI scans.

We have an even better solution for intermediate-risk patients who are considering AS and also have one or two tumors. Focal laser ablation (FLA) is a minimally invasive outpatient procedure that safely and accurately destroys PCa with minimal to no risk of side effects. It is guided by real-time MRI; special thermometry tracks temperature changes to assure that the tumor is completely destroyed, along with a safety margin of surrounding tissue. It is a precise treatment that spares healthy tissue and preserves both continence (100%) and potency (approaching 100%) for our patients.

Why is FLA a better solution? Knowing that it is the natural history of Gleason 4 PCa to progress, FLA removes the risk of waiting to see when and how this will occur, and possibly missing a treatment window. FLA is a middle ground between no treatment and radical treatment, and all future treatment options are still possible. If you or a loved one has been diagnosed with PCa that includes Gleason pattern 4, call our Center for a free consultation to find out how we can help.

 


 

[i] https://www.auanet.org/education/guidelines/prostate-cancer.cfm

[ii] Sathianathen NJ, Murphy D, van den Bergh R, Lawrentchuk N. Gleason pattern 4, Active Surveillance No More. BJU international. 2015 Sep 21 [Epub ahead of print]

 

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