Sperling Prostate Center

Focal Therapy: Just Because You Can, Does That Mean You Should?

I came across a July 6, 2022 commentary piece published in Journal of the American Medical Association (JAMA).[i] It raises an interesting 2-part question about focal treatment for prostate cancer (PCa): For which patients is this approach effective in controlling their PCa, and how is cancer control defined?

The three authors hail from Ohio State University’s Department of Urology. I don’t believe they are biased against focal treatments like our Center’s Focal Laser Ablation (FLA), but rather they are raising a sincere concern about which patients are most likely to gain long term benefits from targeted ablation. They open by noting the considerable enthusiasm over focal therapy that arises from the desire to reduce the “bothersome urinary and sexual adverse effects” of whole-gland treatments. No doubt, as urologists they share this desire.

Historically, urologists as a group tended to be initially skeptical—if not downright cynical—about the introduction of focal cryoablation (freezing) in the late 1990s. At that time, cryo was the only ablation modality, and it was a small a handful of practitioners who dared to offer ultrasound-guided focal cryo to patients who were motivated to reject prostatectomy and radiation treatments. Much of the urology community’s skepticism was justified. Back then, there was a universal belief that all PCa is multifocal, so urologists’ perceptions came through that filter. In addition, the ability to establish unifocal disease was hampered by lack of today’s multiparametric MRI and by flawed systemic TRUS-guided biopsies. Therefore, focal treatment was seen as irresponsible, in light of the belief that it leaves active cancer still growing with the gland, even if only microscopically.

However, times have changed. The authors acknowledge that energy ablation effectively destroys its targeted tumor: “A number of technologies are known to be efficacious in histologically eradicating prostate cancer, including cryoablation and high-intensity focused ultrasonography.” Of course, we can add FLA to the list, as well as focal treatments that are in clinical trials, e.g., photodynamic treatment and irreversible electroporation. So, if these treatments work to kill PCa, what’s the problem?

The authors express the issue thus: “The difficulty behind focal treatment is that it is unclear what pathologic and clinical factors in localized prostate cancer actually warrant treatment to reduce prostate cancer-specific mortality.” In other words, they imply that if a given patient’s PCa is diagnosed as intermediate-to-high risk, such disease warrants radical (whole gland) treatment. On the other hand, if a given patient’s disease is diagnosed as low risk, Active Surveillance (AS) should be the order of the day. Their implication seems to be that a middle-ground treatment is superfluous: a) it’s not enough for aggressive cancer, and b) it’s a waste of time and money for patients whose cancer can safely be monitored because it may never kill them, so why put them through a treatment that still has some level of risk, however small?

In short, the authors object to the lack of defined knowledge regarding which patients are most likely to benefit from focal therapy, and who is to do the defining.

In fact, much of that is already accomplished, while much is ongoing. There have been many gatherings of experts who strive for consensus on such definitions. For one, I would draw the authors’ attention to a 2015 consensus panel composed of luminaries in urology, oncology and radiology. They published the work they put in “to gather expert opinion on patient selection, interventions, and meaningful outcome measures for focal therapy in clinical practice and trial design.”[ii] If the authors haven’t read this paper, they might be surprised to learn that their concerns have been well addressed.

More importantly, it’s the patient community that provides the answer. Since the first focal ablations were successfully performed with the majority of patients having no recurrence while enjoying high quality of life and freedom from anxiety, the surge in numbers of men who prefer focal therapy (if they’re qualified for it), and the research and development of modalities for delivering such treatment, bear witness to patient preferences.

Focal treatment is not for every patient. Neither is radical treatment, and neither is AS. If the authors are asking, “Just because you can do, does that mean you should?” the positive response of tens of thousands of patients who have chosen focal therapy stands as a resounding YES.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Sheetz T, Ray S, Dason S. Focal Therapy for Prostate Cancer—Moving Beyond Technology Assessment. JAMA Surg. Published online July 06, 2022.
[ii] Donaldson IA, Alonzi R, Barratt D, Barret E et al. Focal therapy: patients, interventions, and outcomes–a report from a consensus meeting. Eur Urol. 2015 Apr;67(4):771-7.

 

About Dr. Dan Sperling

Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.

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