I am frequently asked by patients how Focal Laser Ablation (FLA) compares to Radical Prostatectomy (RP) in terms of cancer control. After all, many of the men with localized prostate cancer (PCa) who come to Sperling Prostate Center have already been told by a urologist that they qualify for a nerve-sparing robotic RP that will get rid of all the cancer but still leave them potent and continent. Despite the fact that “getting rid of all” the PCa is appealing, the patient is skeptical that preserving potency is going to be the walk in the park portrayed by the surgeon. Thus, these patients are exploring the option of a focal treatment—but they’re not sure whether they’re taking a chance of shortening their lives by leaving untreated cancer behind. So, the question they ask me is reasonable. However, until the Dec. 2019 issue of the journal Clinical Genitourinary Cancer I have not had the kind of published data that can offer them objective assurance that their lives are as protected by FLA as they might be with RP. All that has now changed.

FLA vs. RP – a new analysis

An industrious team of Chinese researchers tackled the comparison challenge by turning to the Surveillance, Epidemiology and End Results (SEER) database. According to the SEER website, this stored collection of clinical results has amassed “…information on cancer statistics in an effort to reduce the cancer burden among the U.S. population.” SEER is linked with Medicare, and both population-based sources contain detailed clinical records on tens of thousands of cancer patients who receive Medicare benefits. Support for this enormous database comes from the National Cancer Institute’s Surveillance Research Program, and it is a great gift to researchers, scientists and clinicians.

In order to compare FLA with RP in terms of cancer treatment outcomes, the Chinese team started with 12,875 PCa patient records from SEER. 12,433 men had undergone RP whereas 442 had FLA. The researchers were then able to generate 321 pairs of patients whose baseline characteristics were well-matched (age, PSA, tumor stage and Gleason score). They also chose cases with roughly 5 years of follow-up (average 62.6 months for the FLA group, 59.62 months for RP). They applied established statistical calculations before and after matching to generate meaningful comparisons. Their two main measures were PCa-specific mortality (death from PCa during the follow-up period), and all-cause mortality (death from any cause).

Results

Before matching, the FLA group had lower (but not statistically significant) PCa-specific mortality and higher all-cause mortality compared with the RP group. This pattern was maintained even after the pairs were matched and statistically balanced. Therefore, the authors concluded, “Our study suggests that FLA had a higher risk of [all-cause mortality] but an insignificantly lower risk of [PCa-specific mortality] compared with RP.”^[i]

Thanks to this study, I now have concrete evidence that the ability of FLA to control cancer is very close to that of RP. In fact, when compared by cancer-specific deaths within an average of 5 years after treatment, FLA has a slight edge over RP.

I attribute this advantage to the close monitoring we expect from our FLA patients after treatment. Since they still have the majority of their prostate gland, we rely on PSA tests at regular intervals coupled with multiparametric MRI scans if PSA results suggest suspicious activity. Should there be such activity, a real time MRI-targeted biopsy is done. Then, if results are positive for PCa, all treatment options—including a second FLA—are still available. On the other hand, if PCa recurs after RP, it’s because it has already left the gland, which limits the treatment choices available to the patient because a local treatment is no longer possible. In this case, death specifically due to prostate cancer after becomes a greater possibility.

Where can we get a genie?

At the end of their article, the Chinese authors state that more “high-quality trials” are needed to validate and expand their results. If I had Aladdin’s lamp genie at my command for wish-granting, I would ask for the existence of a long-term, Level I clinical research study comparing FLA, RP and Active Surveillance (AS). By “long-term” I mean 10 years of follow-up, and by “Level I research” I mean randomized, controlled, double-blind studies. While I’m at it, I might as well add large numbers so that the study includes at least 500 patients in the FLA arm, the RP arm and the AS arm of the study. Is that too much to ask? Well, there is the thorny issue of randomly assigning patients to treatments they might not have chosen, even if they are equally qualified for all three strategies. Even if we had an ethical solution to that, without enormous financial resources, we’d have a long way to go to design and implement such a study without the help of a genie.

Until then, the Chinese team has given us an excellent window into the cancer-control comparison of FLA vs. RP, and the reassuring knowledge that patients have high probability of safely enjoying the lifestyle benefits of FLA without losing the many years of life ahead they hope to have.

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.

References

[i] Zheng X, Jin K, Qiu S, Han X et al. Focal Laser Ablation Versus Radical Prostatectomy for Localized Prostate Cancer: Survival Outcomes From a Matched Cohort. Clin Genitourin Cancer. 2019 Dec;17(6):464-469.e3.