Prostate cancer (PCa) is the most common non-skin cancer in men. In the U.S., it is estimated that 1 out of 8 men will be diagnosed with PCa in their lifetime. Once diagnosed, the next step is making a decision whether or monitor it or treat it. And, if treatment is necessary, what’s the best approach?
Is whole gland treatment the best strategy?
The idea that prostate cancer is a multifocal disease has long dominated strategies for treating this disease. Multifocal means if you find a tumor in one area of the prostate, it is reasonable to assume there are other prostate cells in other areas but they were either too small to show up on imaging, or they were missed by biopsy needles.
Thus, patients who were candidates for treatment were usually advised to have whole gland (radical) treatment by surgery or radiation. This was a “take no chances” strategy to ensure against leaving untreated disease in the prostate gland. Until focal therapy was developed, the best strategy patients were offered was radical treatment.
Indeed, when biopsy or imaging reveals detectable tumor activity on both side of the prostate gland, but it is all still contained within the gland (localized PCa) there is professional consensus that removing or radiating the entire prostate is the advised course of treatment.
Is prostate cancer always multifocal?
The idea that all PCa is multifocal was a difficult one to challenge without scientific proof. It takes conviction and commitment to take the road less traveled. Pushing back against that assumption began in 1968 with researchers at Stanford University who studied the biology and anatomy of prostate cancer. In noting that even within the same gland, there could be more than one cell line.
More importantly, they established that not all cell lines posed the same degree of danger to a patient. Another way to say this is, not all apparent tumor activity is created equal. This led to the idea of an “index lesion,” a single focus of cancer that has the largest volume and contains cells with the highest known aggression level.
Meanwhile, pathologist Dr. David Bostwick—an expert on prostate cancer cells—and colleagues analyzed 393 prostatectomy specimens collected between 2000-03. In 2008 they published their findings: 23% of the specimens had unifocal prostate cancer.[i] This study was a gamechanger, validating that focal therapy was a valid treatment strategy for carefully qualified patients.
What percent of cases are qualified for focal treatment?
There is a range of PCa cases that qualify for a focal approach. According to a 2010 published paper:
One of the greatest difficulties in the localization of prostate cancer is its frequent multifocality, but prostate cancer is unifocal in 13% to 43.7% of cases and unilateral in 19.2%. In cases of multifocality, it seems that the index tumor is the biologic driving force behind the malignant potential of prostate cancer. Not only is the Gleason score of the secondary nodes lower than that of the index node, but 80% of the secondary nodes are smaller than 0.5 cc and almost all extraprostatic extensions are associated with the largest cancers.
Obviously, numerous studies have reported varying statistics, so the most important consideration is careful and thorough diagnosis of each individual’s case.
How are patients evaluated for focal therapy?
An accurate evaluation for focal therapy includes clinical factors: size, location, and Gleason grade of the index lesion; ruling out potentially dangerous PCa activity in other areas of the gland. Also, personal factors include the patient’s willingness to comply with a monitoring protocol after treatment, the patient’s lifestyle, overall health, and preferences.
Gathering the clinical factors requires biomarker tests (PSA, PSA variants, genomic analysis if indicated), multiparametric MRI, precision biopsy (preferably targeted by real-time MRI rather than fusion). Gathering personal factors involves honest and empathic doctor-patient discussion.
The Sperling Prostate Center is recognized as a leading practice for 3T MRI-based detection, diagnosis, and image-guided focal treatment. Drs. Dan Sperling and Eric Walser are recognized experts in qualifying patient candidates and offering several focal therapy methods. The Center’s commitment to excellence includes profession and empathic patient care.
If you or a loved one is at risk for prostate cancer, contact us for more information on how we can help.
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] Iczkowski KA, Hossain D, Torkko KC, Qian J et al. Preoperative prediction of unifocal, unilateral, margin-negative, and small volume prostate cancer. Urology. 2008 Jun;71(6):1166-71.
[ii] Algaba F, Montironi R. Impact of Prostate Cancer Multifocality on Its Biology and Treatment. Journal of Endourology. 2010;24(5):799-804.
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.
