A hot-off-the-presses published review in the journal Urologic Oncology by Dr. Hashim Ahmed (Division of Surgery and Interventional Science, UCL, London) offers a comprehensive paper on focal therapy for prostate cancer.[i] In addition to his clinical and research work, Dr. Ahmed has authored or co-authored scores of paper, and hold editorial and peer review positions with numerous professional journals. His work deserves respectful listening.
Dr. Ahmed boldly states that today’s diagnostic and therapeutic strategy for localized prostate cancer is “severely flawed and, as such, fraught with controversy.” He explains that this is the result of diagnostic techniques that are imprecise, leading to either overtreatment or undertreatment. He bemoans the consequences that radical (whole-gland) treatments have had on the quality of men’s lives, as they struggle to live with urinary, sexual or bowel dysfunction.
But there is hope, thanks to multiparametric MRI and its ability to guide diagnosis using an “intensive sampling strategy (targeted biopsies).” Citing the 90-95% negative predictive value of this approach (confidence that if no cancer is found, then it truly is not there), a greater number of patients may be candidates for focal therapy.
I will quote rather than paraphrase the data he includes in his article:
Current data from more than 3,000 men treated internationally show that incontinence after focal therapy is 0% to 5% (radical therapy can lead to incontinence in 15%-20%) whereas erectile dysfunction occurs in 5% to 10% of men with good baseline function (radical therapy rates vary between 30% and 60%). Early to medium cancer control using biopsies after treatment shows between 80% and 90% of patients have a successful treatment, with 10% to 15% of men requiring redo-treatment with minimal additional morbidity.
We are at a history-changing crossroads in the detection, diagnosis and treatment of localized prostate cancer. Our ability to distinguish insignificant from significant cancer is leaping forward, due not only to mpMRI but also genomic analysis. By contributing our Center’s 3T imaging abilities and our Focal Laser Ablation (FLA), we believe we are in the vanguard of a new world of prostate cancer. As our own database grows and we develop long term, publishable results, we expect our numbers to be at least as good as those cited by Dr. Ahmed.
[i] Ahmed HU. Introduction—Targeting the lesion, not the organ. Urol Oncol. 2014 aug;32(6):901-2.