By Dr. Sperling

Is there a place for focal therapy in treating prostate cancer? A significant analysis of the criteria for considering focal therapy was presented over a year ago in the journal Future Oncology¹. After thoughtfully reviewing the literature and exploring key determinants, the authors concluded that there is indeed a future for focal treatment.

Focal therapy is intended as a middle ground between no treatment vs. radical (whole-gland) treatment. A growing number of younger men are being screened and diagnosed with early stage, moderate risk cancer. They face a dilemma. Radical treatments have a 50% rate of side effects, while active surveillance carries monitoring responsibilities, a psychological burden, and the risk of progression. The authors point out that efforts have been made to reduce the impact of radical therapies with either robotics (surgery) or intensity modulated radiotherapy.

How many men are potentially candidates for focal therapy? With increased screening comes earlier detection, and approximately 20-40% of newly diagnosed patients have unilateral disease (more than one tumor focus on only one side), and 10-44% have unifocal disease (only one tumor focus). A review of retrospective data on unilateral cases where only the cancerous side of the gland was destroyed (ablated) by either cryotherapy or HIFU (high intensity focused ultrasound) showed impotence rates of 10-15% and little to no incontinence. This is a truly significant reduction in treatment burden. The key to identifying appropriate candidates for focal treatment is accurate diagnosis. The authors discuss several means of imaging, including technologies that fuse more than one type of technology for real-time imaging, as having great promise for pinpointing clinically significant lesions, meaning of a large enough size to warrant focal treatment at the time of diagnosis. In addition, the article discusses the importance of determining Gleason grade, which can only be done through biopsy, for further determination of the nature of the malignancy.

The article identifies the most common ablation technologies that can be applied to focused ablation (cryotherapy, HIFU and photodynamics) and points out that other technologies are in various stages of testing and use. Though not specified in the article, laser ablation is one of the most promising, especially since it is already FDA approved for various applications and easily applied to the prostate.

The authors conclude, “Ultimately, if there is a consistent finding that the burden of treatment can be significantly reduced, it is likely that patient choice will dictate its true role within the urology and oncology clinic.” In short, this article is highly valuable for newly diagnosed prostate cancer patients, especially younger men with active lifestyles, who are interested in focal therapy. There is great merit in reading the entire piece at http://www.medscape.com/viewarticle/717471. For those wishing to pursue this treatment option, there is equal merit in arranging a consultation with a physician experienced in ablation technologies who has access to state-of-the-art, image-guided biopsy equipment. A high degree of confidence in the diagnosis and tumor location, and a high degree of trust in the practitioner, are pointers to a successful focal treatment experience.