Originally published 3/30/2015
It’s been 9 years since we posted the blog below, during which time the FDA has approved two more focal treatment methods to add to the focal therapy family: TULSA-PRO (Transurethral Ultrasound Ablation of the Prostate) and Exablate Prostate (MRI-guided Focused Ultrasound).
The importance of monitoring for recurrence after focal treatment is as true today as it was in 2015. Back then, we cited an article by a French team that recommended monitoring using PSA, multiparametric MRI (mpMRI) and control biopsies at specified intervals. Nearly a decade of ongoing research has validated mpMRI as the state-of-the-art monitoring technology. And finally, control biopsies are fading away thanks to the PI-RADS scoring/reporting system.
When performed by an expert on a powerful 3T magnet, imaging is highly accurate for identifying areas suspicious for significant prostate cancer. If a suspicious area is revealed, real time MRI-guided targeted biopsy has taken precise diagnosis to an all-time high. Thus, we can identify potential recurrence (or new tumor activity) when it is still confined to the prostate, and all treatment options are open.
Before a prostate cancer patient makes a final decision to have focal laser ablation, I go over the details of MRI-guided FLA and what to expect after treatment. I always point out that we do not yet have long term data on the success rates as far as cancer control, so we don’t know how many men might have their cancer recur (come back). I remind each person that it’s important to monitor for PCa recurrence. After any focal treatment (cryo, HIFU, Focal Laser Ablation, MRgFUS, TULSA) PCa can either come back in the treatment site—called treatment failure, meaning the treatment did not destroy all the cancer at the site—or recur in a different location.
Last year [2014], the journal Current Opinion in Urology carried an article by a French team[i]. I was struck by their point that focal prostate therapy “…presents a clinical challenge to the urologist, as typical disease surveillance parameters are not as reliable in post-ablation follow-up.” What they mean is that an elevated or rising PSA, which is used most often by urologists as a tip-off that prostate cancer may be back, does not give enough information. I wholeheartedly agree!
In their article, the authors suggest an integration of three ways to monitor for the return of PCa: PSA kinetics (upward movement in the PSA), mpMRI and control biopsies (prescribed at regular intervals). They state that “good treatment response” is indicated by a reduction in pre-treatment PSA of at least 50%, absence of lesion as demonstrated on imaging, and a negative control biopsy.
At our Center, we recommend an annual 3T mpMRI unless PSA movement sends up a “red flag” that imaging is needed sooner. The earlier any recurrence is identified, the more treatment options the patient has, including another focal ablation, a radical treatment, or active surveillance.
We know that FLA is a blessing for many patients who would otherwise have undergone a radical treatment that might have left them with short- or long-term reduced quality of life. Patients who are qualified for focal therapy benefit from the high probability of successful cancer control with low risk of side effects.
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] Barret E1, Harvey-Bryan KA, Sanchez-Salas R et al. How to diagnose and treat focal therapy failure and recurrence? Curr Opin
Urol. 2014 May;24(3):241-6.
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.
