Originally published 4/13/2018
In the blog below, Dr. Zequi asked if focal therapy would be the next step in prostate cancer (PCa) treatment. Now, six years later, a French presentation at the 2024 annual conference of the European Association of Urology posed a new question in its title, “Has focal therapy for prostate cancer come of age?”
The author cited almost identical 30-month treatment success rates for 1,967 focal HIFU patients and 1,361 prostatectomy patients. “The primary oncologic endpoint was survival without salvage treatment (SWST) for significant prostate cancer after post-HIFU biopsies or biological recurrence or significant positive margins after RP.”[i] The French investigators calculated that the focal HIFU group had 29% less risk of salvage treatment than the surgery group, a statistically significant difference.
They concluded that focal therapy was “noninferior” to prostatectomy, a technical statistics term meaning “no worse than.” However, “noninferior” overlooks an important fact: focal therapy offers superior probability of greatly reduced side effect risks.
We hope that Dr. Zequi made the trip from Brazil to the Paris conference so he could hear for himself that focal therapy indeed appears to be affirmed as the next step in PCa management.
A “snapshot” of this moment in PCa treatment
I came across a journal article by a Brazilian urologic specialist, Dr. Stênio Cássio Zequi of the Camargo Cancer Center in São Paulo, Brazil.[ii] He asks if focal therapy will be the next step in prostate cancer (PCa) management. Before expressing his opinion, he writes what amounts to a “snapshot” of the current state of PCa treatment.
Dr. Zequi points out that whole gland therapy (WGT) such as radical prostatectomy, beam radiation, seed implants, cryotherapy and HIFU) continues to dominate the field of treatment options, despite the fact that early detection turns up many low-risk cases in which PCa is only in 5-10% of the gland. Admittedly, cancer control and survival rates are very good with these radical treatments. However, they are associated with high rates of urinary, sexual and bowel morbidities (side effects).
At the same time, there is a growing trend to offer Active Surveillance (AS) to newly diagnosed patients where there is a high degree of confidence that their cancer is indolent and/or clinically insignificant. Dr. Zequi writes that AS and delayed intervention “are well stablished as competitive, secure and ethical options, resulting in few urinary, sexual and intestinal side effects in short or mid-term follow-up.” However, AS comes with its own challenges: adherence to follow-up protocols, repeat lab work, MRI scans, medical visits, and anxiety can burden patients – not to mention the chance of under-staging a tumor, and the infection risks associated with repeat biopsies. Yet both radical therapy and AS, though in many respects opposite approaches, are both “absolutely ethical.” Thus, the majority of PCa patients will likely end up at one extreme or the other.
The question of focal therapy
Which brings him to the question: “Philosophically, why not adopt a ‘middle term’, in which we could treat focally the cancer that affects the small percentage of the prostate (eliminating the cancer, as with WGT) and, at the same time, maintain under surveillance the rest of the gland (similarly to AS)?”
He admits that the idea of focal therapy faces ongoing skepticism, though the number of critics is diminishing. He traces the rapid evolution from treating a minority of patients who had a small, low-risk unifocal (one location) tumor to today’s slightly broader standards. He says that the prevailing standard now is to treat the index lesion [having a lethal cell line that can become aggressive] while sparing surrounding healthy gland tissue – or even “secondary lesions that can be submitted to surveillance, as in AS protocols.”
The history of focal therapy research
Starting about 20 years ago, focal treatment began with image-guided tumor ablation using extreme cold (cryotherapy) or heat (HIFU). Different focal approaches included treating just the tumor plus safety margin, hemi-ablation (half the gland) and “hockey stick” ablation (half the gland plus a small ablation extended into the opposite gland side). Advances in imaging, specifically multiparametric MRI (mpMRI), knowledge of how PCa progresses, genomics, and more precise delivery of energy-based ablation are redefining who qualifies for focal therapy. Dr. Zequi cites numerous published studies of focally-treated patients, demonstrating comparable cancer control with WGT and very favorable side effect profiles.
Looking to the future
Looking ahead, there is a beginning acceptance about treating carefully qualified PCa patients with focal Gleason 7 – and in some cases, Gleason 8 – who have a favorable disease profile. There is also a new array of technologies capable of delivering a focal treatment: “Focal HIFU, Focal cryotherapy, laser ablation, interstitial laser thermotherapy, photodynamic therapy, irreversible electroporation, focal brachytherapy, focal radiotherapy, nanoparticles thermotherapy, interstitial thermal microwave therapy and interstitial radiofrequency ablation.”
Given all of the above, Dr. Zequi answers YES to his own question about focal therapy as the next step in prostate cancer management. Interested readers may be interested in Dr. Zequi’s entire article, which is not long but is filled with excellent information and research summaries.
At our own Sperling Prostate Center, we offer three approved MRI-guided focal therapies: 1) Focal Laser Ablation (FLA), TULSA-PRO, and Exablate MRI-guided Focused Ultrasound. Dr. Sperling works with each individual patient to determine which method best suits his disease and meets his lifestyle preferences. Our results more than satisfy Dr. Zequi’s ideal for a best-of both-worlds treatment for PCa. In line with published studies, our patients benefit from cancer control that is competitive with whole gland therapies, yet with minimal-to-no risk of urinary or sexual side effects.
For more information, visit the Sperling Prostate Center website.
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] Jody Charnow. “Focal Therapy not Inferior to Radical Prostatectomy for Prostate Cancer.” Renal & Urology News, Apr. 9, 2024. https://www.renalandurologynews.com/reports/prostate-cancer-focal-therapy-not-inferior prostatectomy/
[ii] Zequi SC. Focal therapy will be the next step on prostate cancer management? | Opinion: Yes. Int Braz J Urol. 2017 Nov-Dec;43(6):1013-1016.
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.
