Washington, DC (Urotoday.com) Prostate cancer is the most common malignancy facing urologist. Traditional therapy either with radical surgery or radiation, while oncologically effective, place patients at an increased risk for impotence and incontinence. Over the last decade, treatment paradigms have been rapidly evolving to reduce overtreatment and its associated exposure to these side effects.
To that end, many have looked to focal therapy as the future for the management of prostate and Dr. Scott Eggener the Director of the Prostate Cancer Program at the University of Chicago was invited to speak on this emerging arena.
To begin his talk, Dr. Eggener reiterated that the quintessential organ preservation strategy for prostate cancer is instituting appropriate cancer screening and active surveillance protocols. Reminding the audience that an intact prostate is the ultimate organ preservation. Moving on to focal therapy, he drew parallels from the evolution of breast cancer treatment, describing the migration from Hallsteadian thinking to a more Fisherian approach. He reported that compared to breast cancer, which first explored focal therapy in the 1930s, focal therapy for prostate cancer is still in its infancy and its role is yet to be determined. The first proof of concept studies was only published in 1995, with early adaptors publishing more robust reports only the last decades.
As with any novel therapy, the key to its adoption lays in both its efficacy, as well as, selection of appropriate patients. Dr. Eggener highlighted that he believes that focal therapy would be best suited for men with Gleason 7 prostate cancer. Reiterating that treating Gleason 6 disease, even with focal therapy, would still be overtreatment. It is exceptionally rare for these patients to have an adverse pathologic feature (extra-capsular extension, seminal vesical invasion or lymph node metastases) and that the 15-year cancer mortality is less than one percent. Further, at this point, he postulated that Gleason 6 should be renamed as a benign entity, Indolent Neoplasm Rarely Requiring Treatment (INeRRT).
Dr. Eggener additionally discussed the role of MRI in patient selection. In tandem with biopsy, the rate of missing a higher-grade lesion should be less than 10% and that a restaging biopsy prior to focal therapy should further reduce the chances of missing large, higher-grade cancers that require whole gland treatment. Lastly, MRI helps select patients with tumors that are best located for focal therapy, those away from critical structures, such as the neurovascular bundle and bladder neck.
To focus on specific modalities, Dr. Eggener briefly discussed HIFU and TOOKAD. Ahmed et al, demonstrated that at 5-year follow up after hemiablation with HIFU, 85% of patients had no further treatment or development of metastatic disease, with 97% remaining continent and 95%with preserved erectile function. Similarly, TOOKAD, a vascular-targeted photodynamic therapy demonstrated lower rates of progression and need for whole gland therapy when compared to surveillance alone, offering a promising alternative to men looking to avoid whole gland therapy.
As this technology is still in its early stages of development and implementation, longer-term data is still being accrued. With that, Dr. Eggener discussed the importance of informed consent, as well as, the need to prospectively collect outcomes data. Specifically, he finished his talk with a discussion of FDA oversight and its need to avoid indiscriminate use of focal therapy and overtreatment. To that end, the FDA met with industry and physicians to discuss meaningful endpoints for analysis. The consensus being a delay in the time to whole gland therapy or the need for whole gland therapy, with a focus on improving the overall quality of life for men with prostate cancer. He ended his talk looking forward to the upcoming results of randomized controlled trials in this space expected in the near future. Dr. Eggener concluded that while focal therapy is not for every patient, in the properly selected man it is a promising modality with more information is still need.
Presented by: Scott E. Eggener, MD, Director, Prostate Cancer Program, University of Chicago, Chicago, Illinois
Presented by: Scott E. Eggener, MD, Director, Prostate Cancer Program, University of Chicago, Chicago, Illinois
Written by: Adrien Bernstein, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Fox Chase Cancer Center, Philadelphia, PA at the 20th Annual Meeting of the Society of Urologic Oncology (SUO), December 4 - 6, 2019, Washington, DC
References:
1. Ahmend et al. A Multicentre Study of 5-year Outcomes Following Focal Therapy in Treating Clinically Significant Nonmetastatic Prostate Cancer. European Urology. October 2018 Volume 74, Issue 4, Pages 422–429