NEW YORK (Reuters Health) – Focal therapy for primary localized prostate cancer should remain investigational pending further study, according to a 2018 European Association of Urology (EAU) position paper.
“The method is promising, but the often multifocal nature of prostate cancer renders it not applicable for all prostate cancer,” Dr. Henk G. van der Poel from Netherlands Cancer Institute, Amsterdam, the Netherlands told Reuters Health by email. “Selection of patients, as well as follow-up protocols for early recognition of disease recurrences, is being studied.”
At least six focal therapy options for primary prostate cancer management currently exist: cryotherapy, high-intensity focused ultrasound (HIFU), irreversible electroporation (IRE), laser ablation, photodynamic therapy, and brachytherapy.
Dr. van der Poel and colleagues on the EAU Prostate Cancer Guidelines panel review the evidence on the use of these modalities in their January 18 European Urology online report.
They agree that focal therapy can ablate cancer cells, but they note that current imaging methods cannot reliably identify all high-risk cancer clones within the prostate.
Moreover, the oncologic effectiveness of focal therapy remains unproven due to the lack of reliable data comparing it with the current standard of care, including active surveillance.
To date, there has been insufficient long-term follow-up regarding toxicity and cancer progression after focal therapy, as well as the toxicity of secondary treatments and retreatments after focal therapy.
Given these considerations, the panel concludes that “focal therapy should be considered an investigational modality only.”
“Focal therapy for prostate cancer is extremely interesting, but further study, including the risk of (longer-term) recurrences, is needed,” Dr. van der Poel said.
Dr. Ryan P. Werntz from the University of Chicago, who recently reviewed focal therapy treatment options for prostate cancer, told Reuters Health by email, “Active surveillance and more minimally invasive treatments, such as focal therapy, in theory aim to minimize treatment-related side effects while maintaining therapeutic efficacy. We have good data now to support active surveillance in men with very low-risk cancers (as defined by National Comprehensive Cancer Network, but in general low volume Gleason 3+3).”
“In my mind, focal therapy really is for patients with a clinically significant (Gleason 3+4, debatably 4+3) MRI visible solitary lesions (maybe 2) who want to avoid radical therapy (radical prostatectomy, radiation) to minimize treatment-related side effects,” he said. “Multiple energy platforms and phase 1 and 2 trials have been performed, as mentioned in this review, with mixed short-term oncologic results.
“There are no cancer-specific survival data,” Dr. Werntz said. “In the low-risk (main active surveillance) cohorts that are being treated in these studies, 15-20 years are needed to adequately determine if the treatment impacts either metastasis-free or cancer-specific survival.”
“Surveillance is still required after focal therapy and is difficult to do,” he added. “There are no defined PSA guidelines to hint at a cancer recurrence.”
“Patients who wish to pursue this treatment option should do so only in the setting of a clinical trial,” Dr. Werntz agreed.
SOURCE: http://bit.ly/2E8q605
Eur Urol 2018.
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