“New” treatments for localized prostate cancer: an expert overview

A small international group of very highly respected experts has just published an important review of the current evidence surrounding the application of a  number of the new and/or evolving treatments available for management of localized prostate cancer, with an emphasis on the potential of focal therapy.

Marberger et al. have addressed the available data related to the clinical use of such techniques as high-intensity focused ultrasound (HIFU) in focal therapy and in total prostate ablation, cryotherapy as a focal treatment option, and the even newer technique known as vascular-targeted photodynamic therapy (VTFT). They make the following key points:

  • Recent interest in focal therapy for prostate cancer has been driven by downward stage migration, improved biopsy and imaging techniques, and the prevalence of either unifocal cancer or a dominant cancer with secondary tumors of minimal malignant potential.
  • Several techniques have potential for focal ablation of prostate cancer.

Writing about cryotherapy, they state that:

  • Cryotherapy has been used for some time as a form of first-line therapy for complete ablation of the prostate or and as a second-line therapy for local recurrence after radiotherapy.
  • Enthusiasm for cryotherapy as first-line therapy has been tempered by the uncertainty about complete ablation of the cancer, the frequent persistence of measurable PSA levels after the procedure, and a high rate of erectile dysfunction.
  • To date, studies have reported the applicationof  “focal ablation” of prostate cancer with cryotherapy, targeting one lobe (either the left or the right side) of the gland to eliminate a cancer confined to that lobe with less risk of urinary or sexual complications.
  • Whether cryotherapy has sufficient power to eradicate focal cancer and can be targeted with sufficient accuracy to avoid damage to surrounding structures remains to be demonstrated in prospective clinical trials.

Similarly, in writing about HIFU, they state:

  • HIFU has been used widely in Europe for complete ablation of the prostate, especially in elderly men who are unwilling or unable to undergo radical therapy.
  • For low- or intermediate-risk cancer, the short- and intermediate-term oncologic results have been acceptable but need confirmation in prospective multicenter trials (which are now under way).
  • Whole gland therapy with transrectal ultrasound guidance has been associated with a high risk of acute urinary symptoms, often requiring transurethral resection before or after HIFU.
  • Adverse effects on erectile function seem likely after a therapy that depends on heat to eradicate the cancer, but erectile function after HIFU has not been adequately documented with patient-reported questionnaires.
  • HIFU holds promise for focal ablation of prostate cancer.
  • Focal use of HIFU should reduce the adverse sexual, urinary, and bowel effects of whole gland ablation.
  • New techniques are being developed to allow HIFU treatment under real-time guidance using magnetic resonance imaging, which could improve the precision and reduce the adverse effects further.

Thirdly, writing about VTFT, they state:

  • VTFT is another promising technique, currently in clinical trials.
  •  VTPT has been used for whole gland ablation of locally recurrent cancer after radiotherapy and for focal ablation of previously untreated cancer.
  • In combination with a new, systemically administered photodynamic agent, laser light is delivered through fibers introduced into the prostate under ultrasound guidance.
  • This technique does not heat the prostate but destroys the endothelial cells and cancer by activating the photodynamic agent.
  • Damage to surrounding structures appears to be limited and can be controlled by the duration and intensity of the light.

The fact that this authoritative group of experts came together to develop this review would seem to give increased support for the perceived value of these techniques (when appropriately applied to suitable patients) and the general potential of focal therapy. However, The “New” Prostate Cancer InfoLink would continue to encourage patients to consider these techniques in the context of well coordinated clinical and registry trials so that we can accumulate the best posiblel evidence related to their benefits and risks compared to other, currently widely available, forms of treatment.

3 Responses

  1. Brachytherapy is the only one of these “newer” techniques currently being reimbursed by the social security system in Belgium. It is also the only new technique that is widely supported by most community urologists in Belgium (as opposed to “expert panels”).

  2. Dear Dr. Vanderkerken:

    Thank you for your input on the current situation in Belgium. We fully appreciate that the fact that these types of therapies are now being studied (as they should be) in clinical trials, is not the same as their broad acceptance and use by the majority of the urology community (in any counrty). It took almost a decade for brachytherapy to become a widely accepted technique. Focal therapy has a similar uphill battle ahead of it before is can be considered as an “accepted” standard form of therapy.

  3. HIFU is currently in Phase III clinical trials in the USA so that its use can be approved by the FDA. It’s taken surprisingly to get there. It’s shown promising outcomes so I’m looking forward to the results.

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