More from the GU oncology symposium — Part 2

During the oral sessions on prostate cancer management yesterday, there were two topics that generated significant differences of opinion between presenters: the relative benefits of salvage vs. adjuvant radiotherapy in men post-surgery and whether focal therapy (whether executed with HIFU or cryotherapy or any other means) is actually a valid from of treatment.

In the first case, Thompson argued that adjuvant radiotherapy is an appropriate form of care for men shown to have pathologic T3 disease post-surgery. In other words, because of their risk for disease progression, such patients should have immediate radiotherapy once they have recovered continence following surgery. Parker, on the other hand, presented the argument that adjuvant radiation almost certainly guaranteed a lower quality of life among such patients because of the short- and long-term side effects of radiation, and that salvage radiotherapy was invariably a wiser option unless there were clear signs of an early and rapid rise in the PSA.

It is fair to say that there was no consensus reached on this subject, with a single exception. All parties did agree on the importance of allowing sufficient time between surgery and radiation (if it was to be given) such that the patient would recover an optimal continence level prior to initiation of radiotherapy because radiotherapy would tend to “freeze” recovery of continence. Thompson perhaps was nearest to finding some common ground that all could agree with, writing in the symposium proceedings that, “a patient with pT3 prostate cancer should be informed that adjuvant radiotherapy will reduce his risk of metastasis, PSA recurrence, local recurrence, and need for hormonal therapy, and improve his overall likelihood of survival. He should also be advised of the greater initial risk of gastrointestinal and urinary toxicity.”

The current RADICALS trial, which is enrolling patients in the UK and in Canada, may help to resolve this issue.

The discussion around the use of focal therapy was perhaps even more contentious, with Koch presenting the argument that focal therapy is little better than “sham therapy” and Emberton taking the position that focal therapy is a viable investigational form of treatment for patients meeting well defined criteria for disease localized to specific areas of the prostate.

The critical issue in this discussion is, of course, whether it is actually possible to tell any specific patient that his cancer really is localized to a specific region of his prostate. If it really is not possible to do this, then arguably focal therapy is unethical because it really is not curative treatment.

Having said that, it seems to The “New” Prostate Cancer InfoLink that this discussion, as framed, is really irrelevant because “the cat is out of the bag.” What is perhaps more important is how a physician can really ensure that patients understand the risk they are taking when they opt for focal therapy: that risk being that they may be about to undergo non-curative therapy if there is a focus of cancer in the portion of the prostate that is not going to be treated.

In all truth, we do not see this as something that is much different than the decisions that patients are asked to make all the time about the relative risks and benefits of other types of prostate cancer treatment — many of which have to be made on equally little reliable data.

It is not as though we are asking physicians who disapprove of focal therapy to approve of it or recommend it, let alone carry it out. What we are asking everyone to do is to acknowledge that it is an investigational treatment, and to ensure that data about every patient who undergoes such treatment is accumulated as part of a clinical trial or in some form of trial registry database so that we can optimize our knowledge about the potential of and the risks associated with this type of treatment as fast as possible.

3 Responses

  1. Mike,

    I look forward to our conversation in May. I enjoyed reading your summary statements of the meeting. They are both physician and patient appropriate. Is the readership more patient majority?


  2. Dear Paul:

    Thanks you for your kind remarks. We believe that the current readership is probably 75-80 percent patients and family members, but there is a significant minority of physician and other health care professionals who we know monitor the site, particularly for issues that may be relevant to their area of specialty.

    We have made very little attempt to promote the site to the professional audience to date. Do you think that we should?

  3. Mike: Historically, it is generally acknowledged that prostate cancer tends to be a multi-focal disease. This is a major reason for the 35-45% of change in grading applied to excised surgical specimens, following removal (generally UPWARD). Since there is no clinical way to reliably detect tumors that are too small to be seen on imaging, it seems that there would be a substantial risk of recurrence in treating only a single detected tumor.

    However, providing it is CLEARLY identified as “experimental” at present, it is an option available to a few appropriate prostate cancer patients. My layman’s opinion is that, it is NOT likely to be found to be as curatively effective as removing and/or treating the entire prostate. More likely, it may prove to be found to be most successful in those patients who have an indolent form of prostate cancer and that may have required NO treatment in the first place.

    In the case of this experimental procedure, the selection of suitable patients almost surely would be limited to such very early stage patients, who are most likely to equally qualify for existing “active surveillance” studies.

    Just my observations and OPINION. — John (aka)

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