Focal therapy for prostate cancer: two opposing views

The debate within the urologic  oncology community about the merits of focal therapy as a form of treatment for selected patients with localized prostate cancer shows no sign of slowing down.

In two “Opposing views” articles in the October issue of the Journal of Urology, Dr. Mark Emberton (“Why focal therapy is a legitimate and necessary response to a changing world“) and Dr. Mark Gonzalgo (“Focal therapy for prostate cancer: don’t believe the hype“) lay out their very different perspectives on the potential merits and risks associated with focal therapies as treatments for small volumes of carefully located and highly defined prostate cancer. The two different perspectives are also well summarized in a commentary on the Medscape web site.

In the view of The “New” Prostate Cancer InfoLink, focal therapy is an option that some patients can certainly consider, but in making decisions they need to appreciate that:

  • The available data on short- and long-term outcomes of focal therapy are very limited. Focal therapy is best considered to be “investigational” at this stage.
  • It is quite clear that the skill of the clinical team in identifying and selecting appropriate patients and in actually treating those patients using specific types of focal therapy is a very crucial factor.
  • There is a “learning curve” involved before any physician can identify appropriate patients and treat them with a high skill level using focal therapy
  • Not all healthcare insurance carriers are going to reimburse for focal therapy (although they may now have to if the form of focal therapy being used is high-intensity focused ultrasound or HIFU).
  • We are not going to resolve the question about the harms and benefits of focal therapy without well-conducted, prospective trials in relatively large, highly defined groups of patients which include data on such endpoints as
    • 10- and 15-year prostate cancer-specific survival with PSA-based follow-up that leads to stable PSA levels and (ideally) negative follow-up biopsies
    • Detailed, prospective comparisons to outcomes of very similar patients using other appropriate forms of management (active surveillance very definitely included)
    • Sophisticated assessment of patient-reported quality of life data

While theoretical debates of this nature are interesting, the bottom line is that we are going to need high-quality, long-term data to demonstrate whether or not there is any real benefit to focal therapy over time; if so, in which patients; and which clinicians are actually sufficiently skilled to identify, select, and treat patients such that they can produce such benefits in a reliable and consistent manner.

In discussion of the potential of HIFU as a form of focal treastment for prostate cancer, which, as the Medscape article notes, Dr. Emberton’s group has been using for about 8 years, Emberton is quoted as follows:

It does need the operator to be skilled (just like surgery), and some users have found it hard to gain the competencies required.

The “New” Prostate Cancer InfoLink thinks that this may well be one of the two really crucial statements in this entire pro/con discussion of the role of focal therapy. It’s not really about whether focal therapy can and will work well for selected patients. It almost certainly can and will. It’s about which clinicians using which forms of focal therapy really have the ability to carry it out with high levels of effectiveness and minimal levels of side effects and complications in the patients who are most likely to benefit.

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