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Will focal therapy become a standard of care for men with localized prostate cancer?

Nature Clinical Practice Oncology volume 4, pages 632–642 (2007)Cite this article

Abstract

The current treatment choice for men with localized prostate cancer lies between active surveillance and radical therapy. The difference between these two extremes of care is 5% in terms of cancer-related absolute mortality at 8 years. It is generally accepted that this small difference will decrease for men diagnosed in the prostate-specific-antigen era. Radical therapy is associated with considerable adverse effects (e.g. incontinence, impotence, rectal problems) because it treats the whole gland, and damages surrounding structures in up to half of men. Men are being diagnosed at a younger age with lower-risk disease, and many have unifocal or unilateral disease. We propose a new concept whereby only the tumor focus and a margin of normal tissue are treated. This paradigm might decrease adverse effects whilst, at the same time, retaining effective cancer control. The arguments for and against active surveillance and radical therapy are reviewed in this article, with focal therapy presented as a means for bridging these two approaches.

Key Points

  • The current choice for men with localized prostate cancer lies between active surveillance and radical therapy

  • Radical therapy carries significant side effects (e.g. incontinence, impotence, rectal problems) because it treats the whole gland and damages surrounding structures in up to half of men

  • Active surveillance might exclude men who have risk factors at presentation, and it is likely that those excluded are therefore more likely to benefit from treatment

  • The decision to choose radical therapy is not only confounded by the lack of clear evidence for a survival benefit but also the degree of morbidity

  • Focal therapy might be almost as effective as radical (whole gland) treatment with similar low adverse effects as seen in those with active surveillance

  • A significant proportion of men with organ-confined, low-to-moderate risk prostate cancer may be spared from disease progression and have a high probability of preserving genitourinary and bowel function with focal therapy

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Figure 1: Radical prostatectomy step sections.
Figure 2: MRI scan (1.5 Tesla, 15 °, T1-weighted dynamic contrast-enhanced (gadolinium) VIBE image) demonstrating avidly enhancing bilateral lesions (right base and left anterior; same patient as in Figure 3).
Figure 3: Template mapping biopsies demonstrating 4 cores positive for adenocarcinoma out of a total of 30 cores.

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Acknowledgements

Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. HU Ahmed is a Clinical Research Fellow and a Specialist Registrar in Urology, D Pendse is a Clinical Research Fellow in Urological Oncology, R Illing is a Specialist Academic Registrar in Radiology and C Allen is a Consultant Radiologist, all at University College London, London, UK.,

    Hashim Uddin Ahmed, Doug Pendse, Rowland Illing & Clare Allen

  2. R Illing is also a member of The Royal College of Surgeons of England.JHP van der Meulen is a Reader in Clinical Epidemiology at the London School for Hygiene and Tropical Medicine and Director of the Clinical Effectiveness Unit at The Royal College of Surgeons of England.,

    Clare Allen & Jan HP van der Meulen

  3. M Emberton is a Reader in Interventional Oncology and a Consultant Urological Surgeon, University College London, and Clinical Director of the Clinical Effectiveness Unit, The Royal College of Surgeons of England, UK.,

    Mark Emberton

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Correspondence to Hashim Uddin Ahmed.

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Competing interests

Hasim U Ahmed and Mark Emberton receive funding from The Prostate Research Campaign UK (charity), Prostate Cancer Research Centre UK (charity) and Pelican Cancer Foundation UK (charity), for work in focal therapy. Mark Emberton is a Medical Consultant to Misonix Inc. In addition, Mark Emberton receives funding from Negma Lerads, France (manufacturers of TOOKAD, a photodynamic agent used in prostate cancer therapy) and Misonix Inc (distributors of the Sonablate® 500 HIFU device). Doug Pendse receives funding from Negma Lerads. Rowland Illing receives funding from the Pelican Cancer Foundation charity, UK. Clare Allen and Jan van der Meulen declared no competing interests.

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Ahmed, H., Pendse, D., Illing, R. et al. Will focal therapy become a standard of care for men with localized prostate cancer?. Nat Rev Clin Oncol 4, 632–642 (2007). https://doi.org/10.1038/ncponc0959

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