Is focal therapy for every man with localized prostate cancer? No way. In fact, says Northwestern University urologic surgeon Ashley Ross, MD, Ph.D., it’s not even a good choice for the majority of patients. But for a few carefully selected menwith close monitoring, “it can be a treatment option with minimal side effects.”
Ross, one of the leaders in the growing field of focal therapy, is the expert I interviewed for 5u our version book –where we are not just talking about focal treatment for localized prostate cancer. we dedicate a whole chapter to it! This is a major milestone, especially if you look at all the previous editions of our books dating back to 1993, where we basically offered zero encouragement to take this approach.
But – but – focal therapy is out there! It’s here to stay! It is available worldwide! Yes this is true. Does it work long term? Nobody knows yet. Current National Integrative Care Network (NCCN) guidelines state that “cryotherapy or other topical treatments not recommended as routine primary treatment for localized prostate cancer due to a lack of long-term data comparing these treatments with radical prostatectomy or radiation.” Also, in addition to follow-up biopsy, there is no way to prove the cure with focal treatment. PSA does not become undetectable because much of the prostate is still intact and this prostate tissue is still producing PSA.
This is why long-term follow-up is critical: you need to keep monitoring the PSA, and if it changes, you need a repeat MRI. So, no matter what anyone says, focal therapy is not the standard of care. it is still considered research.
The last post (part 1 of this series) was devoted to all the reasons why men interested in this approach should proceed with great caution. This post begins to look at who may consider focal therapy.
Why am I talking about it now? What changed; Illustration, for one thing; prostate MRI and targeted MRI fusion biopsies (also called mpMRI). There are also smart blood and urine tests that can help determine if a cancer is clinically significant (we have updated information on this at 5u edition of the book).
Overall, perhaps with genetic testing if there is a strong family history of cancer, it is possible to get a decent idea of the type of cancer you have. You can’t just say, oh, I have localized cancer! You need a more nuanced understanding of this cancer, and that requires gathering every available piece of information you can get. Don’t rely on the biopsy alone. Remember, a biopsy only looks at 1/10,000u prostatic. Yes, that’s a tenth of a thousandth. Not much tissue! Just because the biopsy says Gleason 6 doesn’t mean there isn’t a higher-grade cancer in your prostate. Many men are “inverted,” meaning a higher grade of cancer is found after prostatectomy when the pathologist examines the removed prostate tissue.
And don’t trust all your MRIs. As good as an MRI is, some prostate cancers still don’t show up on it. they are spread out, like plankton in the ocean, rather than all bound up in a dense ball. But if you put the imaging, the biopsy and the other tests togetheryou can deal very well with the type of cancer you have.
Do you have the type of cancer that needs to be treated immediately? If not, active surveillance is a great initial option. It saves you time and has zero side effects. If you have a Gleason 3+3 (low risk or very low risk) or 3+4 (favorable intermediate risk cancer), with not much pattern 4 and the cancer appears to be safely contained within the prostate, then be thankful! You have some breathing room. Plenty of time to make a treatment decision when and if your cancer should be treated.
If you have localized cancer but there is a lot of Gleason 4 pattern, or any Gleason 5 pattern, (4+3=7, 4+4=8, 4+5, 5+4 or 5+5), then you have cancer it is not just clinically significant, but it’s likely to spread and the prostate needs to be removed – either with surgery or radiation, and if it’s higher grade, bulkier and close to the border of the prostate and you’re considered high risk, you may need to be escalated and with a temporary course of hormone therapy. We analyze all these scenarios in detail at The Book.
Who is the ideal candidate for focal therapy?
Ross believes there is a “sweet spot” for focal treatment: men with high volume low risk disease (Gleason 3+3) and favorable intermediate risk of prostate cancer (a bit of the Gleason 4 pattern), “as long as their disease is located in one area of the prostate,” he says. Preferably with a single lesion and ideally, “a lesion that is more anterior (above the urethra), as it allows preservation of the neurovascular bundle.”
Ideal candidates for focal therapy, he continues, should have a life expectancy of 10 years or more. They should be willing and able to undergo an MRI and biopsy, or they should consider a saturation biopsy to make sure there are no areas of higher-grade cancer lurking in the prostate. “Men should also be willing, in my opinion, to undergo a confirmatory biopsy’, to make sure the focal treatment worked. “They have to have a very low likelihood of lymph node involvement, because obviously you’re not going to treat with focal therapy a disease that has spread into the pelvis.”
The dot points here:
- 10 years or more life expectancy
- Unilateral cancer (one area or focus), preferably away from the neurovascular bundles on both sides. A man who has multifocal disease (many pieces of cancer growing inside the prostate at the same time, like seeds in a strawberry) “has a higher tendency to develop more prostate cancers” and should not be considered for focal treatment.
- You need a follow-up biopsy to make sure you are cured.
- Also, Ross says, you should get genetic testing if it’s recommended. In the book, Ross mentions two kinds of genetic tests: one looks for mutations in genes like BRCA2, which increase the risk of aggressive cancer; “Patients with genetic risks are potentially poor candidates for focal therapy,” says Ross. There is another type of genetic test: one that looks for multiple genetic variants that are known to increase the risk of prostate cancer. These are not mutated genes, but mutated DNA sequences. Men with high polygenic risk scores are more likely to have multifocal disease and “may also be poor candidates for focal therapy.”
Here’s a case study that Ross presented at Northwestern that we used in the book.
“Daniel” is 74, with a PSA of 7.1 No cancer was palpable on his rectal exam, but an MRI showed a lesion, with a PI-RADS score of 5, in the right transition zone. MRI-targeted prostate biopsy found cancer, Gleason 3+4=7 – but not much. Cancer was found in only three of the 12 biopsy cores, but in two of those cores, 40 percent of the cancer was Gleason 4.
Daniel is still working and quite active. Ross estimates its life expectancy to be about 10 years. Daniel has some health issues, including atrial fibrillation, and takes a blood thinner called Eliquis. Before coming to see Ross, he met with another urologist to discuss robotic prostatectomy and a radiation oncologist. “He wasn’t interested in radiation therapy,” says Ross. He was “worried about bleeding episodes” because of Eliquis. “She was also worried about the surgery.”
Daniel underwent cryoablation, killing cancer cells with extreme cold – creating an ‘ice ball’ of tissue, which then dies). This focal procedure spared both neurovascular bundles (the nerves on either side of the prostate responsible for erection) and, because of the location of the tumor, did not affect the urethral sphincter. It was done as an outpatient procedure and Daniel went home the same day. “He had a smooth recovery, he had immediate continence, which was complete when the catheter was removed in seven days. He had no decline in sexual function,” although Daniel had already experienced some ED prior to the procedure. Three months later, Daniel’s PSA dropped to 0.94. “We will continue PSA monitoring and do an MRI and confirmatory biopsy at 12 months.”
Part 3 of this series will be my interview with Johns Hopkins urologist Arvin George, MD, who is researching several different types of focal therapy and believes this therapy will be useful for a wider window of patients.
Additionally with BookI have written about prostate cancer on the Prostate Cancer Foundation website, pcf.org. The stories I have written are in the “Understanding Prostate Cancer” and “For Patients” categories. I firmly believe that knowledge is power. Saving your life can start with going to the doctor and knowing the right questions to ask. I hope all men put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s and if you are of African descent or have a family history of cancer and/or prostate cancer, you should be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask.
©Janet Farrar Worthington
