Focal therapy: Promising or insufficient?
Focal therapy is a general term for a variety of non-invasive techniques aimed at destroying small tumours inside the prostate, leaving the remaining gland intact and sparing most of its normal tissue. The efficacy of focal therapy was examined in the point-counterpoint session “Focal therapy in which setting?” during “Thematic Session 02: Focal Therapy”, chaired by Prof. Chris Bangma (NL) and Prof. Arnauld Villers (FR).
“I do think focal therapy will play a role in the future. However, active surveillance remains the preferable option for low-risk PCa,” stated Prof. Ofer Yossepowitch (IL) in his presentation “Focal therapy ready for which recommendations in the guidelines?”.
He agreed that in terms of functional outcomes, focal therapy is “unequivocally superior” to whole gland therapy (risking urinary and erectile dysfunction), but inquired, “With oncologic outcomes, can focal therapy cure those who need to be cured?”
Prof. Yossepowitch cited the results of the Prostate Cancer Intervention versus Observation Trial (PIVOT) study wherein the median follow-up was 23 years. He stated, “During this timeframe, 553 patients out of 695 (80%) of the patients have died. The absolute benefit associated with radical prostatectomy increased by a factor of more than two, between years 10 and 23. A Gleason Score (GS) > 7 was associated with 10 times higher risk of PCa death compared to GS 6.”
According to Prof. Yossepowitch, focal therapy for unilateral International Society of Urological Pathology (ISUP) grade 2/3 lesions is a plausible alternative in intermediate to high-risk disease. However, he advises informing patients about follow-up data, which is currently inadequate to ascertain its curability potential. He added that patients also need to know that there is a 20 to 30% local failure rate, and that focal therapy is best considered for relatively older male patients. Prof. Yossepowitch stated that the optimal salvage strategy is still unknown.
Dr. Hashim Uddin Ahmed (GB) counter argued that focal therapy is advantageous for patients. In his lecture Dr. Ahmed stated, “The new targeted biopsy paradigm inevitably requires us to match our treatment to the biology of the disease. Focal therapy has shown a low side-effect profile.”
Adverse effects of focal therapy on functional outcomes include no long-term bowel problems; 1 to 2% urinary incontinence; 5 to 20% erectile dysfunction; and 50% dry orgasm (men can remain naturally fertile). Complications included 0.1% rectourethral fistula, 1% urethral stricture and 5% infection.
Focal therapy in men who have clinically significant prostate cancer has good medium-term cancer control. Long-term comparative data are awaited but patients should be counselled about focal therapy.