Point counter point for prostate cancer treatment

Presentation of the Con position for Focal Therapy

The goal is to bring about cure without causing significant side effects. Focal therapy has the potential to reshape treatment of prostate cancer; however a significant group of appropriately credentialed professionals believe that the efficiency of focal therapy has yet to be proven. These professionals believe that the multifocal nature of prostate cancer makes treatment using the focal approach inadequate.

It is clear that the majority of prostate cancers are the result of a mixture of low grade, low volume disease. However, some of these cases have larger deposits of high grade large aggressive cancer in a localized area. This is known as an index lesion. On the other hand, prostate cancer that is purely low grade and low stage does not progress and has led to the concept of active surveillance. This means patients who have tumors, with these characteristics, are being treated with “surveillance” rather than aggressive therapy such as radical prostatectomy or high density radiation therapy.

It is also clear however, in this surveillance group some patients will demonstrate evidence of progressive disease.  They are then treated differently and taken out of the surveillance group. When they are studied with the new techniques of imaging in some cases there is an identification of a grouping of more aggressive cells known as the index lesion. This lesion is most likely to be causing the PSA elevation.

Regardless, in many cases prostate cancer is multi focal. The question that needs to be answered simply is; what type of cancer are we dealing with? Low volume and low grade the kind that people can live out their normal lives, or is it high grade and aggressive cancer which unless appropriately treated can be life ending?

Knowing the answers to this question opens the opportunity for a number of well established prostate cancer treatments to be considered. These include aggressive therapy such as radical prostatectomy, or total gland therapy with techniques such as high density radiation, total gland treatment with cryoablation or with HIFU which is high intensity focused ultrasound. 

We have entered into a new era in the treatment of prostate cancer. We have a wide variety of options which include radical surgical removal, total gland therapy with either cryoablation or radiation and although not yet completely accepted by the medical community focal treatment with either cryoablation or HIFU.

A fully informed patient working with a urological oncologist, radiation oncologist and/or medical oncologist will have the opportunity to be treated with a therapy customized to their particular problem which will minimize or eliminate the risk that most of us associate with the diagnosis of prostate cancer. 

Point counter point for prostate cancer treatment

Presentation of the pro position for focal therapy

Focal therapy for prostate cancer is controversial. It is believed that prostate cancer occurs in more than one area within the prostate at the time of diagnosis. Focal therapy is designed however to treat a very precise area within a gland.

An example of focal therapy that clearly has been established as a prime treatment is that of renal cancer and techniques such as partial nephrectomy which is removal of a portion of the organ and small cancer within the kidney can be destroyed by using a freezing technique known as cryo ablation.

Dr. Mark Emberton and his colleagues at University College London are the world leaders in applying the principles of focal therapy for the cure of prostate cancer. There is a concept in defining prostate cancer that is referred to as an index lesion. This is the largest deposit of cancer in the prostate and is usually greater than 5 mm in diameter. This size lesion can be diagnosed by an imaging study known as the 3Tmri.

Using the information provided by the MRI, the technique of targeted biopsy results in early diagnosis of low volume disease.

It is known that there are prostate cancers that people can live with and they have no significant affects from this. These lesions when studied are low grade, small volume and less than 2 mm in diameter. This type of cancer is frequently found on autopsy and never creates a problem during the patient’s life. The index lesion is the problem and with our ability to identify this and make early diagnosis it is possible to provide curative therapy to many people without removing the prostate gland by using focal treatment. With careful selection of low grade, low volume tumor that make up an index lesion that occupies only one side of the prostate, it can be cured by using a freezing technique known as cryo ablation. This does destroy the part of the prostate that contains the tumor. The opposite side of the prostate does not demonstrate cancer. Therefore this is a method of curative focal therapy. Here are 3 educational videos from our website: Focal Cryotherapy Hemiablation Part 1 , Focal Cryotherapy Hemiablation Part 2 , Focal Cryoablation Minimally Invasive Treatment of Prostate Cancer

There currently are ongoing studies with High Intensity Focused Ultrasound (HIFU). We will discuss this in a forthcoming blog, however there is an educational video, HIFU The Latest Trend for the Management of Prostate Cancer , on our website www.riversideurolgy.com where you can learn much more about this effective treatment.

Our next blog will deal with the other side of this controversy explaining why focal therapy is felt by some experts not to be ready to be considered for treatment of prostate cancer currently.

Cryoablation is a procedure that is used to cure recurrent prostate cancer after failed radiation therapy.

Each year approximately 50,000 men in the U.S. are treated with radiation therapy for curative treatment for prostate cancer. Sixty percent of this group will have what is known as PSA failure. This means the PSA rises above acceptable limits usually thought to be 2 ng/ml. Not all patients in this group will be diagnosed with recurrent cancer, but a significant number will. This number can be as high as 15-30,000 patients. It is clearly troublesome. However, good answers for this problem exist.

As soon as the PSA failure is recognized, a timely workup is indicated. This will include new methods of imaging known as multi parametric MRI. In addition there are new tumor markers, the most important beyond PSA is known as PCA3.

The good news is that if this workup is done early many times it is possible to see the problem that has developed within the prostate. It may be a single area of cancer that has reoccurred. Using the advanced MRI this can be detected then biopsies can be guided to the specific target representing recurrent disease.

Unfortunately today, this type of workup is not common. Many times the patient is put on LHRH inhibitors (androgen deprivation therapy). The reason for this is that many believe that failure following radiation has no good answer; clearly this is not the case! Additionally, the androgen deprivation therapy has side effects; adverse affects on the heart, blood, in the sense of increased cholesterol, and depression of testosterone which results in thinning of the bone otherwise known as osteoporosis.

With current imaging cryoablation can be targeted to the area of recurrence and result in cure.

This may sound familiar. Twenty five years ago when women were diagnosed with breast cancer the answer was radical mastectomy, today that term is rarely heard. What has replaced it is lumpectomy and many women treated in this way live very full and productive lives. 

Likewise when cryoablation is used to eliminate the area of recurrent prostate cancer after radiation failure, the PSA rapidly falls to undetectable levels. Studies done in 2010 at Columbia University in New York City have demonstrated in a group of 900 patients that the 10 year cure rate is approximately 90 percent.

The key to achieving this level of cure is early diagnosis, early workup is indicated, and appropriate treatment based on today’s technology is required. Today many doctors immediately administer androgen deprivation therapy, this needs to be replaced by early diagnosis of the recurrence with the contemporary technologies that are available.  

We have produced a short video that overviews the current and evolving treatment utilizing Cryo as Salvage Treatment for Failed Radiation Therapy of Prostate Cancer Please take a few minutes to review this very useful information.