To the benefit of patients and urologists worldwide, focal therapy for prostate cancer bridges the sizable gap between active surveillance and radical prostatectomy. Its ability to provide effective disease control, minimize the potential for chronic incontinence and erectile dysfunction and deliver the peace of mind that comes with action instead of watchful waiting explains why many clinicians with whom we have spoken recently believe focal therapy for prostate cancer will become the dominant form of treatment in the not-too-distant future.
Urologist Matthew Ercolani, MD, FACS recently shared with us his thoughts on the benefits of focal therapy for appropriate candidates and the status of existing focal modalities.
“For low or mild-to-intermediate risk categories, focal therapy is minimally invasive, easy for the patient and better than active surveillance, particularly when it comes to quality of life and patient satisfaction,” Dr. Ercolani says. “Among the three existing focal therapy modalities for prostate cancer currently available in the United States, each appear to have their own advantages based on the location of the lesion or lesions.”
An “a la carte approach to focal therapy for prostate cancer”
Dr. Ercolani points us to a 2016 opinion piece by Drs. Arjun Sivaraman and Eric Barret with the Department of Urology, Institut Montsouris from European Urology. “According to the limitations and complication profile, better selection of an energy modality depending on the PCa characteristics can improve oncologic and functional results, and represents a step towards personalized medicine.”
The authors compare cryotherapy, HIFU and brachytherapy modalities and propose HIFU as the preferred modality for posterior tumors in close proximity to the rectum and laterally to the nerves given the shorter focal distance and more precise contouring of the target area.
For anterior cancers, “the ease of accessibility via transperineal needles and established oncologic efficacy make cryotherapy more desirable for cancers in anterior locations. And for apical cancers, “results for brachytherapy show superior continence rates, so this approach may be more appropriate for apical cancers very close to the sphincters.”
An effective, familiar, billable focal therapy for prostate cancer option
“Cryotherapy and HIFU are wonderful modalities, but done wrong they can be devastating,” Dr. Ercolani says. “It is unfortunate that brachytherapy is considered an outmoded modality given the advent of robotics, proton beam therapy and HIFU.
“Advancements in imaging allow for ultra-detailed maps of the prostate that enable the delivery of brachytherapy seeds to just one quadrant. The flexibility to deliver fewer seeds to a highly targeted area decreases the risk of disease spreading compared to active surveillance, while only slightly increasing the risk of radiation damage to nearby healthy tissues and organs. It’s almost a no-brainer.”
Brachytherapy is familiar and comfortable for most urologists, is consistently covered by insurers and – thanks to the newly available Cesium-131 isotope – a cutting edge option urologists can offer in an outpatient setting. When used as a focal therapy modality, brachytherapy also allows for definitive treatment in the unlikely event of a salvage requirement.
“Brachytherapy is a great option for focal therapy of low risk prostate cancer,” Dr. Ercolani says. “It is proven effective, quick, well-tolerated by patients, easily billed and allows for all other options should additional treatment be needed. What can I do that’s better than active surveillance with the lowest level of risk of damaging something? Focal therapy is the answer every time. The urology community needs to know that brachytherapy has evolved in the past 20 years and should be closely considered in most, if not all, low grade, localized prostate cancer cases.”
If you are a urologist willing to take another look at brachytherapy, contact firstname.lastname@example.org to arrange a call, visit or meeting onsite at AUA 2018.