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Speaker: Kai Zhang, Beijing United Family Hospital, China
Important Takeaways
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Focal Therapy as a Middle Ground: Focal therapy provides an option between conservative active surveillance and radical treatments, which can lead to complications like incontinence and erectile dysfunction.
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Techniques in Focal Therapy: The most studied techniques include high-intensity focused ultrasound (HIFU), cryotherapy, and irreversible electroporation (IRE), each with its own advantages and limitations.
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Oncological Control and Recurrence: Focal therapy offers favorable oncological control, but challenges remain in managing in-field and out-of-field tumor persistence.
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Quality of Life Benefits: Patients undergoing focal therapy experience significant preservation of urinary and erectile function, with most regaining baseline function within three months post-treatment.
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Future Directions: There is a need for improved imaging techniques, such as PSMA PET-CT, to better identify recurrence and ensure accurate tumor mapping before focal therapy.
Key Highlights
The Role of Focal Therapy:
Dr. Zhang emphasized that focal therapy is a less invasive option for low to intermediate-risk prostate cancer, akin to breast-conserving surgery in breast cancer. It bridges the gap between active surveillance and more invasive treatments that may lead to complications.
Techniques in Focal Therapy:
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High-Intensity Focused Ultrasound (HIFU): Widely studied but may damage nearby structures due to thermal effects.
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Cryotherapy: Effective but can lead to urethral strictures if tumors are near the urethra.
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Irreversible Electroporation (IRE): Dr. John highlighted IRE as a newer, non-thermal technique that is safer for treating tumors near sensitive structures like the urethra and neurovascular bundles (NVBs). Its ability to minimize damage to surrounding tissues makes it a valuable option in focal therapy.
Oncological Outcomes:
A multi-centre randomized trial on IRE demonstrated favorable oncological results, with nearly 80% of patients having no residual prostate cancer in follow-up biopsies and only 10% experiencing clinically significant recurrence. MRI follow-ups at 6, 12, and 24 months confirmed tumor resolution in most cases. Despite the technique’s relatively short learning curve, it has shown consistent success across different centers.
Quality of Life and Functional Outcomes:
Dr. Zhang discussed the quality of life outcomes for patients undergoing IRE. Urinary function was temporarily affected in the first month post-treatment but returned to baseline by three months. Erectile function also followed a similar recovery timeline, with most patients reporting restored function within six months. This preservation of quality of life compared to more aggressive treatments is a significant advantage of focal therapy.
Limitations and Challenges:
One of the main challenges with focal therapy, including IRE, is the risk of tumor persistence. Tumor recurrence can occur within the treated area and, more concerning, out-of-field recurrence. Dr. Zhang emphasized the importance of thorough initial tumor mapping and biopsies to avoid missing multi-focal disease. Additionally, current imaging tools, like MRI, have low sensitivity for detecting recurrent cancer post-focal therapy, underscoring the need for better imaging technologies, such as PSMA PET-CT.
Dr. Zhang concluded that it is essential to prioritize the quality of life for prostate cancer patients. Focal therapy presents a promising approach, achieving favorable oncological control while minimizing treatment-related functional detriments. As we look to the future, focal therapy is likely to become a new perspective for managing localized prostate cancer, particularly for patients with low to intermediate risk.
Société Internationale d'Urologie Congress, 23-26 October 2024, New Delhi, India.
