Two new discussions of AS and focal treatments for PCa

[Guest guest]

Below are summaries of two discussions of dealing with early prostate cancer by Active Surveillance or Focal Therapy.

The online PSA monitoring program mentioned by Dr. Klotz can be accessed at: http://PSAkinetics.sunnybrook.ca

It is interesting that focal treatment is being discussed as an alternative between treating the entire prostate, with potential side effects, and deferring treatment by Active Surveillance, with potential anxiety issues. Focal treatment attacks the identified principal, or presumed only, index tumor and is followed by Active Surveillance to monitor for recurrence or progression of any missed micro tumors. The premise is that the focal treatment can be repeated if any subsequent tumor development is identified. Depending upon the doctor, focal treatment can range from treating all of one side of the prostate (thus preserving the neurovascular bundles on the untreated side) to treating just a small target area (thus preserving both nerve bundles).

The Best to You and Yours!

Jon in Nevada

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SUO 2008 - Update on Active Surveillance: Mini-symposium on Focal Therapy - Session Highlights Tuesday, 09 December 2008

BETHESDA, MD (UroToday.com) - Dr. Scardino introduced the session on focal therapy for prostate cancer. He defined low-risk prostate cancer and the excellent oncologic outcomes for this group as a whole. While some low-risk patients turn out to have higher risk features, this is presently rare and more commonly the pathologic analysis reveals possibly very minimal disease. In this context, the session addressed active surveillance (AS) and focal therapies.

Dr. ce Klotz addressed AS in prostate cancer. He initially published a 7-year follow-up of almost 400 patients on AS. Approximately one-third converted to active therapy at 7 years. He provided follow-up on this cohort. In the CaPSURE database, 10% of low-risk patients accept AS. In other published literature, assessing 1,833 patients in 6 cohorts, it appears that none address the number of patients who are appropriate candidates for AS and who actually undergo it. There are a variety of physician, patient, and social factors that influence this. Educational aspects turn out to be less influential in the Toronto database. He discussed the difference between disease progression and the trigger for intervention. What should be evaluated is the re-classification to a higher risk group, he stated. Criteria for re-classification include a PSADT<3 years and higher grade on biopsy. Mass spec and biomarkers may eventually contribute to elucidating this. The website PSAkinetics.sunnybrook.ca incorporates an AS nomogram that anyone can use to follow their AS patients.

In the literature, about one-third of AS patients convert to intervention within 10 years. The most common reason for conversion to treatment was a PSADST<3 years in 13%, and grade progression is 6%. Patient preference accounted for 5%. Anxiety is not a common variable if patients are appropriately reassured.

Dr. Klotz discussed the overall survival in 453 Toronto patients. The OS is 70% at 10 years and only 5 deaths due to CaP. In only one patient did an analysis reveal that he may have benefited from initial treatment and not AS. Patients are more likely to die of other causes. Patients who underwent active treatment were not found to be at increased risk for treatment failure. A global START trial will further help us understand AS and related outcomes.

Presented by ce Klotz, MD in a session moderated by Scardino, MD at the 9th Annual Winter Meeting of the Society of Urologic Oncology (SUO) - December 4 - 6, 2008 - Natcher Conference Center, National Institutes of Health, Bethesda, land

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SUO 2008 - Focal Therapy – Promises and Controversies - Session Highlights Tuesday, 09 December 2008

BETHESDA, MD (UroToday.com) - This session included presentations by three speakers.

Dr. Wheeler, the Pathology Chairman at Baylor began the discussion by mentioning that in the 1970’s up to 20% of men undergoing a TURP had prostate cancer in the specimen, but many did not undergo treatment. However, undergoing TRUS/biopsy ultimately results in almost all patients getting treated. He asked whether a small amount of cancer on biopsy is possibly indicative of a much greater tumor volume. A repeat prostate biopsy can help to stratify these patients, as do nomograms.

Most patients have multifocality of their tumors on pathologic assessment of radical prostatectomy specimens. The level of capsular invasion, surgical margin status, and Gleason grade all influence outcomes. Yet are the smaller non-index foci of cancer in the specimen significant or not? Pathologic assessment shows that these small foci share chromosomal abnormalities and altered ploidy status by FISH (this single institution observation has not been reproduced, he said). The percent risk of failure in Dr. Stamey’s series, however, is not driven by the tumor volume of the accessory tumor foci. Multifocal cancer in the Baylor dataset actually did better, but this may be driven by characteristics of tumor volume, he said.

The rationale for focal therapy is thus based upon treating the index cancer, and following the small foci and treating them should it ever be needed. The treatment morbidity of using focal therapy is balanced by the imaging ability to identify changes in the small tumor foci. The challenge is thus to develop better imaging to differentiate the significant from the insignificant cancers, he concluded.

Dr. Trachtenberg from Toronto then talked about interstitial phototherapy. Ten to 20% of all prostate cancers removed are unifocal, and thus might be considered for focal therapy. Even if not a unifocal tumor, the index lesion represents 86% of the total cancer volume. Imaging for focal therapy is critical, he stated. Single modality imaging presently is inadequate. However, multi-modality imaging using a variety of MRI technologies that are merged on a platform is much better. They used MR targeted ultrasound guided laser ablation of a 3-D reconstruction of the tumor. Fusion of the MR to ultrasound is under development and he provided images illustrating this technology. Their early series has 14 patients in an ongoing Phase I trial. They have had no significant peri- or post-operative complications. One patient was found to have more extensive disease and underwent an uncomplicated radical prostatectomy.

Dr. J. from the Cleveland Clinic, who participates in the COLD cryotherapy registry, then presented the technique and outcomes for prostate cancer cryotherapy. With 5-year follow-up, biochemical recurrence was about 23-27%. Many, however, had post-treatment erectile dysfunction which thus establishes a rationale for focal cryoablation. Post-treatment potency was up to 80% with focal therapy. Their selection criteria are unilateral disease on prostate biopsy with low risk disease in patients who is not accepting active surveillance. Focal cryotherapy must be weighed against active surveillance, targeted radiotherapy and focal brachytherapy he concluded.

Moderated by Scardino, MD at the 9th Annual Winter Meeting of the Society of Urologic Oncology (SUO) - December 4 - 6, 2008 - Natcher Conference Center, National Institutes of Health, Bethesda, land