Focal therapy meets prostate cancer

Prostate cancer remains the most common, noncutaneoushuman cancer with about 186 000 newcases diagnosed in 2008 in the USA1 and 214 cases per1000 men in Europe, outnumbering lung and colorectalcancer.2 With current trends of testing for prostatespecific antigen (PSA) and the lowered PSA thresholdfor biopsy in some countries of the developed world,more and more men will be diagnosed with prostatecancer. Controversy about the unproven benefi t of PSAscreening, as well as the known side-eff ects, highlightthe concerns about overdetection and overtreatment.3,4The present choice of treatment for men with localisedprostate cancer lies between active surveillance andradical therapy. The rationale of active surveillance forlow-risk prostate cancer (PSA<10 ng/mL, Gleason grade 6or less, and clinical stage T1c–T2a) is sound. However, theinherent risk of active surveillance is undertreatment.About a quarter to a third of patients who are thoughtto be ideal candidates for a no-treatment approach arelater recommended to have therapy once additionalinformation is obtained.5,6 The no-treatment approachalso carries a psychological burden of allowing a knowncancer to grow, and it might have consequences on thepatient, his family, and his job performance, with anadverse eff ect on an individual’s quality of life.Prostate cancer is dogmatically regarded as a heterogeneousand multifocal disease, and is therefore usuallytreated with a radical whole-gland approach. Radicalprostatectomy is an eff ective therapy for patients withclinically localised prostate cancer. Despite improvementsin surgical techniques, such as the introduction of roboticassistedlaparoscopic prostatectomy which allows adetailed dissection with a water-tight vesical-urethralanastomosis and a nerve sparing procedure, urinaryincontinence and erectile dysfunction are not uncommonafter radical prostatectomy.7,8 External beam radiotherapyand brachytherapy are eff ective and non-invasive butthey might carry long-term risks too, such as troublesomebowel, sexual, and urinary dysfunction.In the past, the use of breast-sparing surgery, such aslumpectomy, to treat breast cancer revolutionised localcontrol of the disease. Experience with lumpectomyshows that quality of life can successfully be integratedinto the equation of cancer treatment, without majorloss of treatment effi cacy. Physicians and the public havestarted to be interested in the notion of prostate-sparingfocal therapy for prostate cancer. It was the topic of the3rd International Symposium on Focal Therapy andImaging of Prostate and Kidney Cancer that was held inWashington DC, USA, in February, 2010. Focal therapyfor prostate cancer is defi ned as therapy that selectivelyablates known disease while preserving existing functions,with the overall aim of minimising lifetime morbiditywithout compromising life expectancy. Faculty at thesymposium agreed that the two main crucial points forfocal therapy were ideal selection of patients and presenceof focal cancer. Although multifocality represents atheoretical contraindication to focal therapy, data aboutthe predominant, or index lesion, provide insightfulinformation, and faculty agreed that reliability and precisionin tumour localisation is essential for cancer controland to minimise morbidity. Precise localisation can beobtained by template-guided transperineal biopsies andmultiparametric imaging techniques, such as dynamiccontrast-enhanced diff usion-weighted MRI or magneticresonance spectroscopy. The symposium did not reachconsensus on the ideal therapeutic strategies for focaltherapy and diff erent ablative energies were suggested,such as cryotherapy, high-intensity focused ultrasound,vascular-targeted photodynamic therapy, brachytherapy,radiotherapy, or tomotherapy. The crucial point aboutchoice of ideal follow-up was addressed but no consensuswas reached about the defi nition of biochemical-freesurvival after focal therapies for prostate cancer.