Background
Total or whole prostate gland treatment for a localised prostate cancer (particularly after the radical surgery/robotic prostatectomy) is associated with:
> significant complications
> insignificant numbers of lives saved
> gross overtreatment especially for the favorable-risk Gleason 6 (3+3) prostate cancer which is commonly, not a health risk.
Warnings to the public and physicians about these concerns and lack of obvious benefits for prostate cancer treatments have come from several fronts:
> the USPSTF reports outlining the great harm and insignificant numbers of lives saved ( http://www.uspreventiveservicestaskforce.org/)
> class action lawsuits against the makers of the robotic equipment for robotic prostatectomy
> publications such as “The Big Scare, the business of prostate cancer” by A. Horan MD
> PSAs and Prostate Cancer: Mayhem and Gore (https://urologyweb.com/wp-content/uploads/mayhemgore.pdf)
> https://urologyweb.com/exclusve-medical-reports/
> Bad Surgery on the Uro Health Blog (https://urologyweb.com/bad-surgery/)
This treatment evolution from whole gland treatment of localized prostate cancer to focal treatment of the cancer is in part from a realization, finally, of the very significant complications associated with the radical surgery/robotic prostatectomy treatment as well as a recognition that breast cancer lumpectomy and focal ablation of kidney cancer seem to deliver similar results to the radical surgery for these cancers but at substantially less risk. In addition, this rethinking was also allowed due to the fortuitous development of sophisticated noninvasive imaging methods such as the MRI and the detection of cancers earlier and of a smaller size.
Goals of Focal Treatment for Localised Prostate Cancer
> to decrease the significant incidence of lasting complications
> to save significant numbers of lives
Possible Benefits of Focal Treatment
> less urinary issues and incontinence
> preservation of erections and manhood through nerve sparing techniques
> preservation of orgasm
> preserving most of the prostate to preserve ejaculate fluid
> preserving bladder neck to preserve antegrade ejaculation
> less collateral damage to adjacent structures such as rectum and sphincter
> less negative quality of life (QoL) issues
> single outpatient treatment
> focal treatment and downsizing of the index lesion may benefit ongoing active surveillance
Which Men may Benefit from Focal Treatment? (Candidate Selection)
> younger men
> significant and high-risk localized disease. This will require special BIOMARKERS (still waiting to be discovered) which will be able to predict RELIABLY prostate cancers which truly demand treatment from those prostate cancers which can be monitored through active surveillance
Potential Downsides of Focal Treatment
> possible incomplete treatment of prostate cancer
> apical cancers may be difficult to eradicate for fear of damaging the urethral sphincter
> inability of imaging to assess reliably local infiltration or stage of disease
> imaging with 3T MRI is still associated with too many false positive and negative diagnoses to dispense with the needle biopsy of the prostate
> 75% of prostate cancers are multifocal and identifying the real index lesion for treatment may be problematic
> more rigorous follow up after focal treatment with office visits, PSA tests and evaluations
> even more exploitation and abuse of men made vulnerable by the word cancer
Concerns about Focal Prostate Cancer Treatment
> most Gleason 3+3 cancers are very slow growing
> most Gleason 3+3 cancers tend not to progress or spread
> most Gleason 3+3 cancers are a function of the aging of the prostate
> most Gleason 3+3 cancers are not a health risk
> most prostate cancers are favorable-risk Gleason 3+3 cancers and most of these cancers do NOT require treatment whether focal treatment or whole gland treatment (OVERTREATMENT)
Treatment Options for Focal Treatment of Localised Prostate Cancer
> nerve sparing focal HIFU (high frequency focused ultrasound, www.hifurx.com/
> nerve sparing focal cryoablation
> focal laser ablation techniques and other options are available only at a few centers in the US
Conclusion
Since roughly 75% of all prostate cancers are classed as favorable-risk Gleason 6 (3+3) cancers and commonly, these do not require treatment, focal therapy ablation is very unlikely to produce any significant benefits for the majority of men with these cancers. In fact, evidence suggests now that MOST Gleason 3+3 prostate cancers do NOT progress or pose a health risk and should not even be labelled a cancer. The cure rate and survivorship for men treated with these favorable-risk Gleason 3+3 prostate cancers, which posed no health threat and did not need treatment, will of course be as good as for those men who never had any prostate cancer.
Employing sophisticated imaging techniques such as the multi-parametric 3T MRI is simply going to try to detect more and more small volume Gleason 3+3 cancers which do not benefit from any treatment and will simply contribute to more and more mismanagement and the continued squandering of precious healthcare dollars. The current cancer management approach with combining or fusing these sophisticated imaging techniques such as the 3T MRI with treatment devices such as HIFU in a single step detection/treatment process when most Gleason 3+3 prostate cancers do not require any treatment will squander most certainly additional healthcare dollars. Even worse, the call for immediate focal therapy treatment without biopsy validation (when image cancer detection reliability is still suspect with too many false positives and false negatives) will lead to further overtreatment, risks and even more wasted healthcare dollars. Real benefit from these advanced technologies will come only when they can detect and identify reliably and treat effectively (with minimal complications) the 25% or so of significant and high-risk prostate cancers which do demand treatment.
What will make a big difference also in eliminating unnecessary as well as risky Gleason 3+3 prostate cancer treatment eventually, will be the discovery of BIOMARKERS which can predict reliably, significant high-risk prostate cancers as well as those prostate cancers likely to progress or upgrade and which will benefit from focal treatment. Till then, many men will still be made vulnerable by the word cancer, exploited and mistreated as if their favorable-risk Gleason 3+3 cancer were in the same category as the 25% or so high-risk prostate cancers which do demand treatment. Whether through whole gland or focal treatment, for most urologists, overtreatment of favorable-risk Gleason 3+3 prostate cancers remains an inconvenient truth.