Is focal therapy hope or hype? Urologists weigh in

Panelists and audience members at the recent AUA “crossfire” debate on focal therapy show why the treatment is so controversial.

Despite advances in imaging and treatment, the use of focal therapy in localized prostate cancer remains a contentious issue, as evidenced by comments from four experts who debated focal therapy’s merits and shortcomings at the AUA annual meeting in New Orleans.

Focal therapy: Magic bullet or unproven treatment?

The discussion, part of the meeting’s popular new “Crossfire: Controversies in Urology” format, took place in front of a packed plenary session room. Urologists exiting the session talked about which side came out ahead in the below exclusive video by Urology Times Content Specialist Annamarie Iannetta.

Session moderator Peter T. Scardino, MD, of Memorial Sloan Kettering Cancer Center in New York, defined focal therapy as “partial ablation of the prostate gland, or ablative treatment targeted to the region of the prostate harboring the only (unifocal) or the index (largest/highest grade) malignant lesion.” While the treatment has a precedent in other cancers, including those kidney and bladder tumors, its use in prostate cancer is controversial.

NEXT: "Is there hope? Yes, there is."

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“Is there hope? Yes, there is,” said Mark Emberton, MD, MBBS, of University College London, one of two panelists representing the “pro” side of the debate. “There’s huge hope for patients and also hope for the profession to develop this new class of therapy and deliver it to our patients.”

Eric A. Klein, MD, of Cleveland Clinic, a “con” debater, pointed out that the use of MRI to pinpoint biologically significant tumors has shortcomings, and he showed new data that suggest “biologically significant disease exists outside of visible MRI lesions more often than we think.”

“If you take the approach of just treating what you can see, your miss rate and your non-cure rate of biologically significant cancer is at least 15%,” Dr. Klein said.

The use of advanced imaging (MRI/fusion biopsies), genomics of prostate tissue, and even older tools such as PSA, PSA density, and tumor volume can detect significant disease, rule out aggressive cancers, and identify unifocal disease, argued panelist Aaron E. Katz, MD, of Winthrop-University Hospital, Garden City, NY.

“This gives us a more personalized and targeted approach to the cancer itself, and that’s where we should be in 2015,” he said.

“Prostate cancer is a multifocal disease,” countered panelist Mark Gonzalgo, MD, PhD, University of Miami. “While in theory, focal therapy may be a good idea that aims to kill cancer while minimizing side effects, for now, it appears that the hype associated with focal therapy outweighs the hope.”