Focal therapy’s future in prostate cancer is bright, says Arvin George, MD

Arvin George, MD

In this interview, Arvin George, MD, discusses his 2024 LUGPA Annual Meeting talk “Focal therapy: Killing cancer not the prostate,” as well as the current state and future directions in the focal therapy space. George is an associate professor of urologic oncology at Johns Hopkins University in Baltimore, Maryland.

This transcription was AI generated and edited by human editors for clarity.

Could you share some of the key points from your LUGPA presentation "Focal therapy: Killing cancer not the prostate"?

It's a short time, and I'm going to try my best to be able to cover a lot of ground during that session. And I'd like to be able to communicate, how do we choose the right patients for focal treatments, review some of the outcomes that we can potentially achieve, and also try to understand how we can follow these men afterwards, and really, what's the future direction for the field?

Can you also touch on how the adoption of global therapy has evolved in the past few years?

I think it's been really changing leaps and bounds every year. I would say, about 10 years ago, there was a real skepticism—a healthy skepticism, I would say—in the beginning. Now, that has slowly changed into optimism. We're starting to see a number of community-based practitioners start to offer focal treatments within their practice. We're starting to see academic programs where, historically, they have been reluctant to initiate that process. Also, when we see what it looks like in the academic community, both from within professional organizations and also within the literature, we're really starting to see publications in the area flourish, and sessions discussing it and talking about its potential really grow. The field has really grown in the in the last few years.

You're currently leading a trial on water vapor thermal therapy for prostate cancer. Could you share some background on this treatment modality?

Water vapor is actually familiar to most urologists. We use it clinically right now for BPH, of course, and that's the Rezum treatment. It's essentially the same treatment modality, using steam or water vapor and using convection rather than conduction to be able to treat prostate cancer or prostate tissue. And so it's really a reapplication of the existing technology for BPH that is familiar to many of us already and we use in our clinical practices, but now, it has been redesigned to be able to perform the treatment directionally, meaning ensuring that we can get the water vapor or steam exactly where we want it within the prostate, and also under image guidance or ultrasound MRI guidance. So those are the 2 major changes that have come forward from the BPH treatment to the current vapor technology.

What are the goals of the study?

This is actually a very unique and interesting study. It's probably the first study in the ablative space that the Food and Drug Administration have approved for such a study design. The study is actually looking at 2 things. One is what we see in many different technologies in the ablative space, which is 510k prostate tissue ablation approval, which is essentially being being able to prove that with this technology, we're able to destroy or ablate prostate tissue. In addition to that, we will certainly evaluate the safety of the treatment, but also we are evaluating a cancer management strategy, and the goal for that is to ensure that we eliminate any grade group 2 or Gleason 3 plus 4 equals 7 prostate cancer by 3 years as those men will be followed at a final biopsy endpoint at 3 years.

You're also leading the PRESERVE trial, which is using irreversible electroporation (IRE). When can we expect to see results from that study and how will this change the use of IRE for prostate cancer?

It's interesting that you asked that question, because stay tuned. These results are imminent. At the current time we're waiting for the FDA, and then, based on that, we'll be able to release the results, and that will be, hopefully, even potentially, as a late-breaking abstract at the AUA. Irreversible electroporation is already being used commercially, because it does have FDA approval for soft tissue ablation. The current trial, which is the PRESERVE trial, is looking at prostate tissue ablation, which would give it essentially a more specific indication that I think will expand our ability to use it in our patients.

What are some future directions or emerging technologies in focal therapy?

I think that the future is really, really bright. Even the existing technologies that we have, our knowledge relative to other treatments that we offer in prostate cancer is very limited. So as we go further and further into this field of partial gland ablation, I think we're going to learn just more and more about the existing technologies we have for one, of course, but coming down the line, there are a number of potential technologies that I think, I would say, address some of the challenges that we have with our existing technologies. One of those things would be theranostic treatments. I've previously done some work with nanoparticle-directed therapy, but the ability to conjugate these to PSMA and to augment treatment will allow us to deliver much more personalized treatments, and then also our improvements in imaging. We've seen that grow leaps and bounds of the last few years. So specifically, the use of prostate MRI, which, many years ago, was a very niche space where many urologists weren't familiar with it, and it felt cumbersome to be able to start to offer it to patients, but that's largely not a concern anymore. Many urologists use MRI routinely in their practice. Following that, it was PSMA-PET. And I think that our imaging modalities will continue to be refined, and when we look at focal therapy in general, the better we're able to see, localize, identify and risk stratify prostate cancers, the better we're able to treat them and offer more personalized and focal treatments.