Prostate Ca focal therapy’s value awaits high-quality data

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In the arena of focal therapy for prostate cancer, standardization of management will be a key component of quality data going forward, says Scott Eggener, MD.

San Antonio-In the arena of focal therapy for prostate cancer, standardization of management will be a key component of quality data going forward, says Scott Eggener, MD.

Dr. EggenerWith the ever-increasing focus of non-radical management of low-risk prostate cancers, the topic of focal therapies is a rapidly evolving one. At the 2016 Society of Urologic Oncology annual meeting in San Antonio, Dr. Eggener provided an overview of focal therapies for prostate cancer. He reviewed the current landscape of prostate cancer screening and treatment, conceptual issues with focal therapies, and current organizations’ consensus statements on these therapies.

Focal therapies for prostate cancer offer the potential advantages of decreasing cancer mortality with the potential of sparing the morbidity of more radical treatment options like prostatectomy or radiation. They also have the potential to be subject to the same concerns that these modalities face, namely over-diagnosis and overtreatment of otherwise indolent cancers.

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Dr. Eggener, associate professor of surgery at the University of Chicago Medical Center, discussed balancing the prostate cancer mortality advances seen since the advent of PSA screening with the need to screen selectively, knowing when to stop screening, and knowing when to appropriately use active surveillance and focal therapies.

With respect to focal therapy being counter to past and current dogma of cancer management, Dr. Eggener pointed out other techniques for managing urologic cancer that were initially met with strong resistance. For example, initially skeptical views of minimally invasive surgery, active surveillance, monitoring of the post-chemotherapy retroperitoneum, and enucleation versus conventional partial nephrectomy have all since changed. Similarly, the use of lumpectomy in breast cancer faced fierce resistance early on, but was eventually backed by both high-quality data and general consensus in the medical community, he said.

Next: What to expect going forward

What to expect going forward

Several consensus statements have been published in the field of focal therapy and provide a preview of what to expect in focal therapy research going forward, Dr. Eggener said. Specifically, he discussed an international multidisciplinary consensus statement published in European Urology (2014; 65:1078-83) and a report from a Delphi consensus project published in the World Journal of Urology (2016; 34:1373-82). Specifically, standardization of management will be a key component of quality data going forward, with recommended inclusion criteria for clinical trials of a PSA <15.0 ng/mL, life expectancy >10 years, and Gleason grade 3+3 or 3+4 as a standard.

Dr. Eggener also offered some standardized definitions of success and failure for data going forward: In-field failures were defined as a higher local Gleason grade, persistence of similar grade cancer (including those undergoing repeat ablation), and use of additional, more radical, management strategies. Out-of-field failures were defined as generally selection failures or representative of cancer progression.

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Intermediate-risk cancers are generally ideal for study in focal therapy, Dr. Eggener surmised. Magnetic resonance imaging-targeted biopsies are recommended to plan treatment; untreated foci of low-grade, indolent cancers are acceptable; and the final word on the value of focal therapies would come from high-quality data sets, he said.

Dr. Eggener closed his talk with a quote from Bernard Fisher, MD, the pioneer of the lumpectomy in breast cancer management: “Scientific method trumps empiricism, anecdotalism, and inductivism.” Dr. Eggener then shared his own addition: “But don’t underestimate market forces, longstanding habits, influence of industry, politics, and profit motives.”

Dr. Eggener is a consultant for NxThera and a consultant/investigator for Profound Medical.