POSTED: April 30, 2019

Focal Therapy For Prostate Cancer: A Urologist’s View

Dr. Edward Schaeffer is the chair of the departments of Urology at Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital.

Prostatepedia spoke with him about focal therapy for prostate cancer.

Why did you become a doctor?

Dr. Schaeffer: I’ve always been fascinated with how things work. My fascination dates back to when I was a child who loved to understand the mechanisms that made an alarm clock work. Over time, that interest in the mechanical nature of things evolved to an interest in the complexities of animals and living things. From there, I got intrigued by not just normal anatomy and physiology, but also by understanding how and why things break down. Restoring things to normal is one appealing part of medicine.

If you can understand why things fall apart, you can understand how to fix them. That is the essence of part of medicine. The other part of medicine is humanism, the ability to help people. It’s truly such an honor to help people with their problems. I’m reminded of that privilege daily.

Have any particular patients over the years stood out in your mind? Any cases that may have changed how you view the art of medicine?

Dr. Schaeffer: I have an open style with my patients, and they can all reach me through my personal cellphone number. I give them my personal number because I view my position in their lives as a privileged one.

Patients come to me with a problem, and they really open up to me about their own health problems, their anxiety and fear, and the psychological impact that their new disease diagnosis has had on their life. Because they’ve been so open with me, I view it as part of my role as a physician to give them access to me if they need me.

I’ve developed personal and close relationships with all of my patients. I maintain objectivity, but the disease I take care of is a personal one. It’s a cancer, and there can be a lot of emotional burdens that go with it. My patients are always changing my view of my role in medicine and my role in life and family. I’ve learned so much from them.

That’s fairly unusual to provide your own cellphone number, isn’t it?

Dr. Schaeffer: It’s highly unusual! But I’ve never done anything based on what other people do. I just do what I think is right.

What is focal therapy, and where does it fit into the spectrum of treatments that are available to men with prostate cancer today?

Dr. Schaeffer: Focal therapy is one type of interventional treatment for men who have localized prostate cancer and for men who have localized prostate cancer that is contained within the particular focused area of the prostate.

Generally speaking, when patients have a low-volume, low-grade prostate cancer, the first go-to option is typically a program of surveillance because we often deem these as cancers that don’t require any active intervention. But some patients want to do something or don’t want to have treatment of their entire prostate, and so they may request that we focally ablate the suspicious or concerning area. That is a potential option.

When we do focal therapy, we always have to follow the patient and monitor not only the area we treated but also the other areas of the prostate for cancers that may crop up.

In some ways, it’s more intensive active surveillance because it’s active surveillance plus something. On the spectrum, it’s a minimalist approach, but the jury is still out as to whether it’s an effective approach. While there are many anecdotes out there where people have thought it’s been successful, it hasn’t been widely studied.

Is that one of the controversies around focal therapy?

Dr. Schaeffer: Yes, I would say so. It has not been rigorously studied with one exception. One type of focal therapy, photodynamic therapy, has been studied in a prospective clinical trial. This trial was promising: it showed that focal therapy can reduce the amount of cancer and reduce the progression of cancer.

Are the side effects fewer with focal therapy than with whole-gland therapy?

Dr. Schaeffer: That is the idea of it. That is correct.

Let’s say someone gets focal therapy and then their cancer recurs. Does the previous focal therapy impact or impede their ability to get another primary therapy like radical prostatectomy or radiation?

Dr. Schaeffer: It makes it more potentially challenging to do what we would then call definitive secondary or salvage treatment, but that’s not true for every patient all the time. When somebody has prostate cancer in one area of the prostate and undergoes focal therapy, they’re monitored for two things.

One is recurrence or regrowth of the cancer locally. Second is the development of additional cancer in another area of the prostate. Individuals who have had focal therapy may require additional treatment for one of two reasons.

One reason may be that the area where the cancer was before was not effectively treated the first time. That would be disease persistence. Then the other reason may be that perhaps a cancer developed in another region of the prostate. We know that prostate cancer is a multi-focal disease, so it certainly is possible that a cancer could occur somewhere else. That is why people who have had focal therapy can’t give up monitoring their cancer over time.

Any other controversies over the role of focal therapy?

Dr. Schaeffer: The main controversy in terms of focal therapy has to do with the fact that many consider focal therapy to be a treatment, that if you can detect the cancer on MRI, for example, you could focally treat the MR-visible area. There is good research from UCLA and other groups that shows that the volume of the cancer that was originally noted on MRI underestimates the true volume of the cancer by two or three times in some cases.

So, what should you treat? Should you treat only the MRI-visible area, or should you treat the MRI-visible area plus a boundary of prostate around it because there’s this possibility that cancer may extend beyond the MRI visibility? That’s a big controversial area because the more broadly you expand your focal treatment area, the more you increase the possibility of having side effects from more extensive treatment.

Do you have any advice for men who are considering focal therapy?

Dr. Schaeffer: For all individuals with a new diagnosis of prostate cancer, they should really seek the advice of an expert. Somebody who’s well-versed in all treatment options for prostate cancer would be very helpful.

I don’t perform focal therapy myself, but I know experts who do. If I believe someone’s a good candidate for it, or if I think that someone’s not a good candidate for focal therapy, but they’re still interested, I’ll refer them to an expert so that my patients can get their advice. I think it’s important that patients seek advice from an expert in the management of prostate cancer who can help them understand the full implications of the treatment options.

Would you encourage most patients to seek a second opinion?

Dr. Schaeffer: I do, unless their diagnosis was at an NCI-designated cancer center or hospital in similar standing. If they’re at a center of excellence already, they don’t have to go to a second one unless you’re uncomfortable with your team. I think that the idea of seeking out somebody with expertise in that particular disease area is very important to get the best advice possible.

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1 Comment

Ethan Boger

Focal margin as noted by Dr, Schaeffer is one concern with FLA, which is mitigated by hemi-ablation. I think the bigger concern is the lack of a well-established, effective follow-up protocol for men who have had any of the focal therapies. Here is why.
1. Unlike prostatectomy, PSA following treatment does not go to zero. In addition, focal treatment seems to cause persistent acute inflammation, which may raise PSA levels. Therefore PSA is an unreliable marker.
2. Follow-up typically relies on MPMRI. There are no known “rules” for interrogating the ablated zone, so the accuracy of MRI depends on the knowledge and experience of the reader. How many radiologists have experience reading post-focal treatment imaging?
3. Follow-up by biopsy has the same issues – biopsy of the ablated zone is difficult to interpret. How many pathologists have had experience reading samples from this area?
4. Genomic tests of ablation biopsy samples do not have the retrospective or prospective data to support conclusions.
5. Non-invasive biomarkers like 4K Score and PCA3 also do not have the retrospective or prospective data to support conclusions and will not be prescribed.
6. Cost: follow-up following focal therapy is expensive for the system, so the “system” is likely to discourage focal therapy. This is a bad reason to do so but it is one reason focal is not being reimbursed.

My suggestion, as an FLA patient, is that the advocates for focal therapy must upgrade these tools, especially MRI reading, biopsy interpretation and the non-invasive biomarkers and come up with a standard follow-up protocol for focal therapy to become mainstream.

Posted: May 14, 2019

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