Focal Targeted Therapy Will Be a Future Treatment Modality for Early Stage Prostate Cancer

Context: Focal targeted therapy of early stage prostate cancer (PCa) can ideally facilitate the concept of personalized medicine in contemporary surgical oncology. Objective: To present indications and outcomes of subtotal glandular ablation. This treatment approach aims at the elimination of the cancer with preservation of uninvolved tissue in an attempt to maintain a patient's quality of life (QoL), including undisturbed erectile function as well as urinary and bowel control. Evidence acquisition: In 2002, the idea of a "lumpectomy" using an organ-sparing approach for very localized PCa was proposed in parallel with organ-sparing breast cancer treatment in women. Since then, a few pilot clinical studies have demonstrated an acceptable short-term cancer control while minimizing the complication rate. At the same time, progress in PCa screening has led to a significant stage and tumor volume migration toward early stage disease. In the past few years, a collection of accumulated data has created a scientific background for further development of this concept toward a wider implementation into clinical practice. In this paper, we review all available literature from PubMed of the past 15 yr-from 1994 to 2008-including the terms localized prostate cancer, focal therapy, organ preservation, and morbidity. Evidence synthesis: Several factors were identified that need to be taken into account to further develop an organ-sparing treatment approach for early stage localized PCa and turn this concept into clinical practice. First, novel thermoablative techniques such as third-generation cryosurgery, high-intensity focused ultrasound (HIFU), vascular photodynamic therapy and, electroporation can precisely target a tumor lesion within the prostate while maintaining the integrity of the surrounding tissues. Second, new ultrasound, magnetic resonance imaging (MRI) and molecular imaging techniques may provide new means to detect small PCa lesions. Third, extended image-guided biopsy protocols using a transperineal rather than a transrectal approach can provide a more exact spatial distribution of PCa lesions within the prostate. Fourth, careful patient selection using an individualized approach is a prerequisite for optimal preoperative planning and a successful treatment outcome. Conclusions: For patients with early stage localized PCa limited to one focus or lobe and who express a great desire not to jeopardize their QoL, targeted focal therapy will likely play a more significant role in the future as a tangible treatment option. Moreover, focal therapy may fill the gap between active surveillance for low-risk PCa and radical treatment for higher-risk forms. © 2009 European Association of Urology.

Duke Scholars

Author Thomas James Polascik Urology