No longer does a diagnosis of prostate cancer lock the patient into a treatment regimen of surgery or radiation that could lead to such other concerns as sexual dysfunction or urinary incontinence. The emerging technique of focal therapy (FT), made possible by advances in imaging and precision biopsies, offers a critical bridge between active surveillance and more radical therapy for men who clinically qualify for the option.
Focal therapy is becoming an increasingly important part of the Mount Sinai Department of Urology’s treatment repertoire, as the Department works to uncover more minimally invasive approaches for prostate cancer that can help to better define and extend the therapeutic benefits of the discipline to even wider populations.
“We’re in a very exciting time for prostate cancer because for many decades we haven’t progressed in our ability to treat the disease in ways that can preserve the quality of life for men,” says Kyrollis Attalla, MD, Assistant Professor of Urology at the Icahn School of Medicine at Mount Sinai. “Our ability now to risk-stratify patients thanks to targeted fusion biopsies that use MRI to precisely map the location of prostate cancers has opened the door to the vast potential of focal therapy.”
“As we increasingly use focal therapy in our practice and are able to better define its role in the prostate cancer treatment algorithm, I believe more and more patients will request the technique," says Kyrollis Attalla, MD, Assistant Professor of Urology at the Icahn School of Medicine at Mount Sinai.
The technologies central to any focal therapy strategy are not new. They include cryotherapy to freeze the tumor; high-intensity focused ultrasound (HIFU) that uses heat from high-frequency sound waves to destroy malignant cells; and irreversible electroporation (IRE) that situates electrodes around the tumor to deliver an electric shock that eliminates the cancer.
“While the modalities have been around for a while, what isnew is our repurposing them to partially ablate the portion of the prostate that harbors disease,” says Dr. Attalla, who treats as many as eight new patients a month with focal therapy. “As we grow our volume of cases, we’re expanding our database around this relatively new technique so we can continue to improve it.”
Focal therapy is not for every prostate cancer patient. Those of intermediate risk who also have a dominant unilateral lesion in the prostate and a PSA level of between 10 and 20 ng/mL, and a clinic stage of below T2c, referring to cancer limited to one lobe of the prostate, tend to be optimal candidates for this protocol according to the guidelines Mount Sinai urologists have established.
Contemporary data show that about 60 percent of patients diagnosed through MRI-guided biopsies have intermediate risk tumors, but that a much smaller subset—about 10 to 15 percent—are deemed appropriate for focal therapy.
“Surveys have shown that focal therapy is catching on with patients who are often resistant to undergoing more radical forms of treatment for prostate cancer,” says Dr. Attalla. “As we increasingly use focal therapy in our practice and are able to better define its role in the prostate cancer treatment algorithm, I believe more and more patients will request the technique. What we’re able to offer them is a multidisciplinary team of urologists, radiologists, and pathologists that has perfected its skills on one of the highest volume prostate caseloads in the country.”
As urologists inform their patients, focal therapy necessitates consistent follow-up and surveillance. For Dr. Attalla’s patients, that means a PSA test every three months through the first year, an MRI at six months, and a biopsy at one year.
“Even with a possibly higher risk of recurrence compared to more radical approaches, the ability to maintain their potency and continence for another five years or more represents a big victory for many men,” says Dr. Attalla. “We still haven’t defined the best role for focal therapy, but as we continue to improve our biopsy and imaging techniques we’ll be able to offer it to more patients across more scenarios with the promising upside of preserving their quality of life.”