Debate to explore focal ablation vs. active surveillance in low-risk prostate cancer

If you haven’t had a patient with prostate cancer ask about focal ablation, you will. Focal ablation is one of the hottest topics in urology today, driven in large part by direct-to-consumer marketing.

“Where focal ablation fits with your low- and intermediate-risk prostate cancer patients who would otherwise be considering active surveillance is on every urologist’s mind right now,” said Kirsten Greene, MD, FACS, MS, Paul Mellon Professor and chair of urology at the University of Virginia School of Medicine in Charlottesville. “Our patients are asking about it every day. They’re not waiting for us to recommend for or against a treatment, which really changes the conversation.”

Dr. Greene will moderate a Controversies in Urology Debate, “Focal Ablation versus Active Surveillance in a 65M with GGG2, MRI Concordant Unilateral Prostate Cancer,” at 3 p.m. on Friday. Debaters are Dipen J. Parekh, MD, University of Miami, Miller School of Medicine, and Robert E. Reiter, MD, University of California, Los Angeles Institute of Urologic Oncology. They will show that both approaches offer advantages.

Pro focal ablation
Focal ablation promises to treat prostate cancer while avoiding or ameliorating the most feared side effects of radical prostatectomy: urinary incontinence and erectile dysfunction. Just as women with breast cancer may benefit from lumpectomy instead of radical mastectomy, men with low volume, intermediate-risk prostate cancer might opt for focal ablation rather than radical prostatectomy. It’s an appealing prospect, especially for patients.

“The trifecta for prostate cancer is continent, potent and cancer-free by whatever means,” Dr. Greene said. “You want to get rid of dangerous cancer and preserve quality of life.”

Advances in prostate imaging make it easier than ever to identify focal prostate tumors, whether by MRI, ultrasound or novel positron emission tomography modalities.

Cryotherapy, high-intensity focused ultrasound and laser are the most common contemporary approaches to focal ablation, but the technique can use almost any energy source to heat, cool or otherwise kill tumor tissue while sparing nearby nerves and critical structures to minimize or avoid side effects.

Pro active surveillance
The problem with ablating focal tumors, Dr. Greene added, is that prostate cancer is a multifocal disease. Not all aggressive tumors can be visualized, and not all tumors that are visible need to be ablated.

“There is concern that we are going to regress to an era of overtreatment of indolent disease,” she said. “My concern is that men who are diagnosed with Gleason 3+3 prostate cancer will not be encouraged to follow active surveillance paradigm and, instead, will be encouraged to ablate indolent disease with or without long-term survival or quality of life benefits.”

There are also unanswered questions about the utility of future salvage treatment if tumors that were not ablated progress. Trials and data on the long-term impact of focal ablation on future radical prostatectomy or radiation therapy are still emerging.

Is there a resolution?
The debate could go either way, but urologists face the same question every day.

“Our patients are struggling between active surveillance, focal therapy, radical prostatectomy and radiation and are very, very attracted to the idea that focal therapy could get them cancer-free without the risks of serious side effects,” Dr. Greene said. “This debate can help us all speak clearly and coherently when we answer these challenging questions.”