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Posted by Dr. Stephen Scionti on Apr 23, 2014 12:22:35 PM

Getting On Board With The Cancer Revolution

Did you know that a quiet revolution has been taking place in treating breast, kidney, bladder and rectal cancers? Today, thanks to increased public awareness and better diagnostic tests, these cancers are often found when they are in an early stage. In such cases, treatment may involve a minimally invasive procedure such as Focal HIFU that targets the tumor while preserving surrounding healthy tissue. In fact, when a cancer is determined to be low risk, doctors and patients no longer rush to the most invasive, widespread treatment possible. Instead, they begin to explore the possibility of minimalist yet effective options.

Sadly, this is not universal practice when it comes to prostate cancer. Robotic radical prostatectomy (RRP), or removing the entire gland, is usually the first suggestion a doctor makes regardless of the risk level, tumor volume or tumor location-despite recent findings that urinary and sexual side effect rates are roughly equal between conventional RP and RRP.  Although the hospital stay for RRP is shorter and the recovery easier than with open RP, the incidence of collateral damage is a huge disappointment.

Another interesting phenomenon that patients learn about is that there is very little difference in survival rates between early-stage patients who had RP vs. those who practice simple observation. The PIVOT trial demonstrated about a 3% survival advantage for the RP patients.  A study of patient choices showed that patients felt survival gains would have to be much greater to make the surgical aftereffects worth it.

This is why increasing professional attention and patient interest is placed on "tissue preserving," targeted, or focal, prostate cancer therapies like HIFU. "Focal therapy is an emerging tissue preservation strategy that aims to treat only areas of cancer."   I find it unacceptable that prostate cancer therapies lag so far behind when many patients could have post-treatment quality of life without sacrificing successful cancer control!

Accurate focal tumor destruction of early-stage tumors offers a huge benefit. It preserves prostate tissue along with the external urinary sphincter and the neurovascular bundles. Tumor-destroying therapy is directed in a way that spares these structures. Even destroying an entire half of a gland that contains cancer (called hemiablation) has far less risk of side effects than robotically removing the entire gland because it preserves roughly 50% of the prostate and the nerves on the untreated side. In addition, focal treatment is minimally-to-noninvasive, depending on the treatment modality. After Focal HIFU, patients literally walk away from the treatment a few hours afterward, and go home comfortably to rest up. Normal urinary and sexual function is quickly resumed.

Tissue preserving treatments bridge the gap between radical (whole gland) treatment and doing nothing (or, for proactive patients, embracing Active Surveillance). But two questions are important to ask:

  1. How do we know which patients are qualified for tissue preserving treatment?
  2. How can we be confident of cancer control when we're leaving untreated tissue behind?

In response to the first question, the answer is Advanced Diagnostics. In my own practice, I first look for suspicious areas using high-resolution MRI images. If I believe that a biopsy is warranted, I use the Artemis® targeted biopsy system which allows me to use the MRI images to guide the biopsy. This assures the most accurate biopsy results possible (from the tumor cores most likely to harbor aggressive cells) yet uses the fewest needles. In referring to early stage prostate cancer, noted clinician Mark Emberton points out that this alternative to TRUS randomized biopsies "will confer a higher yield of clinically significant disease and reduce the false-negative rate for this type of prostate cancer."  If cancer is diagnosed, my goal is to match the treatment to the disease. In many cases, the patient can safely consider focal treatment with a goal to sparing urinary and sexual function by preserving healthy tissue.

As for the second question, my confidence in the effectiveness of focal treatment partly comes from published data as more studies appear. Perhaps more importantly, I track my own patients' results. Again, I turn to imaging (MRI-ultrasound fusion) and Advanced Diagnostics to follow patient progress, which can indicate if a suspicious area has appeared and warrants a targeted biopsy. Just as important, I support the use of healthy nutrition, supplements, exercise and stress management techniques (in essence, an Active Surveillance) approach) to minimize the chances of recurrence.

And, as all of my focal patients are aware, should there ever be a need to treat a recurrence, we will have detected it early (thanks to Advanced Diagnostic follow-up), and we have not burned any bridges as far as future treatment choices, including Active Surveillance.

Let me put it this way: our bodies like it when we keep as much healthy tissue as possible. It's the way we were born, and we should go through as much of life as possible with healthy tissue intact. Tissue preserving cancer treatments help us stay that way, and that's why I offer them to qualified patients.

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