Appropriate Candidates For Hemiablative Focal Therapy Are Rarely Found Among Men Selected For Radical Prostatectomy In Contemporary Cohort

We found that while 20% of men undergoing radical prostatectomy have unilateral disease, only about 1 in 10 have unilateral disease with low risk features (defined as a PSA level <10 ng/mL, Gleason score <7, and PTI <10%). With limitations on prostate imaging, currently hemiablative therapy (HAT) for unilateral disease is the most logical approach to focal therapy. We believe that at this time ideal candidates would be those with small volume, low risk, unilateral disease.

We recently undertook a study to examine if men with unilateral disease had better pathologic and oncologic outcomes than those with bilateral disease. Interestingly we found that while men with unilateral disease had lower rates of biochemical recurrence and favorable pathologic features, this was a result of risk stratification. Ultimately, we found that men with low risk disease (Gleason <7, <10) had similar pathologic and oncologic outcomes regardless of whether they had unilateral or bilateral prostate cancer. This suggests that even men with bilateral disease and low risk disease may one day be candidates for subtotal gland ablative therapy (STAT) with sparing of at least one neurovascular bundle.

The greatest challenge facing focal therapy at this time is appropriate selection of candidates based on biopsy, clinical and imaging data. We have shown that biopsy alone is a poor predictor of laterality. Advances in MRI and other imaging technologies will ultimately be needed in order to accurately map clinically significant lesions. Ideally, with advances in mapping and focal ablative technologies such as high intensity focused ultrasound (HIFU) and photovaporization, the treatment of prostate cancer may very well shift to a precise lesion ablative therapy (LAT) in the near future. Our challenge as a urology community will be to ensure oncologic efficacy by appropriately selecting candidates who are best suited for these types of ablative therapies.

Written by Basir Tareen, MD and Samir S. Taneja, MD as part of Beyond the Abstract on UroToday.com.

1 Tareen, B. Godoy G, Sankin A, Temkin S, Lepor H, Taneja SS. Latterality alone should not drive selection of candidates for hemiablative focal therapy of prostate cancer. Journal of Urology. 2008. In press.
2 Taneja SS, Tareen B. Targeting prostate cancer for focal destruction: can we find it? Cancer. 2008. Oct 1;113(7):1500-1.
3 Tareen B, Godoy G, Sankin A, Temkin S, Lepor H, Taneja SS. Can Contemporary Transrectal Prostate Biopsy Accurately Select Candidates for Prostate Cancer Hemiablative Focal Therapy? BJUI. 2009. In Press.