COMMENTARY

HIFU-Hemiablation for Treatment of Prostate Cancer?

Gerald Chodak, MD

Disclosures

January 31, 2017

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I am Dr Gerald Chodak for Medscape. Today I want to talk about the use of high-intensity focused ultrasound (HIFU) to hemiablate half of the prostate in men with localized prostate cancer who have either low-risk or intermediate-risk disease.

A study was sponsored by the French Urological Association. It enrolled patients between 2009 and 2015 at centers throughout France. Rischmann and coworkers[1] are now reporting on the results of 111 patients who were treated with at least a follow-up of 12 months. Their outcome was to define or identify clinically significant prostate cancer on the follow-up biopsies, which they defined as either Gleason scores greater than 6, a biopsy showing a tumor that measured greater than 3 mm, or more than two positive cores. The patients enrolled were 68% low-risk, and the remainder were intermediate-risk.

They report their results with the follow-up biopsies at 1 year, at which time they found that 5% of the men had clinically significant cancer on the side of treatment whereas 7% had clinically significant cancer on the opposite side. Overall, they did a biopsy on 90% of the patients so far.

The results then looked at quality of life; only a few percent [of patients] reported incontinence, which is not clearly defined as to how much. Twenty-two percent ended up losing the erections that they had before their therapy.

Questions that we can raise are the following: First, because prostate cancer is usually multifocal, is it valid to treat only one side of the gland? Second, with the results reporting such a short follow-up period, what do we really know here? We do not know much about the long-term outcomes in terms of metastasis or its survival.

With the design of the study, how easy will it be to identify what the overall results are compared with other treatments or no treatment at all? Is the goal to simply have a way of doing something to men who are uncomfortable with active surveillance? If that is the goal, then it would seem that so far, the results are questionable, with 22% losing their erections (some maybe due to age) and 7% having positive cancer on the side they did not treat.

For now, one must question the value of a study like this. We are going to have trouble assessing whether it is a reasonable treatment to offer patients unless a randomized trial is done, as I have mentioned in so many videos. At the end of the day, we will have some further idea of how many men need to be treated on the side that was receiving the HIFU, but what about the opposite side? Is it simply enough to treat one side and ignore the other? Of course, that is not going to be the case.

The bottom line here is, I continue to remain skeptical about the long-term value of hemiablation of prostate cancer because it is going to be very difficult to determine whether that is a good way to help men with localized disease. I look forward to your comments. Thank you.

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