Experts Reach Consensus on Focal Therapy, Partial Ablation for Localized Prostate Cancer

By Marilynn Larkin

June 29, 2020

NEW YORK (Reuters Health) - An international, multidisciplinary consensus panel has developed standardized nomenclature and follow-up strategies to support focal therapy (FT) and partial gland ablation (PGA) for select patients with localized prostate cancer.

"Definite treatment options for prostate cancer, including radiation therapy and prostatectomy, are endorsed by current guidelines," Drs. Amir Lebastchi and Peter Pinto of the US National Cancer Institute in Bethesda, told Reuters Health by email. "However, the side effects of these 'whole gland' treatment options are significant, (including) erectile dysfunction as well as urinary and bowel toxicity."

"For this reason," they said, "there is a lot of enthusiasm in the urology community and (from) patients for FT, which offers a nice balance between cancer cure and maintaining quality of life."

FT targets only the cancerous area within the gland, sparing the remaining prostate and adjacent vital structures such as the neurovascular bundles and urethral sphincter. This minimizes side effects, they explained.

FT has been described in more than 18,000 publications over the past three decades, they said, but it has not been incorporated into current guidelines because of lack of high-quality data, heterogeneity in study populations, and inconsistent nomenclature.

"Standardized evaluation of treatment outcomes and a uniform nomenclature for treatment templates are urgently needed," they said. "This paper sought to answer this through expert opinion among international thought leaders."

The researchers reviewed the literature, identifying controversial topics with regard to FT. Then they distributed online questionnaires to experts during three rounds, with the goal of achieving consensus on debated topics. The project concluded with a face-to-face meeting in which final conclusions were formulated. The level of agreement to achieve consensus on a topic was 80%.

As reported in European Urology, 65 experts participated: 72% were urologists and 28%, radiologists. The panel agreed that the term "focal therapy" describes guided ablation of an image-defined, biopsy-confirmed, cancerous lesion with a safety margin surrounding the targeted lesion.

Further, they agreed, all biopsy-confirmed, MRI-visible lesions with clinically significant cancer (defined as Gleason grade group (GGG) of 2 or more) are targets for FT.

Success of FT/PGA for prostate cancer was defined as eradication of all identified lesions with a GGG of 2 or more, based on targeted biopsy or systematic biopsy.

Other recommendations include:

- After FT/PGA, outcomes should be evaluated using prostate-specific antigen (PSA) level, imaging, biopsies, and functional outcome assessments.

- Although not a reliable marker for treatment failure, PSA should be measured every three months in the first year and every six months thereafter.

- MRI, the preferred imaging modality, should be done at six and 18 months after treatment.

- A systematic 12-core transrectal ultrasound-guided biopsy combined with a targeted biopsy of the treated area should be performed six months to one year after treatment.

- Functional outcomes should be obtained for the first time three to six months after treatment and until stability is attained.

Drs. Lebastchi and Pinto noted, "Physicians and patients alike should be aware of the relatively high failure rate of this promising treatment modality. It is of paramount importance to diligently follow patients for years to identify treatment failures under close follow-up. Patients undergoing organ-preserving treatment modalities do not burn any bridges and their urologists can always offer whole-gland treatment options down the road."

Dr. James Wysock, a urologic oncologist at NYU Langone's Perlmutter Cancer Center in New York City, commented in an email to Reuters Health, "At NYU Langone, we agree that partial gland prostate ablation in appropriately selected men may offer a treatment option that carries a lower risk of the morbidity associated with whole gland treatment such as radical prostatectomy and radiation therapy. However, robust long-term outcomes for this approach have yet to be defined. Consensus statements such as this are critical to provide a framework for assessing treatment success."

"This consensus statement serves to highlight many of the key challenges for both practitioners and patients when considering a partial gland ablation strategy," he noted. "We have also contributed to similar consensus statements, such as the SPARED CRN collaboration, in order to further develop a multi-institutional outcomes data set." (

SOURCE: European Urology, online June 10, 2020.