F E AT U R E
“THE NEW GOAL OF FUTURE INTERVENTION IN THE TREATMENT OF PROSTATE CANCER IS THE TRIFECTA CONCEPT, WHICH MEANS BEING CURED, CONTINENT AND POTENT” ▼ CO N T I N U E D F R O M P G 15
effort to preserve quality of life. It is an approach focal therapy pioneer, Hashim Ahmed, MD, PhD, senior lecturer at University College London in the United Kingdom, considers to have less morbidity compared to whole-gland therapy options, such as radical prostatectomy or radiation therapy. “Focal therapy is an image-guided prostate pathway for treating patients based on knowing exactly where the tumor is,” said Dr. Ahmed. “Having that degree of preciseness, which was missing up to this point, allows one to accurately target, then treat the section of the prostate gland containing the cancer rather than removing the whole prostate.” This enables men to retain a good quality of life while simultaneously aiming to eradicate meaningful areas of cancer. While focal therapy has a precedent in other cancers, including breast, kidney and bladder, its use in prostate cancer continues to be debated. In the United States, some experts refer to focal therapy as a “questionable scientific paradigm,” while to others it is an approach worthy of evaluation for treating prostate cancer. Since the introduction of focal therapy as a treatment for localized PCa, no uniform, systematic design of studies to evaluate pre- and post-treatment has been developed. This has evolved into uncertainties surrounding the ablative technologies being used to deliver focal therapy, as there is scant evidence showing long-term benefit and no data comparing specific modalities. Several of the technologies are currently undergoing clinical trials to determine their efficacy, safety and long-term benefits as each may have its own set of benefits, limitations and unknowns.
VO L U M E 9 • G LO B A L CO N N EC T I O N S
Although focal therapy is still in its trial stages throughout the world, many urologists believe it holds promise for the treatment of localized PCa and preserving quality of life. Potential advantages identified by urologists include the eradication of all “known” cancer; reduction in the anxiety of living with an untreated cancer (compared to active surveillance); reduction in the risk of over-treating indolent cancers; can be repeated; does not prevent subsequent radical prostatectomy or radiation therapy; lowers risk and severity of side effects, such as incontinence and erectile dysfunction; and is typically performed with minimal anesthesia on an outpatient basis or single overnight hospital stay. Many physicians, including Dr. Luigi Mearini from the Department of Urology at the University of Perugia; Ospedale Santa Maria della Misericordia, Italy; and Dr. Massimo Porena from the Department of Medical-Surgical Specialties and Public Health at the University of Perugia in Italy, believe focal therapy is a successful way to approach clinically localized prostate cancer. “The new goal of future intervention in the treatment of prostate cancer is the Trifecta concept, which means being cured, continent and potent,” Dr. Mearini stated. “This is the mainstay of minimally invasive therapy such as focal ablation,” Dr. Porena added. However, others believe it is a good idea in theory, but have some precautions regarding the approach. The Trifecta concept is very old and refers to all forms of prostate cancer treatment. “The idea that treating the index lesion is equal to treating the whole gland still needs to be scientifically proven.” Giannarini et al., JCO 32:1299-1301, 2014.