Salvage Treatments After Failed Focal Therapy for Prostate Cancer

What is Prostate Cancer and How is It Treated?

What is Prostate Cancer?

Prostate cancer is one of the most common cancers in men, particularly affecting those over the age of 50. It occurs when cells in the prostate gland, a small gland in the male reproductive system, begin to grow uncontrollably. Early detection and treatment are crucial for managing prostate cancer effectively.

What is Focal Therapy (FT) for Prostate Cancer?

Focal therapy is a relatively newer approach to treating prostate cancer that targets only the cancerous part of the prostate, sparing the healthy tissue. The goal of focal therapy is to reduce the side effects often associated with more aggressive treatments, such as radical prostatectomy (complete removal of the prostate) or radiation therapy.

Types of Focal Therapy for Prostate Cancer

There are several focal therapy options available, each using different technologies to destroy cancer cells while preserving as much of the prostate and surrounding tissues as possible:

• High-Intensity Focused Ultrasound (HIFU):HIFU uses focused ultrasound waves to generate heat and destroy cancer cells in a specific area of the prostate. It’s a non-invasive procedure that’s becoming more popular due to its precision and lower risk of side effects compared to traditional treatments.
• NanoKnife (Irreversible Electroporation - IRE):NanoKnife is a technique that uses electrical pulses to create tiny holes in cancer cells, causing them to die. Unlike other treatments, NanoKnife does not rely on heat or cold, which helps to preserve nearby nerves and tissues, potentially reducing side effects such as erectile dysfunction.
• Cryotherapy:Cryotherapy, or cryoablation, involves freezing cancerous tissue to kill the cancer cells. A probe is inserted into the prostate to deliver extremely cold temperatures to the targeted area, which destroys the cancer cells. This method is effective but can carry a higher risk of damage to surrounding tissues if not performed carefully.

What Does NICE Say About Focal Therapy for Prostate Cancer?

The National Institute for Health and Care Excellence (NICE) in the UK provides guidelines and recommendations for medical treatments, including focal therapy for prostate cancer. NICE recognises the potential of focal therapy options like HIFU, NanoKnife, and Cryotherapy, particularly for men with localised prostate cancer. However, NICE emphasises the importance of careful patient selection and long-term follow-up, as more data is needed to fully understand the benefits and risks associated with these treatments compared to traditional methods.

What Are Salvage Treatments After Focal Therapy?

Why Might Prostate Cancer Return After Focal Therapy?

Despite the precision and effectiveness of focal therapy, there is a possibility that prostate cancer may recur, meaning the cancer comes back after the initial treatment. This can happen if some cancer cells were missed or if new cancer develops in the prostate.

What Investigations Might Be Needed After Focal Therapy?

Before deciding on a salvage treatment, doctors will typically recommend a series of tests and investigations to assess the recurrence and the extent of the cancer:

• Prostate-Specific Antigen (PSA) Test: PSA is a protein produced by the prostate gland. A blood test measuring PSA levels is often the first step in monitoring for cancer recurrence. Rising PSA levels after focal therapy may indicate that cancer has returned.

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• Magnetic Resonance Imaging (MRI): An MRI scan provides detailed images of the prostate and surrounding tissues. It helps doctors to see the exact location and size of any remaining or recurring cancer. MRI is particularly useful in identifying areas that might not have been fully treated by the initial focal therapy.

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• Prostate-Specific Membrane Antigen (PSMA) PET Scan: PSMA PET scans are an advanced imaging technique that can detect prostate cancer cells throughout the body, even in very small amounts. This scan is especially useful if the cancer has spread beyond the prostate. It’s a more sensitive test than MRI or traditional bone scans for detecting prostate cancer recurrence.

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What Are the Common Salvage Treatments for Prostate Cancer Recurrence?

When prostate cancer returns after focal therapy, doctors may recommend salvage treatments to manage the recurrence. Common salvage treatments include:

• Salvage Radical Prostatectomy: This surgery involves removing the entire prostate gland. It’s a more extensive procedure and is often considered when focal therapy has not been sufficient to control the cancer.

• Re-do Ablation Therapy: In some cases, repeating the focal therapy (such as another round of HIFU or Cryotherapy) can target the remaining or new cancerous areas.

• Salvage Radiation Therapy: Although less commonly reported in the studies reviewed, radiation therapy can also be used as a salvage treatment. It targets cancer cells with high-energy rays to kill them or stop them from growing.

What Does the Research Say About Salvage Treatments?

How Effective Are Salvage Treatments After Focal Therapy?

A review of 21 studies, involving 1012 patients, found that salvage treatments after focal therapy generally have acceptable outcomes. These treatments can effectively control cancer recurrence, though the success rates can vary depending on the treatment method and individual patient factors.

What Are the Side Effects of Salvage Treatments?

One of the main concerns with salvage treatments is the potential for side effects. The review found that erectile dysfunction is a common side effect, particularly after salvage radical prostatectomy. However, urinary continence, or the ability to control urination, is usually less affected by these treatments.

Are There Complications with Salvage Treatments?

Overall, the studies reported low complication rates, meaning that serious problems during or after salvage treatments are relatively uncommon. However, as with any medical treatment, there are risks, and it’s important for patients to discuss these with their doctor.

What Are the Future Directions for Prostate Cancer Salvage Treatments?

Why Are Prospective Studies Important for Prostate Cancer Treatment?

Most of the existing studies on salvage treatments are retrospective, meaning they look back at what happened to patients who already received treatment. While these studies provide valuable information, prospective studies that follow patients from the start of their treatment journey are needed to give more accurate and reliable data. This type of research will help doctors refine treatment protocols and improve patient outcomes.

How Can We Improve Prostate Cancer Salvage Treatments?

The balance is about cancer control and quality of life, the choice of the surgeon is crucial for those opting for surgery after failed focal therapy, an open conversation regarding the radiotherpay and hormone effects with your oncologist is key for those that are keen to explore this route and last and not least one has to have realistic expectations.