06 October 2010

Control as opposed to curative treatment of low risk, localized prostate cancer

Historically, “success” in the treatment of localized prostate cancer was the elimination of all evidence of cancer from the patient’s prostate and other nearby tissues — through radical surgery or radiation therapy of some type.

But the increasing acceptance of active surveillance and the evolution of focal forms of therapy have introduced whole new ways of thinking about the “successful” management of low- and even intermediate-risk, localized disease.

Today options for the management prostate cancer fall into two very general categories:

Methods intended to “cure” his cancer (i.e., completely eliminate all prostate cancer cells)
Methods intended to control his cancer over time (i.e., minimize risk for clinically significant, progressive disease)
  • Focal therapy with HIFU (investigational in the US)
  • Focal therapy with cryotherapy
  • Focal therapy with laser ablation
  • Other forms of focal therapy (e.g., phototherapy)
  • Active surveillance
The important point here is the distinction between treatments designed to eliminate all organ-confined prostate cancer and prostate-related tissue (“curative” therapies) and forms of management that may not be curative because they are designed primarily to manage the risk that the patient will have progressive (clinically significant) prostate cancer through careful monitoring or through the elimination of signs of cancer that seem to place the patient at possible risk for progressive disease.

All focal therapies for prostate cancer come with the understanding that they may leave behind small areas of cancer that were not evident on biopsy and that cannot currently be identified with accuracy by any known imaging technique technique. Thus the goal of such focal therapies can not truly be described as curative. The goal is to eliminate the evident index lesion or lesions that predispose the patient to the risk for progressive disease, thereby minimizing risk.

A recent article has laid out the importance of the concepts of cancer control as opposed to curative treatment in discussing the future development of clinical trials to assess the effectiveness and safety of evolving forms of focal therapy.

Article authors, two leading UK-based surgeons with strong interests in the potential of focal therapy for prostate cancer, point out that the ideal form of management of localized prostate cancer requires the development of a novel therapy with the ability to minimize risk for progressive disease (in other words, it should have the “curative” impact of radical prostatectomy) while optimizing quality of life (in other words, the side effects should be no worse than those of active surveillance). At least in theory, some forms of focal therapy might be able to meet this standard.

This idea that prostate cancer needs to be “cured” in some men (because they have aggressive forms of disease that need aggressive forms of therapy in order to save their lives) but only needs to be “controlled” in others (because they have relatively less aggressive forms of the disease that should just be prevented from becoming clinically significant) is not unique to prostate cancer. It is already being applied to other forms of cancer for which we are able to recognize specific characteristics that place patients at higher or lower levels of risk for progressive disease that might lead to cancer-specific death.



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NOTE: Issues on this site regarding prostate cancer and treatment options, are provided for information only, and are not meant to substitute for the advice of your own physician or other medical professional. Prostate-Report.org does not endorse any specific product, service or treatment.





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