Ablation/Focal Therapy in the Treatment of Prostate Cancer

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:13latest information on cancer
00:13 --> 00:15care by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:18 --> 00:19of the battle to fight cancer.
00:19 --> 00:22This week it's a conversation about prostate
00:22 --> 00:24cancer with Doctor Preston Sprenkle.
00:24 --> 00:26Doctor Sprenkle is an associate professor
00:26 --> 00:29of urology at the Yale School of Medicine
00:29 --> 00:30Where Dr. Chagpar
00:30 --> 00:32is a professor of surgical oncology.
00:33 --> 00:35So Preston, maybe we can start off
00:35 --> 00:37by you telling us a bit more about
00:37 --> 00:42yourself and what it is you do.
00:42 --> 00:44I'm a urological oncologist,
00:44 --> 00:48so I do urologic cancer
00:48 --> 00:50surgeries and I treat primarily
00:50 --> 00:52men with prostate cancer.
00:52 --> 00:54And my clinical practice focuses
00:54 --> 00:55on the diagnosis of prostate
00:56 --> 00:58cancer as well as its management.
00:58 --> 01:01I think our audience
01:01 --> 01:03has heard a lot about prostate cancer.
01:03 --> 01:05It seems pretty ubiquitous.
01:05 --> 01:08Some of the questions that I think always
01:08 --> 01:10come up include a number of things.
01:10 --> 01:13So first off, the screening for
01:13 --> 01:15prostate cancer that always
01:15 --> 01:18seems like a bit of a moving target.
01:18 --> 01:20You know, back in the day it
01:20 --> 01:22was with digital rectal exams,
01:22 --> 01:24then it was PSA's, then it was,
01:24 --> 01:27well, maybe we don't need to do
01:27 --> 01:28screening for everybody.
01:28 --> 01:31Can you kind of tell us what is
01:31 --> 01:33the latest in terms of screening
01:33 --> 01:34for prostate cancer?
01:34 --> 01:35Who needs it,
01:35 --> 01:37how often and with what?
01:37 --> 01:38Those are great questions.
01:38 --> 01:41And you're right, it does remain
01:41 --> 01:43controversial to a certain extent.
01:43 --> 01:46I think the recommendations to not
01:46 --> 01:50screen for prostate cancer were really a
01:50 --> 01:53reflection of our practice at the time.
01:53 --> 01:55Where we were treating men with
01:55 --> 01:57low grade prostate cancer and we
01:57 --> 01:59were really kind of over diagnosing
01:59 --> 02:01and over treating prostate cancer.
02:01 --> 02:04So people who didn't need identification
02:04 --> 02:05and didn't need treatment,
02:05 --> 02:09were having their prostate cancer treated.
02:09 --> 02:12Where we are now is we have much more
02:12 --> 02:14information about prostate cancer
02:14 --> 02:16about the factors associated with
02:16 --> 02:19high risk prostate cancer in which
02:19 --> 02:21prostate cancers that we need to treat.
02:21 --> 02:23So in terms of screening PSA,
02:23 --> 02:25a blood test screening is the mainstay
02:25 --> 02:28and it is the most important thing
02:28 --> 02:30that we can use for evaluating
02:30 --> 02:32for prostate cancer.
02:32 --> 02:34When to start that varies
02:34 --> 02:36depending on different guidelines,
02:36 --> 02:38but the NCCN early detection
02:38 --> 02:41of prostate cancer guidelines
02:41 --> 02:43recommend consideration of a single
02:43 --> 02:46PSA test as early as age 45 or even
02:46 --> 02:49as early as age 40 in men with some
02:49 --> 02:53higher risk features such as family history,
02:53 --> 02:54genetic conditions known to put men at
02:54 --> 02:57increased risk of developing prostate cancer.
02:59 --> 03:01But that does not necessarily mean
03:01 --> 03:03that these men need to have PSA on an
03:03 --> 03:05annual basis. It is risk
03:05 --> 03:07stratified in terms of how frequent
03:07 --> 03:09PSA testing and prostate cancer
03:09 --> 03:10screening needs to occur,
03:11 --> 03:15but every man after the
03:15 --> 03:19age of 45 should get PSA testing.
03:19 --> 03:21How frequently should that be?
03:22 --> 03:25So it really depends on the result.
03:25 --> 03:27So for men with a very low
03:27 --> 03:29PSA test at the age of 45,
03:29 --> 03:32they can then safely defer another
03:32 --> 03:35PSA test for four to five years.
03:35 --> 03:37If their PSA is elevated,
03:37 --> 03:38those are the men,
03:38 --> 03:40which is actually it's pretty rare,
03:40 --> 03:42but for a PSA to be elevated
03:42 --> 03:43at that age means that
03:43 --> 03:45man is at an increased risk of
03:45 --> 03:47developing prostate cancer at some
03:47 --> 03:49time in the next 5 to 10 years.
03:49 --> 03:51And so we want to follow
03:51 --> 03:53their PSA more closely.
03:53 --> 03:56So it's really a risk adapted kind
03:56 --> 03:58of model based on the PSA value.
03:59 --> 04:03At what point do you
04:03 --> 04:06kind of get worried that the PSA?
04:06 --> 04:09What level is high that you're concerned about
04:09 --> 04:12a potential prostate cancer and further
04:12 --> 04:14imaging and or biopsy is warranted?
04:15 --> 04:20Yes. So the initial cutoff and
04:20 --> 04:22we try not to actually use cutoffs
04:23 --> 04:25because there is no specific cutoff
04:25 --> 04:28that is correct, but a higher PSA
04:28 --> 04:30has a higher risk of their
04:30 --> 04:33prostate cancer being detected
04:33 --> 04:34on subsequent evaluation,
04:34 --> 04:35but in general for a PSA
04:35 --> 04:37over the level of three,
04:37 --> 04:39we would suggest further evaluation
04:39 --> 04:42whether that is a repeat PSA
04:42 --> 04:44or an additional sort of what
04:44 --> 04:46we call second generation PSA
04:46 --> 04:51or urine based test to further risk
04:51 --> 04:54stratify if
04:54 --> 04:58there may be concern for a prostate cancer.
04:58 --> 05:00And then if there is,
05:00 --> 05:03we often will utilize a prostate MRI to
05:03 --> 05:06even further characterize someone's risk
05:06 --> 05:09before going towards a prostate biopsy.
05:09 --> 05:12And a prostate biopsy is really the
05:12 --> 05:14only definitive way to determine
05:14 --> 05:16if a prostate cancer is present.
05:16 --> 05:17So all these other tests, PSA,
05:17 --> 05:20blood tests, urine tests, MRI,
05:20 --> 05:23those help inform whether a biopsy is
05:23 --> 05:27needed and where that biopsy should be
05:27 --> 05:29targeted. In the case of MRI it
05:29 --> 05:31gives us that information as well
05:32 --> 05:34and then once a patient has
05:34 --> 05:37a biopsy that can confirm the
05:37 --> 05:39diagnosis of a prostate cancer.
05:39 --> 05:42But our understanding now is that
05:42 --> 05:44one size isn't the same as
05:44 --> 05:47all in other words there are some
05:47 --> 05:49very low risk prostate cancers
05:49 --> 05:52that can be effectively followed with
05:52 --> 05:54active surveillance versus other
05:54 --> 05:57prostate cancers that might be more
05:57 --> 05:59aggressive that warrant further management.
05:59 --> 06:02Can you talk a little bit about how
06:02 --> 06:04you kind of navigate those nuances?
06:05 --> 06:05Absolutely, yes.
06:05 --> 06:08So I mean the overdiagnosis is not doing
06:08 --> 06:11all of this testing in the biopsies,
06:11 --> 06:13in people whose PSA is low.
06:13 --> 06:15And the overtreatment is recognizing
06:15 --> 06:18exactly as you just said that
06:18 --> 06:20there are some or many cancers
06:20 --> 06:22that do not need treatment.
06:22 --> 06:24We have a grading scale for prostate
06:24 --> 06:26cancer once it has been diagnosed.
06:26 --> 06:29And again, this is based off
06:29 --> 06:30of the biopsy information.
06:30 --> 06:32But that grading scale is
06:32 --> 06:34a 5 point scale where the one is
06:34 --> 06:36low and five is high and really
06:36 --> 06:38pretty routinely grade one disease
06:38 --> 06:42is not treated and there are some
06:42 --> 06:43men with grade 2 disease that
06:43 --> 06:45also do not need treatment.
06:45 --> 06:47And so again it's risk stratified
06:47 --> 06:51and very we try to personalize it to
06:51 --> 06:54the cancer grade but also to the
06:54 --> 06:57man's wishes and because any treatment
06:57 --> 07:00can have side effects
07:00 --> 07:03on urinary function, sexual function,
07:03 --> 07:06even bowel function,
07:06 --> 07:08I think there's a very interesting
07:08 --> 07:09study that just was published
07:09 --> 07:10in the New England Journal,
07:10 --> 07:13I believe it was last week with
07:13 --> 07:16now 15 years of followup of a
07:16 --> 07:18randomized trial comparing men
07:18 --> 07:20who were randomized to surgery,
07:20 --> 07:21to radiation treatment,
07:21 --> 07:24or to an active monitoring.
07:24 --> 07:26And with now 15 years of follow up,
07:26 --> 07:29they saw no difference in prostate
07:29 --> 07:33cancer specific survival or overall survival.
07:33 --> 07:36And this is consistent with what we
07:36 --> 07:39have been learning, is that many men
07:39 --> 07:41are overtreated for their prostate
07:41 --> 07:44cancer and the goal of treatment is not
07:44 --> 07:45s quick fix,
07:45 --> 07:47it's not something that is going to
07:47 --> 07:49result in an improvement in the short term.
07:49 --> 07:52We now are seeing that even within 15 years,
07:52 --> 07:54we may not see a survival benefit
07:54 --> 07:56associated with treatment of men
07:56 --> 07:57with predominantly low and
07:57 --> 07:59intermediate risk prostate cancer.
08:00 --> 08:02So in that trial, did they include people
08:02 --> 08:04who were more in that high risk group?
08:05 --> 08:06So there were a few.
08:06 --> 08:10About 1/3 of the patients had
08:10 --> 08:13intermediate or high risk prostate cancer.
08:13 --> 08:14But it's not really broken down
08:14 --> 08:16more specifically than that,
08:16 --> 08:21but about 2/3 were in the low risk group.
08:21 --> 08:23We do have other studies,
08:23 --> 08:25not this randomized trial that do
08:25 --> 08:27show a benefit to treatment in men
08:27 --> 08:29with high risk prostate cancer.
08:29 --> 08:31So there still is
08:31 --> 08:33a need for treatment,
08:33 --> 08:36but I think it reinforces why
08:36 --> 08:38or how it is important to stratify
08:38 --> 08:40patients and not be hasty to
08:40 --> 08:43treat those with low and sort of
08:43 --> 08:45favorable intermediate risk disease.
08:45 --> 08:48Yeah, I mean because it kind of if
08:48 --> 08:50there is no difference in survival,
08:50 --> 08:52it kind of begs the question
08:52 --> 08:54why go looking for it to begin with?
08:54 --> 08:55It's a very good question.
08:55 --> 08:56You're absolutely right.
08:57 --> 08:58But when we think about
08:58 --> 09:00if there are studies that demonstrate
09:00 --> 09:02for that high risk group that
09:02 --> 09:03there is a benefit for treatment,
09:03 --> 09:05my understanding is that treatment
09:05 --> 09:09continues to evolve and that it's not
09:09 --> 09:10necessarily the radical surgeries
09:10 --> 09:13that we've kind of heard about in
09:13 --> 09:15the past which may result
09:15 --> 09:17in incontinence or impotence and
09:17 --> 09:20all kinds of things like that.
09:20 --> 09:23Can you kind of give us the landscape of
09:23 --> 09:24what prostate cancer treatment
09:24 --> 09:26looks like these days and what
09:26 --> 09:28some of the options are?
09:28 --> 09:31Definitely,
09:31 --> 09:33you're right, the landscape is changing.
09:33 --> 09:35Surgery to remove the entire prostate
09:35 --> 09:37and radiation treatment to treat the
09:37 --> 09:39entire prostate remain the gold standards
09:39 --> 09:41because those are the therapies that
09:41 --> 09:43we've had around for the longest.
09:43 --> 09:47But both of them are definitely plagued
09:47 --> 09:49by significant side effects associated
09:49 --> 09:53with the benefit of treatment.
09:53 --> 09:56Newer treatments are generally
09:56 --> 09:58called ablative therapies,
09:58 --> 10:01where we use energy to destroy
10:01 --> 10:03the prostate tissue.
10:03 --> 10:05Because many of them are done
10:05 --> 10:07in a more targeted fashion and
10:07 --> 10:08more localized in the prostate,
10:08 --> 10:11we are able to control the areas of
10:11 --> 10:13treatment a little bit more precisely
10:13 --> 10:15and limit the damage to the structures
10:15 --> 10:18that relate to urinary continence,
10:18 --> 10:21sexual function and even sort
10:21 --> 10:22of bowel function.
10:24 --> 10:26They're still considered investigational,
10:26 --> 10:29pretty much all of these therapies
10:29 --> 10:31because they are not ready for
10:31 --> 10:34any practitioner to perform.
10:34 --> 10:36But there is definitely a significant
10:36 --> 10:39amount of research and interest in
10:39 --> 10:42increasing evidence of their effectiveness
10:42 --> 10:45and definitely a decreased impact on,
10:45 --> 10:47as you mentioned, erectile
10:47 --> 10:48dysfunction with treatment or
10:48 --> 10:50urinary incontinence with treatment.
10:51 --> 10:55So tell us more about what exactly
10:55 --> 10:58these investigational treatments are,
10:58 --> 11:01how they work, and whether there's any
11:01 --> 11:04kind of clinical trials that are ongoing.
11:04 --> 11:05It may be that
11:05 --> 11:07it's not ready for primetime,
11:07 --> 11:09but hopefully it's being investigated
11:09 --> 11:11so that if it does hold promise,
11:11 --> 11:15it might one day become a standard of care.
11:15 --> 11:19Yes. We hope that it someday will be
11:19 --> 11:22part of the standard of care regimen
11:22 --> 11:24of what is available for patients
11:24 --> 11:26to choose from the current evidence.
11:26 --> 11:29I mean I think an important thing to
11:29 --> 11:31recognize is because we are doing
11:31 --> 11:33in many cases targeted therapy,
11:33 --> 11:35so we're trying to just treat the area
11:35 --> 11:37where the prostate cancer is located
11:37 --> 11:39and not treat the entire prostate
11:39 --> 11:41similar to a lumpectomy and breast
11:41 --> 11:45cancer versus a radical mastectomy,
11:45 --> 11:47by doing that we are leaving tissue behind.
11:47 --> 11:50So we recognize that there may be
11:50 --> 11:52a slight increased risk of cancer
11:52 --> 11:54recurrence because we're leaving
11:54 --> 11:57other prostate tissue that could
11:57 --> 11:59develop a cancer in the future.
11:59 --> 12:01But by doing that we can
12:01 --> 12:03preserve those vital structures.
12:03 --> 12:05And so there are many different types.
12:05 --> 12:08Some use heat,
12:08 --> 12:11some use cold, some use electricity.
12:14 --> 12:18The main ones that have been around the
12:18 --> 12:20longest include Cryoablation which uses
12:20 --> 12:23cold energy to freeze the prostate
12:23 --> 12:25tissue and really destroy the cells.
12:25 --> 12:29There are treatments that generate heat,
12:29 --> 12:31so focal laser ablation uses the
12:31 --> 12:32laser fiber to generate heat
12:32 --> 12:34and similarly kill the cells.
12:34 --> 12:37High intensity focused ultrasound, where we
12:37 --> 12:40use ultrasound waves to generate
12:40 --> 12:42heat and destroy the cells.
12:42 --> 12:43There are clinical trials
12:43 --> 12:45locally here in Connecticut,
12:45 --> 12:47some offered at Yale,
12:47 --> 12:50that include a transurethral ultrasound.
12:50 --> 12:53So Tulsa is the sort of acronym
12:53 --> 12:55and it uses an ultrasound probe
12:55 --> 12:57in the urethra
12:57 --> 12:59which increases the ability
12:59 --> 13:01to treat the entire prostate.
13:01 --> 13:05And there is actually a randomized trial
13:05 --> 13:08comparing surgery to the Tulsa procedure
13:08 --> 13:10to treat
13:10 --> 13:12intermediate risk prostate cancer.
13:14 --> 13:16Wow. So interesting.
13:16 --> 13:20Lots of options for therapy.
13:20 --> 13:22We're going to take a short break
13:22 --> 13:23right now for a medical minute,
13:23 --> 13:25but on the other side,
13:25 --> 13:27we'll learn more about these
13:27 --> 13:28new prostate cancer treatment
13:28 --> 13:30advances with my guest Dr.
13:30 --> 13:31Preston Sprenkle.
13:31 --> 13:33Funding for Yale Cancer Answers
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13:35 --> 13:38Where their prostate and urologic cancers
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13:43 --> 13:46evaluation, and treatment of urologic cancer.
13:46 --> 13:50Smilowcancerhospital.org.
13:50 --> 13:53There are over 16.9 million
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13:58 --> 13:59Completing treatment for cancer
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14:06 --> 14:08The return to normal activities and
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14:50 --> 14:53You're listening to Connecticut Public radio.
14:53 --> 14:55Welcome back to Yale Cancer Answers.
14:55 --> 14:57This is doctor Anees Chagpar,
14:57 --> 14:59and I'm joined tonight by my guest,
14:59 --> 15:00Doctor Preston Sprenkle.
15:00 --> 15:03We're discussing recent advances in the
15:03 --> 15:05management of prostate cancer patients.
15:05 --> 15:07And right before the break, Preston,
15:07 --> 15:09you were telling us about some of
15:09 --> 15:11these newer focal ablative treatments,
15:11 --> 15:15whether using cold or using hot or using
15:15 --> 15:19ultrasound to kind of kill off prostate
15:19 --> 15:22cancer in a way that avoids the bigger
15:22 --> 15:25surgeries and radiation and so on.
15:25 --> 15:27But still is the mainstay of treatment,
15:27 --> 15:29but maybe these newer focal ablative
15:29 --> 15:31treatments which are currently
15:31 --> 15:33under investigation may become a
15:33 --> 15:35standard of care in the future.
15:35 --> 15:39So I have a couple of questions for you just
15:39 --> 15:41about the ablative therapies themselves.
15:41 --> 15:44One is, you know,
15:44 --> 15:48when we think about prostate cancer often
15:48 --> 15:50times as you mentioned before the break,
15:51 --> 15:55we will get an MRI to kind of look
15:55 --> 15:57at where that prostate cancer is.
15:57 --> 16:00So do these ablative treatments use some
16:00 --> 16:03kind of imaging to really target where
16:03 --> 16:05you're going to focus that energy so
16:05 --> 16:08that you at least have a guide as to
16:08 --> 16:10where you're going to kill off these cells?
16:11 --> 16:11With radical surgery,
16:11 --> 16:13you take out the whole gland,
16:13 --> 16:15so you kind of know that you've got it.
16:15 --> 16:17But what about with these
16:17 --> 16:18focal ablative treatments?
16:19 --> 16:20The introduction
16:20 --> 16:22of prostate MRI or I should say
16:22 --> 16:25the increased use of it and the
16:25 --> 16:27ability for us to do targeted
16:27 --> 16:29prostate biopsies infusions or MRI
16:29 --> 16:33guided prostate biopsies is what
16:33 --> 16:36allowed us to begin and to consider
16:36 --> 16:38these focal ablation therapies.
16:38 --> 16:41Around 2015 or so is when we
16:41 --> 16:42really started to see prominence
16:42 --> 16:45of the use of MRI for prostate
16:45 --> 16:47cancer diagnosis and targeting.
16:47 --> 16:49We can very well see lesions
16:49 --> 16:51within the prostate.
16:51 --> 16:53We confirm their location and grade
16:53 --> 16:56with a prostate biopsy or a targeted biopsy.
16:56 --> 16:58And what studies have shown is
16:58 --> 17:01about 80% of the time there is
17:01 --> 17:03what we call an index lesion.
17:03 --> 17:05So there's one main area of
17:05 --> 17:07cancer within the prostate.
17:07 --> 17:09And we can then with these targeted
17:09 --> 17:11therapies or focal therapies
17:11 --> 17:14treat that area of the prostate.
17:14 --> 17:16We visually see it with the MRI.
17:16 --> 17:19We can identify its location within
17:19 --> 17:22the prostates or three dimensionally.
17:22 --> 17:24Many of the treatments do use or
17:24 --> 17:27some of them use MRI for targeting.
17:27 --> 17:30So the Tulsa devices I mentioned that
17:30 --> 17:32treatment is performed inside an MRI scanner.
17:32 --> 17:34So we actually have the MRI on,
17:34 --> 17:37it does an imaging of the prostate
17:37 --> 17:40and then is used for real time
17:40 --> 17:42tracking of treatment and MRI
17:42 --> 17:45thermometry to monitor the
17:45 --> 17:47treatment and treatment success.
17:47 --> 17:48But even when we're not using that,
17:48 --> 17:52so for cryoablation or
17:52 --> 17:53irreversible electroporation,
17:53 --> 17:56it's a long name but it uses
17:56 --> 17:58electricity to destroy the tissue.
17:58 --> 18:00We use the MRI as a reference but
18:00 --> 18:02then have real time ultrasound that
18:02 --> 18:05allows us to visualize the prostate
18:05 --> 18:07in the area that we want to treat.
18:07 --> 18:09I think that very often these
18:09 --> 18:11are called focal therapies.
18:11 --> 18:14I think that's a little bit of a misnomer.
18:14 --> 18:17We are trying to treat the area with cancer,
18:17 --> 18:20but we do know that to achieve adequate
18:20 --> 18:23cancer control we still need to have
18:23 --> 18:25approximately a one centimeter margin.
18:25 --> 18:27SO it is not so focal,
18:27 --> 18:28we're not down to the millimeter level.
18:28 --> 18:30There is a 1 centimeter margin
18:30 --> 18:32around a visible lesion that we
18:32 --> 18:33try to treat to make sure that
18:33 --> 18:35we have excellent cancer control.
18:37 --> 18:38Which brings me to my next question,
18:38 --> 18:43which is, as we've kind of
18:43 --> 18:45seen prostate cancer management move
18:45 --> 18:49more and more towards nonoperative and
18:49 --> 18:52even just active surveillance where
18:52 --> 18:55we don't need to treat at all.
18:55 --> 18:57Has anybody really looked to see,
18:57 --> 19:00even if you do have a high
19:00 --> 19:02grade lesion in the prostate,
19:02 --> 19:04how much,
19:04 --> 19:08how often do you find other areas of
19:08 --> 19:12either prostate cancer or preinvasive
19:12 --> 19:14lesions that would increase risk
19:14 --> 19:17outside of that one centimeter zone?
19:18 --> 19:20You're correct and
19:20 --> 19:24those numbers currently are about 80 to 85%.
19:24 --> 19:27So 80 to 85% of the time when
19:27 --> 19:30we ablate a lesion, we see it.
19:30 --> 19:32There's something that is higher grade
19:32 --> 19:34just sort of on one side of the prostate.
19:34 --> 19:38We treat that 80 to 85% of the time that is
19:38 --> 19:40going to eliminate all of the significant
19:40 --> 19:42cancer that we have to worry about.
19:42 --> 19:46So I think for many people that is a
19:46 --> 19:50high enough number to have a treatment.
19:50 --> 19:51That's 85% effective.
19:51 --> 19:55But to have minimal impact on their
19:55 --> 19:59urinary function and sexual function,
19:59 --> 20:02many men are willing to sort of take
20:02 --> 20:03that 15% risk that they may need
20:03 --> 20:05another treatment in the future.
20:05 --> 20:06And with these ablation therapies,
20:06 --> 20:09we can also repeat them.
20:09 --> 20:10And they could still do surgery,
20:10 --> 20:12could still do radiation.
20:12 --> 20:14So really not burning any significant bridges
20:14 --> 20:17by attempting these kind of therapies first.
20:17 --> 20:20And for those gentlemen who don't
20:20 --> 20:23want to take that 10 to 15% risk,
20:23 --> 20:26are there options to consolidate
20:26 --> 20:28therapy with something else?
20:28 --> 20:29So thinking back to the
20:29 --> 20:30breast cancer analogy,
20:30 --> 20:33frequently when we do a lumpectomy,
20:33 --> 20:36the way that we get local control in the
20:36 --> 20:38rest of the breast is we add radiation.
20:38 --> 20:42So you no longer need the big surgery,
20:42 --> 20:45you can have the smaller
20:45 --> 20:46surgery plus radiation.
20:46 --> 20:48So for people who don't want
20:48 --> 20:51to take that 15% risk of
20:51 --> 20:54local failure is that an option?
20:55 --> 20:57So it's not currently in clinical
20:57 --> 21:00practice that is something where we have,
21:00 --> 21:02I am aware of some people that are
21:02 --> 21:04either writing it up or starting
21:04 --> 21:06some trials to evaluate that.
21:06 --> 21:07I think that you're absolutely right.
21:07 --> 21:09That is an important concept that the
21:09 --> 21:12people are thinking about, but I have
21:12 --> 21:15not heard of it in practice yet.
21:15 --> 21:17And then finally, you know,
21:17 --> 21:20I find so often what happens in
21:20 --> 21:22one cancer kind of has ripple
21:22 --> 21:23effects in other cancers as we
21:23 --> 21:25all try to learn from each other,
21:25 --> 21:28as we try to advance cancer management,
21:28 --> 21:31one of the things that's now being looked
21:31 --> 21:34at in breast cancer is doing even less.
21:34 --> 21:38Can we manage
21:38 --> 21:40some breast cancers nonoperatively,
21:40 --> 21:45so can we just do multiple
21:45 --> 21:48biopsies and not treat at all,
21:48 --> 21:50is there any consideration to
21:50 --> 21:52not getting that one centimeter
21:52 --> 21:54margin of prostate cancer with the
21:54 --> 21:57idea being well you know in that
21:57 --> 21:58latest New England Journal trial
21:58 --> 22:01that you mentioned there were some
22:01 --> 22:04high risk patients in there and
22:04 --> 22:05survival rates were
22:05 --> 22:08the same albeit that they didn't
22:08 --> 22:10look at that particular subset.
22:10 --> 22:13Is there any thought to just
22:13 --> 22:15leaving prostate cancer alone and
22:15 --> 22:17maybe following it or treating it
22:17 --> 22:20even in a more minimally invasive way?
22:22 --> 22:24That's a great thought.
22:24 --> 22:26I mean I think where we
22:26 --> 22:27are seeing that currently
22:27 --> 22:29is for men with low risk prostate cancer,
22:29 --> 22:31we do not treat,
22:31 --> 22:32we just follow them with periodic
22:32 --> 22:34biopsies on active surveillance.
22:34 --> 22:36We're increasing the sort of cohort
22:36 --> 22:39or number of people that we feel
22:39 --> 22:42comfortable following in that surveillance.
22:42 --> 22:44And so now favorable intermediate risk,
22:44 --> 22:46it used to be only low risk,
22:46 --> 22:49now many of us feel more comfortable
22:49 --> 22:50including favorable intermediate
22:50 --> 22:52risk people in that group and
22:52 --> 22:54there definitely is ongoing
22:54 --> 22:56research and we're looking for
22:56 --> 22:59what is an appropriate
22:59 --> 23:00threshold above which treatment
23:00 --> 23:02should be indicated and maybe
23:02 --> 23:04it is observation is all
23:04 --> 23:05we need for many of these men
23:08 --> 23:10and the idea of shrinking the
23:10 --> 23:11margins fortunately with
23:11 --> 23:13many of the ablation therapies,
23:13 --> 23:16you know we are very mindful and then
23:16 --> 23:18the goal is to spare this sexual function
23:18 --> 23:21and urinary function so often
23:21 --> 23:23we'll discuss with the patient
23:23 --> 23:25compromising those margins in those
23:26 --> 23:27areas to try to preserve function.
23:27 --> 23:28So that is ongoing,
23:28 --> 23:31but I have not seen a prospective
23:31 --> 23:33data to evaluate that yet.
23:34 --> 23:36Yeah, what about systemic
23:36 --> 23:38therapy for prostate cancer,
23:38 --> 23:41where are we with that?
23:41 --> 23:44Who needs systemic therapy,
23:44 --> 23:46what are the toxicities and
23:46 --> 23:49is there any thought to using
23:49 --> 23:51systemic therapy alone versus local
23:51 --> 23:54therapies which could potentially
23:54 --> 23:56impact sexual function and urinary
23:56 --> 23:58function incontinence, et cetera?
23:59 --> 24:00Yeah, that's a great question.
24:00 --> 24:01Unfortunately, the systemic
24:01 --> 24:04therapies tend to be more toxic.
24:04 --> 24:07So our baseline sort of leading systemic
24:07 --> 24:10therapy is androgen deprivation therapy,
24:10 --> 24:12which is removing the male
24:12 --> 24:13sex hormone of testosterone.
24:13 --> 24:14And when we do that,
24:14 --> 24:16that results in fatigue,
24:16 --> 24:18decrease in libido,
24:18 --> 24:19decrease in interest in sex,
24:19 --> 24:21decrease in sexual function,
24:21 --> 24:22can cause hot flashes.
24:22 --> 24:24So many men find that some
24:24 --> 24:25men tolerate it very well,
24:25 --> 24:28but many men find it pretty significant.
24:28 --> 24:31And that is sort of our lowest entry
24:31 --> 24:33level treatment with the least
24:33 --> 24:35side effects going further with
24:35 --> 24:37additional systemic therapies tend to
24:37 --> 24:39kind of ramp that up a little bit.
24:39 --> 24:41So we try to avoid that.
24:41 --> 24:43The people who typically will need that
24:43 --> 24:46therapy are those with higher risk,
24:46 --> 24:48so unfavorable intermediate or high
24:48 --> 24:50risk prostate cancer or definitely
24:50 --> 24:52those with metastatic disease.
24:52 --> 24:54And it can be either temporary
24:54 --> 24:56or in the case of patients
24:56 --> 24:57with metastatic disease,
24:57 --> 24:59we often will start that therapy
24:59 --> 25:02and it will be perpetual.
25:02 --> 25:04So that's something that once started,
25:04 --> 25:04they stay on it.
25:06 --> 25:09For patients who are screened and they've
25:09 --> 25:12got low risk disease or favorable
25:12 --> 25:15intermediate risk disease and they're
25:15 --> 25:18on active surveillance, at what point
25:20 --> 25:22do you either
25:22 --> 25:26stop active surveillance or how
25:26 --> 25:29frequently do they flip into that,
25:29 --> 25:31we need to actively
25:31 --> 25:33manage this now either with
25:33 --> 25:35a focal ablation therapy
25:35 --> 25:37or surgery or radiation,
25:37 --> 25:39I mean if you have low risk disease,
25:39 --> 25:43are you out of the woods or how
25:43 --> 25:45frequently are you out of the woods?
25:45 --> 25:46Yeah, so that's
25:46 --> 25:48also a very good question.
25:48 --> 25:50So I think it depends on where you
25:50 --> 25:52start with active surveillance.
25:52 --> 25:54So there are some men that have
25:54 --> 25:56very low risk prostate cancer,
25:56 --> 25:58some with sort of low and some with
25:58 --> 25:59favorable intermediate and their
25:59 --> 26:01progression rates are all different.
26:01 --> 26:05In the longer series for active surveillance,
26:05 --> 26:08we're seeing that around 50 to
26:08 --> 26:1260% of men remain on active
26:12 --> 26:16surveillance 10 years into the future.
26:16 --> 26:18So a pretty significant number are
26:18 --> 26:19able to remain on surveillance
26:19 --> 26:21in the that recently published
26:21 --> 26:23update on the PROTECT trial.
26:23 --> 26:26So even in men who were randomized to the
26:26 --> 26:28observation or active monitoring group,
26:28 --> 26:30by 15 years, 24% of them and
26:30 --> 26:32again this included intermediate,
26:32 --> 26:35maybe even some high risk patients,
26:35 --> 26:3824% of them remained treatment free.
26:38 --> 26:40So they never had any treatment.
26:40 --> 26:41So I think that
26:41 --> 26:43there's definitely a percentage of people
26:43 --> 26:45who do not need to be treated ever,
26:46 --> 26:50which is fabulous except,
26:50 --> 26:51you know, the pessimists in the
26:51 --> 26:53crowd might flip that and say yeah,
26:53 --> 26:58but that means that 76% of people would.
26:58 --> 27:00When we think about the options now
27:00 --> 27:03that might be coming down the Pike
27:03 --> 27:06in terms of focal ablative therapy,
27:06 --> 27:09do you think that there would be any
27:09 --> 27:11benefit in treating those low risk
27:11 --> 27:14or favorable intermediate risks with
27:14 --> 27:17what is hopefully turns out to
27:17 --> 27:19be a fairly non-toxic local therapy?
27:19 --> 27:21Would that get them out of the woods?
27:21 --> 27:24I just think about the anxiety
27:24 --> 27:25that patients have.
27:25 --> 27:26Kind of sitting on a cancer diagnosis
27:26 --> 27:28and some of them might feel like, okay,
27:28 --> 27:31this is a bit of a ticking time bomb.
27:31 --> 27:33It's just a matter of time and
27:33 --> 27:34whether or not
27:34 --> 27:37I'm going to be in the 24% or whether
27:37 --> 27:40I'm going to be in the 76% in terms
27:40 --> 27:42of needing additional therapy.
27:45 --> 27:49There have been some trials geared in
27:49 --> 27:52that direction looking at the low risk
27:52 --> 27:54prostate cancer and intervention did delay
27:54 --> 27:58the time to any additional intervention
27:58 --> 28:01which is I guess what we would hope.
28:01 --> 28:05But I think again that trial included people
28:05 --> 28:09with intermediate and high risk disease and
28:09 --> 28:11knowing that more than 50%
28:11 --> 28:13of people can,
28:13 --> 28:15it takes time and effort
28:15 --> 28:17to sort of reassure people.
28:17 --> 28:20But if we know that within 15
28:20 --> 28:21years or even 20 years,
28:21 --> 28:24it's unlikely that someone is going to
28:24 --> 28:26have death from their prostate cancer,
28:26 --> 28:28you could argue that we were
28:28 --> 28:30treating too early in some of those
28:30 --> 28:3276% and they may not have needed it.
28:33 --> 28:35Dr. Preston Sprenkle is an
28:35 --> 28:36associate professor of urology
28:36 --> 28:39at the Yale School of Medicine.
28:39 --> 28:40If you have questions,
28:40 --> 28:43the address is cancer answers at Yale
28:43 --> 28:45dot Edu and past editions of the
28:45 --> 28:47program are available in audio and
28:47 --> 28:49written form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

Ablation/Focal Therapy in the Treatment of Prostate Cancer with guest Dr. Preston Sprenkle April 2, 2023 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095