Focal therapy: Pro & Contra

Minimal side effects with optimal cure rates - that's the trend in the treatment of prostate cancer. So-called focal therapies no longer treat the entire prostate gland, but try to destroy individual tumour centres. We spoke with Dr. Pedram Derakhshani from the West German Prostate Center about the possibilities and limitations of focal therapy for prostate cancer.

While focal therapies are already part of the daily routine in many cancers such as breast and kidney cancer, they currently play a minor role in prostate cancer. Why?

In contrast to breast cancer, prostate carcinoma is in many cases a multifocal tumour. This means that the cancer appears in several places in the prostate gland. This is why we also speak of individual tumor centres. If therapy is necessary, it is recommended to treat the entire prostate gland to ensure that all malignant cells are destroyed. This is particularly important in the case of medium and high risk prostate carcinomas in order to minimize the risk of recurrence.

Nevertheless, there are currently procedures that already make such partial treatment of the tumor possible today?

Yes, but so far this has only included experimental methods such as HIFU therapy or irreversible electroporation with the NanoKnife. However, there is a lack of long-term experience and healing rates for both techniques. Therefore, it is not possible to make valid statements on the effectiveness at this time. In addition, these forms of therapy are only used for prostate tumors that have a very low risk and can be given active surveillance according to the recommendations of the current guidelines. There is therefore a risk of "over-therapy".

Does this mean that patients with prostate cancer have no other choice but to have their prostate removed completely in an operation?

No, not at all! Thanks to improved early detection methods such as magnetic resonance imaging (MRI), we are now in a position to localize tumor-suspected areas in the prostate more precisely. This already enables us to make the therapy more targeted and to significantly reduce side effects. A special method from modern radiotherapy is particularly suitable for this purpose: brachytherapy. 

Can you explain the procedure in more detail?

Instead of removing the entire prostate gland in an operation that is often stressful for the patient, brachytherapy involves irradiation of the tumor from the inside. For this purpose, small radiation sources (seeds) are brought directly into the prostate gland, destroying the tumor areas directly "on site". The position of the seeds in the prostate depends on the distribution of the individual tumor centres. The prostate is irradiated with pinpoint precision without damaging surrounding structures such as the bladder, intestine or sphincter. The advantage of this is that the men can continue to hold their urine. Problems with potency and libido are also much less common than after surgery. 

Is brachytherapy trend-setting for focal therapy in prostate carcinoma?

Yes, brachytherapy could also be called a semi-focal therapy. However, the great advantage over experimental methods such as HIFU or IRE is that all tumor cells in the prostate are detected during irradiation, which means that prostate cancer of the intermediate risk group or, in combination with external irradiation, even of the higher risk group can be treated effectively. Long-term data also clearly show that brachytherapy achieves the same healing rates with fewer side effects compared to surgery.

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