EMUC16: Managing recurrent PCa: Has focal therapies come of age?

15 September 2016

Rafael Sanchez-Salas Has focal therapies come of age

Managing recurrent prostate cancer (PCa) remains a challenge to cancer experts, but with the wider use of image-guided techniques new approaches such as focal therapy offers a promising option for patients who prefer a less radical treatment plan such as surgery.

“Focal therapy for PCa is today an ‘epidemic subject’ in urological oncology,” said Dr. Rafael Sanchez-Salas (FR) of the Department of Urology at the Institute Mutualiste Montsouris in Paris, as he noted that although a promising option, focal therapy still requires additional evidence for it to occupy a crucial role in managing recurrent disease. Sanchez-Salas will speak on the latest evidence for focal therapy during the 8th European Multidisciplinary Meeting on Urological Cancers (EMUC16) to be held in Milan (IT) from 24 to 27 November.

An inclusive meeting which provides a platform for onco-urological experts, the EMUC is now on its eight year of gathering leading opinion leaders, researchers and cancer specialists to critically examine new and current treatment strategies in urological malignancies. The event is annually organised by three of Europe’s leading and specialised medical associations- the European Society for Medical Oncology (ESMO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU).

Focal therapy for PCa, according to Sanchez-Salas, has been evaluated in the context of salvage therapy, but mainly for disease recurrence following radio- or brachytherapy. He explained that although brachytherapy, cryotherapy and high-intensity focused ultrasound (HIFU) are used as salvage therapies, the long-term oncological outcomes of these approaches are still unknown. Moreover, there is the concern about debilitating side-effects.

Potential challenges

“The potential problems of focal therapy in radio-recurrent disease include accurately localizing recurrent disease within the prostate, and the margins of safe treatment which preserve oncological efficacy whilst minimizing harms and strategies of follow-up,” said Sanchez-Salas.

Despite this drawback, initial studies offer a hint of promise, according to Sanchez-Salas as he mentioned that outcomes regarding disease-free survival rates are relatively favorable.  “Recently published systematic review including cryoablation, brachytherapy and HIFU, showed that one, two, three and five-year biochemical disease-free survival ranges for focal salvage are, respectively, 69-100, 49-100, 50-91 and 46.5-54.5%.  Severe genitourinary, gastrointestinal and sexual function toxicity rates are 0-33.3%,” he noted.

“This data confirm the feasibility of these treatment modalities in selected patients in the attempt to reduce the risk of adverse events while maintaining cancer control. If we look at the development of focal therapy, we can see how radio-recurrent PCa has been like a “boot camp” for energy development,” he said.

He also conceded that although that there is a lack of prospective studies assessing the results of focal therapies, there are improvements which may yet favor the efficacy of focal therapies.

“This (lack of prospective studies) is completely true, but the trends are changing,” he said as he highlighted some factors that may lead to an expanded adaption of focal therapies such as cancer control, its use of image-guided technology, and the strong trend to find a middle ground option between active surveillance and more radical options.

“At this point, the available outcomes to support focal therapy in PCa may still be limited (based) on evidence and we clearly understand that there is a great deal more to be done to further develop this field,” Sanchez-Salas said. “However, we are very confident that developments have passed a point of no return. Today, the die is cast for focal therapy in localized PCa.”

Consolidating gains

What is important is to consolidate the gains made in focal therapy, he pointed out.  He a noted this consolidation can be based on solid imaging and objective planned prostatic biopsies. Based on high-performance imaging, Sanchez-Salas believes the evolution towards a rationalized approach to tackle prostatic tumors is natural.

“Focal therapy for PCa is part of the personalized medicine wave, which is a potential shift in clinical practice that provides a tissue-sparing approach to the PCa armamentarium,” he added.

Whether or not the optimism for less radical approaches in malignant disease will find favor or a wider acceptance among cancer experts is also reflected in the plenary sessions during the EMUC where specialists are known to enthusiastically argue for or against emerging therapies vis-à-vis standard treatments. The fact that expert discussions and meetings may not necessarily find unanimity in a multidisciplinary gathering such as the EMUC does not dampen the optimism of Sanchez-Salas for the opportunities of knowledge-sharing in this international event.

“It is exactly the fact of having multidisciplinary opinions to deal with difficult therapeutical decisions that we see the benefit of the EMUC. We live at a time of personalized medicine but in order to particularize treatment one needs more than just one specialty-isolated view. Team work is of utmost importance,” he said.

The three-day EMUC will be preceded by the 5th annual meeting on November 24 of the EAU Section of Urological Imaging (ESUI) whose programme will focus on new developments, challenges and prospects in imaging.  On the same day, the 2016 EMUC Symposium on Genitourinary Pathology (ESUP) will also take place to highlight new and current diagnostic issues in genitourinary cancers.

For details on the Scientific Programme click here.