Focal therapies vs Radical Treatments
Radical treatments are recognized by the major learned societies as the gold standard in localized and locally advanced prostate cancer. However the most recent and highest scientific evidence ever in the field have cast doubt upon the real impact of radical treatment on survival while confirming their protecting role regarding on the metastatic disease progression [11-13]. Furthermore every year overtreatment by radical treatments is a devastating issue for thousands of men certainly in the Low Risk (LR) and to a less extent in the favorable Intermediate Risk (IR) group of d’Amico (see “Prognosis and Follow-up”). Meanwhile, Prostate Photodynamic Therapy has reached the same high level of scientific evidence than radical treatments and achieved a milestone in the field of focal therapy (picture 87). It is legitimate and relevant to ask if presently focal therapy would not represent an alternative option to reduce drastically overtreatment in less risky prostate cancer such as selected LR and favorable IR while radical treatments are undoubtedly the appropriate solution for more aggressive and advanced prostate cancer (picture 88).
Picture 87 : A very delicate and accurate introduction of the needles
Picture 88 : Therapeutic scheme including focal therapies as alternative to radical treatments in selected LR and favourable IR groups
The shadow of overtreatment on radical treatments
In 2018, the European Association of Urology prostate guidelines panel assumed that “radical treatment of localized prostate cancer is recognized to be an unnecessary intervention or overtreatment in many men”. They also reported :” ProtecT trial showed no difference in 10-yr cancer-specific survival between active monitoring, radical prostatectomy (RP), and external beam radiotherapy (EBRT) in men with mainly low- and intermediate-risk PCa, but considerable differences in functional outcomes “ . In the US, in 2020, the FDA Oncology Center of Excellence Public Workshop acknowledged that “in the last 40 years despite advances in many areas of oncology no treatments of localized prostate cancer have been approved » (picture 89) . Taking in consideration these strong assertions from indisputable institutions the state of art of early prostate cancer would improve patient’s health by integrating further the latest scientific evidence and less invasive therapeutic innovations. In a published letter, to the EAU prostate cancer guidelines panel, amongst the most prominent experts in the prostate cancer focal therapy field advocated the EAU to avoid to : « deny our patients a legitimate strategy that many will want to know about and accept as an alternative treatment option. » . In practice, in every situation where radical treatments are avoidable, the best advices and strategy needs to be proposed to the patient.
Picture 89 : FDA Oncology Center of Excellence Public Workshop report (2020)