Half of Prostate Cancer Focal Therapy Cases Were Inappropriate

@northoftheborder As explained on PCRI but Dr. Scholz recently, getting a focal therapy modality, if it is, e.g., full ablation with TULSA PRO, then the results should equal other options. But then it really isn't "focal" anymore but fits under that rubric.

@marko49 Even with full gland TULSA PRO has difficulty with lesions right next to the prostate capsule. Most doctors will not consider you if lesions are located there. Recurrence risk is much higher.

@johnn01
About 90% of prostate cancer patients end up with a chronic disease only about 10% with a deadly disease.

A lot depends on what was found when you were diagnosed. It could very well be that you could live for a decade or more, even with an aggressive case.

You’ve given us no information about what happened with your diagnosis, That makes it really impossible to tell you anything definitive.

I'm unsure if my IRE nanoknife focal therapy was inappropriate? Perhaps yes and perhaps no. After much reading and being afraid of both surgery and radiation, I sought out a place that might offer focal therapy. At a Philadelphia center of excellence I was told that I was a good candidate. Having 4+3=7 gleason with tumor being only one side of the gland and after several tests including PSMA PET scan which showed no metastasis they told me I was a good candidate. The procedure went well and was confirmed effective by both imaging and biopsy 7 months later. Unfortunately, another 6 months later due to a rise in PSA another PSMA PET was performed indicating metastasis in pelvic lymph nodes. Doctor opined micro metastasis that was not picked up in earlier PSMA PET. I was definitively disappointed but I don't regret taking a chance at it. After which there wasn't too much of a decision process. ADT + ARPI + 40 sessions of IMRT which so far has been effective with PSA being <.05 consistently over a year. Anyhow do you think in my case this was an inappropriate decision by me and my Urological Oncologist?

@jim18 I definitely know folks that have done, and will do this. They are usually the ones with the most experience.
Dr. Scholz was correct in stating that the trials on whether this had better or worse long-term recurrence are not mature yet. So, we really don't know either way. But the chances of side effects are definitely lower.

One reason is that is done live, in-bore with a perimetric MRI. So the doc is viewing exactly what is happening live and the AI programs delineate the borders everywhere. Not perfect but any movement happens live where as most radiation, e.g., is done with static CT scans taken earlier. Truebore, Cyberkife and other brands have mechanisms to deal with those movements with the main one being the use of fiducials. Not a fan of the side effects with those either but the machine developed and trialed at UCLA gets around that with better technology (they claim) with 4 shots per second as the doc also sees live what is happening and any movement stops the machine instantly.

Most of side effect information for radiation are based on older technology but again we don't have mature data on the newer machines or many of the full ablation approaches to know with certainty.

I will trade a shorter life with less toxicities if that is the choice I get to make. The beauty of having options. No one size fits all. Tradeoffs. Always tradeoffs. Do your research with as little bias as possible and pick your poison.

@swl1956 It is unlikely that the metastasis occurred and grew large enough to show on a PSMA in 6 months. With RP they do not take all lymph nodes so you could be in the same situation if you chose surgery. Even with RT, depending on how far the nodes are from the prostate they could have been outside the zone of treatment. ROs try to minimize that to reduce side effects. Now if they had lit up on the previous PSMA than the RT treatment would have included them.

@marko49 I am a big proponent of focal therapy. Looked at IRE, Laser, and Tulsa Pro. Was not a good candidate for any of these a couple of years ago. What I noticed in the study was that most of the inappropriate use was for Gleason 6. Percentage of Gleason 8 & 9 with focal therapy had large decreases. If someone with a 6 cannot take the thought of active surveillance any focal therapy is better than RT or RP. It is bad enough that most insurance will not cover these treatments.

@jim18
It can grow and show in short period of time - happened to my husband after RP. PSA started moving upward after 6 mos and at about 8 mos uPSA 0.16 PSMA showed clearly visible and multiple glands glowing. Aggressive cancers grow fast.

PSMA scans are not 100% reliable - micro mets are not visible until they start growing and I always cringe when patients say with 100% certainty that "cancer is contained". It looks contained but it does not mean that it really is - that is how and why BCR happens *sigh

@jim18 I don't think that is the reason for issues with insurance:
1. They are money driven and don't want to support new interventions that are not SOC from NCCN. Gives them and out.
2. There is little proof that ANY treatment for Gleason 6 folks makes any real sense, other than helping psychologically those who "just want something done!"

Yeah, at the time I was convinced that I had no metastasis with all the negative results of preliminary testing. I do wonder if perhaps the first PSMA wasn't performed properly. I have read where the PSMA pet scans are about 85% accurate.