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We analyzed thousands of messages from men across the country … Dating coaches take a more positive stance on dating after Powered by - Designed with the Hueman theme. Template transperineal biopsies can serve the purpose to detect the so-called index lesion [ 23 ], and it has been accepted as the standard for evaluating patients' eligibility in trials of focal therapy. Modern biopsy strategies, combined with optimal imaging and nomograms, provide a strong basis for the inclusion of patients into prospective clinical trials of focal therapy [ 30 ].
Avoiding Overtreatment of Low-Risk Prostate Cancer The European Screening study showed that men need to be screened and 48 diagnosed in order that one prostate cancer-related death is avoided over a 9-year interval [ 5 ]: However, this difference is probably smaller in a PSA-screened population, since lower-risk disease is detected earlier [ 32 ].
The advantage of radical therapy may also become smaller if watchful waiting is substituted with active surveillance which, however, is characterized by a significant dropout [ 33 ]. Focal therapy lies between the undertreatment of active surveillance and the overtreatment of radical approaches.
Reduction of Side Effects of Whole Gland Therapy It is widely demonstrated that radical whole-gland therapy is associated with significant side effects. Despite improvements in surgical techniques, urinary incontinence UI is not uncommon after radical prostatectomy RP [ 34 ]: Several predictors of postoperative UI have been investigated, but unfortunately, they rarely reach a high level of evidence [ 37 ].
UI after RP or radiotherapy is caused by sphincter damage [ 38 ] and by bladder dysfunction, such as detrusor overactivity and low compliance [ 39 ].
UI is a particularly upsetting problem, and it dramatically worsens quality of life QoL [ 40 ].
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Despite improvements in surgical techniques, ED is not uncommon after radical prostatectomy [ 4243 ]: ED after RP has been related to nerve damage neuropraxia resulting in penile hypoxia, smooth muscle apoptosis, fibrosis, and venous-occlusive dysfunction [ 42 ], and it is a particularly upsetting problem after RP, worsening quality of life [ 45 ].
The best modality to optimize postcancer erectile dysfunction management has not yet been standardized and is still challenging [ 47 — 49 ].
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Problems with bowel function rarely occur after RP [ 50 ], while Widmark et al. Even brachytherapy has an impact on bowel function: More recently, Miller et al. Focal therapy is different from a whole gland treatment: Improving Overall Quality of Life All the studies found that changes in quality of life were significantly related to satisfaction with overall outcome among both patients and their partners.
Treatment-related changes in quality of life among patients due to a whole gland therapy caused distress in their partners. A multicenter trial showed that a patient's therapy had an effect on the well-being of the patient's spouse or partner [ 59 ]: These findings confirm those of single-institution studies suggesting that patients' urinary or sexual symptoms are problematic for their partners [ 60 ]. Cost Saving Various global economic scenarios are altering the landscape of whole gland therapy.
Intensity-modulated radiotherapy is more effective but more expensive than conventional radiotherapy [ 63 ]. It is possible that in the future health care systems required more cost-effective care finding in focal ablation a cost-effective therapy: In conclusion, the overall outcome of whole gland prostate cancer treatment is sensitive to divergent changes in quality of life of patients and their partners due to continence, sexual and bowel function, with increasing costs for the health care system.
Investigation on new organ sparing technique [ 65 — 70 ] which could reduce the incidence of adverse events and improve quality of life might represent a valuable new strategy for management of PC.
Undertreatment of Significant Prostate Cancer The contra of focal therapy lies in the undertreatment of patients with clinically significant disease. Low tumor volume is a favorable prognostic feature and predicts low risk of metastasis; however, low tumor volume does not guarantee unifocality. However, the independent role of Gleason grade cannot be overlooked, and high-grade PC, even in low volume or small foci, represents a risk if untreated.
The concept of treating only the index tumor in selected men is based on a number of pathologic studies. However, although treatment of the index tumor has been suggested, to date, there is no technology for reliable disease mapping; moreover, we lack defined followup protocols for the residual prostate that was not ablated and whether the residual prostate would compromise long-term disease control.
Ideal Candidate to Focal Therapy The major obstacle lies in proper identification of the ideal patient for focal therapy. The most common modality for diagnosing prostate cancer is prostate biopsy, which remains a poor predictor of the extent of tumor on final pathologic specimen: The consequences of improperly designating a patient for focal therapy may be profound.
While the smaller non-index cancer rarely determines prognosis, metastatic deposits have chromosomal alterations discordant with the largest tumor in the prostate, suggesting that nonindex tumors can metastasize [ 78 ]. Problems with Diagnostic Tools Even though template mapping biopsies provide the accuracy needed to administer focal therapy, they have several limitations: Saturation biopsy requires anesthesia, and, finally, the cost of the procedure is another important factor to be taken into consideration.
Magnetic resonance imaging has been proposed as an alternative imaging modality to guide prostate biopsy: Additionally, men who have had recent biopsies often present with hemorrhage, which limits MRI accuracy. Nevertheless, tumor characterization and risk estimation remain imperfect. Definition of Cancer Control The other most problematic area relates to the definition and timing of the surrogate cancer-related outcomes used. Focal therapy will be problematic as some tissue is left untreated, and this inevitably gives rise to PSA increasing.
Definitions of biochemical recurrence-free progression are not well established: Longer followup and validation through other mature series will be needed to define the role of PSA and followup schemes. Absence of cancer in treated lobe is characterized by the same bias of preoperative accuracy of prostate biopsy.
The other unanswered question at least to date is which retreatment is suitable in case of local persistence or relapse; there are few studies in the literature in the feasibility of radiotherapy, radical prostatectomy, or repeating cryotherapy or HIFU. Functional Outcomes Lastly, a presumed but unproven advantage of focal therapy is the lower likelihood and severity of treatment-related morbidity.
While this is intuitive, it must be confirmed through trials: Questionnaires will be principally directed at genitourinary associated outcomes and at global assessment of quality of life; complication will be classified according the Clavien-Dindo Classification. Early Experiences with Focal Therapy The technique of ablating part of the gland may, in practice, represent the most achievable clinical approach.
Focal therapy can be delivered using a number of ablative modalities that treats small, selected tissue, including cryosurgery, high-intensity focused ultrasound HIFU, laser ablation, and photodynamic therapy. Despite paucity of data and a lack of consensus on the most appropriate eligibility and selection criteria, treatment template, and best method of delivering thermal destruction, this approach has become increasingly popular.
Cryosurgery Preliminary clinical trials of focal cryo-hemiablation suggest that it is feasible, with excellent cancer control and minimal complications although the study design and the scientific standard were poor [ 80 — 84 ].
Focal cryotherapy is a promising option for carefully selected patients although optimization of inclusion criteria is required, since selection criteria are associated with cancer-free survival. Further followup will determine optimal patient selection criteria and followup protocols for patients undergoing primary focal unilateral nerve-sparing prostate cancer treatment.
HIFU HIFU is already being used unfortunately outside of formal clinical trialsand the preliminary data are encouraging although different eligibility criteria and parameters of treatment, short followup, and absence of patient-reported outcomes make these results hard to interpret. Laser Ablation Interstitial laser thermal focal therapy experience is at the beginning, and clinical reports are scarce: Photodynamic Therapy Photodynamic therapy shows promise in delivering focal treatment of both primary and postradiotherapy prostate cancer.
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Research is ongoing to evaluate mechanism of action of photodynamic energy delivery, development of newer vascular-acting photosensitizers, and potential advantages and disadvantages in focal therapy [ 91 ]. Conclusion Organ-sparing focal therapy may fill the gap between an active surveillance strategy and whole-gland treatment providing a reasonable balance between cancer control and QoL issues in the future [ 92 ].
Focal therapy is still in its infancy. Currently, we do have the optimal basic technology and experience to carry out focal therapy. Candidates for enrollment in trials of focal therapy for localized prostate cancer should meet low-risk criteria based on clinical biopsy and imaging data [ 79 ]; with inappropriate patient selection, the potential for missing curative opportunities exists.
The important next steps should be to use an evidence-based approach to study the selection of ideal candidates and subsequently define successful oncologic outcomes of focal therapy. Definitions of success or failure and triggers for re-treatment have not been established.
Early results with cryotherapy and HIFU appear encouraging, even if to date experience is limited and followup is immature. Feasibility studies for focal therapy of the prostate are underway [ 93 ]. Attempting to set and meet guidelines for oncologic efficacy is a challenge we must embrace to safely deliver this revolutionary approach to treating men with prostate cancer.
Cancer Journal for Clinicians. Quinn M, Babb P. Patterns and trends in prostate cancer incidence, survival, prevalence and mortality. Mortality results from a randomized prostate-cancer screening trial. The New England Journal of Medicine.
Screening and prostate-cancer mortality in a randomized european study. Expectant management of prostate cancer with curative intent: Active surveillance with selective delayed intervention for favorable risk prostate cancer. Prospective evaluation with standardised criteria for postoperative complications after robotic-assisted laparoscopic radical prostatectomy.
Quality-of-life impact of primary treatments for localized prostate cancer in patients without hormonal treatment. Journal of Clinical Oncology. Fifteen-year results of breast-conserving surgery and definitive irradiation for Stage I and II breast carcinoma: Focal therapy for prostate cancer: Evaluation of combined oncological and functional outcomes after radical prostatectomy: Predictability and significance of multifocal prostate cancer in the radical prostatectomy specimen.
Predicting unilateral prostate cancer based on biopsy features: Analysis of laterality and percentage of tumor involvement in prostatectomized specimens for selection of unilateral focal cryotherapy. Technology in Cancer Research and Treatment. Preoperative prediction of multifocal prostate cancer and application of focal therapy: Pathologic stage T2a and T2b prostate cancer in the recent prostate-specific antigen era: Prognostic factors for multifocal prostate cancer in radical prostatectomy specimens: Copy number analysis indicates monoclonal origin of lethal metastatic prostate cancer.
The index lesion and the origin of prostate cancer.