So, Dr. Scholz, today I would like to talk about focal therapy. So, can you speak to
who is eligible for focal therapy?
Well, the goal of focal therapy is to preserve—usually—sexual function. A lot of the standard treatments,
now, with radiation are very good at sidestepping rectal and urinary problems, but there's still
a risk of erectile dysfunction. So, if someone has a prostate cancer that's on one side of
the gland and the other side of the gland is clear, then it's reasonable to consider
just treating half the prostate. When I say it's reasonable, of course, that's kind of
a common-sense recommendation but actually, it's pretty much not standard. Historically,
to be safe and make sure that all the cancer is covered either surgery or radiation targets
the whole prostate, but now with better imaging and accurate biopsies and all these sorts
of things, we can be pretty confident that there's no cancer on the other side, and,
of course, the question arises, "why not treat half the gland or less than half the gland
and give men a better chance of not losing their sexual function?" So, it really comes
down to that it has to be on one side of the gland if you're going to talk about doing
focal therapy. So, it being on one side of the gland, that means that it cannot have
metastasized or can't be lymph node involvement. It needs to be localized prostate cancer.
Yeah, the people that have metastatic disease, we're not usually trying to cure them and
so they're usually off the table for these sorts of discussions, but the idea of curable
disease could include men with even high-risk disease if it's a small area. Now, especially,
we have these PSMA/PET scans that can confirm that there's no metastatic disease. So, the
whole field is evolving quickly due to all these new and better technologies—better
imaging technologies—that allow us to use treatments that aren't as vigorous as what
we've required in the past.
So, is this like a new form of treatment? Is this like a newer thought process, or has
this been around for quite some time?
Well, it's becoming more popular. It has been around for a while. The people that were good
at imaging like Dr. Duke Bahn up in Ventura who's an interventional radiologist who has
been doing focal cryotherapy for many years, but it's picked up momentum. Doctors who do
HI-FU, electroporation, they have talked about treating sections of the gland for up to 10
years now, but it has become more and more popular as the imaging has gotten better and
as the awareness that this type of approach is available.
So, we've talked about sexual function. How does it affect urinary function?
Sure, the risk of urinary problems should be even less since they're trying to steer
away from the urinary passage in the prostate, the urethra, but you know, even the standard
treatments with modern radiation are affecting urinary problems at a fairly low level already.
Have you ever seen focal therapy done when there is seminal vesicle invasion?
Yes, occasionally. It's a bit unorthodox because we're worried with seminal vesicle invasion
about the possibility of microscopic metastases and many of these men are on hormone therapy,
but modern prostate care is becoming more and more customized, and on the one hand,
you want to minimize toxicity and shrink the area of treatment to make the treatment more
tolerable, but there may be a little higher risk of relapse so each individual patient
has to have an extensive discussion with their physician in terms of what kind of risks am.
I comfortable with taking. This idea of a one size fits all for everybody is kind of
ridiculous when we've got all this flexibility now.
So, if you do have a case where the tumor's on one side, there is seminal vesicle invasion,
you're going to choose focal therapy, and you see that seminal vesicle invasion, have
you seen doctors put, you know, men on low-dose hormone therapy in case they have concern
for microscopic metastases or is that not a common combination?
Well, with high-risk—that's a high-risk prostate cancer—so it's even more unorthodox
to be thinking about doing focal therapy in men with high-risk disease. That would be
something that some patient would sort of have to stipulate, that they want this type
of treatment because, for the most part when you're dealing with high-risk prostate cancer
you want to do your utmost to cure it.
so, there are multiple types of treatments that you can do focal therapy with. Can you
discuss what you think are kind of the best and others you may have concerns about?
I don't necessarily think that any one type of treatment is better than any type of treatment.
it's much more important to have a doctor who knows how to use that treatment, that
is good with imaging, that has a lot of experience. I mean specifically, we're talking about high-intensity
focused ultrasound, electroporation, cryotherapy, and even radiation can be given to a section
of the prostate. All of these approaches are reasonable. They're all effective at destroying
tumors and the issue, for me, is how good is the doctor behind the treatment? And can
that doctor deliver the kind of accuracy that's necessary with this sort of treatment?
So, the next question I have is, you know, PSMA is rising in its popularity. We're seeing
a lot of clinical trials come in, but does normal focal therapy nowadays just kind of
come in with multiparametric MRI? So they're really using 3T MRI to kind of tell where
those tumors are localized?
Pretty much. These PSMA scans are, as they're being utilized—and this is evolving so quickly,
it's a brand new technology—but typically more for the high-risk patients and those
types of patients are not getting focal therapy as commonly as patients with intermediate-risk
disease. So, yes. I would say the primary imaging modality that has accelerated the
use of focal therapy has been 3T multiparametric MRI and that is, I think, has been the game-changer.
It allows doctors to be pretty confident that there's no cancer on the other side and gives
a clear picture of where the tumor is so that the focal therapist can direct his treatment
right at the tumor.
So, that's something we've talked about a lot on this channel is really about the importance
having an experienced physician who, you know, has done these procedures, so can you give
the audience maybe some questions that they can ask the doctors that they're interviewing—maybe
a medical oncologist or someone in order to see what their experience level is?
This is one of the most difficult areas and, of course, I think there's a real advantage
if you find a physician that has dedicated their whole life to doing one type of a treatment
and is doing that over and over and is a leading doctor. That, I think, is important to seek
out. I think the idea of just going to the hospital and whoever gets assigned to you
is a risky way to choose a doctor. I think patients need to be willing to travel outside
of their city or state and go look for the number one person. This type of treatment
you get a chance at getting it right the first time and if you have someone that's doing
this same thing over and over again, you're much more likely to get a result that's going
to be satisfactory.
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