Personalizing prostate cancer care

Choosing the right prostate cancer treatment is more than just a medical decision—it is a personal one. It involves careful evaluation of treatment effectiveness, potential side effects, and overall quality of life and is ideally shaped by the patient’s unique circumstances and personal preferences.

Traditionally, localized prostate cancer has been treated by targeting the entire gland, either through radical prostatectomy, which surgically removes the prostate, or through radiation therapy. Both approaches are highly effective in eradicating cancer for men whose cancer has not spread, but they can also result in permanent side effects that may adversely impact men’s quality of life.

Surgery comes with significant recovery time and potential side effects, including urinary incontinence and erectile dysfunction. Although radiation therapy has a lower risk of urinary incontinence compared to surgery, it may still lead to erectile dysfunction and other potential side effects, like rectal and bladder irritation, which may cause diarrhea, rectal bleeding, fecal incontinence, increased urinary frequency, and blood in the urine. 

Advanced imaging

Advancements in MRI imaging technology have changed the landscape of intermediate-risk prostate therapies by enabling more targeted interventions. Until recently, imaging methods lacked the precision needed to correctly identify tumor margins, leaving providers with only one choice— to treat the entire prostate. With the rise of MRI-targeted biopsies, urologists can pinpoint potentially cancerous areas to biopsy, allowing for more targeted treatment.

Focal therapy, or partial gland ablation, utilizes energy sources to generate temperatures that destroy tumors while preserving the healthy surrounding tissue. This method is widely used for treating other cancers, such as breast and kidney.

“By targeting the tumor and avoiding nearby structures, such as nerves that control erections and the urinary sphincter, focal therapy can reduce side effects for patients,” explains urologist Geoffrey A. Sonn , MD, a member of the Stanford Cancer Institute and professor of urology at Stanford University.

While not suitable for all prostate cancers, focal therapy can be a good option for men with localized disease. Men with low-grade cancers usually benefit from active surveillance, which involves closely monitoring the cancer and only treating it if it shows signs of growth. Conversely, men with high-grade, bulky tumors typically require surgery or radiation with hormone treatment.

“There are a lot of men in the middle who may benefit from an approach that’s more than just observation but doesn’t require the most aggressive treatments,” notes Sonn.

Ultrasound procedures

High-intensity focused ultrasound (HIFU) is an outpatient procedure performed under anesthesia in an operating room. During HIFU, a probe is inserted through the anus into the rectum, delivering ultrasound energy to destroy cancer cells within a targeted area of the prostate identified through imaging.

Similarly, transurethral ultrasound ablation (TULSA) uses ultrasound to kill cancer with heat. TULSA is performed under anesthesia inside an MRI scanner using MRI to plan and guide the treatment. During the procedure, a probe is inserted through the penis into the bladder, delivering ultrasound energy from within the urethra to treat the prostate from the inside out 

HIFU and TULSA are complementary technologies. HIFU is most effective for tumors located toward the back of the prostate, while TULSA is ideally suited to target tumors toward the front. TULSA is versatile; it can treat the entire prostate or specific areas based on tumor location and patient preference. Both HIFU and TULSA are noninvasive outpatient procedures with quick recovery times, allowing patients to resume normal activities almost immediately. Both procedures carry a lower risk of sexual dysfunction and urinary incontinence compared to whole gland treatments, with none of the rectal side effects observed with radiation therapy. Another advantage of these ablative technologies is that they do not limit future treatment options. If a man experiences a recurrence, he can undergo another ultrasound treatment session or consider more aggressive treatments such as prostatectomy or external beam radiation.

"Many men appreciate that even if the treatment doesn't work and cancer recurs, they still have backup options available," relays Sonn.

Evaluating image-guided therapy 

Sonn is working toward improving prostate cancer care by helping to validate new treatment options and integrating ablative therapy into clinical practice in an effort to provide more treatment choices for men diagnosed with prostate cancer.

In a multicenter, single-arm trial, Sonn and others found real-time MRI-guided focused ultrasound therapy is a safe and effective treatment for grade group 2 and 3 prostate cancer, which range from intermediate to high severity. Nearly 90% of men were cancer-free at the 24-month biopsy follow-up, with minimal side effects reported. MRI thermometry monitors tissue temperature during treatment in real-time to ensure that the entire targeted area reaches the necessary heat to destroy the cancerous tissue.

While MRI thermometry is used for prostate cancer ablation under MRI guidance, tissue change monitoring (TCM) is the only quantitative feedback available for ultrasound-guided HIFU procedures. Although the TCM feature is included in HIFU machines, its reliability for monitoring cancer treatment had not been fully validated. In a clinical study, Sonn and his former resident, Yash K. , MD, discovered a strong correlation between intraoperative TCM scores and ablation success.

Sonn is currently participating in a multi-site randomized controlled trial called CAPTAIN, which compares TULSA to radical prostatectomy surgery in men with intermediate-risk prostate cancer. The primary outcomes compare both treatments' side effects and efficacy by measuring the frequency of subsequent treatments required after initial therapy. This trial is significant due to its randomized design, which is considered the gold standard for evaluating medical treatments.

"Trials like this are crucial for introducing new technologies, such as TULSA, into clinical guidelines as standard treatments for prostate cancer. This process is essential for advancing the field of ablation and securing insurance reimbursement, ultimately providing more options for men with prostate cancer."

Personalized care

Historically, prostate cancer treatment has used a one-size-fits-all model, whereas men were treated with either prostatectomy or radiation. However, men do not have a one-size-fits-all set of priorities when it comes to their prostate care. For some, aggressively removing the cancer is paramount, even at the cost of experiencing side effects. Others may prioritize preserving their quality of life.

Sonn emphasizes, "Personalized care, which offers options and focuses on the individual patient’s needs, desires, and priorities, represents the future of prostate cancer treatment."

By Sarah Pelta

#ProstateCancer #StanfordCancer #PersonalizedMedicine