Refers to article:
Morbidity of Focal Therapy in the Treatment of Localized Prostate Cancer
Accepted 27 November 2012
April 2013 (Vol. 63, Issue 4, pages 618 - 622)
Refers to article:
Focal Therapy in the Treatment of Localised Prostate Cancer: Primum Non Nocere
April 2013 (Vol. 63, Issue 4, pages 623 - 624)
We appreciate the opportunity to respond to Challacombe and Murphy's commentary  concerning our study evaluating the morbidity of focal therapy in the treatment of localized prostate cancer (PCa) by one of the few groups that have substantial expertise with a tissue-preserving approach in the management of men . Focal therapy for PCa should be based on three concepts: (1) a reliable determination of cancer location within the prostate, (2) a convenient type of energy for providing safe and reliable intervention on the diseased portions of the organ, and (3) a follow-up approach allowing physicians to objectively decide on further actions to control the disease. The mentioned concepts have not yet been completely defined, and a great part of today's research is focused on the improvement of these elements. That said, we believe that focal therapy is a logical intermediate option to target only the area where the positive biopsies are located, aiming at obtaining solid cancer control while maintaining quality of life.
We agree with Challacombe and Murphy's comments regarding active surveillance (AS) and that many of our focal therapy patients might be suitable for enrollment in an AS program . However, there are still many unresolved issues related to AS. First, eligibility criteria have yet to be defined precisely: In fact, there is wide variation (4–82%) in eligibility criteria among different leading AS groups . Second, the follow-up biopsy strategy for surveillance varies among the major AS series. Prostate Cancer Research International: Active Surveillance (PRIAS) recommends prostate biopsy at 1 yr, 4 yr, and 7 yr, whereas patients in the Johns Hopkins series undergo yearly biopsies. With a median follow-up of 54 mo after diagnostic biopsy, University of California, San Francisco performs follow-up biopsies at 12- to 24-mo intervals . Third, <8% of men presenting with low-risk PCa opt for such treatment, mainly because of anxiety related to the diagnosis itself, and approximately one-third of the patients who initially elect AS will undergo radical treatment after a median of about 2.5 yr of surveillance anyway  and .
Challacombe and Murphy also debated the “acceptability” of complications in our series. We tried to expose a detailed and thorough report for focal therapy morbidity. Most complications occurred in the beginning of our experience, and our team has acquired specialized expertise to avoid most troublesome complications over time. At this point, one question should be raised: Do the other options offered to patients harboring low-risk PCa feature more “acceptable” morbidity? Toxicity related to radical treatments has been widely debated. In contrast, AS protocols involve repeated prostate biopsies over time and therefore raise the question of whether a large number of prostate biopsies might lead to side effects. This is especially concerning in light of growing evidence showing increasing hospitalizations for serious infectious complications after prostate biopsy . In a previous paper, Challacombe et al. stated that many prostate biopsy complications “can be potentially serious” and “result in significant morbidity and at worst death”. Hematospermia, hematuria, urinary retention, and rectal bleeding are commonly seen after prostate biopsy. Loeb et al. even reported two admissions to the intensive care unit after prostate biopsy .
Some reports of erectile function after prostate biopsies have stated acute or long-term erectile dysfunction after biopsies. Van den Bergh et al. reported on 129 men enrolled in the PRIAS study. Questionnaires were completed at 6 mo and 12–18 mo after diagnosis. They noted that 44–51% of men who were sexually active had problems obtaining or maintaining an erection .
In a cross-sectional study, Fujita et al. evaluated erectile function in 152 men under AS. The reported decrease on the Sexual Health Inventory for Men score was 6
Starting from the available knowledge and technology, focal therapy is continuously developing from its infancy, and a more mature era is awaiting. As we have previously said, focal therapy may represent a viable option for low-risk PCa, and, given our results, we think that this kind of treatment could potentially be extended to intermediate-risk patients . Technological development will be essential in the evolution of this approach, from imaging to tissue treatment; we must work with technology scientists to bring patients the tools for highly precise diagnosis, effective tissue treatment, and reliable oncologic follow-up.
Conflicts of interest
The authors have nothing to disclose.
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© 2012 European Association of Urology, Published by Elsevier B.V.