Marc Laniado, Consultant Urologist with The Focal Therapy Clinic and a leading innovator in imaging led diagnostics and targeted treatments for prostate cancer, joins On Focus in this episode.
Marc has been a vocal advocate for the rights of patients to be informed about their treatment choices from his base at Frimley Health, where he is prostate cancer lead at Wexham Park Hospital. He’s also a dedicated practitioner in optimising treatment choices for patients, and has built a reputation in identifying and delivering the right treatment for each patient, based on precise diagnostics and comprehensive discussion about lifestyle, aspirations and relationships. He’s here today to speak about how some recent media attention on Active Surveillance might be interpreted, and what men diagnosed with localised prostate need to know about their treatment choices.
Clare Delmar
Hello and welcome to On Focus, brought to you by the Focal Therapy Clinic, where we connect you with issues facing men diagnosed with prostate cancer that are little known, less understood, often avoided or even ignored. Prostate cancer is the most commonly diagnosed cancer amongst men in the UK and with this sombre fact comes a multitude of challenges and opportunities. I’m Clare Delmar. Joining me today is Marc Laniado, consultant urologist with the Focal Therapy Clinic and a leading innovator in imaging led diagnostics and targeted treatments for prostate cancer. Marc has been a vocal advocate for the rights of patients to be informed about their treatment choices from his base at Frimley Health, where he is a prostate cancer lead at Wexham Park Hospital. He’s also a dedicated practitioner in optimising treatment choices for patients and has built a reputation in identifying and delivering the right treatment for each patient based on precise diagnostics and comprehensive discussion about lifestyle, aspirations and relationships. He’s here today to speak with me about how some recent media attention on active surveillance might be interpreted and what men diagnosed with localised prostate cancer need to know about their treatment choices. Marc, thank you so much for joining me today. I’m really looking forward to digging into this really, really important issue.
Marc Laniado
Sure, it’s a pleasure to be here. It’s always lovely to talk to you and it’s one of my favourite topics, so it’s fantastic for me too.
Clare Delmar
Okay, good. So let’s get started. I mean, I referred in my intro that there’s been recent media attention based on this recent study which compared 15 year outcomes for men with localised prostate cancer who were undergoing as well as other treatments, including radiotherapy and radical prostatectomy, and it concludes that outcomes are similar and suggests that men might be best advised – I’m putting this in inverted commas – to go on active surveillance in the first instance. So what do you think of this study and what are its implications for men with localised disease?
Marc Laniado
It’s a huge study and it’s amazing that it was ever started and completed because it’s so difficult to get men to agree to be randomised into treatment. And it began in about 1999 and ended in around 2009 in terms of recruiting over 1500 patients from the UK and it was men in the relevant age group, so it was men aged around 50 to 70 years. And these are men diagnosed in the area a bit before we had precision diagnostics. So they diagnosed based on elevated PSA and digital rectal examination – that is what the prostate feels like when a urologist examined the prostate and then they went on to have biopsies. And then the men were allocated into various risk groups and randomised to either active monitoring as opposed to active surveillance, radiotherapy and surgery. And as I say, it’s amazing that it managed to get people to agree to this. And the overwhelming, I guess, overwhelming result is that 97% of men who entered this study were alive at 15 years. So it didn’t matter which treatment to which they were allocated at the beginning. It didn’t matter if they were allocated to surveillance, surgery or radiotherapy, 97% of men were still alive. And around a quarter of the men who initially were on monitoring had still not had any invasive treatment by 15 years. So that’s a very important result to note that pretty much it doesn’t seem to matter too much what treatment you allocated are at the beginning in terms of the eventual outcome. And then the other important result to note is that patients from all the three groups that had relatively similar quality of life in terms of general mental physical health but the negative effects of surgery or radiotherapy, both of them on the urinary, bowel and sexual function were also still significant or bothersome for much longer periods than people thought. So initially people thought it would be a few months or maybe a few years, but it seems to go on for quite a considerable period of time. So overall, it’s a great study. It informs us a lot about how we can advise men and we can certainly tell men that they don’t have to rush into any decisions. But it has a massive implication potentially on how people choose how they’re going to manage their prostate cancer beyond the options that were available back in the time before or during the time of this study.
Clare Delmar
Okay, so that really leads me to my next question, which is why focal therapy wasn’t considered in the study and that’s because, as you said earlier, it literally wasn’t around back in 1999 when the study began, is that correct?
Marc Laniado
Yes. I think there was a few cases, maybe in America, where people had tried some ultrasound technologies to ablate cancer very, very early on, perhaps in the early 1990s, but really focal therapy didn’t get talked about until the 2000s. In the late 2000s, people started, if you like, trying it out, and then it became more commonly looked at in late 2010 and going up to 2020, we’ve seen a much greater increase in number of people being offered it. But at the time of this study, focal therapy was just not available. So it wasn’t an option for people to be randomised into that treatment on.
Clare Delmar
Okay, that’s actually an important point, but I just want to circle back to the cohort that were on AS, active surveillance. Now, you said earlier that was it a quarter, you said that actually after 15 years had had no further treatment, is that correct?
Marc Laniado
Yes.
Clare Delmar
But that means that three quarters did.
Marc Laniado
Yes, so three quarters did have treatment. And although the survival was the same in the three groups, there are certain things to consider. So, for example, though, three quarters of the people of men who initially allocated to treatment actually did have treatments eventually. So it’s not like no treatment is going to be the same as actually transitioning to treatment. But also, if you look at the people initially managed by active monitoring, there was a higher chance of the disease having spread. So there are more men who had metastases and more men had locally advanced disease on people initially allocated to active monitoring. So although the actual survival was equal, the number of people with advanced disease or more progressed disease was certainly greater in the active monitoring arm. And the other important, I think, consideration, is that there was some degree of crossover. So, for example, some of the people who were allocated to treatment actually never received treatment, and some of the people who were allocated to active monitoring actually decided to have treatment anyway before they had transitioned. So because of the, if you like, some of the mixing up of the arms, it does render some of the results perhaps less reliable than one would like. But regardless, it doesn’t seem that there’s any major difference in terms of overall survival at 15 years. So when you think about treatment, you really need to be thinking about potentially other things. You need to be thinking potentially about the side effects as well – a lot, in fact, because survival is not going to be hugely different between the three arms, then the side effects obviously will be something you must consider much more as one of the things… One of the decision makers for you, perhaps.
Clare Delmar
And that really wasn’t something that was focused on in the study, given given that,
Marc Laniado
No
Clare Delmar
Okay, that’s important, isn’t it? But if I could again just focus on the men who were undergoing active surveillance, it appears to me that they were doing so under sort of a set of uniform conditions or protocols, and maybe they were optimal. Can you explain what those are and how frequently a man choosing active surveillance today in the UK might find those.
Marc Laniado
In the study protocol it’s more like, it was called active monitoring, and nowadays it’s usually called active surveillance. So in the study, active monitoring was really monitoring PSA tests and digital examinations and possibly repeat biopsies, and it was nowhere near as frequent or as intensive as today in active surveillance. So proper active surveillance performed very well is regular PSA tests, regular MRI scans, well performed MRI scans and well performed prostate biopsies. And the reason the testing programme for active surveillance now is much more, if you like, detailed, is because we want to try and weed out the patients who actually have significant disease that is likely to progress at some point in the future, and also not to treat those people with truly low risk disease. Whereas in the ProtecT trial, if you like, the diagnostic rigour was not as good. And so a lot of the people who were thought to have low risk disease actually had intermediate risk disease. So there was some confounding, if you like, of the groups. And today we’re much better at picking out people who have significant disease. We pick out people with early significant disease much better. And one of the observations in the ProtecT trial was that they actually recognised that there are a group of men who have aggressive disease who are not currently diagnosed well enough through the regimens at that time. So the way that people were diagnosed, that was not sufficiently robust enough to pick up those people who had significant disease or to offer them treatment which was right for them, bearing in mind what was available at that point.
Clare Delmar
Okay, so it’s also, in a lot of ways, this study really demonstrates some of the incredible advances during that period, both in imaging and in precision treatments based on that imaging.
Marc Laniado
Yeah, absolutely. The problem with way ProtecT and patients at that time were managed is that it really was not a very good way of diagnosing patients. In a sense, it wasn’t a good way of stratifying patients into the risk group. And so that’s why I feel like three quarters of the men ended up having treatment when they were on active monitoring. If they’d been adequately sampled, a far fewer, smaller portrait of men would have progressed to treatment.
Clare Delmar
Okay.
Marc Laniado
So we would be in a much better position. They would be in a better position.
Clare Delmar
So, given what you know now, what would you advise men diagnosed with localised disease when they’re considering active surveillance? And is there some kind of toolkit of questions to guide them in these decisions?
Marc Laniado
NICE has given guidance on how people should be monitored and diagnosed in men who are at risk of prostate cancer. The problem is the way it’s delivered is not consistent and probably it’s not quite intense enough in terms of the NICE guidance. Really what you want to know is, when you’re diagnosed with prostate cancer, is, do I have a significant prostate cancer that can change my life in some shape or form in the future? And if I do, where is it located? Is it located in one spot or is it located in multiple areas of my prostate? So you need to know that information. Also, you need to know, can I tell if I’m like to get more cancers in other parts of the prostate at some point in the future as well? That’s another piece of information. That’s a bit more difficult to get at the moment. However, if you have a high quality MRI scan, that is a scan on an MRI scanner which has been particularly tuned for prostates, and you also include it with contrast, so ideally it should be with contrast that many scans in this country are now performed without contrast because of speed reasons and cost reasons. If you have the contrast and you have the diffusion weighted imaging, which is the other component of the study, you can tell much more reliability where cancer is located and where cancer is not located. And if you then have a biopsy in which the needle is directed into the heart of abnormality on the MRI scan, you can tell the nature of the cancer that’s there. And the problem is that in much of the country, that’s not the case. We see in the focal therapy clinic, we get many, many referrals from all over the UK and elsewhere for men who’ve been diagnosed with prostate cancer. But often, unfortunately, the MRI scans are suboptimal. The biopsy strategies are less than adequate. So to give an example, had a sixty year old man recently had a multiparametric MRI on a scanner that wasn’t tuned for prostates. And the imaging was reported by a radiologist who didn’t specialise in prostate cancer. He was told he had prostate cancer and a biopsy was done under local anaesthetic, but without any intentional… Well, they said they were trying to target, but it doesn’t seem the targeting was well performed. But the area which was said to be abnormal, unfortunately was not abnormal. But there was a more significant area in the prostate that was abnormal that hadn’t been reported on the MRI scan. And possibly because the scanner wasn’t very good or possibly the radiologist wasn’t quite as experienced as some of the others. But the problem is that’s what happens commonly in the country, and so we see patients like that and then it’s very difficult then to know for certain whether they’ll be suitable for active surveillance for radical prostatectomy or indeed for focal therapy. It’s really important to have a high quality MRI, a radiologist who’s experienced reporting the MRI scans and then preferably biopsies which are targeted at the abnormality using techniques that enable you to do that more easily. And that tends to be more, unfortunately, under a general anaesthetic because it’s easier to biopsy under general anaesthetic, but also using software. If you use software to target your biopsies, you’re much more like to hit the abnormality than if you’re trying to develop computer software to do it. Certainly our personal experience and experiencing what’s around the country, although in some specialist places that may not be true.
Clare Delmar
Well, I mean, that actually begs the question, you used the word earlier about lack of consistency. Is there a guide to where the set of protocols, if I could describe it that way that you’ve just described, is available to patients. If a patient now knows, okay, I need to have good imaging, I need to have a good biopsy, I can’t make a decision about active surveillance or indeed any other treatment unless I know I have that. That seems to be that’s the root of successful active surveillance. How would you know if your provider, your hospital was actually offering you that quality of diagnosis?
Marc Laniado
So from an individual point of view, you can certainly check the NICE guidance. It’s just you can Google NICE guidance for active surveillance and you’ll find it. And the European Association of Urology also has guidance which, again, you can find by Google or using Chat, GPT or Google Bard, they’ll all come up with it and you can see if what you’re going through is actually matching what’s recommended. But I think really the guidance on perhaps the quality of the MRI scans and how sure you can be that they’re reliable isn’t there. It is in journals, but it’s not broadly distributed and it doesn’t seem that there is widespread checking of the protocols and scanners and the people reporting and the quality of the reporting. It’s just not done really in this country, not at the moment anyway. Maybe at some point in the future. So for breast cancer, it’s much more rigorous. They have a much more detailed and almost examination based way of checking that people can report scans correctly. And we don’t have that for prostate MRIs at the moment and nor do we have that for people taking biopsies either. So we’re probably a little bit behind in terms of that compared to breast cancer.
Clare Delmar
Is that a thing you would recommend?
Marc Laniado
Unequivocally because we see in the focal therapy clinic so much variability in the quality of the scans and the quality of the reports and the quality of the biopsies. For patients trying to decide if focal therapy or surgery or radiotherapy is best for them, it’s very difficult with the information they have because as I say, often they just don’t have it. It hasn’t been done. And it’s okay if everyone you’re going to see is going to get surgery, radiotherapy or monitoring. In a sense it’s okay because, okay, if you’re going to have those treatments, all you need to know really is cancer present, have some idea of the severity of the cancer and then either you just remove it, you irradiate it or you watch it. But if you’re trying to choose more nuanced therapies at an earlier point. So if you’re trying to say, okay, I’ve got a diagnosis of prostate cancer, I’m not quite happy about watching this thing, I don’t really want to play Russian roulette with the tumour, and I don’t quite like the idea of having potentially significant side effects, albeit that the techniques have got better over time. So if you’re in that area that we want to have a more nuanced, more personalised or individualised treatment, you really need to have properly conducted MRI scans, biopsies, and then focal therapy, which is probably, in my opinion, certainly the best way to go for early cancers which are localised to the prostate becomes an option if you have the high quality scans, the high quality biopsies. But if you don’t, it’s really difficult then.
Clare Delmar
Well, I think we’ll leave it there. But I mean, you’ve answered a lot of really, I think, important questions but also raised a number of others. So I think this calls for a follow up at some point. But I want to thank you so much for your time, Marc, and a lot of your insights are extremely valuable coming from some really deep experience. And thanks again for joining me.
Marc Laniado
Thank you. Thanks, Clare. It’s always good to talk to you.
Clare Delmar
A transcript of this interview is available on our website, along with further information on diagnostics and treatment for prostate cancer, as well as additional interviews and stories about living with prostate cancer, please visit www.thefocaltherapyclinic.co.uk and follow us on Twitter and Facebook at The Focal therapy clinic. Thanks for listening and from me, Clare Delmar, see you next time.
