Active Surveillance or Early Focal Therapy? Why the Balance is Shifting Toward Treatment

Clare Delmar:

Hello and welcome to The Focal Therapy Clinic. My name is Clare Delmar. And in this audio series, I’m going to introduce you to some issues facing men diagnosed with prostate cancer that are little known, less understood and almost never talked about.

Earlier this year, prostate cancer was acknowledged as the most commonly diagnosed cancer in the UK. And with this sombre fact comes a multitude of challenges and opportunities. In the fourth of our series, I’m speaking with Alan Doherty, one of the UK’s most renowned prostate cancer specialists and clinical director at the Birmingham Prostate Clinic. Alan has completed one of the largest caseloads of prostatectomies in the UK, undertaking more than 3000 operations. He’s recognised for his expertise in nerve-sparing techniques, reducing the risk of erectile dysfunction and incontinence from prostate cancer surgery, and has published extensive results from his nerve-sparing procedures. Recently, he was voted one of the UK’s top ten prostate cancer specialists in a national poll of consultant urologists published in The Daily Mail. Alan, thanks for joining me.

Alan Doherty:

Hi, Clare.

Clare Delmar:

Wonderful to have you on our audio series. I’m going to dive right in with a little bit of irony. I mean, having just described you as a leader and innovator in radical prostatectomies and other so-called invasive procedures, it’s kind of amusing that I’ve asked you to chat with me today about non-invasive procedures like focal therapy and active surveillance. So, can you tell me how you came to embrace focal therapy into the treatments that you offer your patients?

Embracing focal therapy treatment

Alan Doherty:

Well, it’s a really good question. Good point. I think prostate cancer has such a multitude of different pathways, and patients differ in how they value various outcomes. And it’s not for me as a clinician to just offer one form of treatment, it’s for me to offer a range of treatments which will be appropriate to the patient and their problem. So it would seem wrong to me to just be a specialist in one thing. And I think focal therapies have some advantages but also some disadvantages.

Clare Delmar:

And why has focal therapy in your practice become more popular? If I could use that word but do correct me if that’s not the right word.

Alan Doherty:

I think it’s because focal therapies, particularly HIFU, which stands for high-intensity focused ultrasound is evolving, and we are getting a better understanding of how it works and how we can deliver it and the benefits and the risks involved. So my patients are now able to perhaps understand what the advantages and limitations are a bit better. I mean, I have been doing HIFU for well, gosh, must be seven or eight years that we’ve been I’ve been involved in HIFU.

I think the treatment was offered to perhaps too broad a spectrum of people. It was before the day of MRI scanning, and we can now perhaps better identify where the cancer is. And we used to treat the whole gland. And I think the disadvantage of that was that it did actually cause quite a few problems. So the early use of HIFU was perhaps not quite as good as we seem to have it now. So my enthusiasm has increased as we’ve got better understanding of it.

Clare Delmar:

So, better imaging has clearly led to better diagnostics. And we can now see where prostate cancer lesions are and even measure how aggressive they are. Is that correct?

Improving diagnostic imaging

Alan Doherty:

Well, I think that is absolutely right. And I think the people who are enthusiasts of focal therapy do put a lot of value on the MRI scan. Of course, it’s going to be a good MRI scan, and there are various levels of quality to an MRI scan. They assume that the machine is the machine and the answer is the answer.

I think a really high-quality MRI scan where you can identify the higher-grade cancer does open up this whole chapter of focal therapy to allow you to pinpoint destruction of the cancer and yet not causing a lot of collateral damage, which is what essentially gives the side effects to most treatments.

Clare Delmar:

So, as well as opening up for focal therapy it, the better the MRI, the better we can see this cancer. It also opens up opportunities for active surveillance. Does that mean now that it’s a real option for some men and that we can literally watch them or surveil them, as the term suggests, regularly and closely?

Alan Doherty:

Well, that’s very true. And yet you can also argue that if you have a treatment such as HIFU with very little co-morbidity, then why just watch the cancer go from a situation where it’s not particularly dangerous to one where it is dangerous when you could alter the natural history and at worst delay the progression or at best cure them? And I think people forget with active surveillance, the monitoring does involve quite a lot of… the reasons it is called active surveillance because it is an active process.

You have regular PSA blood tests, which of course can be stressful if the PSA is going up. You have numerous MRI scans which can be expensive and then sometimes you need repeat biopsies and so there is a strong argument that, you know, instead of putting people on active surveillance, well, you should consider treating the abnormal area. I think if the MRI scan picks up an abnormality. You think, well, why not treat that abnormality?

I can see why, if the treatments available are potentially going to make your life miserable, that you might want to just monitor it. But if the treatments don’t do that, then, you know, why not have it treated?

Clare Delmar:

We often find that patients come to us who are on active surveillance, and it kind of comes to them a bit late in the game that the active, as you suggest, this is on their part as well as the clinician.

Alan Doherty:

Well, I think people forget with active surveillance that, you know, what are we waiting for? Are we waiting for it to go from a curable to an incurable cancer? People think that we have this amazing ability to know when that’s gonna happen. We don’t. It’s a probabilities game.

You go from a very high likelihood of being cured to a lower probability of being cured. The question is, what percentage are you comfortable with? Are you comfortable with a 90 per cent chance of being cured? Are you comfortable with a 70 per cent?

So, in other words, the higher the PSA goes, the lower the likelihood of you being cured is. So it’s all very well and good being monitored, but you have to understand the consequences of the monitoring. And the fact that it isn’t quite as scientific as you might think – this is very much looking at a window of curability, which is closing the longer you monitor it for. Now, that doesn’t mean that you necessarily will die of prostate cancer if you missed the window of cure, because we can control cancers very well with hormone treatments, radiotherapy, chemotherapy and lots of new treatments that are coming out.

So, you know, when people see you’re not going to die of prostate cancer if you go on to active surveillance. That’s probably true. But you may end up having lifelong treatments, which had you gone for a curative treatment, that wouldn’t be the case.

Clare Delmar:

Yeah. That’s interesting. So while you have this technology to spy literally on the cancer. There’s a lot of activity and other options that needs to be considered. Some people often have told us, too, that one of the challenges they face under active surveillance are more behavioural or psychological. Can you comment on that?

The anxiety of active surveillance vs focal therapy

Alan Doherty:

Oh, yes, very much so. I think the average time people can stomach active surveillance is about two years.

Clare Delmar:

Have there been studies on that, or is that your observation?

Alan Doherty:

Observation, but also from studies, so if you look at studies like the ProtecT trial, it’s within the first two years that you tend to get that change. It’s around two years where people just seem to have had enough of it and they say, well, fair enough, let’s have treatment. So it’s I suppose it’s more observational than anything else.

But certainly, in the studies I’ve been involved with, I’m not surprised seeing patients at about two years saying enough’s enough, the PSA has gone up, and it’s got into my head. PSAs tend to fluctuate up and down. And so, you know, sometimes people get sort of relief that the PSA has gone down a bit or was stable.

But if the PSA doesn’t and it’s sort of slowly climbing up, which it tends to do over a two year period, you know, people just sort of say enough’s enough, let’s have treatment.

Clare Delmar:

So, like, let’s just assume this two year period is an average of sorts. Would you say that there is a risk if you wait two years that, you know, the curative treatment that you mentioned might have to be more invasive? Is that something to warn someone about?

Alan Doherty:

Yeah, it’s not only more invasive but also more prolonged in that you’ve missed the opportunity to go for a curative intervention, and instead, you’re getting a sort of controlling intervention. And, of course, we’ve never come across a cancer ever that’s gone away. And it tends to grow slowly.

And the question is, what’s the speed of progression? And nobody knows that for sure. So every now and then, you’re going to have someone who you thought was going to progress slowly, who progresses more aggressively. And that’s where this window of curability starts to close in terms of percentage likelihood of cure.

Clare Delmar:

So you will suggest to patients that focal therapy is a real alternative for active surveillance?

Alan Doherty:

That’s very much my philosophy, which is if you are prepared to monitor it, then, you know, why wouldn’t you want to go for a treatment that could potentially cure you? Almost certainly will delay the progression of it in that if you kill the majority of it, that’s surely going to be helpful.

Clare Delmar:

And do most of your patients agree with that and take that action?

Alan Doherty:

Most of my patients will sort of get that. There are patients who worry about HIFU, partly because it’s not available widespread. And I think as I mentioned at the beginning when it was used probably incorrectly and in too widespread a fashion, it’s made some people wary.

Certainly, other urologists are a little bit wary of it, and I think patients pick up on that. But I think the tide’s changed. I think because of better imaging, as we said at the beginning, HIFU is going to become a bigger player.

Clare Delmar:

So a slight shift from this, but picking up on this whole idea of having to wait. And you know that the psychological and the clinical aspects of that. How are the delays in the diagnostics and treatment for prostate cancer based on Covid-19 in the last few months? How have those delays impacted your practice and your patients’ treatment?

COVID-19 pandemic delays and its consequences

Alan Doherty:

I think there are patients who were halfway along the diagnostic pathway and it all suddenly came to an end. And in that group, you know, I’ve seen patients who really got quite stressed by it because they didn’t get to the stage where we were able to tell them whether this was an aggressive tumour or not or if they did have an MRI scan and it suggested that it was aggressive, they weren’t able to go and have the biopsies to confirm it. So I think what’s interesting is that a lot of patients won’t have had their PSA blood test.

Now, as you know, PSA is the way that we assess the risk of having prostate cancer. It’s a prostate health check, in a way. And the charities that used to do the PSA measurements, the GPs that would have done it as part of the sort of symptoms assessment. And then there’s the BUPA health checks, the health assessments. They haven’t been done. So there are probably people who just don’t even know they’ve got a high PSA who will no doubt be found in the next few months or so. And I suspect that’s quite a big cohort of people.

So we’ve definitely had a big effect, the Covid. And it’s ongoing because the NHS is catching up now. And I think that the whole process can be expensive for a self-funder if you include MRI scanning and biopsies and the like.

Clare Delmar:

So are you optimistic that the NHS will be able to pick up some of this? Or, how would you advise somebody listening to this who has an early-stage diagnosis and has been delayed?

Alan Doherty:

First of all, I think these sorts of interviews are really helpful to patients to sort of understand the issues. And I think you’ve got to understand the issues. And you can be very clear on what questions you’re trying to ask when when you have a PSA blood test. You know, what is it you want to know? And then we have an MRI scan. What how are you going to act on it? And then when you have a biopsy, what treatment are you likely to have or not have? I mean if you really think about it, the active surveillance group shouldn’t really exist because, you know, if you have an MRI scan that is normal, you know, why we biopsying them?

And if a patient is found to have a cancer and then you say we’ll leave it alone, well again, that doesn’t make sense, because before you biopsy them, you should say to them, what are you going to do if I find a cancer? And you say the likelihood is if I finally cancer with a normal MRI scan is that it’s not gonna be an aggressive one. So why am I biopsying you?

So I think patients really need to be first of all clear on what they’re asking and what they’re going to find. But if they decide that they do want to proceed.

Am I optimistic that the NHS will catch up? Well, I have found in my experience that the NHS will not tend to have specialists who do nothing else but report MRI scans. So the quality of their MRI is variable. It’s very hard to put value on it. And then when they do the biopsies, they don’t necessarily do them in a way that I would say minimises false negatives.

I think they’re more obsessed about doing it in a way that is quick, easy. And for example, there are different ways and taking biopsies, you can do it through perineum but through one or two holes rather than through 20 holes. So, I think maybe, perhaps nobody’s looking at the efficacy of the interventions and what they are trying to find.

So, yes, I think patients need to ask that question to the urologist saying, how do you know the MRI scan’s up to scratch? Will it serve my purpose?

Clare Delmar:

It’s almost like a supply chain, you know, audit.

Alan Doherty:

Yeah.

Clare Delmar:

There are these key stages, as you say, that have a massive impact on the sequential stage.

Alan Doherty:

Absolutely right. People often get to the end of the pathway without even thinking about what they’re gonna do with the information or how valid the information is.

Clare Delmar:

Alan, I really want to thank you for your insights. I think this has been incredibly helpful, certainly for me, but especially for our patients who are listening.

If you’d like a consultation with Alan Doherty, please contact us at The Focal Therapy Clinic.

And if you’d like to learn more about focal therapy and engage with patients who have chosen to undergo focal therapy instead of active surveillance, please visit our website at www.thefocaltherapyclinic.co.uk. And from me, Clare Delmar, see you next time.