The Imperial Prostate masterclass on Focal Therapy took place last week at Imperial College – refreshingly for the first time in person since 2019, and returning bigger and better.
The faculty – both resident and visiting – is undeniably a collective of world leaders and pioneers in imaging and focal treatments for prostate cancer.
TFTC Consultant Urologist Raj Nigam presented a session on MR/US fusion biopsies of the prostate, with an emphasis on the critical role that clear, detailed radiological reporting plays in successful precision biopsying. Raj was supported by TFTC radiological consultant Dr Clare Allen in demonstrating how state-of-the-art contouring of a patient’s MR imaging provides the essential roadmap for precision biopsying of the prostate.
The panel discussions and debates covered all the “hot” topics surrounding focal therapy’s position and status in the treatment of prostate cancer, including screening, imaging, and building the evidence base for focal therapy.
It was clear that while much has advanced since the last meeting, there is still much that is unknown and untested.
What the presenters made clear are the things we absolutely do know
- Prostate cancer isn’t going away and is increasing worldwide
- Screening for prostate cancer continues to be widely debated with new techniques and new bodies of evidence adding to and lengthening the debate
- Focal therapy continues to advance with patient selection regarded as an essential key to success, and approaches to selection continually improving, both quantitatively and qualitatively.
- Quantitative – genomics, biomarkers, imaging techniques and practice
- Qualitative – contextual patient information, lifestyle, aging
- Imaging continues to advance in its precision and acceptance, and is regarded by most as providing the foundation for the future of diagnostics and treatment.
Further advancement will be driven by improvements in reading and reporting.
There were lots of takeaways from these presentations and discussions, but three stood out.
- The imaging-led pathway is here to stay: “The imaging phenotype is the future” according to Prof Mark Emberton, who argued that detection of prostate cancer is lesion-led, and that there has historically been “too much emphasis on histology” because most practicing urologists “grew up on TRUS” and that current risk stratification systems are antiquated. He believes that we are now in a new era and even described a case where he had treated a patient on imaging information alone – without biopsy.
- While Randomised Control Trials (RCTs) are the gold standard for clinical acceptance of new medical interventions, they present challenges for building evidence on Focal Therapy, often due to securing patient consent. Three recent trials comparing Focal therapy to Radical Prostatectomy and other treatment approaches were presented , each of which experienced >25% of participants refusing to undergo the invasive treatments. The conclusion was that “Unbiased RCT on focal ablation versus RP is difficult to realize due to the preference of patients for a less invasive treatment option”.
- Screening approaches continue to improve which provides some optimism for establishing screening programmes in future. Several new methods have been developed in the last few years which outperform PSA on a number of levels – these include alternative biomarkers detected in both blood and urine as well as new imaging techniques. All were considered in the context of benefits and harms as well as risk factors to patients and healthcare
Discussion ranged from an American perspective on the PSA test suggesting that this is a superior method of screening “but hasn’t been used effectively”, to a case presented by the Imperial Prostate team on its image-based screening approach, called Prostagram, which they argue is superior on all counts – including diagnostic accuracy, patient acceptability, and cost-effectiveness.
Whatever the views on screening modality, there was a consensus that screening for prostate cancer is beneficial and should be pursued. A poll was taken amongst delegates on the question “should there be a screening programme for prostate cancer”– and the results were as follows:
- Yes 60%
- unsure 30%
- no 10%.
More info on the event can be found here
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