28 January 2021
Focal therapy using HIFU and cryotherapy have similar cancer control to prostatectomy
NEW HOPE OF BETTER LIFESTYLE OUTCOMES FOR PROSTATE CANCER PATIENTS
A new study has given real hope of better post-treatment lifestyle outcomes for men suffering with prostate cancer. The treatment has been undertaken on hundreds of men over the last 10 years, one of whom was Peter Duncan, famous for his dare-devil role in Blue Peter.
Doctors at Imperial College Hospital in London, led by Mr Matt Winkler and Professor Hashim Ahmed, have compared new less invasive treatments known as focal therapies against ‘traditional’ treatments, such as radical surgery and radiotherapy. The results, published in a peer-reviewed journal, show that cancer control is the same as radical surgery at 5 to 8 years after treatment.
The above two diagrams show cancer control over time for focal therapy and radical prostatectomy. On the left is a graph illustrating that over time, men needing salvage radiotherapy, prostatectomy or hormone treatment when focal therapy (after up to 2 sessions of HIFU or cryotherapy) compared to salvage hormones or radiotherapy after prostatectomy failure. On the left, comparison between focal therapy and prostatectomy is made for the very small numbers of men who have cancer spread or mortality. Both show no differences between prostatectomy and focal therapy.
Focal therapy targets just the areas of cancer inside the prostate rather than removing or irradiating the entire prostate. This is carried out by focused ultrasound to heat or cryotherapy to freeze tissue and has been likened to a ‘male lumpectomy’. There is less damage to surrounding tissue so risk of urine leak and sexual function problems are much lower. There is also dramatically reduced hospital stays and recovery times.
Even better are the same authors’ findings that in the current Covid-19 pandemic, focal therapy has far less interaction within the hospital setting and was safe to do during the first UK wave and lockdown. All treatment is provided within one self-contained areas meaning minimal involvement with the rest of the hospital, and being a day stay procedure men can usually go home to recover in the safety of their own homes.
Focal treatments have actually been in use for several years in a few hospitals in both NHS and private settings, but until now very little long-term data had been available. Therefore, until now many clinicians favoured the radical approach believing that recurrence of the disease was less likely, but this study clearly shows that longer term outcomes up to 8 years after treatment are no worse than a similar group of men who under radical surgery, called prostatectomy.
Men were treated with high intensity ultrasound (HIFU) which focuses ultrasound waves to a fine point and heats targeted tissue to at least 65 degrees centigrade with millimetre precision. Some men underwent cryotherapy which similarly only targets the tumour itself using minute balls of ice at minus 40 degrees centigrade or lower. The choice of HIFU or cryotherapy is dictated by the location of the tumour and the size of the prostate itself.
The well known actor, Peter Duncan, famed for his daredevil role in Blue Peter and a former UK Chief Scout is a strong advocate for focal therapy. Peter underwent HIFU in 2019 under Professor Ahmed for a prostate cancer diagnosis and is delighted with the outcome. “I was symptom free but after a poor PSA test and MRI scan I was originally offered a radical prostatectomy. I rejected this and chose HIFU as a less invasive option. I truly feel as though the cancer never happened now” he said “and I have had only minor after-effects”
The publication today of this major study by Imperial College London clearly shows that men with cancer that has not spread to other areas, most of whom had medium and high risk cancer, can clearly benefit from less invasive treatment options as much as they would do with whole prostate radical options. This gives new hope of faster treatment and a better lifestyle outcome for up to 10,000 men every year in the UK, without detriment to long term effectiveness.
Senior author and prostate cancer surgeon Mr Matt Winkler of Imperial College Healthcare NHS Trust said, “So far, evidence to support widespread use of focal therapy was rather limited. After diligently collecting data over the last 10-years, we can now for the first time provide comparative evidence of equivalent cancer control rates for up to 5 to 8 years. While our method does not provide the highest level of evidence, a randomised controlled trial, it is as good as it gets at this point in time.”
Mr Winkler added, “As a prostate cancer surgeon I know far too well the devastating impact of erectile dysfunction or urine incontinence on the lives of many men after prostate cancer surgery.
We are proud to provide colleagues and affected men with information that may make it easier to avoid radical prostate removal or radiotherapy.”
Professor Ahmed, one of the UK’s most authoritative prostate cancer experts, said “We know that about 1 in 3 patients who have radical surgery for prostate cancer regret their decision afterwards. Often this is due to not being fully informed of options that carry fewer side-effects.”
“Our study has shown that focal therapy carries up to 10-fold reductions in urine leak and sexual problems. Importantly, for the first time we have shown that it has similar cancer control to radical prostatectomy, at 5-8 years after treatment.” He added “Whilst focal therapy is not suitable for all patients, there are thousands every year who are suitable and they should be fully informed about it.”
This study may provide highly welcome news for men with prostate cancer, but the challenge now is to get the equipment to provide focal therapy out into the NHS to provide access for every man who chooses this option. A charity set up specifically to provide this, Prost8 UK, is launching a campaign this month to raise the funds to deploy 6 new focal therapy suites into hospitals across the UK over the next 18 months at a cost of around £500,000 each, which is much lower than the millions that are required for surgical and radiotherapy equipment. Details can be found on the charity’s website at prost8.org.uk.
At a time when many men are struggling to be seen in the NHS for even an initial consultation for prostate cancer, let alone be treated, this initiative will bring respite and hope to both the creaking health system and the patients themselves. The charity states that this campaign will bring about the single biggest change in treating men with prostate cancer in more than 20 years.
Founder of the charity, Paul Sayer, from Southend on Sea has himself undergone focal therapy for his prostate cancer in 2018 at the age of 62 and is now cancer free. Paul says ‘I was just so lucky to find out about HIFU as my local hospital was just offering me surgery or radiotherapy. I researched my options and found professor Ahmed at Imperial College and I truly owe my lifestyle to him and his team. I am all but unchanged from my pre-cancer self. As a result, I am now driven to make sure as many men as possible know about focal therapy and, more importantly, can access it when needed”.
Peter Duncan has recently produced and appeared in a pantomime film and some of the profits are going to support Prost8. He added “I continue to do everything I ever did before as well as being plant based, staying fit and yesterday I even had my vaccine jab. It’s hard to believe that 1000’s of men are unnecessarily undergoing radical treatments leaving them with long-term life-changing after-effects when this incredible alternative exists”.
“I am fully supporting the Prost8 charity initiative and am working with them to make sure this happens!”.
Until recently men diagnosed with a prostate cancer that had not spread were given the same invasive treatment options as those with advanced and more life-threatening cancers. This invariably results in unnecessary and irreversible lifestyle impairments, not to mention longer recovery times.
Whole prostate treatments such as radiotherapy and surgery can cause damage to surrounding tissue like nerves and blood vessels which aid in sexual function, muscles called sphincters which prevent urine leakage as well as the water passage (bladder and urethra) and the back passage (rectum). As a result, 30-60% have long term sexual problems, 5-25% have long-term urine incontinence or urinary problems, and 5-15% have rectal problems like bleeding, loose stools and discomfort, Like all cancer treatments, recurrence can happen and this requires other cancer treatment.
Focal therapy targets, by heating or freezing, areas of cancer. Many studies over the last decade and mainly led by UK doctors, have shown lower lifestyle problems and complications, Sexual problems happen in 5-15%, urine incontinence or urinary problems in 1-2% and rectal problems are rare. Those studies have shown very good early and medium cancer control. This is the first study that looks at long term cancer control and compares it to medium and long-term outcomes after prostatectomy.
Outcomes were measured from an in-depth study of the treatment, recovery and long-term monitoring of men treated with focal therapy against those having radical surgery to remove the prostate, known as a prostatectomy. The authors used data from 761 men undergoing focal therapy from across the UK and matched them to a group 572 men who had similar cancer undergoing surgery at Imperial College London. After ensuring a good match so that men were being compared like for like as much as possible, there were a total of 492 men in the published paper, with 246 undergoing focal therapy and 246 undergoing prostatectomy. The groups were monitored throughout but cancer control outcomes were reported specifically at 3, 5 and 8 years.
Prostate cancer has tended to be seen as a ‘poor relative’ to breast cancer when it comes to screening, diagnosis and treatment. Advances in breast cancer have seen early diagnosis and survival rates improve year on year whilst prostate cancer diagnosis and deaths continue to rise.
In 2019 prostate cancer fatalities exceeded those for breast cancer for the first time making it the single biggest killer of men. As a result, awareness of the disease, its symptoms and the ways to treat it have all commanded more attention. This study is very timely in bringing the possibility of treating far more men, far quicker and at considerably less cost.
However, despite this, far too many men are still victims of this silent killer. The latest figures show that 1 in 8 men will have a prostate cancer diagnosis in their lifetime with 50,000 new cases every year. One man dies every 45 minutes of every day, that’s more than 12,000 each year and growing. Sadly, most of these deaths are unnecessary simply due to having been diagnosed too late.
A well-used adage for prostate cancer is ’caught early it is one of the most treatable cancers, however caught too late it is one of the least’. However, right now the tragic part of that statement is that although early stage prostate cancer is treatable almost every man with an early diagnosis will be given the same invasive treatments as those used for men with advanced cancer.
The turn-to tools in just about every urology department across the UK are still radiotherapy to blast the tumour or surgery to completely remove the prostate gland. These extreme treatments are very often essential and life saving for men with advanced cancers, but are overkill for those with early stage cancer contained with the prostate capsule.
Focal therapy, although tried, tested and approved for prostate cancer, not to mention being far less costly to deliver and with minimal cost for aftercare, has been far too slow in uptake within the NHS. It is becoming rapidly more available in the private sector but this does not help the many thousands of men who could benefit right now.
Currently, large numbers of urology and oncology specialists too frequently opt for more invasive ‘established’ treatments, often advising men and their families that there was no alternative to sacrificing lifestyle considerations in order to treat the cancer. About 10,000 men in the UK could have focal therapy every year but only a few hundred do. This is because the vast majority are not even informed of focal therapy or are given a very negative viewpoint about it.
For patients interested in focal therapy
The treatment is available in the NHS upon referral to a small number of UK centres and is also available privately under Professor Ahmed at Cromwell Hospital or Imperial Private Healthcare. Focal therapy is continuing to be safely carried out during the Covid pandemic.
Men or their families who want to find out more about focal therapy can also get in touch with Prost8 charity on the following. It is important for you to share copies of medical reports such as the PSA level, MRI findings and full details of the biopsy report so that we can give specific advice on suitability:
Tel: +44 (0)203 858 0848
For NHS referrals, Professor Ahmed works at Imperial College Healthcare NHS Trust. You are entitled to ask for a referral for an opinion about whether you might be suitable on the NHS. Your GP can make the referral through the choose and book electronic referral system and choose the ‘Prostate – established diagnosis’ folder. You consultant team can also make the referral directly to Imperial using the email: email@example.com or letter (addressed to Professor Ahmed at Charing Cross Hospital, Fulham Palace Road, London W6 8RF).
For private referrals, Professor Ahmed works at Cromwell Hospital and Imperial Private Healthcare. Self-pay patients do not need a referral to consult Professor Ahmed and there are competitive self-pay packages offered. Insured patients should check with their insurer.
Please use the online booking portal or email the team on firstname.lastname@example.org