Radiotherapy appears to provide better survival outcomes in men with low- and intermediate-risk localized prostate cancer, compared with focal laser ablation, according to a database study. Active surveillance, radiotherapy and radical prostatectomy are all accepted treatments for men with low-risk or intermediate-risk localized prostate cancer, but focal laser ablation (FLA) is increasingly used to ablate tumors while sparing adjacent structures. Trials of FLA have yielded encouraging short-term oncologic and functional outcomes, but information regarding long-term survival is lacking. Dr. Qiang Wei and colleagues from West China Hospital of Sichuan University, in Chengdu, China, used 2004-2015 data from the Surveillance, Epidemiology, and End Results (SEER) database to evaluate overall survival and prostate-cancer-specific mortality at long-term follow-up in more than 93,000 men treated with radiotherapy and 428 men treated with FLA. On multivariate regression analysis, the hazard ratio for overall survival was 91% higher following radiotherapy than following FLA (P<0.001). The benefit was somewhat diminished (hazard ratio, 1.49) but remained significant after adjusting for age, T stage, PSA level, and Gleason score. In contrast, radiotherapy and FLA provided similar cancer-specific mortality rates, the researchers report in Scientific Reports. In a propensity score-matched subgroup of 2,568 radiotherapy-treated patients and 428 FLA-treated patients, radiotherapy was associated with a 50% better chance of overall survival, but cancer-specific mortality did not differ between the groups. Instrument variate adjusted analyses yielded similar results. "In the future, if FLA can solve its current technical shortcomings, such as navigation, imaging, and precision, its therapeutic effect may be better with favorable survival benefits and functional protection at the same time," the authors conclude. "But at present, radiotherapy should have a priority over FLA in the management of low-risk and intermediate-risk prostate cancer." Dr. Herbert Lepor of NYU School of Medicine and NYU Langone Health, in New York City, who has reviewed focal ablation of prostate cancer, told Reuters Health by email, "This paper is based on a statistical model and absolutely no long-term survival data available regarding focal laser ablation. I am surprised this article was published in the absence of any data to inform the model." "Focal therapy is an emerging treatment option that avoids many of the side effects associated with whole gland treatments of radical prostatectomy and radiation therapy," he said. "Long-term survival data are lacking." "I no longer offer focal laser ablation," Dr. Lepor said. "My energy preference for focal therapy is cryotherapy, since we achieve better energy confluence within the planned ablation zone." "I would offer focal therapy over radiotherapy to an individual with a Gleason 7 (Gleason Grade Group 2 or 3) who has cancer confined to the side of the prostate with a unifocal MRI lesion shown to harbor prostate cancer whose priority is preservation of quality of life (potency, GI and bowel issues)," he said. Dr. Lepor added, "Another advantage of focal therapy in these cases is avoidance of side effects of neoadjuvant androgen-deprivation therapy which is given to men undergoing radiotherapy. This represents a large proportion of cases. Our early data show 98% oncological control following extensive biopsy at 6 months with cryoablation." The study had no commercial funding, and the authors report no conflicts of interest. Dr. Wei and coauthor Dr. Lu Yang did not respond to a request for comments. —Will Boggs MD Source
