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PONDERING ON WHO IT IS WHO SHOULD BE TREATED

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  2. PONDERING ON WHO IT IS WHO SHOULD BE TREATED
  3. REFERENCES

I was asked by the Editor to provide a commentary on the present paper, presumably because I have, on occasion, treated men by using sound waves to create high energy densities within the prostate to induce coagulative necrosis as a means of generating cell kill.

Before reading the paper I thought that my comments would be technical and relate to exploring some of the standard operating procedures required of one HIFU platform vs another but, as I read the paper, it became increasingly obvious that my comments would relate instead to the extent to which practice can vary from one site to another and over a relatively short time frame.

There is one thing I wish to establish first. This is not a critique of the authors. They have been very diligent in reporting their outcomes of care in men who were treated on two iterations of the AblathermTM platform (EDAP SA, Lyon, France) during the period 2002 to 2006. Indeed, given the attributes of the population treated, they have exercised their duty with considerable skill. My comments relate to the population that were treated, because as I read and re-read the paper it dawned on me that it is unlikely that any of the men reported would be treated in the manner described in the present paper, were they to present at the hospital in which I work. The authors describe the series as comprising men with ‘significant comorbidity’ who were all ‘unsuitable candidates for radical prostatectomy and unwilling to undergo radiotherapy’. In fact, just under half were attributed an ASA score of 4–5 – a relative contraindication to elective surgery. In most jurisdictions, men conforming to this degree of operative risk would be managed with selective, delayed androgen suppression. If we look at their risk profile, the majority were attributed a low-risk status as conforming to Gleason 3 + 3 and PSA of <10. Again in many parts of the world these men would be managed expectantly, especially if there were significant comorbidity. At the other end of the spectrum, a significant minority were staged as clinical T3a or T3b and one in 10 men had a PSA level >20 ug/L. It is difficult to imagine how these men with high-risk disease might benefit from localized treatment.

These observations are interesting as they reflect legitimate practice variation across northern Europe. The reasons behind this are going to be both interesting and complex but must relate, at least to some degree, to different thresholds for treatment (held by both patients and caregivers) once a diagnosis has been made, even in the infirm and potentially over-diagnosed. In the UK, in general, we sit at the opposite extreme, where there exists a cultural imperative to do everything we can to avoid treating these men. Not right necessarily, just different.

The argument for universal treatment, supported by the authors, relates to the imprecision of risk stratification. In other words, because we cannot be sure of the true risk attributed to the patient we need to treat everyone, just in case. It is my belief that in 2012 that position is becoming increasingly difficult to defend, although it was entirely appropriate in 2002–2006. Recent developments in assessment should not be ignored as they can help us apply our treatments in an effective and efficient manner, helping us to achieve this aim by virtue of conferring fewer unnecessary diagnoses and more precise risk stratification in those who are diagnosed. Imaging, in the form of multi-parametric MRI, can be used to try to avoid unnecessary biopsy if found to be normal [1]. Targeted biopsy is used in those that have MRI lesions in order to maximize the yield and representative nature of the tissue [2]. Surveillance is offered to those at truly low risk. Tissue selective therapy is offered to men with focal but clinically significant disease, where possible within a trial [3]. This is done in order to try to enhance the therapeutic ratio by reducing harms. Surgery is offered to men with high burden disease who are fit and radiotherapy and androgen suppression to those with locally advanced disease.

What does need to be aired - and I have no current answer – is just what is the acceptable degree of variation with Europe in 2012 for therapeutic intervention in men who present with a prostate cancer diagnosis who carry significant comorbidity on the one hand and those who are well but have very low risk disease, on the other.

REFERENCES

  1. Top of page
  2. PONDERING ON WHO IT IS WHO SHOULD BE TREATED
  3. REFERENCES
  • 1
    Dickinson L, Ahmed HU, Allen C et al. Magnetic resonance imaging for the detection, localisation, and characterisation of prostate cancer: recommendations from a European consensus meeting. Eur Urol 2011; 59: 47794
  • 2
    Moore CM, Robertson NL, Arsanious N et al. Image-Guided Prostate Biopsy Using Magnetic Resonance Imaging-Derived Targets: A Systematic Review. Eur Urol 2012 Jun 13. [Epub ahead of print]
  • 3
    Ahmed HU, Hindley RG, Dickinson L et al. Focal therapy for localised unifocal and multifocal prostate cancer: a prospective development study. Lancet Oncol 2012; 13: 62232