Is The End of Overtreatment Really In Sight?


According to a new German study, efforts to avoid the acknowledged problems of overdiagnosis and overtreatment of insignificant prostate cancer is leading to different treatment patterns.[i] The authors note, “Many centers have reported dramatic changes, with increases in active surveillance (AS) of early cancers and local treatment of advanced disease.” In other words, more patients with low-risk, early stage PCa are being encouraged to practice observation of their disease rather than seek immediate treatment; and physicians are becoming more confident in radical treatment for intermediate-risk disease where localization can be evaluated via advancements in imaging and image-guided biopsies. Both of these trends are in response to the need for improved treatment-to-disease matching to minimize risks but also maximize survival.

The single-institution German drew data from their prostatectomy cases. Their analysis shows reductions in the percentage of patients who had RP from 2004 through the years 2011-13:

Patient category20042011-13
Low-risk PCa patients who had RP60%27%
Candidates for AS who chose RP38.2%14.7%
Men with pure Gleason 6 pattern who had RP56.2%10%

While identifying the trend toward less aggressive treatment for PCa that is believed to be indolent or insignificant, this study sidesteps the increase in patient demand for focal treatment. Focal treatment, which is basically the male equivalent of a lumpectomy, is image-guided destruction of a tumor while sparing healthy tissue. It can be done with minimal-to-noninvasive technologies that deliver extreme heat or cold under controlled conditions. A key advantage of focal treatment is the middle ground it offers between observation (undertreatment) and aggressive whole-gland treatment for cancer that might never become life threatening (overtreatment).

Returning to the German study, the authors note that their analysis “…documents a clear shift in utilization of RP toward significant PCa in men with long life expectancy.” They are saying that for men younger than 65, prostatectomy for significant cancer that may pose a threat to survival is offered more than it used to be. Well, the same goes for focal treatment. Just as surgeons may have been  offering RP to patients with > Gleason 6 PCa, doctors who perform focal cryotherapy (freezing), focal HIFU (high intensity focused ultrasound) and FLA (focal laser ablation) tended to limit treatment to men with a single focus of Gleason 3+3 cancer. However, as imaging technology improved, individual doctors became more experienced, and small but consistent patient series were published, confidence grew that localized, single-focus Gleason 7 lesions could be focally treated under certain conditions.

Our Center’s FLA presents an excellent alternative to AS for men who aren’t comfortable with the idea of cancer growing in their bodies. It is also an excellent alternative to RP for carefully qualified patients with localized tumors that, based on imaging and biopsy, are amenable to laser ablation. With a combination of increased AS, more appropriate selection of patients for prostatectomy, and the additional factor of effective focal treatments, the end of overtreatment is on the horizon.

[i] Huland H, Graefen M.  Changing trends in surgical management of prostate cancer: The end of overtreatment? Eur Urol. 2015 Feb 27. pii: S0302-2838(15)00182-7. doi: 10.1016/j.eururo.2015.02.020