Burden of focal cryoablation versus brachytherapy versus active surveillance in the treatment of very low-risk prostate cancer: a preliminary head-to-head comprehensive assessment

Applications of Focused Ultrasound in the Treatment of Genitourinary Cancers

Simple Summary

Cancer is a prevalent disease globally, and conventional treatment options have been associated with substantial morbidity for patients. The unique acoustic properties and biological effects of focused ultrasound have been investigated for use as an alternative treatment option for various forms of cancer with lower associated morbidity than standard treatments. The objective of our review was to assess the current state and various applications of focused ultrasound for the treatment of genitourinary cancers, including prostate, kidney, bladder, penile, and testicular malignancies. Current research demonstrates that focused ultrasound-based focal therapy shows promise for the treatment of localized prostate and kidney cancer, and the effect of ultrasound on cell membranes may increase the efficacy of chemotherapeutics and radiotherapy. Focused ultrasound-based treatment modalities should continue to be investigated as an alternative or complementary treatment option for cancer patients.

Abstract

Traditional cancer treatments have been associated with substantial morbidity for patients. Focused ultrasound offers a novel modality for the treatment of various forms of cancer which may offer effective oncological control and low morbidity. We performed a review of PubMed articles assessing the current applications of focused ultrasound in the treatment of genitourinary cancers, including prostate, kidney, bladder, penile, and testicular cancer. Current research indicates that high-intensity focused ultrasound (HIFU) focal therapy offers effective short-term oncologic control of localized prostate and kidney cancer with lower associated morbidity than radical surgery. In addition, studies in mice have demonstrated that focused ultrasound treatment increases the accuracy of chemotherapeutic drug delivery, the efficacy of drug uptake, and cytotoxic effects within targeted cancer cells. Ultrasound-based therapy shows promise for the treatment of genitourinary cancers. Further research should continue to investigate focused ultrasound as an alternative cancer treatment option or as a complement to increase the efficacy of conventional treatments such as chemotherapy and radiotherapy.

The psychological impact of active surveillance in men with prostate cancer: implications for nursing care

INTRODUCTION

Active surveillance is a conservative management approach to treating prostate cancer involving regular testing and close monitoring by the health professional. The aim of this literature review is to establish whether men experience a psychological impact of active surveillance and what the prevalent effects might be.

METHOD

The search was carried out in three databases: CINAHL, Medline and PsycINFO. Articles published in English, from October 2015 to March 2018, which focused on the psychological impact of active surveillance, were included.

FINDINGS

A total of eight quantitative studies were included in this report. The review identified key psychological impacts of active surveillance, including anxiety, sub-clinical depression, illness uncertainty and hopelessness. Active surveillance was seen by some patients as a positive treatment approach that limited the side effects associated with active treatment.

CONCLUSION

The evidence found a negative impact of active surveillance might be felt by men at any stage during treatment and at differing levels of severity. The article highlights key demographic areas, including ethnicity and age, for future research and recommends more qualitative studies are conducted.

Making a case "for" focal therapy of the prostate in intermediate risk prostate cancer: current perspective and ongoing trials

Focal therapy is growing as an alternative management options for men with clinically localized prostate cancer. Parallel to the increasing popularity of active surveillance (AS) as a treatment for low-risk disease, there has been an increased interest towards providing focal therapy for patients with intermediate-risk disease. Focal therapy can act as a logical "middle ground" in patients who seek treatment while minimizing potential side effects of definitive whole-gland treatment. The aim of the current review is to define the rationale of focal therapy in patients with intermediate-risk prostate cancer and highlight the importance of patient selection in focal therapy candidacy.

Do rapid emotional thermometers correlate with multidimensional validated structured questionnaires in low-risk prostate cancer?

PURPOSE

To promptly identify mental suffering in low-risk prostate cancer (LRPC) patients, vulnerable to over- and undertreatment, we evaluated the correlation of rapid emotional thermometers (ET) with multidimensional validated structured questionnaires.

METHODS

At diagnosis, consecutive LRPC patients underwent five ET domains: emotional suffering, anxiety, depression (DT), revolt and need for help and multidimensional questionnaires: beck anxiety inventory (BAI), beck depression inventory (BDI), beck hopelessness scale, SF36 (physical functioning PF, role limitations due to physical health RP, bodily pain BP, general health perceptions GH, vitality VT, social functioning SF, role limitations due to emotional problems RE and general mental health MH), international index of erectile function and international prostate symptom score (IPSS).

RESULTS

Among 30 included patients, mean age 67.4 y (52-74), 20 days after the diagnosis (15-30), mean time to obtain ET 27 s (15-57) and all questionnaires 36.7 min (31-49), ETs showed moderate/strong Spearman correlation among themselves. DT domain displayed the best correlation to most of the multidimensional validated structured questionnaires: moderate to BDI, SF-36 (PF, GH, VT, SF, RE, MH) and IPSS and strong to BAI.

CONCLUSION

DT revealed the best correlation to validated structured questionnaires of diverse dimensions with clear potential for quick screening of patients with psychological suffering and in need of further evaluation and support.

T cells CD4+/CD8+ local immune modulation by prostate cancer hemi-cryoablation

PURPOSE

Tumors escape from the immune system by decreasing CD8+ and increasing CD4+ T cells' activity, druggable targets. Thermal ablation might activate tumor-specific T cells by raising the presentation of tumor-specific antigens and hindering tumor negative immune regulation. Our aim was to assess T cell infiltrate pre- and post-cryoablation in a prospective observational study.

METHODS

A total of 240 sextant prostate biopsies cores (12 cores/patient) were collected from 10 unilateral prostate cancer patients (T1c, PSA density < 0.15 ng/dL, Gleason grade group 1, ≤ 2 cancer biopsy cores, and < 50% cancer core involvement) at diagnosis and 12 months after hemi-cryoablation. Cancer-positive (Diag+) and cancer-negative (Diag-) lobes at diagnosis and the same areas 12 months after hemi-cryoablation (Cryo+ and Cryo-, respectively) were explored by immunohistochemistry for infiltrating CD4+ and CD8+ T cells (in 45 random fields per prostate lobe, 400× magnification). The quantitative analysis of cells/mm² and CD4+/CD8+ ratio were performed and compared among Diag+, Diag-, Cryo+, and Cryo- using ImageJ software.

RESULTS

There was a significant increase in tumor-infiltrating CD8+ T cells/mm² in the Cryo+ tissue (mean, SD 0.31, 0.30) compared to Diag+ (0.18, 0.15), p = 0.015; confirmed in prostate acini (hot spots), p = 0.029, in which infiltrating CD4+/CD8+ T cells' ratio decreased after hemi-cryoablation, p = 0.006. Infiltrating CD4+ T cells/mm² presented a trend to decrease in Cryo+ (0.26, 0.27) compared to Diag+ (0.38, 0.32).

CONCLUSIONS

This is the first study to show local immune modulation after prostate cancer cryoablation, characterized by decreasing CD4+/CD8+ T cells' ratio, potential for clinical impact by unleashing the T-cell response to cancer. Future studies are necessary to explore different energies and longer follow-up clinical endpoints.

Prostate cancer "super-active surveillance" era opened by vascular targeted photodynamic therapy

The "super-active surveillance" concept denotes any active surveillance optimization that allows longer surveillance periods, with the main intention of avoiding overtreatment, by safely eliminating or postponing radical treatment. Super-active surveillance might add to the oncological control with minimal functional impact and similar quality of life compared to active surveillance, which has proved to be safe in well-selected patients. Vascular targeted photodynamic therapy has pioneering shown to significantly reduce the upgrade on subsequent biopsies, resulting in fewer cases converted to radical therapy, and any energy source can be applied to the super-active surveillance concept allowing more men to consider a tissue-preserving therapy for prostate cancer.

The Biopsychosocial Burden of Prostate Biopsy at the Time of Its Indication, Procedure, and Pathological Report

Purpose

To explore the burden of prostate biopsy at the time of its indication, procedure, and pathological report in the prostate cancer-screening scenario that is neglected and underestimated in the literature.

Methods

Prostate biopsy was offered to 47 consecutive patients with prostate-specific antigen (PSA) over 4 ng/dl or suspicious digital rectal examination (DRE) of whom 16 had undergone a biopsy. Comprehensive validated questionnaires at Time 0 (prebiopsy), Time 1 (before diagnosis, 20 days after biopsy), and Time 2 (after diagnosis, 40 days after biopsy) accessed patients' erectile (IIEF-5) and voiding (IPSS) functions, Beck scales measured anxiety (BAI), hopelessness (BHS), and depression (BDI), added to the emotional thermometers including five visual analog scales for distress, anxiety, depression, anger, and need for help. The Mann-Whitney or Friedman tests were obtained among times and studied variables.

Results

Prostate biopsy did not significantly impact patients' erectile and voiding functions while a higher Beck anxiety index (BAI) was observed at Time 0 (6.89 ± 6.33) compared to Time 1 (4.83 ± 2.87), p=0.0214, and to Time 2 (4.22 ± 4.98), p=0.0178. At Time 0, patients that experienced a previous biopsy presented higher distress (3.1 ± 3.0 vs. 1.6 ± 2.3), p=0.043, and emotional suffering thermometer scores (2.3 ± 3.3 vs. 0.9 ± 2.4) compared to those undergoing the first biopsy, p=0.036. At Time 2, patients with positive biopsies compared with those with negative ones showed no significant difference in outcome scores. The sample power was >90%.

Conclusions

To be considered in patients' counseling and care, the current study supports the hypothesis that the peak burden of prostate biopsy occurs at the time of its indication and might be higher for those experiencing rebiopsy, significantly impacting patients' psychosocial domains.

Trial Approval

 This trial is registered under number NCT03783741.

The Quality of Life among Men Receiving Active Surveillance for Prostate Cancer: An Integrative Review

Prostate cancer is very common among men in the United States. The current literature on active surveillance (AS) suggests that it is a promising treatment option for men with low-risk prostate cancer. The purpose of this manuscript is to provide a thorough integrative review regarding the effects of AS on the quality of life (QoL) of men with prostate cancer. Utilizing a methodological strategy, electronic databases were reviewed for empirical articles during the time frame of January 2006 to December 2016. A total of 37 articles met the inclusion criteria wherein 20 focused on the QoL among men only receiving AS and 16 reported QoL among men undergoing AS and other forms of treatment for prostate cancer. The review highlights the purpose, common instruments, race and ethnicity, and strengths and limitations of each article. The majority of articles indicated low levels of anxiety and depression and decreased incidences of bladder, bowel and sexual functioning among men undergoing AS in comparison to men who received other treatment modalities. The results indicated that additional research is needed to determine the QoL among men receiving AS on a longitudinal basis. The results support previous literature that indicated the positive impact of AS on low-risk prostate cancer.

Expanding indication of padeliporfin (WST11) vascular-targeted photodynamic therapy: results of prostate cancer Latin-American multicenter study

OBJECTIVES

To explore the proportion of patients with higher risk localized prostate cancer (PCa) that would become safely biopsy negative 12 months after non-thermal focal therapy with padeliporfin vascular-targeted photodynamic therapy (VTP).

METHODS

Multicenter study in a scenario of prostate-specific antigen (PSA) ≤20ng/ml and variable PCa target volumes Gleason pattern 3 or low-volume secondary Gleason pattern 4, all patients received VTP, consisting of intravenous 4mg/kg padeliporfin activated by light-diffusing fibers in the prostate. The prostate was biopsied at baseline, months 6 and 12, PSA, patient-reported functional outcomes and quality of life (QoL) questionnaires were recorded at baseline, months 3, 6, and 12 and adverse events (AE) throughout the study.

RESULTS

In the intention-to-treat population (n=81), the proportion of patients with negative biopsies at month 12 was 74% (60/81 patients; 95% CI: 63.1%,83.2%). In the per-protocol population, the proportion was 79% (58/73 patients; 95% CI: 68.4%,88.0%). Questionnaire results indicated a slight improvement in urinary function and limited deterioration in sexual function. No difference in QoL was observed over time. A total of 42/81 (52%) patients reported mild or moderate and 4 of 81 (4.9%) experienced serious AE, all resolved without sequelae. No phototoxicity, cardiovascular event, fistula or prolonged urinary incontinence, secondary cancer or death was reported.

CONCLUSIONS

Results support the efficacy, safety, and QoL associated with padeliporfin focal treatment for low/intermediate risk localized PCa.