Ablative therapy for people with localised prostate cancer: a systematic review and economic evaluation

Whole-gland or Subtotal High-intensity Focused Ultrasound Versus Radical Prostatectomy: The Prospective, Noninferiority, Nonrandomized HIFI Trial

BACKGROUND AND OBJECTIVE

High-intensity focused ultrasound (HIFU) has emerged as an interesting ablative alternative to radical prostatectomy (RP) and radiation therapy (RT) for localized prostate cancer (PC). However, no prospective comparative data have been published for HIFU.

METHODS

We performed a prospective nonrandomized nationwide trial in 46 centers in France comparing RP versus HIFU. The main inclusion criterion was low- to intermediate-risk PC. The primary endpoint was salvage therapy-free survival (STFS). Secondary endpoints were metastasis-free survival, PC-specific survival, overall survival, and functional outcomes.

KEY FINDINGS AND LIMITATIONS

From 2015 to 2019, 3328 patients were included (1967 HIFU and 1361 RP). Median age was 74.7 versus 65.1 yr (p < 0.001) and median PSA was 7.1 versus 6.9 ng/ml (p = 0.5) in the HIFU and RP groups, respectively. Intermediate-risk PC was diagnosed in 61% of patients in the HIFU group and 64% in the RP group (p = 0.10). The 30-mo STFS was not inferior in the HIFU group (hazard ratio 0.71, 95% confidence interval 0.52-0.97; p = 0.008). Some 10% of patients experienced urinary retention after HIFU. Grade >IIIa complications occurred in 54/1967 cases in the HIFU group and 29/1361 cases in the RP group (p = 0.3). In the HIFU group, fewer patients experienced a deterioration in 12-mo urinary continence (29% vs 44%) and the decrease in median International Index of Erectile Function-5 score was lower (difference -7 vs -13) in comparison to RP. Internal Prostate Symptom Scores and quality-of-life scores were comparable in the two groups. The main limitations are the lack of randomization and the age difference between the groups.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This large prospective trial demonstrates that whole-gland or subtotal HIFU provides comparable medium-term STFS outcomes to RP. Urinary continence and erectile function were less impaired after HIFU. These results should be interpreted with caution owing to the lack of randomization and the age difference between the groups. Future research should consider longer follow-up and evaluate focal treatments. This trial is registered on ClinicalTrials.gov as NCT04307056.

Prostate cancer treatment recommendation study based on machine learning and SHAP interpreter

This study utilized data from 140,294 prostate cancer cases from the Surveillance, Epidemiology, and End Results (SEER) database. Here, 10 different machine learning algorithms were applied to develop treatment options for predicting patients with prostate cancer, differentiating between surgical and non-surgical treatments. The performances of the algorithms were measured using the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, positive predictive value, negative predictive value. The Shapley Additive Explanations (SHAP) method was employed to investigate the key factors influencing the prediction process. Survival analysis methods were used to compare the survival rates of different treatment options. The CatBoost model yielded the best results (AUC = 0.939, sensitivity = 0.877, accuracy = 0.877). SHAP interpreters revealed that the T stage, cancer stage, age, cores positive percentage, prostate-specific antigen, and Gleason score were the most critical factors in predicting treatment options. The study found that surgery significantly improved survival rates, with patients undergoing surgery experiencing a 20.36% increase in 10-year survival rates compared with those receiving non-surgical treatments. Among surgical options, radical prostatectomy had the highest 10-year survival rate at 89.2%. This study successfully developed a predictive model to guide treatment decisions for prostate cancer. Moreover, the model enhanced the transparency of the decision-making process, providing clinicians with a reference for formulating personalized treatment plans.

French AFU Cancer Committee Guidelines - Update 2024-2026: Prostate cancer - Diagnosis and management of localised disease

OBJECTIVE

The aim of the Oncology Committee of the French Urology Association is to propose updated recommendations for the diagnosis and management of localized prostate cancer (PCa).

METHODS

A systematic review of the literature from 2022 to 2024 was conducted by the CCAFU on the elements of diagnosis and therapeutic management of localized PCa, evaluating references with their level of evidence.

RESULTS

The recommendations set out the genetics, epidemiology and diagnostic methods of PCa, as well as the concepts of screening and early detection. MRI, the reference imaging test for localized cancer, is recommended before prostate biopsies are performed. Molecular imaging is an option for disease staging. Performing biopsies via the transperineal route reduces the risk of infection. Active surveillance is the standard treatment for tumours with a low risk of progression. Therapeutic methods are described in detail, and recommended according to the clinical situation.

CONCLUSION

This update of French recommendations should help to improve the management of localized PCa.

Transperineal biopsy devices in people with suspected prostate cancer - a systematic review and economic evaluation

Background

People with suspected prostate cancer are usually offered either a local anaesthetic transrectal ultrasound-guided prostate biopsy or a general anaesthetic transperineal prostate biopsy. Transperineal prostate biopsy is often carried out under general anaesthetic due to pain caused by the procedure. However, recent studies suggest that performing local anaesthetic transperineal prostate biopsy may better identify cancer in particular regions of the prostate and reduce infection rates, while being carried out in an outpatient setting. Devices to assist with freehand methods of local anaesthetic transperineal prostate may also help practitioners performing prostate biopsies.

Objectives

To evaluate the clinical effectiveness and cost-effectiveness of local anaesthetic transperineal prostate compared to local anaesthetic transrectal ultrasound-guided prostate and general anaesthetic transperineal prostate biopsy for people with suspected prostate cancer, and local anaesthetic transperineal prostate with specific freehand devices in comparison with local anaesthetic transrectal ultrasound-guided prostate and transperineal prostate biopsy conducted with a grid and stepping device conducted under local or general anaesthetic.

Data sources and methods

We conducted a systematic review of studies comparing the diagnostic yield and clinical effectiveness of different methods for performing prostate biopsies. We used pairwise and network meta-analyses to pool evidence on cancer detection rates and structured narrative synthesis for other outcomes. For the economic evaluation, we reviewed published and submitted evidence and developed a model to assess the cost-effectiveness of the different biopsy methods.

Results

We included 19 comparative studies (6 randomised controlled trials and 13 observational comparative studies) and 4 single-arm studies of freehand devices. There were no statistically significant differences in cancer detection rates for local anaesthetic transperineal prostate (any method) compared to local anaesthetic transrectal ultrasound-guided prostate (relative risk 1.00, 95% confidence interval 0.85 to 1.18) (n = 5 randomised controlled trials), as was the case for local anaesthetic transperineal prostate with a freehand device compared to local anaesthetic transrectal ultrasound-guided prostate (relative risk 1.40, 95% confidence interval 0.96 to 2.04) (n = 1 randomised controlled trial). Results of meta-analyses of observational studies were similar. The economic analysis indicated that local anaesthetic transperineal prostate is likely to be cost-effective compared with local anaesthetic transrectal ultrasound-guided prostate (incremental cost below £20,000 per quality-adjusted life-year gained) and less costly and no less effective than general anaesthetic transperineal prostate. local anaesthetic transperineal prostate with a freehand device is likely to be the most cost-effective strategy: incremental cost versus local anaesthetic transrectal ultrasound-guided prostate of £743 per quality-adjusted life-year for people with magnetic resonance imaging Likert score of 3 or more at first biopsy.

Limitations

There is limited evidence for efficacy in detecting clinically significant prostate cancer. There is comparative evidence for the PrecisionPoint™ Transperineal Access System (BXTAccelyon Ltd, Burnham, UK) but limited or no evidence for the other freehand devices. Evidence for other outcomes is sparse. The cost-effectiveness results are sensitive to uncertainty over cancer detection rates, complication rates and the numbers of core samples taken with the different biopsy methods and the costs of processing them.

Conclusions

Transperineal prostate biopsy under local anaesthetic is equally efficient at detecting prostate cancer as transrectal ultrasound-guided prostate biopsy under local anaesthetic but it may be better with a freehand device. local anaesthetic transperineal prostate is associated with urinary retention type complications, whereas local anaesthetic transrectal ultrasound-guided prostate has a higher infection rate. local anaesthetic transperineal prostate biopsy with a freehand device appears to meet conventional levels of costeffectiveness compared with local anaesthetic transrectal ultrasound-guided prostate.

Study registration

This study is registered as PROSPERO CRD42021266443.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR134220) and is published in full in Health Technology Assessment Vol. 28, No. 60. See the NIHR Funding and Awards website for further award information.

EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer-2024 Update. Part I: Screening, Diagnosis, and Local Treatment with Curative Intent

BACKGROUND AND OBJECTIVE

The European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Urological Pathology (ISUP)-International Society of Geriatric Oncology (SIOG) guidelines provide recommendations for the management of clinically localised prostate cancer (PCa). This paper aims to present a summary of the 2024 version of the EAU-EANM-ESTRO-ESUR-ISUP-SIOG guidelines on the screening, diagnosis, and treatment of clinically localised PCa.

METHODS

The panel performed a literature review of all new data published in English, covering the time frame between May 2020 and 2023. The guidelines were updated, and a strength rating for each recommendation was added based on a systematic review of the evidence.

KEY FINDINGS AND LIMITATIONS

A risk-adapted strategy for identifying men who may develop PCa is advised, generally commencing at 50 yr of age and based on individualised life expectancy. The use of multiparametric magnetic resonance imaging in order to avoid unnecessary biopsies is recommended. When a biopsy is considered, a combination of targeted and regional biopsies should be performed. Prostate-specific membrane antigen positron emission tomography imaging is the most sensitive technique for identifying metastatic spread. Active surveillance is the appropriate management for men with low-risk PCa, as well as for selected favourable intermediate-risk patients with International Society of Urological Pathology grade group 2 lesions. Local therapies are addressed, as well as the management of persistent prostate-specific antigen after surgery. A recommendation to consider hypofractionation in intermediate-risk patients is provided. Patients with cN1 PCa should be offered a local treatment combined with long-term intensified hormonal treatment.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The evidence in the field of diagnosis, staging, and treatment of localised PCa is evolving rapidly. These PCa guidelines reflect the multidisciplinary nature of PCa management.

PATIENT SUMMARY

This article is the summary of the guidelines for "curable" prostate cancer. Prostate cancer is "found" through a multistep risk-based screening process. The objective is to find as many men as possible with a curable cancer. Prostate cancer is curable if it resides in the prostate; it is then classified into low-, intermediary-, and high-risk localised and locally advanced prostate cancer. These risk classes are the basis of the treatments. Low-risk prostate cancer is treated with "active surveillance", a treatment with excellent prognosis. For low-intermediary-risk active surveillance should also be discussed as an option. In other cases, active treatments, surgery, or radiation treatment should be discussed along with the potential side effects to allow shared decision-making.

A Systematic Review and Meta-Analysis of the Cancer

OBJECTIVE

Prostate cancer is the second- leading cause of cancer death among men. We aimed to evaluate high-intensity focused ultrasound (HIFU), open radical prostatectomy (ORP), robot-assisted radical prostatectomy (RARP), and external beam radiation therapy (RT) in the treatment of localized low- and intermediate-risk prostate cancer.

METHODS

We searched bibliographic databases for case-control, cohort, and randomized controlled studies. We used MeSH subject headings and free text terms for prostate cancer, HIFU, ORP, RARP, RT, failure-free survival (FFS), biochemical disease-free survival (BDFS), urinary incontinence (UI), and erectile dysfunction (ED).

RESULTS

Fourteen studies were included in the review, for a total of 34 927 participants. Among the 8 studies of HIFU as the primary treatment of localized low- and intermediate- risk prostate cancer, 4 studies reported 5-year FFS rates ranging from 67.8% to 97.8%, 3 studies reported 5-year BDFS ranging from 58% to 85.4%, 5 studies reported 1-year UI rates ranging from 0% to 6%, and 4 studies reported 1-year ED rates ranging from 11.4% to 38.7%. Furthermore, our search revealed a 5-year FFS benefit favoring ORP compared to RT, a 1-year UI rate favoring ORP compared to RARP, and a 1-year ED rate favoring ORP compared to RARP.

CONCLUSION

Our systematic review and meta-analysis revealed lack of studies with active comparators comparing HIFU to standard of care (ORP, RARP, or RT) in primary treatment of localized low- and intermediate-risk prostate cancer. Open radical prostatectomy has favorable efficacy outcomes compared to RT, while RARP has beneficial functional outcomes compared to ORP, respectively.

Survival After Cryotherapy Versus Radiotherapy in Low and Intermediate Risk Localized Prostate Cancer

BACKGROUND

Focal therapy, including cryotherapy, reduces overtreatment in low- and intermediate-risk prostate cancer (PCa) patients with multiple comorbidities, which seems to increase in popularity compared with whole gland treatment. However, there is currently no consensus regarding the medium-term outcomes of cryosurgery as a prospective alternative to radiotherapy (RT) for such patients. Our study aims to find the available evidence that directly compares the medium-term overall survival (OS) and cancer-specific mortality (CSM) outcomes between cryotherapy and RT in patients with low- and intermediated-risk PCa.

MATERIALS AND METHOD

Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified 47,787 patients with low- and intermediate-risk PCa diagnosed between 2004 and 2015, of which 46,853 (98%) received treatment with RT, while only 934 (2.0%) received treatment with cryotherapy. Kaplan-Meier methods were used to estimateOS and cancer-specific survival (CSS) between the 2 groups. We performed multivariable Cox regression analysis to assess overall mortality (OM), while the cumulative incidence function (CIF) was used to illustrate cancer-specific mortality (CSM) and noncancer-specific mortality (non-CSM) for all patients. Additionally, competing risks regression (Fine-Gray) was implemented to evaluate any differences. After propensity score matching (PSM), all the aforementioned analyses were repeated. After the inverse probability of treatment weighting (IPTW), we repeated Kaplan-Meier methods on OS and CSS, and performed multivariable Cox regression analysis to assess OM in cryotherapy versus RT. Sensitivity analyses were conducted by excluding patients who died of cardiovascular disease.

RESULTS

After applying 1:4 PSM to the cryotherapy group with the RT group, the resulting RT cohort consisted of 3,736 patients who were matched with 934 patients in the cryotherapy cohort. The 5-year OS and cumulative CSM rates for PS-matched groups (N = 4670) receiving cryotherapy (N = 934) or RT (N = 3736) were 89% versus 91.8%, 0.65% versus 0.57, respectively. Multivariable Cox regression analysis demonstrated that cryotherapy was associated with a poorer OS outcome compared to RT (hazard ratio [HR] 1.29, 95% confidence interval [CI]: 1.07-1.55, p < .01). Multivariate competing risk regression analysis revealed that both treatments were not associated with CSS, with HR = 1.07 (95% CI: 0.55-2.08, p = .85). IPTW-adjusted analyses showed that the 5-years OS rates were 89.6% versus 91.8% for cryotherapy versus RT, respectively. Multivariate regression analysis for OS demonstrated that cryotherapy was more likely to have inferior OS in comparison to RT (HR = 1.30; 95%CI: 1.09-1.54; p < .01). The outcome of sensitivity analyses indicates that there was no significant difference in OS and CSS between the 2 groups.

CONCLUSION

For low- and intermediate-risk PCa patients treated by cryotherapy or RT, we could not demonstrate a survival difference. Cryotherapy may be a feasible option as a viable alternative to traditional radiation therapy.

An Update on Focal Therapy for Prostate Cancer

Radical treatments and active surveillance are valid therapeutic approaches for low-risk prostate cancer. The oncologic effectiveness and morbidity of Radical Prostatectomy (RP) and radiotherapy have been broadly validated. Focal therapies pursue to reduce the morbidity observed after radical treatments, while preserving the oncologic effectiveness. This study aims to review the state-of-the-art about principles, oncologic effectiveness, morbidity, and side-effects associated with leading focal therapies. We review and summarize articles related with Cryotherapy, High-Intensity Focal Ultrasound (HIFU), Photodynamic Therapy (PDT), and Irreversible Electroporating (IRE) published in MEDLINE from 2000 to 2022. There is a wide heterogeneity in terms of the measurement of effectiveness and morbidity. Hence, comparing different energies, strategies and protocols seem to be unprecise and controversial. Cryosurgery and HIFU have reported more clinical experience than PDT and IRE. Biochemical recurrence rate after the first session varied from 4.5% to 23%, and up to 20% of patients underwent a salvage radical treatment. The reported incidence of erectile disfunction and urinary incontinence ranges from 3% to 50% and 0% to 34%, respectively. None randomized clinical trial comparing any focal therapy to any radical treatment has been published. We conclude that the expansion of focal therapies requires the consolidation of MRI-guided fusion biopsies in everyday clinical practice. Short-term oncologic effectiveness has been proved and supports their usefulness in low-risk patients unfit for surgical treatment. However, long-term effects and the clinical experience in intermediate and high-risk patients remains limited. Currently none of the focal therapies can be considered the Gold Standard for low-risk patients.

Biopsy and Erectile Functional Outcomes of Partial Prostate Ablation: A Systematic Review and Meta-analysis of Prospective Studies

OBJECTIVE

To provide a systematic summary of prospectively performed studies evaluating ablative therapies for the treatment of prostate cancer (PCa) that included protocol-mandated assessment of (1) residual disease by post-treatment biopsy and/or (2) erectile functional outcomes.

MATERIALS AND METHODS

We performed a comprehensive literature search in September 2022. Studies were evaluated according to a predefined and registered plan in PROSPERO (CRD42022302777). Only prospective trials with protocol-mandated post-treatment prostate biopsies or functional assessments were included. Targeted focal therapy was the only ablation pattern with sufficient data to perform meta-analyses (29 studies, 1079 patients).

RESULTS

At baseline, 65.0% of patients treated with targeted focal therapy harbored grade group (GG) ≥2 PCa. One year after treatment, in-field treatment failure with ≥GG1 and ≥GG2 PCa occurred in 25.7% (range 11.1%-66.7%) and 8.8% (range 0%-27.8%) of men, respectively. In patients that received whole-gland biopsies 1year after ablation, residual ≥GG1 and ≥GG2 PCa was detected anywhere in the prostate in 43.7% (range 19.4%-71.7%) and 13.0% (range 0%-35.9%) of men. Erectile function was negatively affected by treatment, but 78.7% were potent 1year after targeted focal therapy (7 studies, 197 patients), and the average decrease in erectile function scores was 8.8% at 1year (21 studies, 760 patients).

CONCLUSION

Though long-term data after targeted focal therapy are limited, oncologic and treatment failure occurred in 13% and 9% (≥GG2 at 6-12months after treatment). Most men were able to maintain potency. This work can help benchmark new techniques and power future trials.

Urinary outcomes of new ultra-minimally invasive treatments for prostate cancers

PURPOSE OF REVIEW

The aim of this narrative review is to evaluate the current available literature on urinary outcomes following cryotherapy and high-intensity focused ultrasound (HIFU) for localized prostate cancer (PCa).

RECENT FINDINGS

The available literature is heterogeneous in terms of intervention modalities and assessment of urinary outcome measures. Nevertheless, ultra-minimally invasive treatments seem to provide good urinary outcomes. Technological advancement and the adoption of more conservative ablation templates allow for a further reduction of toxicity and better preservation of urinary function. Urinary incontinence occurs in 0-10% of the patients and, is mostly transient. Voiding and storage lower urinary tract symptoms (LUTS) mostly occur in the early postoperative period and rarely require surgical treatment. Focal therapies performed with a salvage intent after external beam radiotherapy have a significantly higher impact on patient's urinary function.

SUMMARY

Ultra-minimally invasive treatment for PCa show a good safety profile concerning urinary function, but consensus on when and how best to assess this is still lacking. Efforts should be made to standardize the report of preoperative and postoperative urinary function to provide higher level of evidence.

MRI-Guided Salvage Focal Cryoablation: A 10-Year Single-Center Experience in 114 Patients with Localized Recurrent Prostate Cancer

Patients with localized recurrent prostate cancer (PCa) are eligible for androgen-deprivation therapy, salvage radical prostatectomy (RP) or radiation therapy. These treatments are associated with serious side-effects, illustrating the need for alternative local treatment options with lower morbidity rates. All patients who underwent magnetic resonance imaging (MRI)-guided salvage focal cryoablation (SFC) with localized recurrent PCa between 2011-2021 (n = 114) were included. Two subgroups were formed: patients without (n = 99) and with prior RP (n = 15). We assessed the recurrence- (RFS) and treatment-free survival (TFS), measured from date of treatment to date of recurrence or initiation of additional salvage treatment, using Kaplan-Meier plots. Complications were reported using the Clavien-Dindo (CD) scale. Overall 1-year and 5-year RFS were 76.0% and 25.1%, and overall 1-year and 5-year TFS were 91.5% and 58.2%, respectively. Patients without prior RP showed a significantly higher 1-year (78.5% vs. 52.5%) and 5-year RFS (28.1% vs. 0.0%; p = 0.03), and a trend towards a higher 1-year (92.6% vs. 79.0%) and 5-year TFS (60.2% vs. 23.0%; p = 0.10) compared to those with prior RP. A total of 46 complications occurred in 37 patients, and the overall complication rate was 32.4% (37/114 patients). The majority (41/46; 89.1%) of complications were minor (CD 1-2). Overall (31.3 vs. 40.0%) and major (3.0 vs. 13.3%) complication rates were lower in patients without compared to those with prior RP, respectively. MRI-guided SFC is an effective and safe therapy for patients with recurrent PCa, and has proved to delay and potentially prevent the initiation of salvage treatments. Patients with locally recurrent PCa after prior RP had an increased risk of recurrence, a shortened time to additional treatment, and more complications compared to those without prior RP, which should be considered when selecting patients for SFC.

A phase I prospective, non-randomized trial of autologous dendritic cell-based cryoimmunotherapy in patients with metastatic castration-resistant prostate cancer

Metastatic castration-resistant prostate cancer (mCRPC) is an immunologically cold disease with dismal outcomes. Cryoablation destroys cancer tissue, releases tumor-associated antigens and creates a pro-inflammatory microenvironment, while dendritic cells (DCs) activate immune responses through processing of antigens. Immunotherapy combinations could enhance the anti-tumor efficacy. This open-label, single-arm, single-center phase I trial determined the safety and tolerability of combining cryoablation and autologous immature DC, without and with checkpoint inhibitors. Immune responses and clinical outcomes were evaluated. Patients with mCRPC, confirmed metastases and intact prostate gland were included. The first participants underwent prostate cryoablation with intratumoral injection of autologous DCs in a 3 + 3 design. In the second part, patients received cryoablation, the highest acceptable DC dose, and checkpoint inhibition with either ipilimumab or pembrolizumab. Sequentially collected information on adverse events, quality of life, blood values and images were analyzed by standard descriptive statistics. Neither dose-limiting toxicities nor adverse events > grade 3 were observed in the 18 participants. Results indicate antitumor activity through altered T cell receptor repertoires, and 33% durable (> 46 weeks) clinical benefit with median 40.7 months overall survival. Post-treatment pain and fatigue were associated with circulating tumor cell (CTC) presence at inclusion, while CTC responses correlated with clinical outcomes. This trial demonstrates that cryoimmunotherapy in mCRPC is safe and well tolerated, also for the highest DC dose (2.0 × 108) combined with checkpoint inhibitors. Further studies focusing on the biologic indications of antitumor activity and immune system activation could be considered through a phase II trial focusing on treatment responses and immunologic biomarkers.

Narrative review-focal therapy: are we ready to change the prostate cancer treatment paradigm?

Background and Objective

Prostate cancer (PCa) has seen improved detection methods with a subsequent rise in disease prevalence, making novel prostate cancer treatment options an exciting yet controversial topic. Current treatment modalities encompass traditional approaches, namely surgery (radical prostatectomy) and radiation therapy. While heralded as a standard of care, these modalities may come with significant risk profiles, primarily sexual (erectile dysfunction) and urinary incontinence. Advances in technology and imaging, specifically multi-parametric MRI, have afforded great leaps in targeted focal therapy as a primary treatment option for localized PCa. This review identifies and highlights published data for novel and emerging PCa focal therapy (FT) modalities.

Methods

Our study identified and reviewed the current literature for relevant investigations related to primary FT modalities as they apply to the treatment of prostate cancer. After an internal review, relevant studies (published in English, between 2000-April 2022) were included for analysis and summarization.

Key Content and Findings

We provide a concise review of several novel focal therapy modalities that offer realistic potential for primary treatment of localized prostate cancer. Our narrative includes studies that primarily include their respective results, specifically focusing on those that reported both oncologic and quality-of-life outcomes after focal therapy. While still in its cumulative infancy, we discuss the current limitations, future directions, and advancements that hopefully push focal therapy into the limelight.

Conclusions

While many of the mentioned focal therapies for PCa have shown promising pathologic and quality of life outcomes, further clinical evidence is required to change overall management guidelines and recommendations. The advantages of FT in avoiding sexual and urinary side-effects of radical surgery or radiation are apparent; however, it is necessary to recognize the need for further long-term evidence that is durable over time and comparable to current gold-standard treatment options.

Focal therapy versus radical prostatectomy and external beam radiotherapy as primary treatment options for non-metastatic prostate cancer: results of a cost-effectiveness analysis

AIMS

Focal therapy treats individual areas of tumour in non-metastatic prostate cancer in patients unsuitable for active surveillance. The aim of this work was to evaluate the cost-effectiveness of focal therapy versus prostatectomy and external beam radiotherapy (EBRT).

MATERIALS AND METHODS

A Markov cohort health state transition model with four health states (stable disease, local recurrence, metastatic disease and death) was created, evaluating costs and utilities over a 10-year time horizon for patients diagnosed with non-metastatic prostate cancer. National Health Service (NHS) for England perspective was used, based on direct healthcare costs. Clinical transition probabilities were derived from prostate cancer registries in patients undergoing radical prostatectomy, EBRT and focal therapy using cryotherapy (Boston Scientific) or high-intensity focused ultrasound (HIFU) (Sonablate). Propensity score matching was used to ensure that at-risk populations were comparable. Variables included age, prostate-specific antigen (PSA), International Society of Urological Pathology (ISUP) grade group, maximum cancer core length (mm), T-stage and year of treatment.

RESULTS

Focal therapy was associated with a lower overall cost and higher quality-adjusted life year (QALY) gains than either prostatectomy or EBRT, dominating both treatment strategies. Positive incremental net monetary benefit (NMB) values confirm focal therapy as cost-effective versus the alternatives at a willingness to pay (WTP) threshold of £30,000/QALY. One-way deterministic sensitivity analyses revealed consistent results.

LIMITATIONS

Data used to calculate the transition probabilities were derived from a limited number of hospitals meaning that other potential treatment options were excluded. Limited data were available on later outcomes and none on quality of life data, therefore, literature-based estimates were used.

CONCLUSIONS

Cost-effectiveness modelling demonstrates use of focal therapy (cryotherapy or HIFU) is associated with greater QALY gains at a lower overall cost than either radical prostatectomy or EBRT, representing good value for money in the NHS.

Evolving imaging methods of prostate cancer and the emergence of magnetic resonance imaging guided ablation techniques

Established therapies for prostate cancer (PCa), surgery and radiotherapy, treat the entire gland regardless of the location of the cancerous lesion within the prostate. Although effective, these methods include a significant risk of worsening genitourinary outcomes. Targeted image-guided cancer therapy has gained acceptance through improved PCa detection, localization, and characterization by magnetic resonance imaging (MRI). Minimally-invasive ablative techniques aim to achieve comparable oncological outcomes to radical treatment while preserving genitourinary function. Transurethral ultrasound ablation (TULSA) and next-generation transrectal high-intensity focused ultrasound (HIFU) utilize MRI guidance to thermally ablate prostate tissue under real-time MRI monitoring and active temperature feedback control. Previous trials performed by our group and others, including a large multicenter study in men with localized favorable-risk disease, have demonstrated that TULSA provides effective prostate ablation with a favorable safety profile and low impact on quality of life. Recently, MRI-guided HIFU focal therapy was also shown as a safe and effective treatment of intermediate-risk PCa. Here we review the current literature on ablative techniques in the treatment of localized PCa with a focus on TULSA and HIFU methods.

Salvage external beam radiotherapy after HIFU failure in localized prostate cancer: A single institution experience

Purpose/objectives

High-intensity focused ultrasound (HIFU) remains investigational as primary treatment for localized prostate cancer but is sometimes offered to select patients. At HIFU failure, data guiding salvage treatment is limited to small retrospective series with short follow-up. We evaluated our institutional experience using salvage radiation therapy (SRT) after HIFU failure.

Materials/methods

We conducted a retrospective analysis of patients with local failure post-HIFU who received salvage image-guided external beam radiation therapy (EBRT) delivered via intensity-modulated radiotherapy (IMRT). Our primary endpoint was biochemical failure-free survival (bFFS) defined as prostate-specific antigen (PSA) nadir + 2 ng/mL. Secondary endpoints included metastasis-free survival (MFS) and overall survival (OS). Endpoints were evaluated using Kaplan-Meier analysis.

Results

From 2013 to 2018, 12 out of 96 patients treated with primary HIFU received SRT via conventional or moderate hypofractionation. Median time from HIFU to SRT was 13.5 months. Seven patients had stage migration to high-risk disease at the time of SRT. Mean PSA prior to SRT was 8.2ug/L and mean nadir post-SRT was 1.2ug/L. Acute International Prostate Symptom Score (IPSS) as well as International Index of Erectile Dysfunction (IIEF) scores were similar to baseline (p = 0.5 and 0.1, respectively). Late toxicities were comparable to those reported after primary EBRT for localized prostate cancer. At a median follow-up of 46 months, the OS was 100%. The 5-year bFFS and MFS were both 83.3%.

Conclusions

To our knowledge, we report one of the largest series on contemporary SRT post HIFU failure. We show that SRT is feasible, effective and carries no additional acute or delayed toxicity.

Boosting the Immune Response—Combining Local and Immune Therapy for Prostate Cancer Treatment

Due to its slow progression and susceptibility to radical forms of treatment, low-grade PC is associated with high overall survival (OS). With the clinical progression of PC, the therapy is becoming more complex. The immunosuppressive tumor microenvironment (TME) makes PC a difficult target for most immunotherapeutics. Its general immune resistance is established by e.g., immune evasion through Treg cells, synthesis of immunosuppressive mediators, and the defective expression of surface neoantigens. The success of sipuleucel-T in clinical trials initiated several other clinical studies that specifically target the immune escape of tumors and eliminate the immunosuppressive properties of the TME. In the settings of PC treatment, this can be commonly achieved with radiation therapy (RT). In addition, focal therapies usually applied for localized PC, such as high-intensity focused ultrasound (HIFU) therapy, cryotherapy, photodynamic therapy (PDT), and irreversible electroporation (IRE) were shown to boost the anti-cancer response. Nevertheless, the present guidelines restrict their application to the context of a clinical trial or a prospective cohort study. This review explains how RT and focal therapies enhance the immune response. We also provide data supporting the combination of RT and focal treatments with immune therapies.

Rectourethral fistula following focal irreversible electroporation for prostate cancer

A man in his 50s presented 4-week postirreversible electroporation (IRE) for low-to-intermediate risk prostate cancer with urinary symptoms, diarrhoea and passing fluid per rectum when urinating. Urine microscopy and sensitivities showed raised leucocytes, erythrocytes and pansensitive Escherichia coli. A CT cystogram revealed a rectourethral fistula (RUF). Urinary diversion with insertion of an indwelling catheter for 6 weeks was performed. A rigid cystoscopy 6 weeks after urinary diversion revealed that the fistula was still present, confirmed by intraoperative contrast. The fistula was repaired with diathermy and a fibrin glue. The patient reported resolution of urinary and bowel symptoms. This is the first case report in the literature of an RUF following IRE for prostate cancer. It is important to report these rare complications as novel treatments become more common across the world.Background

Different effects of intravenous and local anesthesia in patients undergoing ultrasound-guided radiofrequency ablation of thyroid nodules: a prospective cohort study

PURPOSE

To compare the efficacy and safety of intravenous anesthesia (IV) with local anesthesia (LA) in patients undergoing ultrasound (US)-guided radiofrequency ablation (RFA) of thyroid nodules.

METHODS

50 patients with American Society of Anesthesiologists classification grades I-II undergoing US-guided thyroid RFA were enrolled and randomly (1:1) divided into IV (conscious sedation with Ramsay Sedation Scale [RSS] scores of 2-3 with an anesthesiologist) and LA (subcutaneous anesthesia with lidocaine without an anesthesiologist) groups. Pre-, intra- and post-procedural blood pressure (BP) (SBP₀/DBP₀, SBP₁/DBP₁, and SBP₂/DBP₂), intra- and post-procedural pain (NRS₁ and NRS₂), ablated area volume, treatment time and adverse events were analyzed and compared.

RESULTS

Age, sex, weight, number, nature, volume of nodules, and SBP₀/DBP₀ showed no difference between both groups. 11 and 0 patients' SBP₁/DBP₁ were elevated in the LA and IV groups. NRS₁ differed between both groups. 6 patients in the LA group had moderate or severe pain, but none in the IV group. No between-group difference in SBP₂/DBP₂, NRS₂, ablation completion rate and ablated volume was noted. The median procedure duration differed from 1109 (176) s in IV group and 723 (227) s in LA groups. There was no increased incidence of adverse events in IV group.

CONCLUSIONS

IV with RSS scores of 2-3 maintained intra-procedural BP and relieved intra-procedural pain better, without affecting the ablation efficacy and increasing complications. Despite increased treatment time, IV is a potential option for patients undergoing US-guided RFA of thyroid nodules.

Long-term outcomes of whole gland high-intensity focused ultrasound for localized prostate cancer

OBJECTIVES

To report the 10-year oncologic and functional outcomes of whole-gland HIFU as first-line treatment for localized prostate cancer (PCa).

PATIENTS AND METHODS

Patients were retrospectively included between January 2005 and July 2018 from a prospectively maintained database at a single academic institution. No patient underwent androgen deprivation therapy prior to HIFU. Primary endpoint was biochemical recurrence-free survival (BRFS). Secondary oncological endpoints included salvage treatment-free survival (STFS), cancer-specific survival (CSS) and overall survival (OS).

RESULTS

A total of 97 patients met our inclusion criteria and were included in the final analysis. According to D'Amico classification, the numbers of patients with low-, intermediate-, and high-risk disease were 38 (39.2%), 52 (53.6%), and 7 (7.2%). A total of 21 (21.6%) patients received salvage treatment at a mean of 4.1 years (± 2.8) after HIFU. The 10-year OS, CSS and BRFS rates were 91.8%, 100% and 40.3% in the overall cohort, respectively. In multivariate analysis, predictive factors for biochemical recurrence were intermediate-risk group (RR = 2.065; 95% CI 1.008-4.230; p = 0.047) and PSA nadir > 0.5 ng/mL (RR = 4.963; 95% CI 2.251-10.947; p < 0.001). Symptoms related to bladder outlet obstruction were the most frequently recorded adverse events. In multivariate analysis, positive biopsy on the prostatic apex was predictor of obstructive complications (RR = 3.2, 95% CI 1.092-9.476, p = 0.034). Only four patients developed severe urinary incontinence (> 1 pad/day).

CONCLUSIONS

HIFU showed low PCa-specific mortality, but biochemical recurrence rates were highly variable among patients. Future studies are needed to improve patient selection.

Rectourethral Fistula Induced by Localised Prostate Cancer Treatment: Surgical and Functional Outcomes of Transperineal Repair with Gracilis Muscle Flap Interposition

BACKGROUND

Transperineal repair of rectourethral fistula (RUF) following prostate cancer treatment with gracilis muscle flap interposition (GMFI) leads to favourable outcomes, but published data are still lacking, notably concerning functional aspects.

OBJECTIVE

To assess surgical and functional outcomes of this treatment of RUF.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective study was conducted in two referral hospitals including 21 patients who underwent RUF transperineal repair with GMFI between 2008 and 2020.

SURGICAL PROCEDURE

The standard vertical perineal approach is performed for fistula dissection. Bladder and rectal defects are closed separately. After dissection from its facia, the flap is harvested, preserving its pedicle; it is brought to the perineum and placed between the urethra and the rectum to fully cover the sutures.

MEASUREMENTS

Fistula closure (clinical data and postoperative cystography), digestive stoma closure, and complications graded according to the Clavien-Dindo classification were reviewed. Functional results were assessed using the Urinary Symptom Profile (USP) questionnaire, anal incontinence St Mark's score, Patient Observer Scar Assessment Scale (POSAS) score, and a nonvalidated Likert scale questionnaire assessing issues with lower extremity functionality.

RESULTS AND LIMITATIONS

The median (interquartile range) follow-up was 27 (8-47) mo. Fistula closure was successful for 20 patients (95% success). Digestive stoma was closed in 10/12 shunted patients (83%). Two (9%) Clavien-Dindo grade ≥3b complications were reported (one urinoma in a kidney transplant patient and one thigh haematoma evacuation). Eighteen patients (86%) completed the postoperative questionnaire; 11/18 (61%) had significant urinary incontinence. The mean (standard deviation) USP dysuria score was 1/9 (1.2), mean St Mark's score was 5/24 (5), mean POSAS score was 19/70 (11), mean lower extremity functionality score was 2/20 (4), and mean procedure patient satisfaction score was 9/10 (2). The retrospective design and limited number of patients are the main limitations.

CONCLUSIONS

The present study found an excellent success rate and low morbidity for RUF transperineal repair with GMFI. Functional outcomes were satisfactory despite a high urinary incontinence rate.

PATIENT SUMMARY

We performed an analysis of the outcomes of perineal approach surgery with muscle interposition for closing abnormal communication between the bladder and the rectum after prostate cancer treatment. This surgical technique was found to be safe to perform and provides a high success rate, with patients being satisfied despite poor urinary continence outcomes.

Prevalence and outcomes of focal ablation versus prostatectomy for elderly patients with prostate cancer: a population-based study

Background

Despite rapid advances in the treatment of prostate cancer (PCa), the optimal treatment for elderly patients with PCa remains unclear due to a lack of high-quality evidence. This study aimed to evaluate whether surgical procedures are beneficial for PCa patients aged 75 years and older and compare the effects of focal ablation and prostatectomy.

Methods

Male patients aged 75 years and older who were diagnosed with Tis-T2/N0/M0 PCa between 2000 and 2017 were retrospectively identified from the Surveillance, Epidemiology, and End Results program database. Cox regression models were used to test for statistical differences between the overall survival (OS) and disease-specific survival (DSS).

Results

A total of 114,506 patients aged 75 years and older with PCa were included in this study, among which 60,131 died during the study period. The most prevalent surgical procedure for these patients was focal ablation. The local excision rate increased with advancing age, while the prostatectomy rate decreased sharply with age. The proportion of the elderly patients who underwent a focal ablation also increased with the age at diagnosis. The survival rate of patients aged 75 years and older who underwent a focal ablation was significantly worse than that for those who did not undergo any surgical procedures (OS: HR, 1.32, P<0.001; DSS: HR, 1.58, P<0.001). Although only a few of the patients underwent prostatectomy, the procedure was still related to improved OS and DSS (OS: HR, 0.60, P< 0.001; DSS: HR, 0.37, P<0.001) rates.

Conclusions

Focal ablation has gradually replaced prostatectomy as the most common surgical procedure for elderly patients with PCa in the United States. However, our results revealed that the procedure might not provide benefits for elderly patients with PCa; instead, we found that focal ablation resulted in increased negative effects on patient prognoses. Elderly patients should have the same opportunity to be treated with standard surgical interventions as younger patients.

Determinants of pyelonephritis onset in patients with obstructive urolithiasis

BACKGROUND

Acute obstructive pyelonephritis due to urolithiasis represents a medico-surgical emergency that can lead to life-threatening complications. There are still no established factors that reliably predict progression toward acute pyelonephritis in patients presenting with a simple renal colic.

OBJECTIVE

To investigate clinical and paraclinical factors that are associated with the onset of acute obstructive pyelonephritis.

METHODS

Patients presenting to the emergency department for renal colic with obstructive urolithiasis on imaging were enrolled in the study. Demographic data, vital signs, medical comorbidities, blood test results, urinalysis, and radiological findings were recorded. Obstructive pyelonephritis was defined by the presence of two or more of the following criteria: fever, flank pain or costovertebral angle tenderness, and a positive urine culture.

RESULTS

Seventeen patients out of 120 presenting with renal colic, were diagnosed with acute obstructive pyelonephritis (14%). Parameters that were associated with the onset of obstructive pyelonephritis were: diabetes (p = 0.03), elevated CRP (p = 0.01), stone size (>5 mm) (p = 0.03), dilatation of renal pelvis (p = 0.01), peri-renal fat stranding (p = 0.02), and positive nitrites on urinalysis (p < 0.01). Hyperleukocytosis, acute kidney injury, multiple stones, pyuria (>10/mm³), hypertension, and were not associated with the onset of obstructive pyelonephritis.

CONCLUSION

This study showed that known diabetic status, elevated CRP, positive urine nitrites, stone size (>5 mm), pyelic dilatation, and peri-renal fat stranding were associated with the onset of pyelonephritis in patients presenting to the emergency department with obstructive urolithiasis.

Stereotactic Ablative Brachytherapy: Recent Advances in Optimization of Radiobiological Cancer Therapy

Brachytherapy (BT), a type of focal anti-cancer radiotherapy, delivers a highly focused radiation dose to localized tumors, sparing surrounding normal tissues. Recent technological advances have helped to increase the accuracy of BT and, thus, improve BT-based cancer treatment. Stereotactic ablative brachytherapy (SABT) was designed to improve the ablative effect of radiation, which was achieved via improved image guidance, and calculation of ablative dose, shorter treatment duration, and better organ preservation. Recently collected data characterized SABT as having the potential to cure various early-stage cancers. The method provides higher tumor control rate levels that were previously achievable only by surgical resection. Notably, SABT is suitable for application with unresectable malignancies. However, the pathological assessment of SABT irradiated tumors is limited due to difficulties in specimen acquisition. Prostate, lung, liver, and gynecological cancers are the most commonly reported SABT-treated malignancies. This study will give an overview of SABT, focusing on the advances in SABT optimization, and provide insights on the future benefits of the combined application of SABT with cancer immunotherapies.

EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent

OBJECTIVE

To present a summary of the 2020 version of the European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Geriatric Oncology (SIOG) guidelines on screening, diagnosis, and local treatment of clinically localised prostate cancer (PCa).

EVIDENCE ACQUISITION

The panel performed a literature review of new data, covering the time frame between 2016 and 2020. The guidelines were updated and a strength rating for each recommendation was added based on a systematic review of the evidence.

EVIDENCE SYNTHESIS

A risk-adapted strategy for identifying men who may develop PCa is advised, generally commencing at 50 yr of age and based on individualised life expectancy. Risk-adapted screening should be offered to men at increased risk from the age of 45 yr and to breast cancer susceptibility gene (BRCA) mutation carriers, who have been confirmed to be at risk of early and aggressive disease (mainly BRAC2), from around 40 yr of age. The use of multiparametric magnetic resonance imaging in order to avoid unnecessary biopsies is recommended. When a biopsy is performed, a combination of targeted and systematic biopsies must be offered. There is currently no place for the routine use of tissue-based biomarkers. Whilst prostate-specific membrane antigen positron emission tomography computed tomography is the most sensitive staging procedure, the lack of outcome benefit remains a major limitation. Active surveillance (AS) should always be discussed with low-risk patients, as well as with selected intermediate-risk patients with favourable International Society of Urological Pathology (ISUP) 2 lesions. Local therapies are addressed, as well as the AS journey and the management of persistent prostate-specific antigen after surgery. A strong recommendation to consider moderate hypofractionation in intermediate-risk patients is provided. Patients with cN1 PCa should be offered a local treatment combined with long-term hormonal treatment.

CONCLUSIONS

The evidence in the field of diagnosis, staging, and treatment of localised PCa is evolving rapidly. The 2020 EAU-EANM-ESTRO-ESUR-SIOG guidelines on PCa summarise the most recent findings and advice for their use in clinical practice. These PCa guidelines reflect the multidisciplinary nature of PCa management.

PATIENT SUMMARY

Updated prostate cancer guidelines are presented, addressing screening, diagnosis, and local treatment with curative intent. These guidelines rely on the available scientific evidence, and new insights will need to be considered and included on a regular basis. In some cases, the supporting evidence for new treatment options is not yet strong enough to provide a recommendation, which is why continuous updating is important. Patients must be fully informed of all relevant options and, together with their treating physicians, decide on the most optimal management for them.

Acceptance, Indications and Chances of Focal Therapy in Localized Prostate Cancer: A Real-World Perspective of Urologists in Germany

Purpose: Focal therapy (FT) became a frequently discussed treatment strategy of localized prostate cancer (PCa), but the acceptance and evaluation of FT by practicing urologists are still unclear. Methods: A 25-item anonymized online questionnaire (SurveyMonkey^®) was compiled by the German Society of Residents in Urology Academics Prostate Cancer Working Group and sent to the members of the German association of Urology. Logistic regression analysis was performed to determine parameters for suggestion FT. Results: Two hundred ten urologists (median age 49 years) participated, from which 72% stated PCa as their main treatment focus. Ninety-nine percent of urologists were aware of and 54% wanted to improve their knowledge about FT. Sixty-five percent do not treat PCa with FT. FT is seen as an alternative to active surveillance and radiotherapy/radical prostatectomy by 66% and 37%, respectively. Regarding FT treatment strategies, 35% and 45% would treat all or all significant PCa foci, respectively, whereas 19% would treat mainly the index foci. Currently, 27% believe that FT will be an option as standard treatment in future, but 48% would not suggest FT to their patients, owing to an absence of evidence and insufficient diagnostic tools for proper patient selection today. Suggesting FT to patients is associated with self-performing FT (odds ratio [OR] 2.88, 95% confidence interval [CI] 1.31-6.31) and believing in FT as a standard treatment in future (OR 9.05, 95% CI 6.68-22.30) (both p < 0.01). Conclusion: FT has currently no wide acceptance in German practicing urologists, mainly attributable to an absence of evidence for FT superiority compared to standard treatments.

Focal bipolar radiofrequency ablation for localized prostate cancer: Safety and feasibility

OBJECTIVES

To evaluate the safety and feasibility of focal bipolar radiofrequency ablation in men with localized prostate cancer.

METHODS

A review of 10 patients treated with a novel bipolar radiofrequency ablation probe integrated in a coil design (Encage; Trod Medical, Bradenton, FL, USA) between 2011 and 2017 in two prospective pilot trials. All men had clinical stage T1c prostate cancer, prostate-specific antigen <10 ng/mL and Gleason score ≤7. Ablation was carried out under general anesthesia, and bipolar probes were inserted transperineally under transrectal ultrasound guidance. Treatment-related adverse events, quality of life and negative biopsy rate were evaluated at 6 months after ablation. The Wilcoxon signed-rank test was used to compare baseline and post-treatment symptom scores.

RESULTS

The median age was 58 years (range 50-64 years) and the median prostate volume was 49.65 cc (range 21-68 cc). Prostate cancer with a Gleason score of 6 (3 + 3) and 7 (3 + 4) was noted in seven and three patients, respectively. The median number of radiofrequency ablation cycles was 2.5 (range 2-5). All patients were catheter-free and able to void the day of surgery. Within 6 months after ablation, all adverse events were low grade, with the exception of one grade 3 hematuria that required cystoscopy without coagulation. Six months after ablation bowel, urinary and hormonal functions, and overall satisfaction remained stable. Erectile dysfunction occurred in two out of four patients who had normal sexual function before the procedure. Neither urinary incontinence nor urinary infection was noted.

CONCLUSIONS

This first report on focal bipolar radiofrequency ablation documents a safe and feasible treatment option for selected patients with localized prostate cancer.

Whole-gland ablation therapy versus active surveillance for low-risk prostate cancer: a prospective study

Introduction

The objective of this study is assess the outcomes of whole-gland ablation (high-intensity focused ultrasound (HIFU), cryotherapy and brachytherapy) and active surveillance (AS) in patients with low-risk prostate cancer (PCa).

Material and methods

This prospective non-randomised study included 155 patients with low-risk PCa managed with either ablative therapy or AS. Follow-up included mpMRI, biopsies, prostate-specific antigen (PSA), quality of life and complications for up to 24 months. The primary endpoint was cancer progression. The secondary endpoint was the impact of each treatment on the quality of life.

Results

Mean total preoperative PSA was 8.8 ±1.5 ng/ml. Of 155 patients, 125 received treatment: 45 – HIFU; 45 – cryoablation; 35 – brachytherapy. Thirty were under AS. Mean nadir PSA levels were 0.64 ±0.55 ng/ml for HIFU, 0.53 ±0.38 ng/ml for cryoablation and 0.48 ±0.34 ng/ml for brachytherapy. In the AS group, mean PSA was 9.9 ±3.8 ng/ml. Biochemical relapse-free survival rates at 24 months were 81.8% for HIFU, 85% for cryoablation, 93.9% for brachytherapy and 93.3% for AS. In only one HIFU patient relapse was not confirmed on biopsy. Increased anxiety was found in up to 6.7% after treatment and in 36.7% of patients undergoing AS. The Kaplan-Meier analysis revealed no statistical differences between the techniques.

Conclusions

Whole-gland ablative therapy can be considered a viable treatment modality for carefully selected patients with low-risk PCa who are reluctant to select AS due to anxiety.

Active monitoring, radical prostatectomy and radical radiotherapy in PSA-detected clinically localised prostate cancer: the ProtecT three-arm RCT

BACKGROUND

Prostate cancer is the most common cancer among men in the UK. Prostate-specific antigen testing followed by biopsy leads to overdetection, overtreatment as well as undertreatment of the disease. Evidence of treatment effectiveness has lacked because of the paucity of randomised controlled trials comparing conventional treatments.

OBJECTIVES

To evaluate the effectiveness of conventional treatments for localised prostate cancer (active monitoring, radical prostatectomy and radical radiotherapy) in men aged 50-69 years.

DESIGN

A prospective, multicentre prostate-specific antigen testing programme followed by a randomised trial of treatment, with a comprehensive cohort follow-up.

SETTING

Prostate-specific antigen testing in primary care and treatment in nine urology departments in the UK.

PARTICIPANTS

Between 2001 and 2009, 228,966 men aged 50-69 years received an invitation to attend an appointment for information about the Prostate testing for cancer and Treatment (ProtecT) study and a prostate-specific antigen test; 82,429 men were tested, 2664 were diagnosed with localised prostate cancer, 1643 agreed to randomisation to active monitoring (n = 545), radical prostatectomy (n = 553) or radical radiotherapy (n = 545) and 997 chose a treatment.

INTERVENTIONS

The interventions were active monitoring, radical prostatectomy and radical radiotherapy.

TRIAL PRIMARY OUTCOME MEASURE

Definite or probable disease-specific mortality at the 10-year median follow-up in randomised participants.

SECONDARY OUTCOME MEASURES

Overall mortality, metastases, disease progression, treatment complications, resource utilisation and patient-reported outcomes.

RESULTS

There were no statistically significant differences between the groups for 17 prostate cancer-specific (p = 0.48) and 169 all-cause (p = 0.87) deaths. Eight men died of prostate cancer in the active monitoring group (1.5 per 1000 person-years, 95% confidence interval 0.7 to 3.0); five died of prostate cancer in the radical prostatectomy group (0.9 per 1000 person-years, 95% confidence interval 0.4 to 2.2 per 1000 person years) and four died of prostate cancer in the radical radiotherapy group (0.7 per 1000 person-years, 95% confidence interval 0.3 to 2.0 per 1000 person years). More men developed metastases in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring, n = 33 (6.3 per 1000 person-years, 95% confidence interval 4.5 to 8.8); radical prostatectomy, n = 13 (2.4 per 1000 person-years, 95% confidence interval 1.4 to 4.2 per 1000 person years); and radical radiotherapy, n = 16 (3.0 per 1000 person-years, 95% confidence interval 1.9 to 4.9 per 1000 person-years; p = 0.004). There were higher rates of disease progression in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring (n = 112; 22.9 per 1000 person-years, 95% confidence interval 19.0 to 27.5 per 1000 person years); radical prostatectomy (n = 46; 8.9 per 1000 person-years, 95% confidence interval 6.7 to 11.9 per 1000 person-years); and radical radiotherapy (n = 46; 9.0 per 1000 person-years, 95% confidence interval 6.7 to 12.0 per 1000 person years; p < 0.001). Radical prostatectomy had the greatest impact on sexual function/urinary continence and remained worse than radical radiotherapy and active monitoring. Radical radiotherapy's impact on sexual function was greatest at 6 months, but recovered somewhat in the majority of participants. Sexual and urinary function gradually declined in the active monitoring group. Bowel function was worse with radical radiotherapy at 6 months, but it recovered with the exception of bloody stools. Urinary voiding and nocturia worsened in the radical radiotherapy group at 6 months but recovered. Condition-specific quality-of-life effects mirrored functional changes. No differences in anxiety/depression or generic or cancer-related quality of life were found. At the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year, the probabilities that each arm was the most cost-effective option were 58% (radical radiotherapy), 32% (active monitoring) and 10% (radical prostatectomy).

LIMITATIONS

A single prostate-specific antigen test and transrectal ultrasound biopsies were used. There were very few non-white men in the trial. The majority of men had low- and intermediate-risk disease. Longer follow-up is needed.

CONCLUSIONS

At a median follow-up point of 10 years, prostate cancer-specific mortality was low, irrespective of the assigned treatment. Radical prostatectomy and radical radiotherapy reduced disease progression and metastases, but with side effects. Further work is needed to follow up participants at a median of 15 years.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN20141297.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 37. See the National Institute for Health Research Journals Library website for further project information.

Cryotherapy shows no inferiority compared with radical Prostatectomy for low-risk and intermediate-risk localized Prostate Cancer: a real-world study from the SEER database

Background: For localized prostate cancer (PCa) with a low disease burden, whole-gland resection seems like overtreatment, while focal therapy, including cryosurgery, can achieve similar outcomes. We aimed at comparing the long-term survival outcomes of cryotherapy and radical prostatectomy (RP) and further exploring whether RP can be replaced by cryosurgery for those with low-risk PCa.

Methods: We conducted analyses from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015) and performed propensity score matching and used an instrumental variate to reduce the influence of bias and unmeasured confounders to the greatest extent.

Results: In the multivariate regression, patients who received cryotherapy had higher risk of overall mortality (OM) (hazard ratio [HR] = 2.52, 95% confidence interval [CI] 1.99-3.20, p < 0.001), but no significant difference was observed in decreasing cancer-specific mortality (CSM) (HR = 1.38, 95% CI 0.63-3.03, p = 0.41) after adjusting the confounders. After propensity score matching, patients who underwent cryotherapy had higher OM and CSM rates (HR = 2.70 [95% CI 1.99-3.66, p < 0.001] and HR = 2.99 [95% CI 1.19-7.48, p = 0.02], respectively). In the IV-adjusted analyses, RP was superior to cryotherapy in decreasing OM (HR = 2.52, 95% CI 1.99-3.20), while no obvious decrease of CSM was observed in the comparison of RP and cryotherapy (HR = 1.38, 95% CI 0.63-3.03). The subgroup analyses showed that RP displayed an obvious benefit in decreasing CSM (HR = 5.02, 95% CI 1.30-19.39, p = 0.02) for those with a prostate-specific antigen (PSA) level higher than 10 ng/ml.

Conclusion: RP ranked as the best treatment in regard to tumor control, but the advantages of cryotherapy became evident when taking functional and oncological outcomes into account, especially for low- and intermediate-risk PCa with low PSA levels.

Cohort study of high-intensity focused ultrasound in the treatment of localised prostate cancer treatment: Medium-term results from a single centre

We report medium-term results in men receiving primary whole-gland HIFU (WG-HIFU) and following salvage treatment. One hundred and twenty-eight patients in a single hospital were enrolled. The enrolled patients were treated with WG-HIFU for primary localized prostate cancer. Salvage treatment include androgen deprivation therapy, secondary HIFU and salvage radiation therapy. Our primary outcomes were biochemical recurrence–free survival, salvage treatment–free survival, and metastasis-free survival. Secondary outcomes included urinary incontinence, de novo erectile dysfunction, acute epididymitis, bladder neck contracture, and urethral stricture. The 5-year biochemical recurrence–free survival rates were 85.7%, 82.7%, and 45.2% for D’Amico low-, intermediate-, and high-risk groups, respectively. Multivariate analysis revealed high risk group is the only predictor of significant shorter biochemical recurrence free survival, salvage treatment free survival, and metastasis free survival. Of 38 patients receiving salvage treatment after biochemical recurrence, 29 (76.3%) became free from biochemical recurrence. Rates of the adverse events of urinary incontinence, acute epididymitis, bladder neck contracture or urethral stricture, and de novo erectile dysfunction were 2.3%, 10.9%, 20.3%, 65.6%, respectively. In conclusion, WG-HIFU is an effective treatment option for localised prostate cancer, especially in D’Amico low- and intermediate-risk cases. The success rate of salvage treatment with radiation therapy and secondary HIFU for biochemical recurrence was acceptable. Fewer adverse events were caused by HIFU, especially incontinence and erectile dysfunction, than by radical prostatectomy and radiotherapy.

Post-HIFU locally relapsed prostate cancer: high-dose salvage radiotherapy guided by molecular imaging

PURPOSE

To evaluate tolerance and biochemical control rates of salvage external beam radiotherapy (EBRT) in patients with local relapse from prostate cancer (PC) after high-intensity focused ultrasound (HIFU) as primary treatment.

METHODS

Twenty-four patients presented biochemical failure of PC. Salvage EBRT to the residual prostate was performed with moderate hypofractionation schedule (MHRT) in 28 fractions (n = 16) or with extreme hypofractionation schedule (SBRT) in 5 fractions (n = 8) by means of image-guided volumetric modulation arc therapy. In case of MHRT, the median dose was 71.4 Gy, whereas in case of SBRT it was 32.5 Gy.

RESULTS

The median follow-up was 28 months. The median PSA nadir was 0.26 ng/mL. In case of MHRT, the median PSA nadir was 0.15 ng/mL and occurred within a median time of 19 months. In case of SBRT, the median PSA nadir was 0.64 ng/mL and occurred within a median time of 8 months. No G3 higher acute or late toxicity after EBRT was observed. Only three patients presented with G2 acute GI toxicity (actinic proctitis). Twelve patients experienced acute G1 GU toxicity: 8/16 of men treated with MHRT and 4/8 of men treated with SBRT. Complete local control of disease was achieved in 23/24 patients (96%).

CONCLUSIONS

Our data confirm the feasibility and the low toxicity of salvage EBRT with both schedules of treatment after HIFU failure. The findings of low acute toxicity and good biochemical control rates are encouraging, but a larger number of patients and a longer follow-up are needed to confirm these results.

[Percutaneous MR-guided prostate cancer cryoablation: Predictive factors and oncologic outcomes]

OBJECTIVE

To determine the pejorative predictive factors on oncologic outcomes of percutaneous MR-guided whole gland prostate cancer cryoablation (CA).

METHODS

Medical records of patients treated from 2009 to 2012, to assess medium-term oncologic outcomes, were reviewed. Prostate biopsies were performed in local recurrence suspicion (biochemical failure, MR follow-up failure).

RESULTS

Among 18 patients, mean age of 72.6 (61-78), 2 (11 %) and 7 (38.9 %) biological and reported biopsy-proven local recurrence respectively with our initial technic of CA. Mean follow-up and recurrence were 56.3 (±21.7) and 20.7 (±13.9) months respectively. A previous treatment of prostate cancer (P=0.5), pre-treatment PSA (P=0.2), pre-treatment Gleason/ISUP score (P=0.4), nadir PSA post-CA (P=0.22) were not associated with recurrence. Bilateral positive cores appears as a pejorative predictive factor (P=0.04). However mean pre-treatment positive cores percentage, 25 (±16.5) in responding patients versus 40.7 (±25.2) in case of recurrence, and maximum percentage of cancer extent in each positive core, 10.6 (±9.3) in responding patients versus 18.7 (±16.5) in case of recurrence, seemed associated with local recurrence after prostate CA but our analysis wasn't able to find a difference (P=0.09 and P=0.3 respectively) due to a lack of power.

CONCLUSION

Bilateral positive cores appears as a pejorative predictive factor. In our experience, important tumor volume seem to be a pejorative predictive factor for oncologic outcomes after PCA whereas treatment, PSA, Gleason/ISUP score, nadir PSA are not.

LEVEL OF EVIDENCE

4.

Salvage cryoablation for local recurrence of prostatic cancer after curative therapy

PURPOSE

The purpose of this study was to determine the efficacy of salvage cryotherapy for intra-prostatic and local extraprostatic recurrences after curative treatment of prostate adenocarcinoma.

MATERIAL AND METHOD

Twenty-eight men (mean age, 69±6 [SD] years; range: 51-82 years) treated with cryoablation for prostatic (N=21) or extraprostatic (N=7) recurrent prostate cancer after radiotherapy with or without associated prostatectomy were included. Technical success, complication and recurrences were reported. Biological recurrence was defined as an elevation ≥2ng/mL of prostate specific antigen (PSA) serum level after the treatment.

RESULTS

The mean follow-up was 18 months. Among the 21 patients with intraprostatic recurrence, 14 had successful cryotherapy with a mean decrease in serum prostate-specific antigen (PSA) levels of -5.7±2.6 (SD) ng/mL (range: -2.1 to -16.9ng/mL). Four patients (19%) had early progression and three patients (14%) had delayed biological recurrence (mean time: 15 months). Among the 7 patients with extraprostatic recurrence, 2/7 (291%) had successful cryotherapy with a decrease in PSA serum level of -2.7±1.6 (SD) ng/mL (range: -0.5--5.5ng/mL) and 4/7 (57%) had early biological recurrence after cryotherapy that required androgen deprivation therapy, whereas 1/7 (4%) was lost to follow-up. No major complications were observed for both intra- and extraprostatic recurrence.

CONCLUSION

Salvage cryoablation of locally recurrent prostate cancer after curative treatment is feasible and safe when the half prostate is treated. It could delay initiation of androgen deprivation therapy in these patients.

Partial ablation versus radical prostatectomy in intermediate-risk prostate cancer: the PART feasibility RCT

BACKGROUND

Prostate cancer (PCa) is the most common cancer in men in the UK. Patients with intermediate-risk, clinically localised disease are offered radical treatments such as surgery or radiotherapy, which can result in severe side effects. A number of alternative partial ablation (PA) technologies that may reduce treatment burden are available; however the comparative effectiveness of these techniques has never been evaluated in a randomised controlled trial (RCT).

OBJECTIVES

To assess the feasibility of a RCT of PA using high-intensity focused ultrasound (HIFU) versus radical prostatectomy (RP) for intermediate-risk PCa and to test and optimise methods of data capture.

DESIGN

We carried out a prospective, multicentre, open-label feasibility study to inform the design and conduct of a future RCT, involving a QuinteT Recruitment Intervention (QRI) to understand barriers to participation.

SETTING

Five NHS hospitals in England.

PARTICIPANTS

Men with unilateral, intermediate-risk, clinically localised PCa.

INTERVENTIONS

Radical prostatectomy compared with HIFU.

PRIMARY OUTCOME MEASURE

The randomisation of 80 men.

SECONDARY OUTCOME MEASURES

Findings of the QRI and assessment of data capture methods.

RESULTS

Eighty-seven patients consented to participate by 31 March 2017 and 82 men were randomised by 4 May 2017 (41 men to the RP arm and 41 to the HIFU arm). The QRI was conducted in two iterative phases: phase I identified a number of barriers to recruitment, including organisational challenges, lack of recruiter equipoise and difficulties communicating with patients about the study, and phase II comprised the development and delivery of tailored strategies to optimise recruitment, including group training, individual feedback and 'tips' documents. At the time of data extraction, on 10 October 2017, treatment data were available for 71 patients. Patient characteristics were similar at baseline and the rate of return of all clinical case report forms (CRFs) was 95%; the return rate of the patient-reported outcome measures (PROMs) questionnaire pack was 90.5%. Centres with specific long-standing expertise in offering HIFU as a routine NHS treatment option had lower recruitment rates (Basingstoke and Southampton) - with University College Hospital failing to enrol any participants - than centres offering HIFU in the trial context only.

CONCLUSIONS

Randomisation of men to a RCT comparing PA with radical treatments of the prostate is feasible. The QRI provided insights into the complexities of recruiting to this surgical trial and has highlighted a number of key lessons that are likely to be important if the study progresses to a main trial. A full RCT comparing clinical effectiveness, cost-effectiveness and quality-of-life outcomes between radical treatments and PA is now warranted.

FUTURE WORK

Men recruited to the feasibility study will be followed up for 36 months in accordance with the protocol. We will design a full RCT, taking into account the lessons learnt from this study. CRFs will be streamlined, and the length and frequency of PROMs and resource use diaries will be reviewed to reduce the burden on patients and research nurses and to optimise data completeness.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN99760303.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 52. See the NIHR Journals Library website for further project information.

Addition of Docetaxel to First-line Long-term Hormone Therapy in Prostate Cancer (STAMPEDE): Modelling to Estimate Long-term Survival, Quality-adjusted Survival, and Cost-effectiveness

BACKGROUND

Results from large randomised controlled trials have shown that adding docetaxel to the standard of care (SOC) for men initiating hormone therapy for prostate cancer (PC) prolongs survival for those with metastatic disease and prolongs failure-free survival for those without. To date there has been no formal assessment of whether funding docetaxel in this setting represents an appropriate use of UK National Health Service (NHS) resources.

OBJECTIVE

To assess whether administering docetaxel to men with PC starting long-term hormone therapy is cost-effective in a UK setting.

DESIGN, SETTING, AND PARTICIPANTS

We modelled health outcomes and costs in the UK NHS using data collected within the STAMPEDE trial, which enrolled men with high-risk, locally advanced metastatic or recurrent PC starting first-line hormone therapy.

INTERVENTION

SOC was hormone therapy for ≥2 yr and radiotherapy in some patients. Docetaxel (75mg/m2) was administered alongside SOC for six three-weekly cycles.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The model generated lifetime predictions of costs, changes in survival duration, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs).

RESULTS AND LIMITATIONS

The model predicted that docetaxel would extend survival (discounted quality-adjusted survival) by 0.89 yr (0.51) for metastatic PC and 0.78 yr (0.39) for nonmetastatic PC, and would be cost-effective in metastatic PC (ICER £5514/QALY vs SOC) and nonmetastatic PC (higher QALYs, lower costs vs SOC). Docetaxel remained cost-effective in nonmetastatic PC when the assumption of no survival advantage was modelled.

CONCLUSIONS

Docetaxel is cost-effective among patients with nonmetastatic and metastatic PC in a UK setting. Clinicians should consider whether the evidence is now sufficiently compelling to support docetaxel use in patients with nonmetastatic PC, as the opportunity to offer docetaxel at hormone therapy initiation will be missed for some patients by the time more mature survival data are available.

PATIENT SUMMARY

Starting docetaxel chemotherapy alongside hormone therapy represents a good use of UK National Health Service resources for patients with prostate cancer that is high risk or has spread to other parts of the body.

Overcoming difficulties with equipoise to enable recruitment to a randomised controlled trial of partial ablation vs radical prostatectomy for unilateral localised prostate cancer

OBJECTIVE

To describe how clinicians conceptualised equipoise in the PART (Partial prostate Ablation vs Radical prosTatectomy in intermediate-risk unilateral clinically localised prostate cancer) feasibility study and how this affected recruitment.

SUBJECTS AND METHODS

PART included a QuinteT Recruitment Intervention (QRI) to optimise recruitment. Phase I aimed to understand recruitment, and included: scrutinising recruitment data, interviewing the trial management group and recruiters (n = 13), and audio-recording recruitment consultations (n = 64). Data were analysed using qualitative content and thematic analysis methods. In Phase II, strategies to improve recruitment were developed and delivered.

RESULTS

Initially many recruiters found it difficult to maintain a position of equipoise and held preconceptions about which treatment was best for particular patients. They did not feel comfortable about approaching all eligible patients, and when the study was discussed, biases were conveyed through the use of terminology, poorly balanced information, and direct treatment recommendations. Individual and group feedback led to presentations to patients becoming clearer and enabled recruiters to reconsider their sense of equipoise. Although the precise impact of the QRI alone cannot be determined, recruitment increased (from a mean [range] of 1.4 [0-4] to 4.5 [0-12] patients/month) and the feasibility study reached its recruitment target.

CONCLUSION

Although clinicians find it challenging to recruit patients to a trial comparing different contemporary treatments for prostate cancer, training and support can enable recruiters to become more comfortable with conveying equipoise and providing clearer information to patients.

Functional results in the treatment of localized prostate cancer. An updated literature review

Prostate cancer is the second most frequently diagnosed cancer in men. The initial diagnosis is made in increasingly younger patients, so it seems to be essential to guarantee optimal functional results. We carried out a systematic search to define the functional results of each of the therapeutic options for localized prostate cancer. Radical prostatectomy generates a greater negative effect on urinary continence and erectile function compared to active surveillance and radiotherapy. Robotic surgery seems to offer better functional results, especially at the level of erectile function. Urinary and bowel symptoms are more pronounced after radiotherapy compared to other options. Patients must be warned of the possible functional results prior to choice of treatment.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : cancer de la prostate French ccAFU guidelines – Update 2018–2020: Prostate cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.007. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.007. That newer version of the text should be used when citing the article.

Is cryosurgery a feasible local therapy for bone metastatic prostate cancer?

INTRODUCTION

This study aims to assess whether cryosurgery is a feasible local therapy for bone metastatic prostate cancer (bmPCa).

METHODS

A total of 23 patients with bmPCa who received cryosurgery and adjuvant androgen deprivation therapy (ADT) were included in the cryosurgery group (Group 1). Another 23 matched patients who received only ADT served as the control (Group 2). Prostate-specific antigen (PSA) nadir level, time to PSA nadir, time to castration-resistant prostate cancer (CRPC), progression-free survival and therapy response of bone metastases were compared between the groups.

RESULTS

The median follow-up time in Group 1 and Group 2 patients was 37 (range 19-53) months and 42 (range 24-56) months, respectively. Patients in Group 1 had fewer local complications, lower PSA nadir level (0.23 ng/mL vs. 4.01 ng/mL; p = 0.024), shorter median time to PSA nadir (3 months vs. 7 months; p < 0.001), longer median time to CRPC (36 months vs. 27 months; p = 0.002) and longer progression-free survival (35 months vs. 26 months; p = 0.003) compared to those in Group 2. Therapy responses of bone metastases were similar in the two treatment groups (p = 0.689).

CONCLUSION

Cryosurgery is a feasible local therapy for bmPCa patients with prostate volume less than 50 mL and without bulk tumours outside the prostate capsula. Cryosurgery may decrease PSA nadir level, local complications and time to PSA nadir, delay time to CRPC and improve progression-free survival.

Focal therapy for localized prostate cancer: is there a "middle ground" between active surveillance and definitive treatment?

In recent years, it has come a long way in the diagnosis, treatment, and follow-up of prostate cancer. Beside this, it was argued that definitive treatments could cause overtreatment, particularly in the very low, low, and favorable risk group. When alternative treatment and follow-up methods are being considered for this group of patients, active surveillance is seen as a good alternative for patients with very low and low-risk groups in this era. However, it has become necessary to find other alternatives for patients in the favorable risk group or patients who cannot adopt active follow-up. In the light of technological developments, the concept of focal therapy was introduced with the intensification of research to treat only the lesioned area instead of treating the entire organ for prostate lesions though there are not many publications about many of them yet. According to the initial results, it was understood that the results could be good if the appropriate focal therapy technique was applied to the appropriate patient. Thus, focal therapies have begun to find their "middle ground" place between definitive therapies and active follow-up.