© 2002 by Oxford University Press
Journal of the National Cancer Institute, Vol. 94, No. 13, 963,
July 3, 2002
© 2002 Oxford University Press
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Will Less Drastic Procedures Replace Radical Prostatectomy?
Radical mastectomy was once the preferred treatment for early-stage breast cancer. Then studies showed that lumpectomy followed by radiation works just as well. Radical prostatectomy has been the gold standard treatment for prostate cancer since 1904. Could it meet a similar fate? Could less drastic measures be just as beneficial and have fewer adverse effects—even less drastic measures that leave the gland partially intact?
"If so, it won’t be immediately," said Baylor’s Brian Miles, M.D. "But the idea has occurred to a lot of clinicians and would surely appeal to many prostate cancer patients."
One clinician who looks favorably on the concept is Gary Onik, M.D., an interventional radiologist who pioneered ultrasound imaging of the prostate and heads the Center for Surgical Advancement in Celebration, Fla. While it is his routine practice to destroy cancerous prostates in their entirety, he is studying the possibility that this may not always be required.
At this year’s annual meeting of the Radiological Society of North America, for instance, he reported having rebiopsied a group of recently diagnosed patients to determine which of them had tumor on only one side of their glands. Patients who had tumors on only one side of the gland were then offered "exceptionally aggressive" unilateral cryotherapy.
Of the 12 such patients who received treatment, "none has had a recurrence of his cancer, only two are impotent, and none is incontinent" 17 months after treatment, Onik said. "And should they develop locally recurrent disease, we can repeat the cryotherapy."
As Onik noted, this is because the Center for Medicare and Medicaid Services—formerly the Health Care Financing Administration—has approved coverage of cryotherapy both for primary treatment of prostate cancer and localized treatment failures.
HIFU, of course, is not available in the United States. But Onik is not alone in thinking that it could potentially be used in the same way as cryotherapy. In fact, several urologists interviewed for this article said that it could be better for the purpose than cryotherapy because cell kill, in general, is more predictably achieved with heat than with cooling.
"I don’t have the FDA’s approval to try it," said Miles. "But I can envision what it could mean for patients—particularly those in their 70s and 80s—if their lesions are aggressive enough to make you and them uncomfortable with watchful waiting and you want, if at all possible, to spare them the alternatives and their side-effects. If you had the HIFU option, you could treat them focally and then carefully follow them with PSA and biopsies."
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