Oct. 01--Decades after lumpectomy became a standard option for women with breast
cancer, men are seeking a similarly targeted approach to prostate cancer, one
that gets rid of the tumor while preserving the organ.
This sensible tack has lagged in prostate cancer for many reasons, starting with
the fact that the golf-ball-size gland is inaccessible. It lies deep within the
pelvic cavity, surrounded by sensitive structures that are vital to sexual and
Now, however, an array of technologies is enabling doctors to visualize and zap
away prostate malignancies. Tissue is destroyed, or "ablated," by energy from
lasers, microwaves, extreme cold, or ultrasound.
The presumed -- but unproven -- advantage of focused ablation is less collateral
damage. In other words, less incontinence and impotence.
"I'm very happy with the results," Gary Crissman, 60, of Pittsburgh, said of his
care with high-intensity focused ultrasound (HIFU). "My sexual, urinary, and
rectal function are normal. I feel I won the trifecta."
Still, his experience shows not only a big risk of organ conserving treatment --
more about that later -- but also the eagerness of patients to undergo
treatments before they get U.S. approval. Targeted prostate cancer ablation
remains experimental and is available primarily in research centers.
Nonetheless, HIFU is being marketed to American men by SonaCare Medical and by
some American doctors trained to use its Sonablate HIFU system.
Patients go to a SonaCare "international treatment center" and pay out of
pocket. Crissman went to Puerto Vallarta, Mexico, and paid $25,000 for the
SonaCare, based in North Carolina, did not provide a representative for an
interview. But its website explains that it "operates a unique service
coordination program for physicians and patients" who travel to its clinics in
Canada, Argentina, the Dominican Republic, the Bahamas, and Mexico.
On Wednesday, the Prostate Cancer Foundation -- founded by a survivor, financier
Michael Milken -- will hold its annual Philadelphia fund-raiser, an all-day
event that ends at the Crystal Tea Room in the Wanamaker Building. More than $1
million has been raised this year, exceeding last year's total, to underwrite
The urgency has never been greater. The PSA screening test, once seen as a
lifesaving early-detection tool, is no longer recommended by health experts
because too many men are being treated for cancers that, left alone, would not
Urologists point out that the disease kills 30,000 American men a year, despite
a 30 percent reduction in deaths since the PSA was introduced in the late 1980s.
They urge wider use of an option men find nerve-racking: Monitor rather than
treat early-stage cancer, hoping it doesn't grow.
Targeted ablation is seen as a possible solution to this dilemma, at least for
"We need something more than all or nothing," said Herbert Lepor, a prominent
urologist and surgeon at New York University Langone Medical Center.
Lepor believes targeted ablation is "an exciting new realm." He is studying the
use of laser ablation guided by imaging that marries MRI and ultrasound.
"I don't think it matters whether you laser, HIFU or freeze the cancer," he
said. "The real challenge is patient selection."
That's because studies suggest two-thirds of men have cancer in several
locations in the gland. Even with the best technology, pinpointing these
microscopic malignancies before and during ablation therapy is hard.
It is not yet clear whether the best candidate for ablation has cancer in only
one spot, or whether missing some early malignancies does not undermine
long-term cancer control. What is clear from studies in Japan is that 20 to 40
percent of men had cancer recurrences five years after treatment.
"Men electing to pursue targeted ablation must realize there are uncertainties
as to whether all the cancer has been eradicated," Lepor and coauthors wrote in
their new book, Redefining Prostate Cancer. "These men must be followed with
post-treatment" tests and biopsies.
Leaving cancer cells behind is also a concern with radiation. But if radiation
fails, it can't be repeated, and the gland is usually too damaged to be safely
removed with surgery.
Ablative treatment, in contrast, can usually be repeated if cancer comes back.
Or, the man can opt for radiation or surgery.
That was a deciding factor for Crissman, a manufacturer's representative who was
54 when he was diagnosed in 2007. He and his wife decided "we'll take the chance
that if we don't get all of it, the procedure could be redone, and all the other
options are still open."
Last year, his rising PSA level signaled trouble.
"So I did HIFU again," he said. "When they redid it, I got a discount. They
While Crissman has had no lasting side effects, the safety profile of HIFU has
not been established in controlled studies. Less rigorous work in several
countries suggests HIFU has a 2 to 3 percent risk of incontinence, and a 20 to
30 percent risk of impotence.
David Chen, a urological oncologist at Fox Chase Cancer Center, is not convinced
that HIFU is safer or more precise than radiation, especially when the tumor is
at the edge of the prostate.
Chen is testing Sonablate as part of a multi-center clinical trial for men whose
cancer recurred after radiation. SonaCare hopes to use the results to get Food
and Drug Administration approval.
"It's like weeds," Chen said. "If weeds are in the middle of the yard, you can
use a shovel or weed-killer. But if the weeds are against the fence, how do you
treat it without damaging the neighbor's lawn? I worry that men who give these
testimonials were undertreated."
In a recent review, Memorial Sloan-Kettering Cancer Center urological surgeons
concluded that targeted ablation methods are not yet "game-changing." But they
are changing attitudes.
"They have contributed to a movement towards less invasive, focal treatment,"
wrote lead author Jonathan Coleman.
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