Are you ready for ...lasers?

[dentaltwin]

I hope time will bear out the rather extravagant (but short-term) findings.

utmb.edu/newsroom/article12...

[Tall_Allen]

That's the problem with FLA - not enough long-term data and many unanswered questions. There are high out-of-pocket costs (not covered by insurance), often requires re-dos, and uncertain benefits (in spite of hype in articles like that).

[dentaltwin in reply to Tall_Allen]

I admit to a bias against lasers. Laser advocates in dentistry are--ardent. My brother has been threatened for coming out against them. But they're great because...dentistry apparently isn't expensive enough.

[Hindemith]

Tall Allen is right of course, but it's certainly a tempting notion. I know there's a (supposedly) big (and expensive - so much for not paying for clinical trials...) trial of this procedure ongoing in Southern California that hopefully will yield substantive data. I'd like to think that like HIFU, FLA will one day in the not-distant future be something akin to a gold standard. I'd also like to win one of those billion dollar lotteries. Though I will settle for a few hundred mill.

[dentaltwin in reply to Hindemith]

Paying to get into a clinical trial? What do the medical ethicists have to say about this? The advantage cited for laser surgery is mainly the precise focus and minimal damage to surrounding tissue, so I don't know that it WOULDN'T be effective. Seeing is believing.

[AlanMeyer Moderator]

I haven't got citations to support this but I seem to recall that focal treatment with both HIFU and cryotherapy did not provide the success rates of either surgery or radiation. Even many HIFU and cryo specialists now treat the entire prostate instead of parts of it.

One reason for this is that we don't have good ways of detecting small colonies of tumor cells in the prostate and so cannot be sure that we've got all of them with focal therapy.

If I'm reading the article correctly it appears that Dr. Walser understands this. He says: "FLA offers men more peace of mind than active surveillance or ‘watchful waiting’, the traditional alternative to radical treatment". He seems to be suggesting that it should be used by people who could be on active surveillance but are nervous about it and want to do something rather than nothing.

Is that a good idea? We don't know. We'll need longer term data from a well designed, controlled trial.

Since focal therapy is not new, I would also like to have seen Dr. Walser compare his treatment to cryotherapy and HIFU and address the question of what advantages and disadvantages laser treatment has in comparison to them.

Alan

[Hindemith in reply to AlanMeyer]

Excellent points, Alan. As someone new to this forum who's in the throes of making an AS/treatment decision, these are all valuable posts.

[dentaltwin in reply to AlanMeyer]

So, it's better for the head--not necessarily for the cancer.

[AlanMeyer Moderator in reply to dentaltwin]

"So, it's better for the head--not necessarily for the cancer."

Could be. One of the difficult things about prostate cancer is that there are so many treatments and the experts disagree about what is best. Surgery/radiation/cryo/HIFU/Active Surveillance/hormone therapy/... And there are multiple modes for some of them, for example for radiation - IMRT/hypofractionation/Cyberknife/proton beam/LDR brachytherapy/HDR brachy/ ... with or without adjuvant ADT.

A lot of us are wishing for someone to just tell us what to do, but I think the most responsible doctors give guarded opinions. The docs who have no doubts in their minds about the best treatment, especially if they recommend it for everyone, seem to me to be the least trustworthy.

It's enough to give anyone a headache.

Alan

[dentaltwin in reply to AlanMeyer]

Yes, and of course prostate cancer is not the only issue in medicine where this is true. Even those with sincerely held beliefs have their prejudices. Just as MOs and ROs have their own perspective, think of interventional cardiologists vs. cardiac surgeons. You have to hope that they're all very smart and very competent.

[Londear1992]

ncbi.nlm.nih.gov/pubmed/306...

[Londear1992]

liebertpub.com/doi/abs/10.1...

[Londear1992]

researchgate.net/publicatio...

[AlanMeyer Moderator in reply to Londear1992]

I think that one of the problems in medical research is that the publications advocating particular treatments are generally written by doctors who are specialists in those treatments. Surgeons recommend surgery. Rad oncs recommend radiation. HIFU specialists recommend HIFU, and so on.

I suppose there's no help for this. Do we want a person who doesn't do HIFU to tell us about it? Do we want people who do do HIFU to not publish their findings? Ideally we want collaborative studies done by a group of specialists of different types but, in the real world, that doesn't seem to happen, or at least not often. So we bumble along with what we can get.

However, I do urge people to approach medical publications with some caution. It's possible to gather together a collection of articles in support of almost any plausible treatment. Look at articles on both sides of an issue that is important for your own decision making. If you have some understanding of statistics or clinical trials, use it in your evaluations. Also look at the credentials of the authors and the journals involved, and what conflicts of interest the authors may have.

Alan

[Londear1992 in reply to AlanMeyer]

That is so true, Alan. As I have said to my husband, we could line up a dozen different prostate cancer doctors in our living room and each one would be a specialist in his own area of expertise. He or she would advocate for his treatment and diss the others. This is what we have found. It make things very confusing.

We have a friend in Chicago who opted for HIFU 12 years ago in Germany, and one of the biggest challenges he faced was follow up when he got back to the States. He tried 7 different urologists in Chicago and none would assist in removing his catheter once they heard he had had a HIFU treatment in Germany. He finally found one willing to help him with a tip off from the Cleveland Clinic Maple Leaf HIFU in Toronto.

Our friend still has a PSA of .64 after a hemi-ablation 12 years ago - very good considering he still has half a prostate. He has no issues with side effects.

We are still considering what to do. My husband has very similar stats to this friend, but if you talk to a urologist or a radiation oncologist, you come away scared to death to try HIFU.

The HIFU doctor we have in mind did at first recommend a radical prostatectomy when he thought my husband had cancer in both lobes, but the two small T1c tumors he has are in the left lobe only, so the doctor has said he can treat my husband with HIFU. Dr Thüroff has performed HIFU for 22 years in Germany.

We found it helpful to speak to the Cleveland Clinic Maple Leaf HIFU in Toronto. Dr Orovan's wife, who is his practice manager, said when a doctor devotes years and years to studying and perfecting a certain procedure, he becomes very committed to that particular treatment. He has to believe in it, she said, to provide that treatment day in and day out to his or her patients. That rang true to us.

In the end, for better or worse, a patient has to choose and it is very worrying since so much hinges on the outcome. One benefit we see to HIFU, is that if it does not work, it still may be possible to have additional HIFI, a radical prostatectomy or radiation.

I really wish there were organizations that would provide unbiased reports on a variety of treatments. The best I have found is through the National Health System in Britain. They are non-profit and that helps. Here is there description of treatments and outcomes: nhs.uk/conditions/prostate-...

[dentaltwin in reply to AlanMeyer]

The old saw about specialists: A specialist is a doctor who knows more and more about less and less until (s)he knows everything about nothing.

Yeah, but what does this say about the generalist?

[Hidden]

On a somewhat related subject I did some research prior to surgery for BPH -- enlarged prostate. Heard a bunch of advocates for laser vs conventional TURP. My surgeon could do either but I got the distinct impression that he was far more experienced and comfortable with old fashioned TURP so I went with TURP. That worked out just fine. BTW, in this context laser is suggested for patients on blood thinner medications as it causes less bleeding.

[dentaltwin in reply to Hidden]

That makes sense, and yes--it causes less bleeding. I haven't used a laser myself, but in dentistry both laser and electrosurgery will bleed less. Laser is definitely kinder to tissue.

[MelbourneDavid]

No comparison group means no proof of effectiveness. Randomization is really needed to avoid selection bias.

I am horrified by these non randomized pay to participate trials - they are unable to generate good quality science.

[dentaltwin in reply to MelbourneDavid]

I don't disagree.