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CU urologists explain how enhanced biopsy techniques improve the accuracy of diagnosis and may inform suitability for targeted treatments.

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Improving Patient Outcomes in Prostate Cancer

CU urologists explain how enhanced biopsy techniques improve the accuracy of diagnosis and may inform suitability for targeted treatments.

Author Department of Surgery | Publish Date October 1, 2020

Although prostate cancer is treatable when found early, there are common fears that men share concerning prostate cancer.

“I hear from patients all the time stating they do not want to get tested and they do not want to know if they have prostate cancer. Due to the possible side effects associated with treatment,” says Paul Maroni, MD, associate professor in the Department of Surgery, Urology Division, program director of the Urologic Cancer Care Center and University of Colorado (CU) Cancer Center member.

prostateprovidersHistorically, radical treatments like radical prostatectomy or radiation therapy with hormonal therapy treat the entire prostate gland and can damage nearby tissue.

“Men are going to have more of the negative side effects from these past treatments. This can include urinary incontinence, erectile dysfunction (ED), or even bowel issues to name a few,” says Maroni. “However, new treatments are now reducing these side effects.”

These innovative treatment options have the capabilities to more accurately target the affected cancer cells while also reducing exposure to normal cells. The decrease in toxicity significantly reduces short and long-term side effects.

These new partial treatments, like cryotherapy and targeted radiation, reduce side effects according to a study published in Urology Gold Journal in 2017 from Al Barqawi, MD, associate professor in the Department of Surgery, Urology Division and CU Cancer Center member.

When it comes to deciding what treatment is best and how aggressive the cancer is there are a few things to consider. A routine prostate biopsy includes gathering 10-12 samples. A urologic oncologist must review these samples to make a decision on what treatment would be the best option for each patient.

“If a man has four or more biopsy cores with prostate cancer, that’s an advance cancer and we should be proposing surgery or radiation/hormonal therapy,” says Maroni. “But if there are only one or two biopsies with lower risk cancer, I wonder if aggressive treatments are more than what the patient needs.”

Defending the male reproductive system by localizing the cancer

 As an alternative to treating prostate cancer with radical treatments, treatment plans that incorporate targeted therapies are being used to isolate and attack cancer cells and tumors. These treatments, called targeted focal therapies, are performed in hopes of minimizing the damage to healthy cells and thus minimizing potential side effects.

With targeted therapy, pinpointing the affected areas can be a complex process and requires having the right tools. Prostate biopsies are more accurate when MRI images are fused with real-time ultrasound allowing urologists to better target abnormal areas of the prostate. This relies on a “multiparametric” MRI (mp-MRI) which blends powerful MRI magnets with complicated algorithms and specially trained radiologists.

“Prostate MRI with ultrasound fusion has been a game changer and is much more accurate,” says Maroni.

“Prostate MRI with ultrasound fusion
has been a game changer and
is much more accurate,” says Maroni.

3D mapping biopsy is another enhanced biopsy technique that has been used at the University of Colorado for almost two decades. With this biopsy, the urologist would do 30 to 100 prostate biopsies that are carefully mapped around the prostate. This has been shown to be highly accurate in finding the location and aggressiveness of prostate cancer.

A new study released by researchers from the University of Colorado Cancer Center proposes that 3D mapping biopsy is important to perform prior to targeted therapy. The study published in the Urology Gold Journal shows that men that had 3D mapping biopsy prior to cryoablation had less cancer recurrence than men that had cryoablation without 3D mapping biopsy. This is because 3D mapping biopsy found men that had aggressive cancers and were not good candidates for targeted therapies. These men were appropriately redirected to other therapies like surgery or whole prostate radiation therapy.

“This will then minimize overtreatment and provide a guide for targeted focal therapy with use of cryotherapy or laser guided ablation,” says Barqawi.

Minimizing side effects in prostate cancer treatments

There are a number of therapies that minimize side effects offered at UCHealth University of Colorado Hospital Tony Grampsas Urologic Cancer clinic including cryosurgery as well as advanced image-guided external beam radiation therapy (IMRT) and prostate brachytherapy.

Temporary hydrogel spacers can be utilized with radiation therapy to protect the rectum and some radiation treatments can be accomplished in as few as five treatments spaced out over a few weeks. Other treatments include clinical trials such as the nerve sparing radiation therapy trial, conducted by Tyler Robin, MD, PhD, assistant professor, Radiation Oncologist. Contemporary radiation therapy approaches utilize advanced technologies to reduce exposure to nearby tissues and minimize side effects.

prostateinfographic

What is Cryotherapy

“Among the currently available alternative options, new generation prostate cryotherapy provides an increasingly feasible alternative to bridge the gap of radical treatment and is associated with proven safety profile and reasonable intermediate-term oncologic outcomes,” says Barqawi.

Cryotherapy is simply the use of ‘cold temperatures’ as a form of treatment. As stated by the American Cancer Society, cryotherapy for prostate cancer involves the delivery of cold gases to freeze cancer cells. Treatment is performed by the use of cryoablation needles guided by the transrectal ultrasound. This technique ensures areas with cancerous cells are destroyed without damage to nearby tissues. The doctor monitors the ultrasound during the procedure to ensure proper placement.

Targeted cryoablation can also be accomplished in conjunction with other treatments and may have fewer side effects and complications compared to radical treatments.

What is image-guided external beam radiation therapy (IMRT)?

IMRT is a relatively new delivery method. It is a combined treatment approach that uses CT scans to guide the patient, so they are in the most ideal position for a precise radiation treatment.

Each treatment is based on utilizing daily 3D imaging to identify the exact shape, size, and location of the cancer. This enables the team to adapt to any changes from previous imaging or anatomical differences. The customization will ensure that the highly conformal radiation beam. With this increased precision, healthy tissues have less exposure to radiation.

What is a prostate brachytherapy?

Prostate brachytherapy is sometimes referred to as internal radiation because of the delivery method. Tiny radioactive seeds are placed into the prostate to deliver radioactive material to kill the cancerous cells. These seeds will not be removed and will instead lose their radioactivity over the course of weeks or months depending on the dosage.

As with the other treatment options, this method is often combined with other treatments. This is especially true if there is an increased risk of cancer growing beyond the prostate. For low grade and early stage prostate cancer, brachytherapy is generally used on its own.

Finding prostate cancer early requires a PSA test.

Men are encouraged to talk to their health care providers to learn their specific risk factors for developing prostate cancer. The earlier prostate cancer is detected, the more treatment options will be available leading to the greatest chance for less invasive treatment. Early staged diagnosis will greatly impact the treatment course and long-term side effects associated with therapy.

The CU multidisciplinary faculty at the urologic oncology clinic, which includes experts made up of oncologists, radiation oncologists, radiologists, surgeons and pathologists, want men to keep up with preventative screening and wish to remove many of the common fears associated with prostate cancer.

“Men are more afraid of treatment than they need to be,” says Maroni. “We can tailor a treatment approach that hopefully helps men avoid some of the side effects they fear.”

To learn more about your screening and treatment options, reach out to our partners at UCHealth.