Advanced Treatments for Prostate Cancer

Prostate cancer is one disease, but it presents itself along a spectrum. Some men may have cancer that’s considered  lower risk, or clinically insignificant, which doesn’t require treatment, while others have cancer that is deemed higher risk, or clinically significant, and does require treatment.  

These days, prostate cancer specialists make their treatment decisions via a strategy called risk stratification. They determine a man’s level of risk, taking into account his overall health and priorities, and they tailor his treatment accordingly, in full collaboration with the patient. 

Risk stratification is a key component in diagnosing and managing prostate cancer, says Dr. Timothy McClure, an Assistant Professor of Urology spanning two departments—Medicine and Radiology—at Weill Cornell Medicine. The goal is to avoid over-treating prostate cancer. “That was common practice years ago, but things have changed dramatically with our better understanding of prostate cancer,” he says  

Low-risk prostate cancer 

Patients considered low-risk can now be safely monitored during their annual visit to the urologist’s office. Doctors call it “active surveillanc”  

Low-risk prostate cancer patients on active surveillance undergo a simple annual blood test to measure their PSA, or prostate-specific antigen, and imaging with a prostate MRI.  

The second part of active surveillance is to perform biopsies of the prostate gland. “We use an advanced technique called transperineal prostate biopsy, which can be done either with local anesthesia or sedation, depending on patient preference. 

Transperineal biopsy is safer than transrectal biopsy, an older method. The latter requires going through the wall of the rectum and comes with a higher risk of infection. Urologic oncologists at Weill Cornell Medicine use advanced imaging techniques to identify potential trouble spots and guide the needle used to take samples from the prostate gland. These are then sent to the lab for analysis.   

Higher-risk prostate cancer 

Patients with high-risk cancer generally require treatment via radiation and surgery. Traditional surgery is used to remove a discrete tumor or even the entire prostate gland, if absolutely necessary to save a man’s life.  

But there’s a gray zone that Dr. McClure calls “intermediate-risk” prostate cancer. That’s where many innovations are being brought to bear—most notably an approach known as focal therapy. 

Focal therapy for intermediate-risk prostate cancer 

The goal of focal therapy is to treat the precise areas of the prostate that contain cancerous cells. The approach comes with minimal side effects of the kind you may see with surgery and radiation. With focal therapy, “we minimize damage to the surrounding muscles and nerves during treatment, thus preserving both urinary and sexual function,” he says. “The goal of focal therapy is to minimize the side effects of treatment while reducing the risk of metastatic disease.” 

At Weill Cornell Medicine, there are three ways that Dr. McClure delivers focal therapy: cryo-ablation, high-intensity focused ultrasound (HIFU) and irreversible electroporation (IRE). 

Cryo-ablation is a minimally invasive treatment that entails the freezing of cancerous tissue within the prostate. It allows the surgeon to use data from biopsies to guide the needles and kill only the specific parts of the prostate that are cancerous. 

High-intensity focused ultrasound (HIFU), also minimally invasive, uses focused ultrasound waves to heat and destroy problematic areas of the prostate, leaving normal surrounding tissue unharmed.  

Irreversible electroporation (IRE) uses short electrical pulses to kill cancerous cells while preserving both nerves and connective tissue both in and around the prostate. This minimizes side effects while at the same time optimizing tissue destruction. 

Dr. McClure continues to lead clinical trials of focal therapy treatments, with highly promising results. 

Advanced imaging 

All of the advanced diagnostic methods and treatments available at Weill Cornell are dependent on equally advanced imaging methods. These include PMRI—an MRI scan designed to look for prostate cancer— and PSMA PET. 

PSMA, or prostate-specific membrane antigen, is a protein on the surface of many prostate cells. PSMA PET is designed to detect that protein, a marker of prostate cancer.  

PSMA PET scans are currently used in cases of advanced prostate cancer that has already spread. But there may be a role for PSMA PET in identifying those with localized, intermediate-risk cancer who may be appropriate candidates for one of the focal therapies described above.  

In yet another clinical trial, Dr. McClure is exploring the use of PSMA PET scans in patients on active surveillance. “One day soon, we may even be able to replace biopsy with advanced imaging like PSMA PET. Even with biopsy’s diagnostic benefits, it’s an invasive procedure after all, so it would be a welcome change to substitute imaging for biopsy in appropriate patients.” 

Individualized treatment 

Risk stratification aside, every patient is unique, he says. Treatments--even the most advanced focal therapies—can be tailored to a man’s preferences and priorities, especially around quality of life issues. Is he deeply concerned about the possibility of urinary incontinence? Is sexual function top-of-mind? Treatments for metastatic cancer may be more limited than those available to low- or intermediate-risk cancer patients, but at Weill Cornell, every man is treated first and foremost as an individual.  

“For us, categories serve as general guidelines. Just because you’re considered at intermediate risk doesn’t mean you’ll receive some particular, pre-ordained treatment. You are central to every decision, so be prepared to speak openly with your doctor if and when the time comes to decide which way to go.” 

Takeaway points