17 October 2014 by Manit Arya
There has been considerable discussion around the training and quality-control of radical therapies in prostate cancer. A similar discussion is vital for focal therapy of clinically significant prostate cancer. Focal therapy is complex intervention, heavily reliant on accurate diagnostic and risk stratification information. Case selection should be consistent with the UCL Focal Therapy programme which is in turn consistent with the NCRN INDEX LITE study.
As a minimum disease must be localised using,
- accurate high quality mpMRI conducted and reported to British Society of Uro-radiology and European Society of Uro-radiology guidelines by radiologists trained and expert in such reporting. This should be followed by accurate targeted and/or transperineal systematic biopsies.
- If mpMRI is not appropriate due to contraindications then transperineal systematic template biopsies will be required as an alternative
Surgical expertise for delivery of focal therapy is critical. Whilst there are advisory/indicative numbers for radical therapy, driven by the evidence-base, there are currently no studies evaluating the learning curve and requisite minimum numbers for focal therapy. Nonetheless, the skills required for focal therapy are to easy and there is a need to set minimum numbers now in order to ensure quality is maintained. The Focal Therapy User group executive has consulted with expert focal therapy users in order to obtain a guidance on a starting point for defining minimum numbers.
Once physicians have fulfilled the training requirements set by each manufacturer for each modality (specific knowledge-based and observation in expert centres training followed by a number of proctored cases), the minimum numbers should apply:
- For focal HIFU in the treatment of primary clinically significant disease, we advise that surgeons conduct a minimum of 12 focal HIFU cases per year in the entirety of their practice (excluding redo cases)
- For focal HIFU in the treatment of radio-recurrent prostate cancer, we advise that surgeons only conduct these if they have an active high volume programme in primary disease as salvage cases are considerably more difficult.
- For other needle based interstitial therapies such as cryotherapy, we advise that surgeons conduct a minimum of 12 focal cases per year in the entirety of their practice (excluding redo cases)
- For focal interstitial needle-based treatment of radio-recurrent prostate cancer, we advise that surgeons only conduct these if they have an active high volume programme in primary disease as salvage cases are considerably more difficult.
- Surgeons should give strong consideration to ensuring redo cases are sent to higher volume expert centres or carried out with a proctor present.
The expectation is that this is a starting point and going forward we expect these minimum numbers to increase and regions to identify focal therapy experts.
Manit Arya, Hashim Ahmed, UCL/UCLH, Co-chairs, Focal Therapy User group, UK