Prostate Cancer Recurrence and Persistence After Irreversible Electroporation Focal Ablation
Mené entre 2015 et 2020 sur 106 patients atteints d'un cancer de la prostate de stade localisé à risque faible ou intermédiaire de récidive (âge médian : 64 ans ; durée médiane de suivi : 30 mois), cet essai randomisé multicentrique compare l'efficacité d'une électroporation irréversible focale et d'une électroporation irréversible étendue
Résumé en anglais
Focal therapy is appealing to both patients with prostate cancer and clinicians in its promise of curative treatment with minimal quality-of-life adverse effects. In this issue of JAMA Surgery, Zhang et al, in fact, powered their trial to describe the health-related quality-of-life impact of irreversible electroporation (IRE) and report in their article on short-term oncologic outcomes and recurrence up to 48 months. They applied exceptional rigor in following up all patients with transperineal biopsy and describe both in-field and out-of-field disease recurrence or persistence. Although their trial is not powered to address oncologic outcomes and therefore truly cannot be viewed as showing equivalence with standard treatment, there is still a great deal to be learned from their results. One of the most challenging aspects of focal therapy is how to follow up patients for recurrence and whether this treatment should be viewed as a cure or simply a way to reset the active surveillance clock. Further, for patients with intermediate-risk disease, the decision to pursue focal therapy rather than conventional treatment (surgery or radiation) is problematic because the incidence, type, and timing of recurrence or persistence has not been well described. The ease, complications, and efficacy of salvage options after focal therapy are only starting to be understood but are not as widely available as focal therapy itself. Understanding how likely patients with intermediate-risk disease will need a salvage backup plan will be vital to shared decision-making. While this study is not powered to speak to oncologic outcomes, with only 103 of the 200 intended patients enrolled and the majority of these patients having a Gleason score of 3 + 3 (grade group 1) and therefore being more suitable for active surveillance, this article does answer the critical question of how many patients will experience short-term recurrence and therefore will need to consider salvage therapy with either surgery, radiation, or additional focal therapy. The authors also very nicely demonstrate the multifocality of prostate cancer and the fact that focal ablation of a dominant lesion without close follow-up is likely to miss recurrent or untreated disease elsewhere. With current controversies surrounding the appropriateness of a Gleason score of 3 + 3 even being classified as cancer, as well as level 1 evidence that curative treatment of low-risk prostate cancer does not prolong overall survival, future efforts should be focused on intermediate-risk prostate cancer to evaluate focal therapy effectiveness. The ongoing PRESERVE trial (NCT04972097) focuses on IRE ablation in the patient population with intermediate-risk disease and will hopefully provide more answers in March 2024.
