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Focal Laser Ablation - FLA

Good day to all and Merry Christmas! My story starts...

In 2017-2018, my PSA rose from under 2.0 to under 3.0, then to 3.7. The large urology firm that I was seeing told me at that time that they suspected an infection, prostatitis, and not cancer at that time as my PSA had risen fairly rapidly. In Jan 2019, my PSA reached 4.16 and by July 2019, it had reached 4.44. At that time a "blind" TRUS biopsy of 12 cores was recommended and was done in early Sep 2019. In mid-Sep 2019, the results came back as follows:

1 - RAM - 30% - 3+3=6
2 - RAL - Benign
3 - RMM - 30% - 3+3=6
4 - RML - Benign
5 - RBM - Benign
6 - RBL - Atypical
7 - LAM - 60% - 3+4=7 in 10%
8 - LAL - 30% - 3+4=7 in 5%
9 - LMM - <5% - 3+3=6
10 - LML - 10% - 3+4=7 in 40%
11 - LBM - Benign
12 - LBL - Benign

The urologist gave me a good book called 100 questions about prostate cancer and told me the only options were radical prostatectomy or forms of radiation. I went home and read the book right away. The book mentioned other forms of treatment and mentioned 3 "Focal" treatments:
1. HIFU - High Intensity Focal Ultrasound - Burns the cancer tissue
2. Cryotherapy - Freezing cold gas is injected and cancer tissue is frozen
3. Laser Therapy - A laser is used to burn the caner tissue

These treatments seemed like better options, if I was a candidate, because the side effects were not nearly like those of surgery or radiation. So I started using the best information resource I had, the Internet. I learned a tremendous amount about these therapies.
In short here’s what led me to my decision. While HIFU seems to have a great deal of promise, it is not a good option for someone who has calcification in his prostate. This is due to the ultrasound being deflected by the calcification. My understanding is that the ablation of tissue via HIFU is not as precise as laser but more so than Cryotherapy. If the ablation is not precise, then the chances of side effects due to destroying noncancerous tissue is greater. So, for example, a tumor in close proximity to one of the neurovascular bundles or the urethra may mean the ability to control the precise edge of destroying tissue when taking margins is very important. So, without belaboring all of the information and data involving my decision, at this juncture I will share that I chose FLA, Focal Laser Ablation, as my treatment.

So the not-so-great parts of this treatment…
1. There are a limited number of places to have it done such as the academic and commercial institutions below, including some clinical trials.
a. UCLA Jonsson Comprehensive Cancer Center ( https://cancer.ucla.edu/Home/Components/News/News/1118/1631 )
b. Memorial Sloan Kettering Cancer Center (https://www.mskcc.org/departments/surgery/surgical-facilities/image-guided-interventions-cigi )
c. Mayo Clinic – Rochester – Clinical Trial (https://www.mayo.edu/research/clinical-trials/cls-20167647 )
d. NYU Langone’s Perlmutter Cancer Center (https://nyulangone.org/conditions/prostate-cancer/treatments/minimally-invasive-ablation-treatment-for-prostate-cancer )
e. Cleveland Clinic (https://my.clevelandclinic.org/health/treatments/16265-prostate-cancer-focal-therapy )
f. University of Chicago Medicine Comprehensive Cancer Center (https://www.uchicagomedicine.org/cancer/types-treatments/prostate-cancer/treatment/focal-therapy )
g. Desert Medical Imaging – Clinical Trial (https://desertmedicalimaging.com/clinical-trials/ , https://clinicaltrials.gov/ct2/show/NCT02243033 )
h. Prostate Laser Center (https://www.prostatelasercenter.com/ )
2. Cost - Insurance and Medicare do not cover it.
a. The cost for the procedure, even if a clinical trial, is typically $22,000-28,000.
b. Add to that expense the cost of any traveling.
3. There is no “long term” data available.

For the items above, my thinking included…
1. This is a significant life matter. Travel is not even a consideration.
2. Again, this is a significant life matter. How much will my life and quality of life be affected if I choose surgery or radiation over FLA (i.e., how much will ED, incontinence and other related side effects impact my life and what is that worth)? Hands down, life and the quality of it override money.
3. Long-term data means things like randomized studies with data at least 10 years old. This is a good point to consider, but perhaps so is this… radical prostatectomies were not “sanctioned” by the AUA (and other organizations) until 2005. Do you have any idea how long they were performed before being “sanctioned” (hint, may be worth a look… it’s a very long time)?

So what are some positive parts of this treatment…
1. Minimal side effects.
2. Still leaves all treatment options open for the future if necessary (for example, radiation often means surgeons do not want to do any surgery because of the radiation).
3. Relatively non-invasive.
4. Minimal-to-no pain.
5. Recovery is 1-2 days. Often men travel home on day 2 after the procedure.

Recurrence (https://zerocancer.org/learn/survivors/recurrence/ )
Fortunately the five year survival rate for men with localized prostate cancer is nearly 100 percent. Although up to 40 percent of men will experience a recurrence, so it is important to understand your risk for recurrence as well as live your life after cancer.

Recurrence Statistics after Radical Prostatectomy (https://www.hopkinsmedicine.org/brady-urology-institute/specialties/conditions-and-treatments/prostate-cancer/prostate-cancer-questions/long-term-cancer-control-after-radical-prostatectomy )
Ten years after surgery, nearly 70 percent of the patients remained cancer-free, with no trace of PSA in their bloodstream. Eighteen percent had experienced a lone elevated PSA level while 8 percent had local recurrence of cancer. (Some of these men then underwent external-beam radiation treatment, which seemed to work. Their PSA level again dropped to the undetectable range and stayed there for at least two years.) Nine percent had distant metastases.

(https://www.ascopost.com/News/59877 ) …other studies have shown that after completely removing the prostate, 15% to 30% of patients have a cancer recurrence within 5 to 10 years of surgery.

Recurrence Statistics after Focal Laser Ablation
(https://www.ascopost.com/News/59877 ) In 120 men with low- to intermediate-risk prostate cancer treated with focal laser ablation, 17% needed additional cancer treatment after 1 year, with no noticeable change in quality of life or urinary function. In a small group of men who underwent a more aggressive focal laser ablation, only 6% had evidence of cancer 1 year later.

(https://journals.lww.com/co-oncology/FullText/2019/05000/Contemporary_treatments_in_prostate_cancer_focal.14.aspx ) The largest study assessing transrectal FLA is currently ongoing. Interim results were recently reported in 2018 (Feller et al.) on the treatment of 98 patients and 138 tumor foci using real time MRI guidance [40]. They reported 23% rate of in-field cancer recurrence, with no serious adverse events and no statistically significant changes in International Prostate Symptom Score or SHIM scores at 12 months

Researchers identified several factors that increased the odds of recurrence:
1. Advanced clinical stage
2. Gleason score (particularly 8 or greater)
3. PSA before surgery (particularly greater than 20)
4. Pathologic stage (determined when a pathologist examines the actual tissue removed during surgery)

A note on recurrence, and perhaps on getting disease in the first place… NUTRITION/DIET IS KEY! Personally I truly and deeply believe that what we eat yields much of what we get in the way of disease. There are numerous sources on this.
My “go-to” is: https://nutritionfacts.org/

Healthy Nutrition Movies:
• What The Health
• The Magic Pill
• The Game Changers

My FLA treatment was done Dec 2019. I will provide updates in 2020. The first check of status will be a PSA test and a 3T MRI in June 2020.

Various links

https://www.auajournals.org/doi/10.1016/j.juro.2016.07.074

https://www.jvir.org/article/S1051-0443(1😎31506-9/fulltext

http://dx.doi.org/10.1155/2011/584784

https://www.hindawi.com/journals/pc/2011/584784/

https://www.ncbi.nlm.nih.gov/m/pubmed/31100236/

https://euoncology.europeanurology.com/article/S2588-9311(1😎30021-X/pdf

https://www.uclahealth.org/laser-ablation-becomes-increasingly-viable-treatment-for-prostate-cancer

https://www.mskcc.org/cancer-care/patient-education/about-prostate-ablation-procedure

https://www.ncbi.nlm.nih.gov/m/pubmed/30671638/

https://my.clevelandclinic.org/health/treatments/16265-prostate-cancer-focal-therapy

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4080850/

https://www.sciencedaily.com/releases/2019/03/190320132051.htm

https://nyulangone.org/conditions/prostate-cancer/treatments/minimally-invasive-ablation-treatment-for-prostate-cancer

https://www.ascopost.com/News/59877

https://www.mayo.edu/research/clinical-trials/cls-20167647

    1. Update - I mentioned the procedure and recovery being basically painless... but want to mention that, since I had some BPH treatment done at the same time, that changed the # of days the catheter had to stay in from 2-3 to 7-10. After 5 days I had bladder spasms start and they are no fun. So I wanted to be sure to communicate that. My understanding is that the catheter has to stay in for a similar length of time after a radical prostatectomy.

      1. Update – I mentioned the procedure and recovery being basically painless… but want to mention that, since I had some BPH treatment done at the same time, that changed the # of days the catheter had to stay in from 2-3 to 7-10. After 5 days I had bladder spasms start and they are no fun. So I wanted to be sure to communicate that. My understanding is that the catheter has to stay in for a similar length of time after a radical prostatectomy. Some ablated tissue clogged the catheter on day 10; I tried to flush it out but was unable to do so, so I had to take the catheter out (which I greatly appreciated once I knew I was able to urinate on my own).

        1. Update – I had/have BPH and had some FLA for that at the same time as the FLA for the cancer. This causes swelling which makes urinating worse before it gets better. I was told to expect this to be the case and that it would be about a month before it gets better. Procedures on 12/19, catheter out on 12/29. So very happy to have that out. Wishing a healthy, happy and prosperous 2020 to all.

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