Cryotherapy for prostate cancer: ready for prime time?

Although prostate-specific antigen testing and prostate cancer treatment undoubtedly saves lives, there are growing concerns regarding overtreatment. There has also been a shift toward less invasive approaches to prostate cancer, including cryotherapy. Cryotherapy has undergone considerable change. It is important for clinicians to be aware of the evidence to support its use.

Technical improvements in cryotherapy delivery systems have reduced the complications of primary cryotherapy to a low and acceptable level. With the latest generation argon-based cryoprobes, the risk of long-term incontinence defined as pad use is typically less than 5% and the risk of rectal fistula is 0.5% or less. The Cryotherapy On-Line Data Registry (COLD Registry) used the Phoenix (nadir + 2 ng/ml definition) to report 5-year biochemical disease-free survival in 1198 patients as 91% in low-risk, 78% in intermediate-risk, and 62% in high-risk patients. These biochemical results compare quite favorably to the results of radiation therapy as a monotherapy. A recent randomized trial of cryotherapy compared with radiation therapy shows similar biochemical outcomes and a significantly lower rate of positive post-treatment biopsies in the cryotherapy-treated patients. Routine biopsies are negative in up to 87-98% of patients after one or more cryotherapy treatments. Focal cryotherapy shows promising early results with potency rates between 71 and 90%.

Whole-gland cryotherapy is ready for prime time based on favorable biochemical outcomes, a high rate of negative post-treatment biopsies and a low and acceptable rate of complications. The long-term biochemical outcomes following cryotherapy compare favorably to those achieved with radiation therapy as monotherapy. The rate of negative post-treatment biopsies of the prostate appears to be higher for cryotherapy than for initial radiation therapy. Taken together, these results suggest that clinicians should consider cryotherapy as an alternative treatment to initial radiation therapy. Focal cryotherapy shows very high potency rates and warrants further investigation.