Phase 3, Multicenter, Randomized Study, Evaluating the Efficacy and Tolerability of Focused HIFU (High Intensity Focused Ultrasound) Therapy Compared to Active Surveillance in Patients With Significant Low Risk Prostate Cancer

Phase 3

Active, not recruiting

• Conditions: Prostate Cancer
• Interventions: Biological: PSA dosage; Procedure: treatment with focal HIFU; Device: MRI; Other: Questionnaires; Procedure: Prostatic biopsies

• Registration Number: NCT03531099
• Lead Sponsor: Hospices Civils de Lyon

Brief Summary

The percentage of malignant prostate tumors detected very early is constantly increasing and the number of well differentiated tumors, with small volume and low risk of progression increases. When a tumor of this type is identified, radical prostatectomy remains the reference treatment, but this treatment is not without side effects. Active surveillance is a strategy which aims at detecting an early development of the cancerous disease in order to propose curative treatment in a timely manner and thus improve specific survival. Patients are therefore re-evaluated each year by rectal examination, PSA (Prostate-Specific Antigen) assay. Active surveillance remains difficult to manage psychologically for both the patient and the practitioner, because of the lack of treatment on the one hand and a rate of non-curable cancers close to 50% when signs of progression trigger a radical treatment.

The aim of the focal treatment HIFU (High Intensity Focused Ultrasound) is to destroy the cancer without causing side effects in contrast to radical treatments. It is in this sense that it is positioned both as an alternative to radical surgery and as an alternative to active surveillance.

Detailed Description

Not available

Study Timeline

• Study First Submitted: 2018-05-09
• Study First Submitted QC: 2018-05-09
• Study First Posted: 2018-05-21
• Study Start: 2018-10-02
• Status Verified: 2024-02
• Last Update Submitted: 2024-02-27
• Last Update Posted: 2024-02-28
• Primary Completion: 2025-10-02
• Study Completion: 2026-10-02

Recruitment & Eligibility

• Status: ACTIVE_NOT_RECRUITING
• Sex: Male
• Target Recruitment: 108

Inclusion Criteria

• Patient having been clearly informed of the study and having accepted, with sufficient reflection time, to participate by signing the informed consent form of the study.

• Age between 50 and 80 years with a life expectancy of more than 5 years. Patients between the ages of 75 and 80 will need to have G8 score > 14.

• Initial diagnosis of localized prostate cancer (T1c or T2a) with the following characteristics:

  • Only one Target tumor on MRI on a maximum of 2 contigous sextants. Case allowed:

    • If more than one target tumor on MRI, only one of them must be confirmed by targeted prostate biopsies.
    • If no target tumor on MRI, only 2 contigous sextants must be positive on prostate biopsies

  • A maximum tumor length> 3 mm or at least 3 positive biopsies on all biopsies performed (randomized biopsies and/or MRI/Ultrasound Fusion-Guided Prostate Biopsy).

  • Gleason 6 score (risk group 1 of the D'Amico classification).

  • Tumor positioned so that a safety distance of at least 9 mm from external sphincter can be defined during HIFU-FOCAL treatment in prostate tissue around the target.

• PSA ≤ 15ng / ml.

• Patient affiliated with health insurance or beneficiary of an equivalent plan.

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Exclusion Criteria

• Contraindications to treatment with HIFU-F:

  • Tumor not accessible.
  • Multiple intra prostatic calcifications inducing, on ultrasound, a shadow cone in the prostate preventing the penetration of ultrasound and thus the realization of the treatment.
  • History of pelvic irradiation
  • Presence of an implant (stent, catheter) located less than 1 cm from the treatment area.
  • Fistula of the urinary tract or rectum.
  • Anal or rectal fibrosis, anal or rectal stenosis or other abnormalities making it difficult to insert the Focal One® probe.
  • Anatomical abnormality of the rectum or rectal mucosa.
  • Patient with artificial sphincter, penile prosthesis or intra prostatic implant, eg stent.
  • History of intestinal inflammatory pathology.
  • Uro-genital infection in progress (the infection to be treated before HIFU treatment).
  • Anterior surgery at the level of the anus or rectum making the introduction of the probe impossible.
  • Allergy to latex.
  • Thickness of the rectal wall> 10mm.

• TURP indication. Bladder neck incision is allowed .

• Patient with a medical contraindication to Sonovue® injection.

• Patient with a medical contraindication on MRI.

• Patient already treated for prostate cancer (hormone therapy, radiotherapy, surgery).

• History of uncontrolled cancer and / or treated for less than 5 years (with the exception of basal cell skin cancer).

• History of sclerosis of the bladder neck or urethral stenosis.

• Patient with a several bleeding risk according to medical advice (patient with oral anticoagulant therapy must receive an alternative therapy if randomized in HIFU-F arm).

• Patients with unstable neurological pathology.

• Patient who has been treated for a therapeutic trial within 30 days of enrollment or who wishes to participate in an ongoing study that may interfere with this study.

• Legal person protected by law.

• Patient not able to understand the objectives of the study or refusing to comply with postoperative instructions.

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
HIFU treatment	MRI	65 patients will receive the immediate treatment with focal HIFU in order to destroy the cancer without causing side effects. HIFU treatment will be conducted with the Focal One® device. The treatment area will be defined using MRI data and 3D biopsies. A safety distance of at least 9 mm will be defined around the tumor. An intraoperative contrast echocardiographic control will be performed to evaluate the necrotic area. If necessary, additional HIFU lesions will be performed during the same session. In case of residual tumor demonstrated during control biopsies, additional treatment of this tumor with focal HIFU may be proposed. Patients randomized in this arm will also have PSA dosage, MRI exam, questionnaires and prostatic biopsies during their follow up.
Active surveillance	Questionnaires	65 patients will be randomized to active surveillance and will have exactly the same follow-up as treated patients excepting the HIFU treatment. Active surveillance is a therapeutic option that shifts the eventual moment of curative treatment while remaining within a window of curability of the disease. Patients randomized in this arm will also have PSA dosage, MRI exam, questionnaires and prostatic biopsies during their follow up.
Active surveillance	PSA dosage	65 patients will be randomized to active surveillance and will have exactly the same follow-up as treated patients excepting the HIFU treatment. Active surveillance is a therapeutic option that shifts the eventual moment of curative treatment while remaining within a window of curability of the disease. Patients randomized in this arm will also have PSA dosage, MRI exam, questionnaires and prostatic biopsies during their follow up.
HIFU treatment	PSA dosage	65 patients will receive the immediate treatment with focal HIFU in order to destroy the cancer without causing side effects. HIFU treatment will be conducted with the Focal One® device. The treatment area will be defined using MRI data and 3D biopsies. A safety distance of at least 9 mm will be defined around the tumor. An intraoperative contrast echocardiographic control will be performed to evaluate the necrotic area. If necessary, additional HIFU lesions will be performed during the same session. In case of residual tumor demonstrated during control biopsies, additional treatment of this tumor with focal HIFU may be proposed. Patients randomized in this arm will also have PSA dosage, MRI exam, questionnaires and prostatic biopsies during their follow up.
HIFU treatment	Prostatic biopsies	65 patients will receive the immediate treatment with focal HIFU in order to destroy the cancer without causing side effects. HIFU treatment will be conducted with the Focal One® device. The treatment area will be defined using MRI data and 3D biopsies. A safety distance of at least 9 mm will be defined around the tumor. An intraoperative contrast echocardiographic control will be performed to evaluate the necrotic area. If necessary, additional HIFU lesions will be performed during the same session. In case of residual tumor demonstrated during control biopsies, additional treatment of this tumor with focal HIFU may be proposed. Patients randomized in this arm will also have PSA dosage, MRI exam, questionnaires and prostatic biopsies during their follow up.
Active surveillance	MRI	65 patients will be randomized to active surveillance and will have exactly the same follow-up as treated patients excepting the HIFU treatment. Active surveillance is a therapeutic option that shifts the eventual moment of curative treatment while remaining within a window of curability of the disease. Patients randomized in this arm will also have PSA dosage, MRI exam, questionnaires and prostatic biopsies during their follow up.
HIFU treatment	treatment with focal HIFU	65 patients will receive the immediate treatment with focal HIFU in order to destroy the cancer without causing side effects. HIFU treatment will be conducted with the Focal One® device. The treatment area will be defined using MRI data and 3D biopsies. A safety distance of at least 9 mm will be defined around the tumor. An intraoperative contrast echocardiographic control will be performed to evaluate the necrotic area. If necessary, additional HIFU lesions will be performed during the same session. In case of residual tumor demonstrated during control biopsies, additional treatment of this tumor with focal HIFU may be proposed. Patients randomized in this arm will also have PSA dosage, MRI exam, questionnaires and prostatic biopsies during their follow up.
HIFU treatment	Questionnaires	65 patients will receive the immediate treatment with focal HIFU in order to destroy the cancer without causing side effects. HIFU treatment will be conducted with the Focal One® device. The treatment area will be defined using MRI data and 3D biopsies. A safety distance of at least 9 mm will be defined around the tumor. An intraoperative contrast echocardiographic control will be performed to evaluate the necrotic area. If necessary, additional HIFU lesions will be performed during the same session. In case of residual tumor demonstrated during control biopsies, additional treatment of this tumor with focal HIFU may be proposed. Patients randomized in this arm will also have PSA dosage, MRI exam, questionnaires and prostatic biopsies during their follow up.
Active surveillance	Prostatic biopsies	65 patients will be randomized to active surveillance and will have exactly the same follow-up as treated patients excepting the HIFU treatment. Active surveillance is a therapeutic option that shifts the eventual moment of curative treatment while remaining within a window of curability of the disease. Patients randomized in this arm will also have PSA dosage, MRI exam, questionnaires and prostatic biopsies during their follow up.

Primary Outcome Measures

Name	Time	Method
patient proportion who needed to seek radical treatment	48 month	The primary endpoint is the comparison between the 2 groups of the proportion of patient converting to a radical treatment at 48 months of follow-up. Conversion to a radical treatment is define as a medical decision based on the following criteria: * An increase in Gleason score to a score 7 (3 + 4) with bilateral involvement (Gleason 6 or 7).; * An increase in the Gleason score to a score 7 (3 + 4) with tumor whose location is not compatible with a focal treatment (impossibility to apply safety margins of 9mm).; * An increase in Gleason score to a score of 7 (4 + 3) or higher.; * Risk of lymph node invasion\> 5% (calculated with the MSKCC nomogram); * An extension of the tumor beyond the prostatic capsule (MRI and / or biopsies).; * Appearance of pelvic ganglion metastases.

Secondary Outcome Measures

Name	Time	Method
Appearance of another cancerous focus in the other half of the prostate	48 months	Appearance of another cancerous focus in the other half of the prostate will be supervised and will be used to evaluate the oncological evolution at 48 months.
Proportion of serious adverse effect	48 months	comparison between the 2 groups of the proportion of serious adverse effect at 48 months
STAi-YB score	Over the 48 months	Anxiety will be compared between the two groups and assessed using the STAi-YB questionnaire
proportion of patients needing additional treatment	48 months	The objective is to compare between the 2 groups the proportion of patients needing additional treatment (focal or radical) at 48 months. This includes patients who wish or require radical treatment (prostatectomy, radiotherapy), total focal treatment, focal treatment for patients in the active surveillance group or additional treatment for patients in the treatment group.
Overall survival	48 months	Overall survival at 48 months will be measured from the date of inclusion to the date of death, all causes of death combined or the date of last new or point date to 48 months.
Prostate cancer specific survival	48 months	Prostate cancer specific survival at 48 months will be measured from the date of inclusion to the date of death related to prostate cancer or the date of last new or point date to 48 months
Recurrence free survival	48 months	Prostate cancer specific survival at 48 months will be measured from the date of inclusion to the date of first metastasis , or the date of last new or point date to 48 months
EPIC-26 score	over the 48 months	urinary function will be compared between the two groups and assessed using the EPIC-26 questionnaire.
Gleason score	48 months	Evolution of the Gleason score (appearance of Gleason ≥7) will be measured and will be used to evaluate the oncological evolution at 48 months.
IIEF-5 score	over the 48 months	Sexual function will be compared between the two groups and assessed using the IIEF-5 questionnaire
clinically significant cancer rate	48 months	The clinically significant cancer rate (Gleason 7 or invasion of more than 3 biopsies or invasion\> 3 mm regardless of Gleason) in the untreated lobe and the treated lobe will be measured and will be used to evaluate the oncological evolution at 48 months.
rate of positive biopsies	48 months	The rate of positive biopsies in the untreated lobe and treated lobe will be measured and will be used to evaluate the oncological evolution at 48 months.
IPSS score	over the 48 months	urinary function will be compared between the two groups and assessed using the IPSS questionnaire.
Quality of life score	over the 48 months	quality of life will be compared between the two groups and assessed using the QLQC30 questionnaire
Appearance of metastases	48 months	Appearance of metastases (lymph node or bone) will be supervised and will be used to evaluate the oncological evolution at 48 months.
Appearance of an extra capsular extension	48 months	Appearance of an extra capsular extension will be supervised and will be used to evaluate the oncological evolution at 48 months.

Trial Locations

Locations (14)

Clinique Saint-Vincent; 🇫🇷 Besançon, France

Polyclinique du parc Rambot; 🇫🇷 Aix-en-Provence, France

Service d'Urologie CHRU de Lille, Hôpital HURIEZ; 🇫🇷 Lille, France

Service d'Urologie et Chirurgie de la Transplantation, Hôpital Edouard Herriot,; 🇫🇷 Lyon, France

Service d'Urologie Générale de Santé - Hôpital Privé La Louvière; 🇫🇷 Lille, France

Groupe Hospitalier Pellegrin - CHU; 🇫🇷 Bordeaux, France

Service d'Urologie, CHU de Guebwiller Colmar; 🇫🇷 Colmar, France

Service d'Urologie, Clinique Tivoli Ducos; 🇫🇷 Bordeaux, France

Service d'urologie Assistance Publique - Hôpitaux de Marseille - Hôpital Marseille Nord; 🇫🇷 Marseille, France

Département d'Urologie, Institut Montsouris; 🇫🇷 Paris, France

Centre Hospitalier Lyon Sud; 🇫🇷 Pierre-bénite, France

Clinique Urologique Nantes Atlantis; 🇫🇷 Saint-Herblain, France

Service d'Urologie, Hôpital Foch; 🇫🇷 Suresnes, France

CHU de Toulouse - Hôpital de Rangueil; 🇫🇷 Toulouse, France