What is Cryotherapy for Cancer?
Have you heard about the thermal, or focal, ablation of cancer? This is a form of treatment that eliminates the need for surgery, radiation, or chemotherapy. Cryotherapy wipes out tumors through thin probes that convey extreme cold. (Other probes use radio waves or ultrasound vibrations.) Cryotherapy, also called cryosurgery or cryoablation, are the ‘cold’ form of the treatment. RFA (radiofrequency ablation) and HIFU (high intensity focused ultrasound) are ‘hot’ forms. Some doctors are also using light, as in lasers, to destroy tumors. Another option is photodynamic therapy, which combines the use of a sensitizer drug and light.
Cryotherapy Ablation vs Conventional Treatment for Cancer
Cryotherapy treatment has advantages over conventional treatment, such as surgery. Focal ablation of cancer destroys just the tumor, along with a small safety margin, but leaves normal tissues intact and functional. Nowadays, real-time MRIs and ultrasound (sonography) are used guide the treatment, neither of which involves dangerous x rays.
Specialized physicians, called interventional radiologists, administer this treatment as a same-day, outpatient procedure. For prostate cancer, specially trained urologic oncologists often give the treatment. (Urologic oncologists are doctors who have special training in treating cancers of the male and female urinary tract and male reproductive organs.)
Benefits of Cryotherapy for Cancer
- Focal ablation of cancer causes a minimum of side effects. It avoids damage to healthy tissues.
- There is a reduced risk of infection.
- Patients have a very rapid recovery time and return to normal activities, sometimes starting on the following day.
- It doesn’t involve the trauma or significant loss of blood after surgery.
- If necessary, it can be repeated in the future.
- Having ablation doesn’t limit the option to have radiation therapy or surgery in the future.
- Does not cause second cancers, the way that ionizing radiation can do.
- FDA has approved it for several indications and Medicare and other insurance plans will usually pay for them. This includes the ablation of colon-to-liver metastases and many prostate tumors.
But focal ablation of cancer is not for everyone. It is a good option for patients who have been accurately diagnosed (such as with MRIs and biopsies) and found to be candidates for this approach.
Lack of Attention to Cryotherapy
Yet, despite these many advantages, cryotherapy, or more specifically, focal ablation of cancer, has gotten a fraction of the attention it deserves. In other words, studies progress to a point, but no further. In particular, there is a lack of rigorous long-term studies to prove, once and for all, the superiority of focal ablation over conventional treatment in certain select situations. This modality remains controversial. According to a news report from the 2018 meeting of the American Urological Association (AUA):
“Few controversies in urology have ignited as much heated argument as focal ablation (cryotherapy) for prostate cancer. Some urologists are firmly convinced that focal ablation is the future of prostate cancer therapy for many men. Others are equally convinced that focal ablation is little more than a sham.”
Some conventional urologists (who practice surgery or radiation for prostate cancer) say it is “illogical” to remove just the main cancers in the prostate, because you might possibly leave some other foci of cancer behind. Advocates counter that, in practice, this doesn’t matter. You have in fact rendered slow-growing tumors unthreatening for the duration of the patient’s lifetime.
To me, it seems as if surgeons and radiologists are trying to keep their monopoly as the providers of choice, a privileged position they have maintained for over a hundred years.
Why is there a mystery about cryotherapy in cancer treatment?
Here’s a mystery. If you put the terms “focal ablation” and cancer into the standard PubMed data base, you come up with a total of 121 articles on the topic. By contrast, if you search for radiotherapy and cancer you get 283,102 articles!
Last year there were a total of 13 such articles versus 11,610 for radiation therapy of cancer. That’s a ratio of almost 1,000 to 1!
As to clinical trials, if you search clinicaltrials.gov, for tests of focal ablation of cancer that are currently recruiting patients in the United States, you come up with twelve, three of which concern prostate cancer: these are at Johns Hopkins in Baltimore, Mayo Clinic in Minnesota, and Weill Cornell Medicine in New York City.
This is a good start, for sure, but it is a drop in the bucket compared to the overall research effort. By contrast, there are presently 1,675 clinical trials underway on the topic of chemotherapy and cancer. There are 1,411 such trials of radiation therapy and cancer. Therefore, both chemotherapy and radiation clinical trials outnumber those of focal ablation by more than 100 to 1!
So, if you haven’t heard of the focal ablation of cancer, well, maybe you wern’t meant to.
The Male Lumpectomy
Gary Onik, MD, of Florida, who invented ultrasound-guided ablation of the prostate, has called the focal ablation of prostate cancer the “male lumpectomy.”
In other words, cryotherapy, or cryoablation, is to prostate cancer what breast-sparing surgery is to breast cancer. But breast lumpectomy had a few advantages that are lacking in its male counterpart.
In the days of its ascendancy, it had powerful national spokespersons, such as the author Rose Kushner, and two prominent surgeons, George W. Crile, Jr., MD and Bernard Fisher, MD. They made it into a cause. But focal ablation has no public champions, at least none with a big enough megaphone to attract public attention.
Also, the switch from radical mastectomy to lumpectomy rode a wave of feminist militancy, i.e., the “pink ribbon” movement. But all attempts to create similar enthusiasm among middle-aged men have failed to generate any equivalent excitement. In fact, according to Google Trends, online searches of the phrase “breast lumpectomy” outnumber those of “prostate ablation” more than five to one, and the gap is only widening.
Varieties of Ablation
In “cryotherapy” for prostate cancer, doctors locates the tumors through a combination of ultrasound and MRI scans. They then insert small needles and cause those needles to become super cold. These cold probes effectively destroy the tumor and a safety margin of surrounding tissue. In this way, they minimize the risk of impotence and urinary incontinence (“leakage”) after prostate surgery.
A related technique, radiofrequency ablation (RFA), uses radio waves to destroy tumors. RFA can wipe out colon cancer that had spread to the liver. According to the 11th (2019) edition of the DeVita textbook:
“RFA is currently the most widely used ablative technique for the treatment of small liver malignancies. The term radiofrequency (RF) applies to all electromagnetic energy sources with frequencies <30 MHz, although most clinically available devices function in the 375 to 500 kHz range.”
James Arnott and “Congelation”
According to the Cleveland Clinic, the “focal therapy for prostate cancer first began…in about 2007.” But in fact, the treatment has had a long and distinguished history. An English surgeon, James Arnott (1797-1883), used frozen salt water to treat cancer in the 1840s! And he even demonstrated his technique, which he called “congelation,” at London’s Crystal Palace Exhibition in 1851.
As a result, six million visitors to the Crystal Palace that year had the opportunity to see the first cancer cryoablation in action. Visitors to the Exhibition included Charles Dickens, Charles Darwin, and of course, Queen Victoria, who kicked off the ceremonies. So it was a well known technique in the 19th century.
“Congelation [freezing], properly employed…enables us to remove cancerous growths without pain and, if not absolutely without danger, with much less danger than any other means.”
And, by the way, this is still true.
Arnott even won a medal for his apparatus, but then a host of technical difficulties prevented its general acceptance. In time, doctors completely forgot about cryoablation. In fact, by the year 1960 there were zero articles on the topic in the medical literature!
Modern Pioneers of Ablation
A few years later, in 1964, another pioneer, Maurice J. Gonder, MD and his colleagues revived the field when they reported on their work with cryotherapy to treat prostate cancer. But they too ran into technical difficulties.
Medical engineer Leslie W. Organ, MD, is credited with the invention of the modern form of cryoablation in 1976. In 1990, Gary Onik, MD, finally perfected the method of using ultrasound guidance for the focal ablation of cancer. And the field took off from there.
Rate of ED with Ablation
What’s so great about cryotherapy for prostate cancer? Of all the techniques in use today, it leaves men as close to normal as possible. This means it causes a low rate of sexual impotence and urinary incontinence after treatment. Here are some representative results concerning impotence:
- In a 2019 series from various British universities, erectile dysfunction (defined as erections insufficient for penetration) occurred in 16.1% of cases.
- A French study showed almost no change in the International Index of Erectile Function (IIEF)-5 scores before and after the procedure.
- An American series said that patients maintained potency “to the satisfaction of the patient in of 36 of 40 patients who were potent preoperatively,” i.e., a 10% rate of ED.
So men have a good chance of avoiding sexual impotence after prostate treatment with cryoablation. There is a similar reduction in urinary incontinence with the need to wear an adult diaper.
Where to Get It?
Where can one get these FDA- and Medicare-approved cryotherapy focal ablation of prostate cancer? Some of the doctors who use this method are found at these ten outstanding centers:
- Samir Taneja, MD, NYU Langone Medical Center, New York, NY
- Aaron Katz, MD, NYU Winthrop Urology, Garden City, NY
- Gary Onik, MD, Fort Lauderdale, FL
- Duke K. Bahn, MD, Prostate Institute of America at Community Memorial Hospital, Ventura, CA
- Dan Sperling, MD, Sperling Prostate Center, New York City and Florida
- Cleveland Clinic, Cleveland, Ohio
- Ara Karamanian, MD, Houston, TX (laser ablation)
- University of Chicago Medicine, Chicago, IL
- Mayo Clinic, Rochester, MN
- Mark Emberton, MD, Professor in Interventional Oncology at University College London, UK
To find a trained medical practitioner of the ablation of non-prostate related cancers, check out the website of the Society of Interventional Radiology.