Doctors at Duke University Medical Center are now treating some early-stage prostate cancers with a targeted approach that appears to let more men retain bladder control and remain sexually active.

Focused prostate therapy, much like lumpectomy for breast cancer, aims only at the part of the gland that has cancer, avoiding nerve damage and trauma that can cause impotence and incontinence.

One approach involves injecting the diseased part of the prostate with freezing gas. No surgical cuts are needed and patients can typically return to regular activities in a few days. Duke is one of a handful of medical centers in the nation that does the procedure outside research studies.

"I really believe this is the new wave of the future," said Robert Bryant Sr. of Clayton, who had focused cryosurgery at Duke last Friday. Scores of visiting prostate specialists viewed Bryant's procedure via a video feed to a nearby lecture hall. The experts were in Durham for an international workshop at Duke devoted to focal therapy for prostate cancer.

The prostate is a small gland beneath the bladder and wrapped around the urethra. It makes the fluid that carries sperm as it is ejaculated.

Treating only part of the prostate is controversial among cancer specialists. The standard of care is to attack the disease, even when it is considered early stage and low risk. Typically, a surgeon removes the entire gland. As an alternative, the cancer is bombarded with hormones and radiation that destroy the prostate.

Doctors think such an aggressive approach is one reason more than 99 percent of prostate cancer patients are alive five years after diagnosis. Both advocates and critics of focused therapy say techniques that treat only part of the prostate may not be as effective.

"Before there's a bandwagon to them, I think they need to be studied," said Dr. Raj Pruthi, director of urologic oncology at UNC Hospitals' Lineberger Comprehensive Cancer Center. He said Lineberger doesn't do any focused therapy for prostate cancer now, but will soon begin a clinical trial. Doctors from UNC-Chapel Hill attended the Duke workshop.

Ten percent to 25 percent of men with prostate cancer have bladder control problems two years after surgery or radiation therapy, according to research compiled by the Prostate Cancer Foundation. Impotence is even more common; up to 80 percent of men report problems after surgery or radiation. Some men's symptoms get better in time; other patients are never the same.

Recent studies show that men treated with focal cryosurgery fare considerably better. Up to 90 percent of men who have just one side of the prostate frozen are potent after treatment. Incontinence troubles about 10 percent. No long-term data are available about rates of cancer recurrence.

Pruthi said doctors and patients who are concerned about complications should keep in mind that there is already one approach with no side effects: doing nothing. Prostate cancer typically grows so slowly that men with early-stage disease sometimes forgo treatment and monitor their cancer. Older patients are often told they may die with prostate cancer, but not from it.

Less radical choices

Dr. Thomas Polascik, a Duke urologic oncologist and specialist in focal cryosurgery, said most men want less radical treatment options with fewer side effects and said cancer specialists must try to provide them.

All men with prostate cancer aren't good candidates for focal therapy. Men with cancer throughout the prostate gland could not benefit from it, Polascik said. But a study done at Duke suggests that about one in five men have cancer on only one side of the gland, and Polascik said those men could benefit.

Polascik thinks many patients will find the less-invasive option an acceptable compromise between radical therapy and doing nothing.

Bryant, the Clayton man, was diagnosed this summer at age 73. He said more than one oncologist suggested that doing nothing might be best. He said he was told his cancer was inoperable. Radiation was not an option because of an additional medical problem. Bryant, determined to find another option, found out about focal cryosurgery last month when he became a patient at Duke.

"I had a couple of doctors tell me, 'You've had a good long life,' " Bryant said. "I couldn't get with that mind-set."