Month: July 2023

Think of prostate cancer surgery and what likely comes to mind is a radical prostatectomy, which is an operation to remove the entire prostate gland along with the seminal vesicles that produce semen. However, men with localized prostate cancer — meaning cancer that is still confined to the prostate — have another surgical option.

Called focal therapy, this alternative procedure treats only the cancerous part of the prostate and leaves the rest of the gland intact. The aim is to remove “clinically significant” tumor tissue, cancer that would spread further if it wasn’t treated at all. While there is a small risk that some cancer may be left behind after treatment, focal therapy also has the benefit of minimizing risks for erectile dysfunction and urinary incontinence, which are both potential side effects of radical prostatectomy. And growing evidence shows it can be an effective strategy.

Last year, researchers reported that 1,379 men treated with focal therapy or radical prostatectomy had similar cancer outcomes after five years of follow-up. The men were 66 years old on average, and doctors treated them with a technique called high-intensity focused ultrasound, or HIFU. This approach destroys cancer by subjecting it to high-energy ultrasound waves that heat tumors to high temperatures.

Now, findings from the same research team show that focal therapy is also an effective option for older men with prostate cancer. During this newer study, researchers assessed outcomes for 649 men ages 70 and above who were treated at 11 sites in the United Kingdom. Two-thirds of the men had cancer with an intermediate risk of further spread, and the remaining third had more aggressive, high-risk prostate tumors that are more dangerous.

All the men were treated with HIFU or a different type of focal therapy, cryotherapy, that destroys cancer by freezing it. The primary goal of the study was to assess “failure-free survival,” whereby treated men avoid a prostate cancer death, or worsening disease leading to further interventions.

What the data reveals

After follow-up durations ranging up to five years, 96% of the men were still alive, and the overall failure-free survival rate was 82%. No differences in outcomes between HIFU- and cryotherapy-treated men were reported. The men with high-risk cancer had worse outcomes: their failure-free survival rate was 75%, compared to 86% among men with intermediate-risk disease.

But 88% of the high-risk men and 90% of the intermediate-risk men also avoided hormonal therapy, a treatment that — because of its side effects — most men don’t want. The authors concluded that focal therapy may be an acceptable treatment that controls prostate cancer in older men as well as radical prostatectomy does.

It’s important to note that complications from focal therapy are possible. For instance, a small percentage of men in the new study developed urinary tract infections, and some also wound up with urinary retention, a treatable condition that occurs when the bladder can’t empty completely. The authors didn’t assess functional outcomes after surgery, such as erectile dysfunction or urinary incontinence. But mounting evidence from other studies shows that long-term urinary incontinence after focal therapy is very rare.

The findings are encouraging, but Harvard experts emphasize that more evidence with focal therapy is still needed. “Despite promising results such as those reported in this and other studies, long-term outcomes (e.g., 10 to 15 years or more) following focal therapy must still be assessed to fully determine how this treatment option compares to radical prostatectomy or radiation therapy,” says Dr. Boris Gershman, aurologist at Beth Israel Deaconess Medical Center and an assistant professor at Harvard Medical School focusing on prostate and bladder cancer. “Additional studies can also help us refine the types of prostate cancer that focal therapy is most appropriate for, and which types should be given therapies that treat the entire prostate gland.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

Wriggling toes in the sand and wearing sandals are warm weather treats, unless you’d rather keep your toes under wraps due to thickened, yellowish nails. Nail fungal infections (known as onychomycosis) are common, affecting up to 14% of the general population. In advanced cases, nails can become brittle, crumbly, or ragged, or even separate from the nail bed.

While completely curing these fungal infections is difficult, the right treatments can discourage the problem from spreading and make your nails look better.

Do nail fungal infections only affect toenails?

No, fingernails can become infected, too. However, toenails are a more common target because of certain habits, including wearing shoes, so we’ll concentrate on them in this post.

How do people get toenail fungus?

“Feet are more likely to be sweaty and damp, which provides a better environment for the fungi, yeasts, and molds that are naturally present on your skin to flourish,” says Dr. Abigail Waldman, a dermatologist at Harvard-affiliated Brigham and Women’s Hospital.

People also can be exposed to various fungi, known as dermatophytes, by walking barefoot in locker rooms, spas, or near swimming pools, or getting a pedicure at a nail salon, she says. A fungal overgrowth can infect the area between your toes and the skin or your feet, causing athlete’s foot. The fungus can then spread to the toenails.

What makes toenail fungus hard to treat?

While antifungal creams can easily treat skin infections, toenails are another story.

“Nail tissue is harder and thicker, so these medications don’t penetrate very well,” Dr. Waldman explains. That’s also true for antifungal drugs taken as pills. Toenails grow slowly and the tissue isn’t very metabolically active. So although the medication gets into your bloodstream, only small amounts end up in your toenails. That’s why it’s hard to get rid of toenail fungus once it takes hold.

What counts as a cure?

Research reports so-called clinical cure rates between 60% to 80%, but this means only the absence of symptoms — that is, your toenails return to their normal appearance. The fungal infection may still be lurking under your nails, says Dr. Waldman.

In fact, in clinical trials when investigators recheck toenail clippings for any residual fungus after treatments applied to nails, only around 10% to 15% show no detectable fungal spores. As a result, recurrences of toenail fungal infections are fairly common.

Despite this, there’s a reasonable chance that different treatment approaches can improve your symptoms and the appearance of your toenails.

What works for treating toenail fungus?

Here is a rundown of the different treatment options, starting with Dr. Waldman’s go-to first-line suggestion, which uses inexpensive products you may already have in your home.

Home remedies

Soaking your toes to soften your nails before applying a fungus-fighting agent will help the remedy penetrate the nail. For the soak, Dr. Waldman recommends mixing one part white or apple cider vinegar to three parts warm water. Soak your toes for at least 10 minutes (but up to 40 minutes is better). Instead of vinegar, you can use Listerine, which contains thymol, the main compound in the herb thyme. Like vinegar, thymol has antifungal properties.

Then dry your feet well and apply an antifungal substance to all the affected nails. One option is a paste of crushed garlic, but most people will probably find the over-the-counter drugstore products listed below more convenient to use.

Over-the-counter products

The best evidence is for 100% tea tree oil, but another popular option is Vicks VapoRub (which also contains thymol and other essential oils that may fight fungus), Dr. Waldman says. Or you can use one of the various creams sold to treat athlete’s foot on your toenails.

Be sure to apply the product right after soaking. The clinical cure rates for each of these approaches vary between products, and depend on the severity and duration of the infection. But about 60% of people notice improvements after a few months of treatment, Dr. Waldman says.

Drugstores also carry several other toenail treatments, including a treated patch you put on your nails overnight. It contains urea, an acidic substance that improves the look of your nails by making them less brittle and discolored. Another product that promises similar results uses a tiny LED light that you clip onto your toenail after applying a liquid containing polyethylene glycol, which softens nails.

Prescription treatments to put on toenails

These topical products, which are best for milder infections, include amorolfine (Loceryl, others), efinaconazole (Jublia), tavaborole (Kerydin), and ciclopirox (Penlac). They are clear lacquers that you brush on your toenails once daily, usually for months. It may take as long as a year to see results. Clinical cure rates range from 35% to 60%.

Prescription pills

More severe infections may respond better to oral drugs, which include fluconazole (Diflucan), griseofulvin (Grifulvin), itraconazole (Sporanox), and terbinafine (Lamisil). These are taken daily in pill form for three months. While the clinical cure rates are higher (around 80%), these drugs have more side effects, including stomach upset, diarrhea, and (in rare cases) liver damage.

Laser therapy

Lasers penetrate and break down nail tissue, helping to destroy the fungus. There are many different types of lasers and protocols. Clinical cure rates are hard to pin down, but some have been reported as ranging between 60% and 75%.

Advice on toenail clippers, nail polish, new shoes, and more

During and after treatment, Dr. Waldman advises people to use two sets of toenail clippers — one for infected nails and one for noninfected nails — to prevent fungal spread. If you’re embarrassed by the appearance of your toenails, it’s okay to use nail polish for short periods of time, she says.

Once you finish treatment, buying new shoes will help avoid reinfection. “I also always recommend people do a diluted vinegar soak once or twice a week after finishing treatment, which helps prevent any lingering fungus from reinfecting the nail,” says Dr. Waldman.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD