Dr. Adam Kibel discusses Focal Therapy as a treatment option for Prostate Cancer.

After you are diagnosed with prostate cancer, your urologist may recommend treatment. The traditional (and currently guideline-recommended) treatment approaches include surgery (radical prostatectomy), radiotherapy, or active surveillance.

The recommendation for each of these approaches is based on a balance of your overall health and symptoms, including urinary and sexual function. You also need to consider your priorities in terms of quality of life, and your cancer aggressiveness/risk.

With each of these approaches, the whole prostate is treated. This means that both the areas known to have cancer and the remainder of the prostate gland receive the same treatment. Treating the whole prostate gland has been the traditional approach for many years because it is known that prostate cancer is often found in multiple areas of the prostate at the same time (so-called “multi-focal” disease). However, many patients ask if it is possible to only treat the areas of prostate cancer and not the entire prostate gland.

It is increasingly recognized that some patients may have a single area of disease (“unifocal cancer”). Or they may have a single area that needs treatment with other areas being low risk and suitable for observation.

In many cancers (breast, thyroid, lung, kidney, and others), surgeons and oncologists focus treatment on the tumor while avoiding treatment effects on the surrounding tissues. For example, in breast cancer, many years ago, there was a move from surgically treating the whole breast (radical mastectomy) to a localized treatment (lumpectomy). In prostate cancer, focal therapy received a big boost when magnetic resonance imaging (MRI) became more commonly used. This is because MRI allowed urologists to take biopsies of specific areas of the prostate and then when appropriate, target focal therapies to these areas.

Focal therapy in prostate cancer seeks to balance cancer control and side effects. However, it is important to note that these treatments should, for the most part, still be considered experimental as we do not have the same, long-term outcome information for these treatments as for surgery and radiotherapy.

Who may be suitable for focal therapy?

While early studies in focal therapy used this treatment approach in low-risk prostate cancer, most clinicians would agree that active surveillance is a more appropriate treatment approach for most of these men. Because of this, focal therapy is often best suited for patients with intermediate-risk prostate cancer who have a single tumor that can be seen on MRI and no other cancer in their prostate.

How is focal therapy delivered?

Focal therapy is more of a concept (the idea of treatment of a specific area of the prostate/tumor) than a specific treatment technology or modality, of which there are many. In fact, there are many ways to perform focal therapy. Many different ways of destroying prostate tissue may be used for focal therapy. These include:

  • High-intensity focused ultrasound (HIFU; which uses ultrasound waves to heat prostate tissue and tumor to destroy it)
  • Cryoablation (which cools the prostate tumor to freeze and kill it)
  • Photodynamic therapy (which uses laser energy to activate drugs in the prostate that then kills the cells nearby)
  • Irreversible electroporation (in which electrical pulses are used to break up cell membranes and kill the cells)
  • Laser ablation (which uses a laser to heat tumor tissue)
  • Radiofrequency ablation (which uses radio waves to heat the tumor tissue)

Radiotherapy approaches that are traditionally used to treat the whole prostate including brachytherapy and external beam radiotherapy can also be used for focal therapy. Surgical approaches to focal therapy are not frequently considered.

In most studies, focal therapy has decreased rates of standard complications of prostate cancer treatment such as urine leakage (incontinence) and impotence (erectile dysfunction), compared to traditional treatments. However, there are other complications that may result from these treatments, including damage to the rectum (although infrequently).

The choice of a specific focal therapy technique depends on a number of factors, including your doctor’s comfort with each technology. If you are interested in focal therapy, you should discuss with your urologist if it is appropriate in your situation and, if so, what approach they would suggest.

While the idea of focal therapy is very exciting to many patients with prostate cancer (and to their physicians as well!) it is important to remember some important caveats.

First, focal therapy is not always the right treatment for a patient. In some cases, it may be too much treatment. In these cases, a patient is better off with active surveillance for low-risk disease. For others, it may be too little. In these cases, traditional therapies such as surgery or radiotherapy may be more appropriate for higher-risk disease.

Second, even for patients in whom focal therapy is reasonable, we do not have long-term information on outcomes both in terms of cancer control and complications. Patients who are interested in focal therapy for prostate cancer should speak with their urologist to learn more about this treatment approach to find out if it is suitable for them.

Zachary Klaassen, MD, MSc
Urologic Oncologist, Georgia Cancer Center, Augusta University, Augusta, GA, USA