Focal Therapy: As Good or Better Than Radical Prostate Treatment
Originally published 12/5/2016
Nearly six years since the blog below was posted, an excellent comparison of focal therapy vs. radical prostatectomy was published.[i] The study was conducted by a European multinational team, and compared two matched groups of patients, 246 in each group. One group had focal treatment (either HIFU or cryo) while the other had prostatectomy. Both groups were tracked over an 8-year period for failure free survival (no additional treatment or metastasis).
Failure-free rates were:
| 3 years | 5 years | 8 years | |
| Focal therapy | 91% | 86% | 83% |
| Prostatectomy | 86% | 82% | 79% |
While these rate trends are similar, in this study focal treatment provided slightly more cancer control than surgical gland removal.
Although this study did not report treatment side effect rates, virtually all published data, including what’s cited in the blog below reflects significantly less risk of urinary and sexual impairment following focal therapy vs. prostatectomy.
As one author puts it, “The real impetus behind focal therapy is the chance of a benefit—and an even better chance of avoiding complications—in situations where treatment is desired, but life is not in immediate danger.”[ii]
NOTE: The Sperling Prostate Center now offers all three approved methods for focal treatment: Focal Laser Ablation, TULSA, and Exablate. Contact us for more information.
Within the past 20 years, skepticism and even ridicule over the idea of focal prostate cancer treatment has transformed into broad acceptance. A November, 2016 journal article (Baydoun et al., 2016[iii]) indicates that with focal therapy, cancer control appears comparable to whole gland surgery or radiation while having far fewer side effect risks. In other words, for the appropriate patient, focal therapy may be as good as – or even better than – radical treatment.
Baydoun et al. define focal therapy as “a targeted ablation of a limited area of the prostate expected to contain the dominant or only focus of cancer.” Thanks to advanced imaging, especially multiparametric MRI (mpMRI), it is now possible to ablate (destroy) the index lesion, meaning the largest tumor seen on an imaging scan. How accurately can mpMRI identify the index lesion? Many studies involving radical prostatectomy patients who had mpMRI before surgery have compared the MRI findings with the actual gland specimen. These studies have found a very high degree of correlation between the MRI index lesion and the “largest sized tumor measured in the [post-surgical] pathological specimen if no other tumor of similar size was found with established capsular involvement or a definitive higher Gleason score.” Thus, based on a) mpMRI scans, b) in-bore targeted biopsy, and c) all other clinical factors such as PSA, tumor stage, genomics etc., it is possible to determine which patients are appropriate candidates for focal therapy.
The Baydoun article is a review and summary of 18 published focal therapy studies using any of the following modalities: cryotherapy (freezing), HIFU, MR-guided focal laser ablation (FLA), photothermal therapy, radiofrequency ablation, microwave therapy, external beam radiation, and brachytherapy. The strict selection criteria led to a choice of 18 out of possible 10,000+ published studies. It was not possible to perform apples-to-apples analysis across the 18 articles because of study design and reporting differences. Even so, the authors’ findings on the cancer control and low side effect rates of focal treatment constitute a landmark contribution in favor of focal therapy. The team has demonstrated how focal treatment may address
…the controversy of overdiagnosis and overtreatment by simultaneously providing local disease control, preserving sexual, urinary and gastrointestinal function, and alleviating the usual anxiety of watchful waiting. The concept is further supported by the increasing incidence of unilateral disease and the index lesion prediction of progression when there is multifocality.[iv]
Eleven of the papers analyzed contained reports from prospective studies (designed in advance) while seven were retrospective (analysis after the fact). The total number of patients involved was 2288, with average follow-up under 2 years (23.8 months) and average patient age of 63.8. In terms of the D’Amico risk stratification, 61% were low risk, 32% were intermediate, and 7% were high risk.
Key findings
The research team derived average data of greatest interest to patients regardless of method:
- Urinary incontinence – Only 11 of the 2288 experienced post-treatment incontinence
- Potency – In general, potency preservation averaged 70%, significantly better than average potency preservation in radical prostatectomy. With the exception of one study, when sexual function was assessed by standardized scoring, there was no significant difference between pre and post-treatment scores. Again, this is markedly better than post-prostatectomy potency results.
- Cancer control – Out of 2288 cases, a total of 160 biopsy-proven recurrence was observed (6.9%) Only six of the studies included data on biochemical disease-free rates (no rise in PSA seen after treatment) as follows: one focal brachytherapy study reported 91.5% at 5 years (no rise in PSA) and 78.1% at 8 years; six retrospective cryotherapy studies reported a range from 84.2% at 6 months to 92.9% at 70 months.
The authors conclude, “The outcomes of FT [focal therapy] in PCa [prostate cancer] seem to be similar to those observed with whole gland therapy and with fewer side effects.” They acknowledge that their analysis is limited by the diversity of the 18 studies, and point to the lack of cohesive long-term cancer control results. However, patients considering focal therapy are not discouraged by the relatively short term results in the literature. They know that focal therapy leaves all future options open – including another focal treatment – if prostate cancer recurs. Focal therapy satisfies their desire to handle the cancer while avoiding treatment risks and the anxiety that can accompany Active Surveillance.
The Baydoun team has done a tremendous service for focal therapy by compiling and analyzing 18 carefully chosen studies. In addition to all other focal modalities, we are confident that FLA provides equal or better cancer control with superior preservation of manhood.
[i] Shah TT, Reddy D, Peters M, Ball D et al. Focal therapy compared to radical prostatectomy for non-metastatic prostate cancer: a propensity score-matched study. Prostate Cancer Prostatic Dis. 2021 Jun;24(2):567-574.
[ii] Marks, L.S. Prostate Cancer: a comparison of focal therapy and radical prostatectomy. Prostate Cancer Prostatic Dis 25, 381–382 (2022).
[3] Baydoun A, Traughber B, Morris N, Abi Zeid Daous M et al. Outcomes and toxicities in patients treated with definitive focal therapy for primary prostate cancer: systematic review. Future Oncol. 2016 Nov 4. [Epub ahead of print]
[iv] Ibid.
