Shooting is an often-overlooked competition during the summer Olympics. Yet the shooting sports have been part of this event for over a century. According to Wikipedia, shooting has been included “at every Summer Olympic Games since the birth of the modern Olympic movement at the 1896 Summer Olympics except at the 1904 and 1928 games.” It tests the precision and accuracy hitting visible targets, whether using a rifle, pistol or shotgun.

Olympic marksmanship and focal therapy

In a very real sense, focal therapy (FT) for prostate cancer (PCa) is similar to Olympic marksmanship. For the first time in history, magnetic resonance imaging (MRI) has transformed a hidden PCa tumor into a visible target. Guided by imagery, this target can be destroyed within the body in a process called ablation. Just as Olympic shooters have a choice of weapons, doctors have a choice of methods for targeted tumor ablation: Focal Laser Ablation, HIFU, cryo, TULSA, etc. By applying cancer-killing energy to the tumor, they can selectively eradicate the PCa while sparing healthy structures. Thus, FT offers patients cancer control with very low risks of incontinence or impotence.  

Experts identify three key elements

A recently published (2025) paper^[i] identifies three key elements to assure focal therapy accuracy:

1. A thorough portrait of the prostate gland and its tumor gained through multiparametric MRI (mpMRI) which uses three imaging sequences called parameters. Each imaging sequence “captures a different aspect of the volume of the tumour, and each will have spatial implications for treatment.” Combining the results of all three is better for planning FT than biparametric MRI, which uses only two.
2. Careful calculation of the targeted area plus an extra safety margin (don’t underestimate the extent of PCa cells beyond the visible tumor), and
3. Choosing the right energy source to encompass the targeted area without collateral damage.

This paper is particularly authoritative because the team of authors includes experts in the departments of Urology, Radiology, Surgery, and Pathology from two noteworthy European institutions.

A 10-step framework to guide treatment planning

Having many years of experience developing and testing image-guided focal therapy, the authors developed a flow of ten steps for planning and implementing a focal procedure. These steps determine if a patient is truly eligible for a FT. (If interested, read the whole article here.) Briefly the steps are:

1. Identify prostate zonal anatomy and tumor location (PCa spreads differently in each zone).
2. Coordinate the overlapping visual information from each parameter to confirm the nature, location, size and shape of the tumor.
3. Based on all parameters, calculate the volume of the tumor to establish the imaging lesion (tumor) zone.
4. Add an extra margin of 7-10 mm to establish the ablation area, taking into consideration the characteristic pattern of tumor spread within the prostate zone where it’s located.
5. Identify critical urinary, sexual and bowel critical structures and their location with respect to the tumor.
6. Decide on a method of ablation. This is similar to a marksman’s choice gun, rifle or shotgun depending on the nature and distance of the target. The doctor should take into account the route for delivering the energy, the energy type used to destroy the tumor (thermal vs. nonthermal), and potential for damaging tissue/structures beyond the ablation zone.
7. Determine which method(s) of ablation are feasible to deliver full ablation, considering the characteristics of the type of energy when applied to tissue, as well as the anatomic location of the target and its neighboring critical structures.
8. Determine if the energy choice of ablation method can avoid collateral damage to the critical structures identified in Step 5.
9. If Step 8 involves risk to one or more critical structures, consider a different energy choice, and repeat steps 6-8 to map a new treatment zone.
10. If Step 9 proves feasible, eligibility is confirmed and treatment planning can proceed.

Why do these 10 steps matter now?

Why are these 10 steps a timely contribution to focal treatment? It’s because FT has become an accepted standard of care for properly qualified candidates. As the authors state, it is at a point where “… thousands of patients in clinical trials or prospective registries have been treated with a number of different energy sources, and there is much agreement on who best to treat and how to treat them.” Of course, no two cases are identical, and there is interplay among four factors: tumor location, its margin and characteristic zonal spread, the type of energy chosen for the ablation, and preserving critical structures. Thus, following the 10 steps outlined above can establish a predicted margin that can be applied in all cases to assure accuracy for tumor ablation.  

As more and more PCa patients find FT an appealing middle ground between whole gland treatment (with its risk of urinary and sexual side effects) and Active Surveillance (with its risks of anxiety and missing a treatment window), confidence in choosing FT can only gain strength knowing that there are universal guidelines for maximizing accuracy while minimizing side effect risks.  

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Orczyk C, Marsden T, Giganti F, Norris JM et al. Applying Focal Therapy to Lesions Detected via Magnetic Resonance Imaging: Delivering Cancer Ablation Beyond the Visibility Phenomenon. Eur Urol Open Sci. 2025 Feb 10;72:36-41.