Sperling Prostate Center

If You’re on Active Surveillance, Should You Consider a Focal Treatment?

A friend of mine had a 2004 Subaru Forester with a whopping 192,000 miles on it. I was starting to see it as the automotive version of immortality. With usual maintenance, that car ran like a top.

One Saturday, my friend discovered an oil spot in the garage. Sure enough, for the first time in the car’s history, it seemed to be leaking oil. An examination by a mechanic revealed the old engine’s head gasket was the source. My friend was sad. He didn’t feel ready to give it up. That reliable car had been a long-time pal. Even the driver’s seat had molded itself to my friend’s body, a comfort he counted on. So, what were his choices? He could spend upwards of $1500 for an engine job on a car likely to start having other major problems, or hold off on major engine work and just monitor the oil level till the leak got worse. If he wanted to keep the car, it looked like an either/or situation with no middle ground. His mechanic offered him a middle ground, a way to buy more time and peace of mind: an oil additive called a head gasket sealer.

I see this situation as similar to someone diagnosed with early, low-risk prostate cancer (PCa). Most patients in this circumstance will be offered an either/or choice: a total gland treatment vs. going on Active Surveillance (AS) to delay treatment while monitoring their PCa. However, there’s a happy medium that buys more time and peace of mind: focal therapy.

Active Surveillance increasingly recommended

Thanks to multiparametric MRI (mpMRI) there’s been a dramatic shift in early PCa detection and accurate staging. Because this imaging provides a detailed baseline portrait of a patient’s tumor, it facilitates much better surveillance technology than the classic PSA blood test alone. Thus, AS is being increasingly recommended to patients as an alternative to a surgery or radiation with their risks of urinary, sexual and bowel side effects. Understandably, this is appealing to patients who have the psychological tolerance for knowing that there’s cancer in their prostate gland.

The downside of AS appears to be small, but not entirely negligible. A large Canadian population-based study of 21,282 low-grade prostate cancer patients compared 10-year survival rates between those who underwent initial total gland treatment vs. those who went on AS.[i] While the 10-year overall survival rates for the 39% who remained on AS that long were excellent, the authors found that AS “… was associated with higher risk of metastasis, overall mortality, and prostate cancer-specific mortality compared to initial treatment.”

AS combined with focal therapy

Just as an oil additive can add to engine life when properly used, focal therapy can add to the duration of AS before other treatment might be needed—and in some cases, it appears to eliminate the need altogether. According to a Urology Times article on 10-year followup of PCa patients who had MRI-guided focal laser ablation,

The procedure yielded a 100% prostate cancer-specific survival rate. The safety profile showed that the rates of erectile dysfunction, infection, and incontinence were all under 1% with MRI-guided laser focal therapy. These rates show a tremendous benefit over standard whole-gland prostatectomy, which is associated with a 25% risk of urinary incontinence and 50% risk of erectile dysfunction.[ii]

Focal treatment is thus a happy medium between prostatectomy and AS. It has the benefit of precision destruction of the tumor while sparing healthy tissues and avoiding delicate nearby structures connected with urinary and sexual function. However, it would be incorrect to assume that no future treatment will ever be needed. After a focal procedure, as with any PCa treatment, monitoring will continue by means of PSA tests and mpMRI scans at prescribed intervals. It is important that patients adhere to their monitoring protocol, to make sure that a) there is no recurrence of the original tumor, and b) no new PCa begins in another area. Should a rising PSA and/or a suspicious MRI result occur, an in-bore MRI-guided needle biopsy is the next step. This type of biopsy returns the most accurate diagnosis, yet requires only a minimum number of needles thanks to the precise real-time imaging. And, if a new lesion is discovered, all treatment options are still open including surgery, radiation, and another focal therapy.

To return to my friend’s leaking engine gasket, he was too sentimental to say a final goodbye to his Forester but too practical to spend over a thousand dollars. He opted for the additive, a middle ground that works for him. He decided his old friend the Forester deserved a chance to make it to 200,000 miles, at which point he felt its long life of service will have earned an “honorable discharge.” He’s setting aside money for a new car, starting with the $1500 he saved by opting for a happy medium.

The Sperling Prostate Center offers three approaches to focal tumor ablation: Focal Laser Ablation (FLA), Transurethral Ultrasound Ablation of the Prostate (TULSA-PRO), and MRI-guided Focused Ultrasound (MRgFUS). If you are on AS, and you want more information so you can consider if such an approach is right for you, contact us.

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.

[i] Timilshina N, Alibhai SMH, Tomlinson G, Sander B et al. Long-term Outcomes Following Active Surveillance of Low-grade Prostate Cancer: A Population-based Study Using a Landmark Approach. J Urol. 2022 Dec 7:101097JU0000000000003097
[ii] Broderick, Matthew. “MRI-guided laser focal therapy achieves impressive precision and safety in prostate cancer.” Urology Times, Jun. 16, 2020.


About Dr. Dan Sperling

Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.

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