SUMMARY:
Low-risk localized prostate cancer, which may never become life-threatening, can be managed with whole gland treatments or Active Surveillance. Whole gland treatments, however, are considered overtreatment for low-risk cancer due to their risk of side effects that lessen quality of life. On the other hand, Active Surveillance risks living with anxiety and the fear of discovering cancer progression. Focal Laser Ablation offers a happy medium by destroying the cancer while preserving high quality of life.
What is low-risk prostate cancer?
Prostate cancer is considered low-risk if it is diagnosed as contained within the prostate gland (localized) and is highly likely to grow very slowly, or not at all (low risk of progression). It is sometimes labeled as indolent, or “lazy,” because it may never become life-threatening.
According to the National Center for Biotechnology Information, clinical criteria include
- The cancer is found in only one of the two sides (lobes) of the prostate.
- The cancer takes up less than half of the affected prostate lobe.
- The cancer cells haven’t mutated (changed) much and aren’t very aggressive.
- The cancer hasn’t advanced to the lymph nodes or spread to other parts of the body.
Thanks to early detection via PSA tests and multiparametric MRI, roughly 33-40% of newly diagnosed cases of prostate cancer are found when the prostate cancer meets the above criteria. This is when treatment has the greatest probability of success.
What are the treatment choices for low-risk prostate cancer?
All whole gland treatments are possible for localized, low-risk prostate cancer. Experts have long recognized, however that radical surgery or radiation for low-risk prostate cancer constitutes overtreatment due to higher rates of urinary, sexual, or bowel complications. These side effects can persist even 12 years after treatment, yet the low-risk cancer may never have progressed.[i]
To avoid overtreatment, therefore, virtually all international guidelines now recommend Active Surveillance as the preferred management strategy for localized low-risk prostate cancer rather than immediate whole gland treatment.
What is Active Surveillance?
Active Surveillance is a strategy for managing low-risk prostate cancer that actively monitors the patient for cancer progression while avoiding immediate treatment with surgery or radiation and their corresponding side effects.
Depending on each doctor’s protocol, Active Surveillance typically involves
- PSA blood test once or twice a year
- Annual digital rectal exam (DRE)
- MRI may be used at specified intervals, and to determine if repeat biopsy is needed
- Repeat biopsies at specified intervals, or if triggered by PSA and MRI evidence of cancer change
- Biopsy-proven progression triggers move to treatment.
It is worth noting that a 15-year survival analysis of localized prostate cancer patients randomly assigned to either radical surgery, whole-gland radiation, or Active Surveillance found that prostate cancer-specific survival was statistically equal among the three groups.[ii]
Why are low-risk prostate cancer patients facing a dilemma?
If patients with low-risk disease must choose between radical treatment (all) or Active Surveillance (nothing), for many it poses a dilemma that requires a risk-benefits calculation.
| Whole gland treatment | Active Surveillance | |
| Risks |
|
|
| Benefits | High cancer control rate | Maintain high quality of life with no side effect risks |
Good news: today’s low-risk prostate cancer patients now have a middle ground choice. Focal Laser Ablation, as performed at the Sperling Prostate Center, resolves the dilemma. The cancer is controlled with minimal-to-no risk of urinary and sexual complications.
What is Focal Laser Ablation for localized prostate cancer?
MRI-guided Focal Laser Ablation is a minimally invasive treatment that targets and destroys prostate cancer tumors without harming surrounding healthy tissue. Guided by real-time MRI, Focal Laser Ablation encompasses the cancer tumor plus a preemptive extra margin with laser-generated heat.
Since the laser’s temperature and zone of destruction can be observed and measured in real time, it provides remarkable precision. This allows confirmation that there is no damage to key urinary and sexual structures. Thus, compared to whole gland treatment, side effect risks of incontinence or erectile dysfunction are minimal to none. And, unlike radiation, tumor destruction is immediate.
Focal Laser Ablation bridges the gap between whole gland treatment and Active Surveillance.
- Like whole gland treatment, Focal Laser Ablation immediately destroys the cancer.
- Unlike whole gland treatment, Focal Laser Ablation has very low chances of urinary and sexual complications.
- Like Active Surveillance, Focal Laser Ablation preserves high quality of life.
- Unlike Active Surveillance, patients have no anxiety, worry, and depression knowing that the tumor has been destroyed.
What does Focal Laser Ablation Treatment Involve?
Focal Laser Ablation is a minimally invasive outpatient treatment guided by MRI. At the Sperling Prostate Center, it is tailored to each individual case based on thorough diagnosis and MRI-based treatment planning. Treatment involves:
Pre-treatment planning
- Includes pre-treatment multiparametric MRI and biopsy to identify and map the target.
Day of treatment
- Bowel cleanse and antibiotic administration, and local anesthesia (no general anesthesia)
- Patient lies on his back in the MRI scanner
- Urinary catheter inserted to protect the urethra
Procedure preparation
- Insertion of a slender hollow needle guide
- Insertion of a laser optic fiber through the needle into the tumor
- Continuous MRI scans confirm successful mapping and fiber placement
Ablation activated
- When the laser is activated, the tumor is immediately destroyed via targeted laser energy
- MRI monitoring and protective catheter ensure no collateral damage to key structures
Treatment Effect Verified and Patient Discharged
- Post-procedure contrast-enhanced MRI verifies complete tumor destruction.
- Devices removed, patient gets dressed and recovers in-office for a few hours
- Doctor meets with patient to discuss procedure, and explain follow-up protocol
- Patient returns home (no overnight stay)
Who is a candidate for Focal Laser Ablation?
Qualifying for Focal Laser Ablation starts with a mindset. Interested patients may already have been recommended by their doctors for Active Surveillance, but they want an alternative middle ground to whole gland treatments vs. monitoring.
There are specific clinical requirements to qualify for Focal Laser Ablation:
- Biopsy-confirmed low-risk prostate cancer
- 3T multiparametric MRI confirms a localized visible lesion in a location accessible for Focal Laser Ablation without damaging urinary or sexual function
Finally, candidates should be willing and able to follow a protocol of follow-up monitoring that includes PSA tests and multiparametric MRI scans at specified intervals. This is important because the untreated areas of the prostate gland may harbor microscopic prostate cancer cells that could not be previously detected, with the potential for future cancer activity.
Frequently asked questions
Q: Why does Active Surveillance cause anxiety?
A: First of all, not every patient on Active Surveillance suffers from worry or anxiety. Much depends on each patient’s tolerance with uncertainty, since some deal better with it than others. However, for patients who are uncomfortable with the idea that cancer is growing in their body, being on Active Surveillance is constantly living with fear of the unknown. Even being shown favorable statistics, or having the biology of low-risk prostate cancer explained to them, may not take the edge off their fear.
Another factor is, testing that is regularly done at 6-month, 1-year or 2-year intervals can raise worry and stress waiting for the results. “Will this be the test that shows my cancer is growing?” can be a very troubling question.
It’s not unusual for a newly diagnosed low-risk patient to refuse to go on Active Surveillance and request surgery or radiation, even when a doctor has reassured him that monitoring is a safe choice for him. These are patients who think, “I’ll take my chances with side effects because I want the cancer gone from my body.”
And, among patients who do start out on Active Surveillance, about 50% drop out in favor of treatment. Of those, 20-40% do so with no evidence that their cancer has progressed. For many, anxiety won out.
Q: My doctor says Active Surveillance is now the preferred treatment for low-risk prostate cancer. Why?
A: Over a decade ago, experts recognized that whole-gland treatment, with its side effect risks, is overtreatment because it harms quality of life for patients whose cancer was not life-threatening. Studies showed that holding off on treatment a) had no urinary or sexual consequences and b) men on Active Surveillance had almost the same life expectancy as men who had surgery or radiation. So, there were two choices with no middle ground: treat the whole gland, or don’t treat it at all.
Between then and now, MRI and targeted biopsy made it possible to identify men with unifocal disease who could have their tumor destroyed with minimal risk of side effects. Thus, focal therapy emerged as a balance between the two extremes. While a patient’s clinical factors point him toward Active Surveillance, in fact many patients don’t like the idea of living with cancer growing in them, or they find monitoring too heavy of a burden, or they don’t want to chance missing a treatment window. In other words, your paperwork might say you should go on Active Surveillance, but you want to get rid of the cancer without harming your lifestyle. In such cases, it’s worth being evaluated to find out if you’re a candidate for focal therapy.
Content reviewed by Dr. Dan Sperling, M.D., DABR — updated September 2026
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] Unger JM, Till C, Tangen CM, Hershman DL, et al. Long-Term Adverse Effects and Complications After Prostate Cancer Treatment. JAMA Oncol. 2024 Nov 7;10(12):1654–62.
[ii] Hamdy FC, Donovan JL, Lane JA, Metcalfe C, et al. Fifteen-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med. 2023 Apr 27;388(17):1547-1558.
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.
