If you went to the Broadway play “Wicked”, or saw the recent film version, the song “Popular” may have stood out for its high fun quotient. The word itself suggests communal agreement that some individuals, styles, cars, actors, etc. stand out because they are well-liked by a LOT of people.

How a person or thing becomes popular depends on a combination of qualities. Is it unique? Does it offer something of value that people want? Does it have an appealing track record? Has it been endorsed by influential people? And so on.

In the medical world, change tends to come slowly. A new drug or treatment that generates a sudden bandwagon among patients is likely to be met with skepticism. It’s not uncommon for a doctor to respond to a patient’s enthusiasm over something he or she saw in a TV ad by saying, “If it sounds too good to be true, it probably is.” Innovations can be a hard sell among physicians who’ve had years of practicing what they learned in medical school.

Thus, I was pleasantly surprised to come across a recently published (Jan. 2025) survey of urologists’ use of focal therapy (FT) for prostate cancer (PCa). I was even more surprised to find that the multi institutional team included authors from prestigious academic urology centers like University of Chicago and University of Michigan. The journal article is titled, “Shifting Tides: A Survey Analysis of Urologists’ Evolving Attitudes Toward Focal Therapy for Prostate Cancer.”^[i]

The team emailed a 22-item questionnaire to members of the American Urological Association. It was designed to poll urologists on their utilization of focal therapy, with answers compared to a 2019 survey.

Survey results

Today, less than half of those who responded use FT but the number has grown since 2019. At that time, only 24% used FT whereas it’s now up to 43% in 2025. In addition, more respondents now believe in the “index lesion” theory. Not surprisingly, it appears that urologists who had fellowship training in urologic oncology and/or saw a higher volume of PCa patients utilized FT than those who did not.

The authors foresee the potential for continued increase in FL. They write, “As urologists gain more experience, the trend of further utilization of FT for [prostate cancer] may continue.”^[ii] In fact, 83% of respondents believe that FT will be a standard of care in the future. Could this mean that FT is gaining in popularity among urologists? On one hand, I hope so, as that will make its benefits available to more patients while reducing the burden of side effect risks from whole gland treatments.

On the other hand, I have a concern. Survey respondents cited better imaging to account for increased FT use. As background, “The increasing use of diagnostic tools to localize and stratify [PCa] patients, such as multiparametric magnetic resonance imaging (mpMRI), has led to the opportunity and desire for innovative focal treatments.”^[iii] More importantly, mpMRI offers accurate planning, guidance, monitoring and post-treatment confirmation for FT, particularly when it is used in real time. And yet, urologists do not perform focal therapy using real time, in-bore mpMRI. Instead, they use either real-time ultrasound, or real-time fusion guidance that incorporates previously captured mpMRI images.

I can understand why more and more urologists are turning to FT for their patients. Since they are trained as surgeons, they have incredible knowledge of prostate anatomy and of PCa itself. They understand the advantages of FT for qualified patients. However, my concern is the use of less-than-the best imaging to destroy a cancer tumor and validate the results. Of course, there are already advances in ultrasound imaging; and as for fusion, new software and Artificial Intelligence programs continue to improve its use for guiding biopsies. However, even the best fusion relies on past, frozen MRI images. When it comes to treating cancer, are those static images as trustworthy as seeing what’s happening in this living, breathing patient right now, that ultrasound can’t see?

I am not a skeptic, but I think my concerns are legitimate. I believe that mpMRI is unparalleled at revealing all that needs to be seen for successful focal therapy. As we continue to watch FT become more acceptable—even popular—among urologists, I for one am grateful to have a state-of-the-art magnet at the service of my patients.

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] Koehler J, Lazarovich A, Tayebi S, Viswanath V et al. Shifting tides: A survey analysis of urologists’ evolving attitudes toward focal therapy for prostate cancer. Indian J Urol. 2025 Jan-Mar;41(1):59-65.
[ii] Ibid.
[iii] Ibid.