SUMMARY:
Focal therapy for localized prostate cancer is a standard of care for qualified patients that bridges the gap between whole gland treatment and surveillance. Advances in imaging and biopsy have improved the precision of focal therapy, boosting successful cancer control by this safe and effective treatment strategy. The Sperling Prostate Center offers four FDA-approved focal therapy methods.
Introduction
Prostate cancer is the most common non-skin cancer in men. The American Cancer Society projects 333,380 new cases in the U.S. for 2026. Most cases are diagnosed while the cancer is still localized, that is, contained in the gland.
Treating localized prostate cancer has traditionally involved the whole gland. There are three methods: surgery (prostatectomy), radiation (radiotherapy), and minimally invasive destruction (ablation). Or, for patients with low-risk prostate cancer (Grade Group 1 or 2), Active Surveillance is increasingly prescribed as a way to monitor for cancer progression while holding off on treatment.
Dr. Dan Sperling points out that both whole gland treatment and Active Surveillance have risks. Whole gland treatment has a risk of urinary, sexual or bowel side effects, depending on the treatment method. Active Surveillance carries a risk of living with anxiety or of missing a treatment window.
Recently, there is growing recognition of the need to balance cancer control with reduced treatment side effects. Today’s advanced focal therapy bridges the gap between whole gland treatment and Active Surveillance. Focal therapy is defined as image-guided ablation of a cancerous tumor identified by biopsy and imaging, with a safety margin surrounding the targeted tumor.[i]
What is the greatest advance that makes focal therapy safe and feasible?
The greatest progress in identifying a suspicious prostate cancer tumor comes from multiparametric MRI (mpMRI). mpMRI scans involve three imaging sequences. Each sequence, or parameter, reveals a specific tissue characteristic that distinguishes cancer from normal tissue.
When all three are combined, a 3-dimensional portrait of the prostate gland and its cancer is created. The key tumor to identify is the index lesion, which shows up clearly on a powerful 3 Tesla (3T) magnet when interpreted by an experienced reader. This tumor contains the cells capable of progressing, so it will be the target of focal therapy. If mpMRI identifies an index lesion, a biopsy is necessary.
According to DesCotes (2019), “Recent advances in mpMRI lead to standardised interpretation and increased prescription by clinicians in order to improve detection of clinically significant PCa and select patients requiring targeted biopsies.”[ii]
One other area of imaging process is PSMA-PET scan, done either on MRI or CT scan. When the index lesion appears aggressive on mpMRI, PSMA-PET scan may be done to rule out prostate cancer that has escaped to other body areas. If that is the case, the patient is not a candidate for focal therapy.
What progress has been made in prostate biopsy?
A needle biopsy of the prostate is necessary to obtain tissue samples in order to diagnose the aggression of an MRI-visible index lesion. Conventional biopsies have been guided by transrectal ultrasound (TRUS).
However, TRUS cannot see tissue differences. Therefore, 12 or more needles are randomly inserted following a grid-like pattern. This comes with risks, including discomfort and infection. Also, this type of biopsy has sampling error rate as high as 46%.[iii]
To overcome sampling errors and risks, a more accurate but minimalist biopsy method is called for. Here again, mpMRI offered the greatest progress in transforming prostate biopsy.
Real-time MRI uses precise imaging to guide a small number of needles directly into the core area of the index lesion where the more dangerous cancer cells are likely to be harbored. Since it is done in the MRI, it is called an in-bore (or in-gantry) MRI-guided targeted biopsy. Usually only 2-4 needles are used.
In-bore biopsy can be done either transrectally (via the rectum) or transperineally (via the outer skin between the scrotum and anus). The small number of needles greatly lowers infection risk for transrectal biopsy; the transperineal approach avoids risk of infection from bowel bacteria.
Note: when real-time MRI is not available, a method called fusion guided targeted biopsy merges previously captured (not live) MRI images with real-time TRUS. There is a slight risk of registration error, so multi-needle random sampling is frequently done in addition to fusion-guided targeting.
How does the progress in mpMRI improve delivery of focal therapy?
Progress in imaging has improved delivery of focal therapy in four ways:
- Lesion localization – Today’s mpMRI, in the hands of an experienced radiologist, pinpoints the location and extent of the targeted index lesion.
- Patient selection – Not every patient with localized prostate cancer is a candidate for focal therapy. The latest guidelines from the American Urological Association state that “MRI and targeted biopsy should be used for patient selection in focal therapy,” and further qualify patients up to and including favorable intermediate disease.[iv]
- Treatment monitoring – Specialized software used during either real-time MRI-guided treatment tracks the size and temperature of the ablation zone. This ensures that the entire lesion plus a margin of safety to preempt tumor advancement are encompassed by the ablating energy.
- Confirming treatment effectiveness – mpMRI immediately after the application of ablating energy establishes that no signs of cancer characteristics exist in the zone of ablation.
Using mpMRI and targeted biopsy to qualify appropriate candidates for focal therapy improves the precision and accuracy of focal therapies, increasing the probability of successful cancer control.
How does today’s focal therapy compare with prostatectomy and radiotherapy?
For appropriate patients, focal therapy compares favorably with whole gland treatments. Cancer control statistics at eight years show that focal therapy is noninferior to whole gland treatment.[v] Plus, focal therapy offers significantly lower post-treatment side effects (incontinence and erectile dysfunction) and better cost-effectiveness than either surgery or radiation.[vi]
How does today’s focal therapy compare with Active Surveillance?
Active Surveillance is recommended for low-risk patients (Grade group 1-2) as a way to hold off on whole gland treatment with its accompanying risks of incontinence and impotence. Studies point to very similar prostate cancer survival rates at 10 years between prostatectomy and Active Surveillance. However, Active Surveillance patients enjoy higher quality of life because they avoid side effects.
Many surveillance patients, however, drop out within 5 years without evidence of disease progression due to “surveillance fatigue,” or having to live with anxiety knowing an active cancer is present.
Focal therapy consists of a minimally invasive outpatient procedure (with rapid recovery) to gain cancer control. This relieves patient anxiety. Even so, focal therapy still requires monitoring by regular PSA tests and mpMRI, similar to Active Surveillance. This is because focal therapy spares normal prostate tissue, where untreated microscopic cancer cells may lurk. Any sign of new cancer activity (rising PSA, lesion visible on mpMRI) will trigger a targeted biopsy.
What happens if new prostate cancer activity is detected?
After focal therapy, if new prostate cancer activity is detected and a biopsy is positive for cancer, all treatment options are open. Depending on clinical factors, a new treatment strategy may include a repeat focal therapy, a whole gland treatment, or even Active Surveillance if the diagnosis is low-risk.
Frequently Asked Questions
Q: What are ablation methods approved by the FDA?
A: Currently, the following methods are FDA-approved to treat prostate tissue: high-intensity focused ultrasound (HIFU), cryoablation (freezing), focal laser, irreversible electroporation (IRE), transurethral ultrasound ablation of the prostate (TULSA-PRO) and photodynamic therapy (PDT). Clinical factors, patient preference, risks, cost and availability are factors to take into account when considering focal therapy. The decision should be made in doctor-patient-patient partner discussion.
Q: What ablation methods are offered at the Sperling Prostate Center?
A: The Sperling Prostate Center offers four image-guided focal ablation methods for localized prostate cancer: Focal Laser Ablation (FLA), TULSA-PRO, Exablate MR-guided Focused Ultrasound, and Transperineal Prostate Laser Ablation (TPLA). Thanks to the Center’s powerful 3 Tesla magnet, Dr. Dan Sperling provides expert mpMRI-based detection, diagnosis, and focal treatment with integrated Artificial Intelligence programs. For more information, contact Sperling Prostate Center.
Content reviewed by Dr. Dan Sperling, M.D., DABR — updated April 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] Roldan-Testillano R, Rodriguez-Sanchez L, Covarrubias C, Durazo-Ruiz F et al. Advances in focal therapy for prostate cancer: current modalities, outcomes, and future directions. Prostate Int. 2026 Mar;14(1):1-9.
[ii] Descotes JL. Diagnosis of prostate cancer. Asian J Urol. 2019 Apr;6(2):129-136.
[iii] Descotes JL. Ibid.
[iv] AUA/ASTRO Guideline. American Urological Association. 2026. https://www.auanet.org/guidelines-and-quality/guidelines/clinically-localized-prostate-cancer
[v] 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.
[vi] Reddy D, van Son M, Peters M, Bertoncelli Tanaka M et al. Focal therapy versus radical prostatectomy and external beam radiotherapy as primary treatment options for non-metastatic prostate cancer: results of a cost-effectiveness analysis. J Med Econ. 2023 Jan-Dec;26(1):1099-1107.
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.
