Abstract and Introduction
Purpose of review: The aim of this study was to summarize the latest evidence, as well as the rationale behind using focal therapy for the treatment of prostate cancer. With patients becoming more educated, knowledge of the available evidence is key when discussing treatment.
Recent findings: In older works, the natural history of prostate cancer has been described as being multifocal, driven by one index lesion. This represents the key argument for most experts, why focal therapy is feasible in prostate cancer. Most modalities have similar results. For high-intensity focussed ultrasound (HIFU), a pooled data analysis with a median follow-up of 2.2 years showed a negative biopsy rate of 77% with a salvage therapy free rate of 92%. A matched pair analysis comparing irreversible electroporation with robot-assisted radical prostatectomy showed a better side effect profile for focal therapy in evenly matched groups, yet with worse disease-free survival. Interestingly, the better outcomes concerning continence and erectile function did not translate into better patient-reported outcomes.
Summary: Focal therapy modalities are generally well tolerated and show good results in terms of continence and potency. Long-term follow-up is not available, and inclusion criteria for trials are not yet uniform. Newer technologies, such as photodynamic therapy, are being developed, as well as improvements to older techniques, such as HIFU.
As our knowledge about the natural history of prostate cancer (PCa) grows, so do the options for treatment. The standard treatments for localized PCa, surgery and radiation, are still option of choice for a lot of patients, yet the demand for more precise treatment with fewer side effects is growing constantly. Observation by either active surveillance or watchful waiting has become a more popular strategy, yet is not always optimal. Also, the burden of a tumour diagnosis without any treatment is unbearable for some patents. Although many of those patients should have never been diagnosed with PCa in the first place, and as imaging technology, and biomarkers become more accurate, many of them will not be diagnosed with PCa in the future, there remains a group of small intermediate risk cancers that do require treatment, yet might be overtreated by surgery or radiation.
Focal therapy seems a logical consequence of this. As with many other tumour entities (e.g. breast, kidney, liver), removal of the entire organ is not always necessary to curatively treat the cancer. Although PCa is often considered multifocal in nature, better understanding of the importance of an index lesion has as well as more accurate diagnostics has shown focal therapy to still be a viable treatment approach. Advances in imaging, urine and genetic biomarkers are of great help in this regard.
The available options when deciding for focal therapy are plentiful, yet solid data, and long-term follow-up is lacking for most of them. For this reason, the European Association of Urology Guidelines only recommend using focal-therapy within clinical trials. Most of the available options for focal therapy were originally used as whole-gland treatment, thus data for whole-gland treatment exist, yet usually shows significant side effects, which might not occur when deciding for a focal approach. Yet, again data are scarce and must be evaluated carefully.
It is the aim of this review to show the most recent publications in the field of focal therapy for PCa in hopes to spark interest and future research. There are many potential benefits to a focal therapy, however thorough investigation is needed to ensure adequate oncological outcome.
Curr Opin Urol. 2018;28(6):550-554. © 2018 Wolters Kluwer Health, Inc.