By Andrew Tan, Urologist, Prostate & Kidney Surgeon, Nedlands
Over the past decade, the management of clinically significant, localised prostate cancer has undergone a significant evolution.
While radical prostatectomy and external beam radiotherapy remain the gold standards for many patients, the associated morbidity – particularly impacting sexual function and urinary continence – has prompted interest in less invasive strategies.
Focal therapy has emerged as a promising middle ground, offering the potential for effective cancer control with minimal impact on quality of life.
Focal therapy is a precise, image-guided treatment that targets the dominant prostate cancer lesion, aiming to ablate the tumour while preserving surrounding healthy tissue.
The goal is to maintain erectile and urinary function by avoiding whole-gland treatment. This targeted approach is supported by improved imaging and biopsy techniques allowing better identification and characterisation of clinically significant lesions.
Despite technical advances in surgery and radiotherapy, functional side effects remain common. The Prostate Cancer Outcomes Registry (2023) provides sobering data:
- One year after radical prostatectomy, 45% of men reported sexual function as a problem; only 22% achieved a fair to very good erection. 20% experienced more than one urinary leak per day, and 31% needed more than one pad daily
- After radiotherapy, 34% of patients still had sexual function issues, with only 24% reporting erections adequate for intercourse. 10% experienced significant urinary leakage.
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Treatment approaches that better preserve quality of life, especially in men with intermediate-risk, organ-confined disease are needed.
The focal therapy opportunity
Focal therapy can treat prostate cancer while minimising side effects, preserving future treatment options if necessary. While most prostate cancers are multifocal, about 20–25% of cases are unifocal.
However, the concept of the index lesion – the dominant tumour driving disease progression – has expanded the potential use of focal therapy beyond unifocal cases.
Treating this main lesion may significantly alter disease trajectory, even if smaller secondary foci remain.
Ideal candidates for focal therapy are carefully selected and well-counselled. Criteria include ISUP Grade Group 2 (Gleason 3+4=7), PSA <15 ng/mL, organ-confined (T2) disease, life expectancy ≥10 years, ability to comply with rigorous follow-up protocols and enrolment in a data registry and understanding of the lack of long-term outcome data.
Patients with low-risk disease, for example low-volume Gleason 6, are better managed with active surveillance. Those with high-risk or locally advanced cancers typically require whole-gland treatment.
The feasibility of focal therapy has been significantly improved by technological advancements, allowing more accurate detection, localisation, and staging of disease.
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These include multi-parametric MRI (mpMRI) for lesion detection and staging, PSMA PET/CT for detecting disease outside the prostate and ensuring concordance with MRI, MRI-ultrasound fusion-guided biopsies for targeted sampling and transperineal robotic-assisted biopsy platforms currently emerging.
Together, these tools reduce the risk of under-staging and increase confidence in patient selection.
Focal therapy modalities
A range of focal therapy techniques are available; all typically performed as day-case procedures with minimal downtime and side effects. These include:
- High-Intensity Focused Ultrasound (HIFU): Uses focused sound waves to thermally ablate the tumour.
- Cryotherapy: Employs rapid freezing to destroy cancer cells.
- Irreversible Electroporation (Nanoknife): Uses electrical pulses to disrupt cancer cell membranes without heat.
- Focal Laser Ablation: Applies laser energy to precisely ablate the lesion under image guidance.
- Focal Brachytherapy: Involves placing radioactive seeds into the tumour zone for localised radiation delivery.
Currently, only focal brachytherapy is fully reimbursed by private health insurers in Australia.
There is no high-level evidence yet to suggest one modality is superior; choice often depends on surgeon experience, tumour location and technological availability, such as HIFU is ideal for posterior lesions.
Post-treatment surveillance and outcomes
Patients require ongoing monitoring with regular PSA testing, post-treatment mpMRI and repeat biopsies to assess both in-field and out-of-field recurrence.
Recurrence can be managed with repeat focal ablation or salvage whole-gland therapy (radical prostatectomy or radiotherapy).
Importantly, salvage treatments remain feasible and reasonably safe, although functional outcomes are understandably reduced, as with upfront whole-gland treatment.
Most published data are from prospective studies with short- to medium-term follow-up. The results are encouraging, with continence preserved in over 90% of cases, erectile function preserved in up to 100% in some series, five-year failure-free survival ~83% and treated zone control 85–90%, with most recurrences occurring outside the treated area.
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These outcomes suggest that focal therapy offers excellent functional preservation with reasonable oncologic control in the short term. As imaging and biopsy techniques continue to evolve, we may reduce out-of-field failures due to under-sampling or staging errors.
Key messages
- Focal therapy can offer curative intent in a minimally invasive, function-preserving format, suited to selected patients with intermediate-risk disease
- Whilst long-term data is evolving, focal therapy is increasingly supported by modern imaging, precision biopsy, and growing clinical experience
- For the right patient, this approach can mean avoiding the morbidity of whole-gland treatment without compromising on cancer control.
Author competing interests – nil
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