Am I a Candidate for Focal Therapy for Localized Prostate Cancer?

After being diagnosed with prostate cancer, your urologist may recommend treatment, which traditionally includes surgery (radical prostatectomy), radiotherapy, or active surveillance. The recommendation for each of these approaches depends on a balance of a patient’s overall health, symptoms such as urinary and sexual function, priorities in terms of quality of life, and cancer aggressiveness and/or risk. In each of these cases, the same treatment is applied to the whole prostate, including those areas known to have cancer but also the remainder of the prostate gland. This has been the traditional approach because, for many years, it has been recognized that prostate cancer is often found in multiple areas of the prostate at the same time (“multi-focal” disease).

However, many patients ask if it is possible to only treat the areas of prostate cancer and not the entire prostate gland. It is increasingly recognized that some patients may have a single area of disease (“unifocal cancer”) or may have a single area that needs treatment, with other areas being low-risk and suitable for active surveillance.

In prostate cancer, the idea of focal therapy received a significant boost when magnetic resonance imaging (MRI) became more commonly used. MRI allows urologists to take biopsies of specific areas of the prostate and then, when appropriate, target focal therapies to these areas of prostate cancer. Focal therapy in prostate cancer aims to balance cancer treatment success and decrease side effects (generally, urinary incontinence and erectile dysfunction). For the most part, because these approaches are still somewhat new (compared to surgery and radiotherapy) and do not have the long-term cancer outcomes of the more traditional approaches, these procedures should only be performed in high-volume centers of excellence by experienced urologists.

Am I Suitable for Focal Therapy?

While early studies in focal therapy utilized this treatment approach in low-risk prostate cancer, most clinicians agree that active surveillance is a more appropriate treatment approach for most of these men. Thus, focal therapy is typically best suited for patients with intermediate- risk prostate cancer who have a single tumor that can be seen on MRI and no other cancer in their prostate (proven with negative biopsies – no cancer – in the other areas of prostate gland).

The following provides a general guide for appropriateness of focal therapy (regardless of type of focal therapy) based on Gleason Grade Group:

• Gleason Grade Group 1 (Gleason score 6): not appropriate (active surveillance best for most patients)
• Gleason Grade Group 2 (Gleason score 3 + 4 = 7): appropriate for patients with unilateral (one side of the prostate) MRI lesions corresponding to the prostate biopsy showing Gleason Grade Group 2 prostate cancer
• Gleason Grade Group 3 (Gleason score 4 + 3 = 7): appropriate for patients with unilateral MRI lesions corresponding to the prostate biopsy showing Gleason Grade Group 3 prostate cancer
• Gleason Grade Group 4 (Gleason score 8): not appropriate (Surgery or radiation with or without hormonal therapy is more appropriate)
• Gleason Grade Group 5 (Gleason score 9 or 10): not appropriate (Surgery or radiation with or without hormonal therapy is more appropriate)

Goals of Focal Therapy

Regardless of the type of focal therapy used to treat the prostate cancer, the goals of treatment are essentially the same:

• Treat only the biopsy-proven/MRI-visible unilateral prostate tumor
• Avoid injury to the bladder, urethra, and rectum
• Preserve erectile dysfunction by not treating the entire prostate gland
• Preserve urinary continence by not treating the entire prostate gland

What Types of Focal Therapy are Available?

There are 5 types of focal therapy typically used for treatment (in no particular order):

1. Cryotherapy: uses cold temperatures to freeze/kill prostate cancer cells. During cryotherapy, metal probes are inserted into the prostate and are filled with gas that causes the tumors and nearby prostate tissue to freeze
2. Focal laser ablation: uses laser energy pinpointed to the tumor to burn away the prostate cancer cells. In some cases, focal laser ablation can be performed at the same time as an MRI to allow “real time” imaging for enhanced precision
3. High-intensity focused ultrasound (HIFU): uses high temperatures, generated by high energy ultrasound waves, to kill prostate cancer cells. These ultrasound waves are focused to the prostate cancer by a transducer, providing precise targeting to the tumor
4. Irreversible electroporation (IRE or NanoKnife): uses pulses of electricity to create small holes in prostate cancer cells (does not use hot or cold temperatures). The electricity is finely pinpointed to the prostate tumor
5. Transurethral ultrasound ablation (TULSA): uses ultrasound waves to create high temperatures to kill the targeted prostate tumor cells. TULSA is performed at the same time as an MRI to allow “real-time” imaging for enhanced precision

What Should I Expect After Focal Therapy?

After focal therapy, your urologist will monitor you closely. While the follow-up plan may differ amongst centers of excellence and urologists, generally this will include:

• PSA tests every 3-6 months initially and annually thereafter
• MRIs every 1-2 years
• Repeat prostate biopsy (typically about 1 year after treatment) to ensure the treatment worked, and in situations where the PSA increases or the MRI shows concern for cancer

The effectiveness of focal therapy can vary (30% to greater than 95%) and depends on many factors, including location of the tumor, type of focal therapy used, and the metric used to define success (i.e., PSA going down, MRI findings, negative post-treatment prostate biopsies).

The choice of specific focal therapy technique depends on a number of factors, including your urologist’s comfort with each technology. If you are interested in focal therapy, you should discuss with your urologist if it is appropriate in your situation and, if so, what approach they would suggest.

It is also important to remember several caveats. First, focal therapy is not necessarily the right treatment for a patient – in some cases, it may represent too much treatment (i.e., active surveillance for low-risk disease), whereas for others it may be too little treatment (traditional therapies such as surgery or radiotherapy may be more appropriate for higher-risk disease). Second, even for patients in whom focal therapy is reasonable, long-term information on outcomes both in terms of cancer control and complications are still needed.

Ultimately, for well-informed, appropriately selected patients, treated at centers of excellence, focal therapy is a reasonable option for patients with intermediate-risk (Grade Group 2 or Grade Group 3), unifocal, MRI-visible prostate cancer.

Zachary Klaassen, MD, MSc – Urologic Oncologist, Georgia Cancer Center, Augusta, GA, USA

Last Reviewed: 06/2025