The future of focal therapy for prostate cancer treatment

Review date: February 2021

The outcomes for patients diagnosed with prostate cancer depend on more than just rates of cure or survival. A considerable burden is experienced by men who require treatment for prostate cancer, in many cases arising from complications of the procedures themselves.

Many men who undergo surgery or radiation therapy have worse urinary, bowel (respectively) and erectile function after treatment than they did before¹, which can have a substantial negative effect on their mental health². Refinement of treatment approaches to prostate cancer have drastically improved survival over the past 20-30 years, but this has come with the cost of long-term morbidity for many men. Some innovations in prostate cancer care during this time have had little, if any, effect on postoperative complications (including the use of robotics³).

With advanced medical imaging techniques, such as multiparametric MRI⁴, specific targeting of prostate cancer tumours has become possible. Focal therapy, in which targeted ablation of only cancerous tissue is achieved (using, for example, high-intensity focused ultrasound, cryotherapy, or laser), offers the possibility of good outcomes in terms of metastasis- and cancer-free survival, and avoidance of treatment complications, in men with low or intermediate stage localised prostate cancer⁵.

In contrast to worsening urinary symptoms and erectile dysfunction after prostatectomy1, focal therapy appears to preserve these functions in men, for years after treatment^5,6. Critically, focal therapy looks to be as effective, for at least eight years, as prostatectomy, for treating prostate cancer⁷.

Unfortunately, there are currently no data available from randomised trials of focal therapy versus prostatectomy to guide practice; these will come soon, from at least three prospective clinical trials. Until then, patients should be encouraged by the continuing advances in prostate cancer treatment, and the potential of good long-term treatment outcomes from the point of view of survival and quality of life.

Citations:

¹Korfage, I.J., Essink-Bot, M.-L., Borsboom, G.J.J.M., Madalinska, J.B., Kirkels, W.J., Habbema, J.D.F., Schröder, F.H., and De Koning, H.J., 2005. Five-year follow-up of health-related quality of life after primary treatment of localized prostate cancer. International Journal of Cancer, 116 (2), 291–296.

²Ilie, G., White, J., Mason, R., Rendon, R., Bailly, G., Lawen, J., Bowes, D., Patil, N., Wilke, D., Macdonald, C., Rutledge, R., and Bell, D., 2020. Current Mental Distress Among Men With a History of Radical Prostatectomy and Related Adverse Correlates. American Journal of Men's Health, 14 (5), 155798832095753.

³Ilic, D., Evans, S.M., Allan, C.A., Jung, J.H., Murphy, D., and Frydenberg, M., 2017. Laparoscopic and robotic-assisted versus open radical prostatectomy for the treatment of localised prostate cancer. Cochrane Database of Systematic Reviews.

⁴Sun, Y., Reynolds, H.M., Parameswaran, B., Wraith, D., Finnegan, M.E., Williams, S., and Haworth, A., 2019. Multiparametric MRI and radiomics in prostate cancer: a review. Australasian Physical & Engineering Sciences in Medicine, 42 (1), 3–25.

⁵Guillaumier, S., Peters, M., Arya, M., Afzal, N., Charman, S., Dudderidge, T., Hosking-Jervis, F., Hindley, R.G., Lewi, H., Mccartan, N., Moore, C.M., Nigam, R., Ogden, C., Persad, R., Shah, K., Van Der Meulen, J., Virdi, J., Winkler, M., Emberton, M., and Ahmed, H.U., 2018. A Multicentre Study of 5-year Outcomes Following Focal Therapy in Treating Clinically Significant Nonmetastatic Prostate Cancer. European Urology, 74 (4), 422–429.

⁶Faure Walker, N.A., Norris, J.M., Shah, T.T., Yap, T., Cathcart, P., Moore, C.M., Ahmed, H.U., Emberton, M., and Minhas, S., 2018. A comparison of time taken to return to baseline erectile function following focal and whole gland ablative therapies for localized prostate cancer: A systematic review. Urologic Oncology: Seminars and Original Investigations, 36 (2), 67–76.

⁷Shah, T.T., Reddy, D., Peters, M., Ball, D., Kim, N.H., Gomez, E.G., Miah, S., Evans, D.E., Guillaumier, S., Van Rossum, P.S.N., Van Son, M.J., Hosking-Jervis, F., Dudderidge, T., Hindley, R., Emara, A., Mccracken, S., Greene, D., Nigam, R., Mccartan, N., Valerio, M., Minhas, S., Afzal, N., Lewi, H., Ogden, C., Persad, R., Virdi, J., Moore, C.M., Arya, M., Emberton, M., Ahmed, H.U., and Winkler, M., 2021. Focal therapy compared to radical prostatectomy for non-metastatic prostate cancer: a propensity score-matched study. Prostate Cancer and Prostatic Diseases.