Focal therapy or surgery?

The major guidelines are cautious about focal therapy, and I tell patients so plainly. The American Urological Association says that men with intermediate-risk cancer who are considering focal or whole gland ablation should be told there is a lack of high-quality data comparing ablation with surgery, radiation, or active surveillance. For high-risk cancer, the AUA says clinicians should not recommend ablation outside a clinical trial.

The European Association of Urology is more restrictive. Its guideline recommends offering focal therapy with HIFU or cryotherapy only within a clinical trial or a prospective registry. The European panel writes that the available evidence suggests focal therapy causes fewer adverse effects than whole gland or radical treatment, and that definitive proof of its cancer control compared with standard treatments is still unavailable. They want long, standardized follow up before recommending it for routine practice.

I read these statements as a fair description of where we are. In the studies we have, focal therapy is gentler on urinary and sexual function. We do not yet have the long comparative data that surgery and radiation have built over decades. So when I offer focal therapy, I offer it to selected men, with that uncertainty spoken out loud, and with a plan to follow them closely. Where a registry or trial is available, I would rather a man be treated inside one, so that his result adds to what we know.

The man I consider for focal therapy usually has a cancer that is clearly visible on MRI, confined to one region, and confirmed by a targeted biopsy, with the rest of the gland sampled and reassuring. His cancer is significant enough that we have agreed it should be treated, and limited enough that treating one region makes sense. He has thought hard about what he values, and he accepts that more imaging and more biopsies are part of the arrangement.

Low-risk cancer is a different conversation. The guidelines prefer active surveillance for low-risk disease, and I agree with them. Treating a cancer that would probably never have harmed a man, even with a gentle tool, still exposes him to side effects and years of testing without a clear gain. The AUA makes this point directly in its discussion of ablation.

High-risk cancer is a different conversation too. Here the evidence for surgery or radiation is strong, and the danger of undertreating is real. I do not offer focal therapy for high-risk disease outside a clinical trial.

The prostate that remains after focal therapy is still a prostate. It can still grow cancer, at the edge of the treated area or somewhere else in the gland. So the follow up is serious. The AUA describes following men after ablation with PSA, examination, MRI, and biopsy tailored to their health and their cancer. I tell men to expect that schedule, and to expect that a repeat biopsy may find something that needs more treatment.

PSA also behaves differently after focal therapy. After a prostatectomy, the PSA should fall to nearly zero, and a rise means something. After focal treatment, the healthy prostate keeps making PSA, and the EAU guideline notes that there is no well-defined, validated PSA cutoff that defines failure after these treatments. That makes the numbers harder to read. It is one reason I lean on imaging and biopsy.

If the cancer returns, options remain. Further focal treatment, surgery, and radiation are all possible. The European panel notes that in smaller series, men who needed a prostatectomy after focal therapy had results comparable to men who had not been treated before. That is reassuring. It also comes from limited data, and I hold it lightly.

For many of the men who come to ask about focal therapy, I end up recommending a robotic prostatectomy. Some are surprised, and a few are suspicious that the surgeon is recommending surgery. I understand that, so I explain my reasons. Surgery removes the whole gland. It gives us the complete pathology. It turns PSA into a clean signal for the rest of his life. For a man with a larger cancer, cancer in several areas, or a cancer the MRI may be underestimating, that certainty is worth a great deal. The operation has real costs to continence and erections, and we talk through them in detail before anyone decides.

For other men, focal therapy is a thoughtful choice. A man with a single visible lesion, who values his function highly and accepts the follow up, may reasonably choose it. I help him make that choice with clear eyes, and I stay with him afterward.

What I try to prevent is a decision made on the appeal of the word focal alone. The right treatment depends on the cancer, on the man, and on what he is willing to carry afterward. Some men will carry a lifetime of surveillance biopsies to protect their function. Some will accept a harder recovery in exchange for a simpler future. Both are reasonable. My job is to make sure each man knows which trade he is making.