Focal therapy

Focal therapy aims to treat only the cancerous area of the prostate rather than the whole gland. Techniques include High intensity ultrasound (HIFU), cryotherapy and other energy-based treatments.

It may be considered in carefully selected men with localised prostate cancer where the cancer is visible, limited and technically suitable.

1

What is it?

Focal therapy aims to treat only the cancerous area of the prostate rather than the whole gland.

The aim is to destroy the known area of cancer while reducing damage to nearby structures involved in urinary control, erections and bowel function.

Focal therapy is not one single treatment. It includes several possible techniques, such as:

High intensity focused ultrasound
Cryotherapy
Irreversible electroporation
Laser ablation
Focal brachytherapy
Other image-guided or energy-based treatments

2

Who is it for?

Focal therapy may suit selected men with localised prostate cancer where the cancer appears limited, visible on MRI, and technically treatable.

Suitability depends on:

PSA
MRI findings (arguably also PSMA findings)
Biopsy results
Grade Group
Tumour location
Tumour size
Prostate size
Urinary symptoms
Whether cancer appears present elsewhere in the prostate

Focal therapy is not suitable for every man.

It is usually more relevant when there is a clearly identifiable target. If the cancer is high-risk, widespread, poorly visible on MRI, multifocal, or close to important structures, focal therapy may not be appropriate.

3

Benefits

The main possible benefit is reducing side effects compared with whole-gland treatment.

Because focal therapy aims to treat only part of the prostate, it may reduce the risk of urinary incontinence and erectile dysfunction in carefully selected men.

Recovery may also be quicker than after radical prostatectomy.

For some men, focal therapy may offer a middle ground between active surveillance and whole-gland treatment.

4

Risks

The main limitation is that focal therapy depends heavily on accurate cancer localisation.

That means it depends on MRI and biopsy.

MRI is very useful, but it can miss prostate cancer lesions. Biopsies are also useful, but they can miss cancer or underestimate grade.

The MULTIPROS study showed that pre-biopsy mpMRI was accurate for detecting clinically significant prostate cancer, but the study also supports the principle that MRI and biopsy are best used together rather than relying on one test alone. Combining MRI-targeted biopsies with systematic biopsies improves diagnostic accuracy. (PubMed)

This matters because focal therapy treats only the visible or mapped target. If there is significant cancer outside the treated area, it may be missed or left untreated.

This is why PSMA scans are increasingly relevent in any decision to have focal therapy

Possible risks include:

Urinary infection
Pain or discomfort
Blood in urine or semen
Urinary retention
Catheter requirement
Erectile dysfunction
Urinary leakage
Urethral narrowing
Rectal injury, rarely
Persistent cancer in the treated area
Cancer elsewhere in the prostate
Need for repeat focal therapy
Need for later surgery or radiotherapy

Retreatment rates after focal therapy can be significant. Recurrence can be in-field, meaning cancer returns in the treated area, or out-of-field, meaning cancer is found elsewhere in the prostate. Follow-up usually needs PSA, MRI and repeat biopsy.

5

Before treatment

Before focal therapy, careful assessment is essential.

This usually includes:

PSA and PSA density
Multiparametric MRI +/- PSMA scan 
Targeted biopsy
Systematic biopsy
Review of cancer grade and volume
Assessment of prostate size
Urinary symptom assessment
Discussion in a specialist team where appropriate

The key question is whether the cancer has been localised accurately enough to justify treating only part of the prostate.

6

During treatment

Different focal therapy techniques work in different ways.

HIFU

HIFU stands for high-intensity focused ultrasound.

It uses focused ultrasound energy to heat and destroy targeted prostate tissue.

HIFU can be delivered using different systems. Examples include transrectal HIFU platforms such as Focal One and Sonablate, and MRI-guided transurethral systems used in some specialist or research settings.

NICE has guidance on focal therapy using HIFU for localised prostate cancer. (NICE)

Cryotherapy

Cryotherapy uses freezing to destroy prostate tissue.

Needles are placed into the prostate and the target area is frozen. The aim is to kill cancer cells in the treated zone while preserving nearby structures where possible.

Irreversible electroporation

Irreversible electroporation, sometimes known by the NanoKnife brand name, uses electrical pulses to damage cancer cell membranes and destroy tissue without relying mainly on heat or freezing.

NICE has guidance on irreversible electroporation for prostate cancer. (NICE)

Focal brachytherapy

Focal brachytherapy uses internal radiation targeted to a specific area of the prostate rather than treating the whole gland.

This is less commonly used than standard whole-gland brachytherapy and depends on specialist expertise and patient selection.

Aquablation

Aquablation is a robotically controlled waterjet treatment mainly used for benign prostate enlargement and urinary obstruction rather than established focal treatment of prostate cancer.

It may be relevant to urinary symptom management in some prostate pathways, but it should not be presented as a standard focal cancer therapy.

Other focal treatments

Other focal approaches include laser ablation, photodynamic therapy, radiofrequency ablation and microwave-based treatments. Availability varies, and some approaches are mainly used in trials or specialist centres.

7

After treatment

Follow-up after focal therapy is important.

This may include:

PSA monitoring
MRI scans, PSMA scans
Repeat biopsy
Symptom review
Assessment of urinary and sexual function

Unlike radical prostatectomy, the prostate remains in place, so PSA does not usually fall to undetectable levels.

A stable PSA is reassuring, but PSA alone is not enough. MRI and repeat biopsy are often needed to check whether cancer remains or has returned. MRI after focal is hard to read and needs an experienced and specialised radiologist. 

8

Has it worked?

Focal therapy is judged by several things together:

PSA pattern
MRI appearance
Repeat biopsy findings
Urinary and sexual function
Need for retreatment
Need for later radical treatment

A good early recovery does not automatically prove the cancer has been fully controlled.

The key long-term question is whether there is persistent or recurrent clinically significant cancer, either in the treated area or elsewhere in the prostate.

9

Questions to ask

Is my cancer clearly visible on MRI? Why am I not having a PSMA scan?

Are there discprepancies between my biopsies, MRI and PSMA scan ?

Has my prostate been sampled thoroughly enough?
Was targeted and systematic biopsy performed?
Is the cancer suitable for focal treatment?
What focal therapy technique is being offered?
What machine or platform is used?
What is the risk of cancer outside the treated area?
What is the retreatment rate?
How often will I need PSA tests?
Will I need repeat MRI?
Will I need repeat biopsy?
What happens if cancer recurs in-field?
What happens if cancer recurs out-of-field?
Would surgery or radiotherapy still be possible later?

10

Useful UK based links

11

Need further help?

Private consultations with Mr Anthony Bates are available through Prostatology for raised PSA, MRI review, biopsy results, prostate cancer treatment planning and second opinions.

Book through Prostatology:
https://www.prostatology.co.uk/consultations

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