.png){kind=small}
.png){kind=small}
BackTable / Urology / Article
Prostate Cancer Focal Therapy: Who is the Ideal Patient?
Kaitlin Sheppard • Updated Nov 16, 2024 • 198 hits
Compared to resection or radiation, focal therapy may offer a less invasive and more precise treatment option for prostate cancer patients. However, the immediate procedural benefits can have long-term trade offs, particularly when it comes to recurrence rates and future treatments. Who is the ideal patient for focal therapy? Which focal therapy modality is best? And how do we optimize care after focal therapy to ensure that recurrence is managed effectively?
Urologist Dr. Matt Cooperberg and urologic surgeon Dr. Arvin George answer these questions with a detailed walkthrough of their approach to focal therapy in prostate cancer, detailing patient selection, when to use which focal therapy modality, and follow-up care. This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• Focal therapy is ideal for the prostate cancer patient that needs treatment but does not require whole-gland therapy. Key anatomical criteria include visible lesion on MRI/ultrasound, and low-grade disease outside the target area.
• Clinicians must balance patient preferences for minimally invasive treatments against the need for thorough discussion of risks, outcomes, and lifelong monitoring.
• Unique cases, such as young patients with a strong family history or well-defined low-volume lesions, may be considered for focal therapy under strict conditions.
• Clear communication with prospective patients about the trade-offs and long-term monitoring required post-treatment is essential. Clinicians must discuss expected recurrence rates (e.g., 20-30% within five years) and prioritize patient understanding of functional outcomes, such as preserved sexual and urinary function.
• High-risk patients often push for focal options, but clinicians must weigh the potential for undertreatment and associated risks.
• Post-focal fibrotic responses can vary unpredictably, influencing surgical difficulty. Cryoablation tends to induce the most fibrosis.
• Anterior lesions may require irreversible electroporation (IRE) or transurethral approaches like TULSA for effective treatment. Meanwhile, apical lesions present challenges due to complex anatomy. Focal radiation and tailored dosimetry may offer solutions.
Table of Contents
(1) Patient Selection for Prostate Cancer Focal Therapy
(2) Balancing Patient Preferences & Clinical Judgment in Prostate Cancer Focal Therapy
Patient Selection for Prostate Cancer Focal Therapy
Patient selection for focal therapy in prostate cancer is nuanced, requiring a balanced understanding of treatment necessity and long-term outcomes. The ideal candidates are those who need treatment but do not require whole-gland therapy. Essential patient criteria include visible imaging findings, ideally from both MRI and ultrasound, and confirmatory biopsy to rule out high-grade or extensive disease. PSA thresholds and cancer risk characteristics also play pivotal roles, indicating strategic use of focal therapy in intermediate-risk cases while preserving active surveillance for those suitable. Urologists Dr. Matt Cooperberg and Dr. Arvin George highlight the importance of patient perspective, particularly given the lower morbidity associated with focal therapy, and the need to educate patients on the lifelong surveillance required post-treatment.
[Dr. Aditya Bagrodia]:
Grade group one, so let's stick to surveillance, high risk, let's stick to our standard options, intermediate risk, it's maybe a bit of the conversation. Let's talk about ideal patients and maybe we could talk about patient-specific factors, prostate and anatomy-specific factors, and then some cancer characteristics when you're thinking about focal. …
[Dr. Matt Cooperberg]:
I'd say you just described it. ... The band is fairly narrow for the ideal focal patient because you need somebody who needs treatment, they're not a good surveillance candidate, but you need somebody who doesn't need whole gland treatment, where you're not worried about the field defect in the prostate genomics, you're not worried about the lymph nodes, the pelvis, and all the rest of it.
... You want imaging visible, either an ultrasound or MRI, ideally on both. You want to find 3, 4, maybe limited 4, 3 in that lesion. We will accept 3, 3 in other parts of the prostate, but ideally no higher grade disease outside of the lesion, unless it's immediately adjacent. …
We definitely strongly encourage confirmatory biopsy with MR guidance if the initial one was done without MR before committing to focal. ... The patients really need to understand that this is not an alternative to surgery or radiation therapy, if we're not talking about whole gland treatment.
I think about it as an augment to active surveillance for patients who are not otherwise great surveillance candidates. ... They can develop a recurrence, they can develop a brand new tumor. They really are on more of a surveillance path.
...
[Dr. Arvin George]:
I think I'm probably a little bit less conservative ... there needs to be some guardrails up. Typically, either a PSA less than 15 or a PSA density less than 0.2 due to the recurrence rates ... I don't treat low-grade disease and I'm also relatively aggressive in putting men who have favorable intermediate risk on surveillance if they're appropriate candidates.
... Mechanistically or procedurally, if there is a cancer that is isolated and I feel that I can destroy it and achieve a reasonable margin, there's no reason that prostatectomy would be superior.
I do think in the future that we will be able to treat high risk ... Then one piece ... is the patient perspective.
... To a certain degree, we have to protect patients from themselves, but at the same time, we also have to be able to understand the patient's perspective and let them also take part in that decision between the trade-off between cancer outcomes and functional outcomes.
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
Balancing Patient Preferences & Clinical Judgment in Prostate Cancer Focal Therapy
Deciding on focal therapy for prostate cancer requires a careful balance between patient preferences and clinical judgment. Experts in the field emphasize the importance of comprehensive biopsy strategies in evaluating potential candidates, particularly to determine whether or not the prostate cancer is high-risk. High-risk patients often request focal treatments, but clinicians must establish clear boundaries to avoid undertreatment that could jeopardize long-term outcomes. Dr. Cooperberg emphasizes that clinicians need to uphold treatment standards and decline cases where focal therapy is not in the patient’s best interest. It can make for difficult conversations, but maintaining a patient-centered yet evidence-based approach has proven to be vital in finding success with focal therapy. While exceptions can be made, they should remain infrequent and based on specific criteria such as strong family history or isolated, well-sampled lesions.
[Dr. Arvin George]:
I don't know who's going to be a focal candidate before. I don't routinely do that. What I do when I sample a target is I sample across the lesion. ... Rather, I'll actually map it across the lesion. Typically every 3 to 5 millimeters, depending on the size of the lesion, both of the anterior posterior and medial lateral directions.
[Dr. Matt Cooperberg]:
I think this is an evolving concept. ... One concept, which I'm not sure how well validated, but it seems to be true is that the higher the grade of the lesion, the more the MR might be under-sampling it. ... I do worry more about under-sampling in higher-grade cancer. For pushing the envelope a little bit, maybe not that they have high-grade disease, but they've got ... biology that seems like it actually might become a problem.
...
[Dr. Aditya Bagrodia]:
I mentioned this earlier and patients insisting on focal, not kind of this narrow candidate and then they'll very reasonably say, well, if you do the focal, and it doesn't work, no harm no foul. You're just to go back in and do something standard and I'm okay with that. How do you respond to that ...?
[Dr. Arvin George]:
... We have a responsibility to protect patients from themselves. ... There has to be some dividing line in which we put our boundaries and we simply refuse treatment. ... I tell patients that there will be somebody out there who will treat you. I said, that's not going to be me. These are the treatments that I think are going to be best for you ... in those cases, ... it gives them some perspective and that this is my genuine opinion.
[Dr. Matt Cooperberg]:
... A big part of our job is to pull them back from that cliff. ... What about the guy with a Gleason 8 who's insisting on–
[Dr. Aditya Bagrodia]:
Let's talk about the high-risk end ... I see more high-risk patients that are like, "Do a focal treatment on me."
[Dr. Arvin George]:
I would apply that to both ends of the spectrum. ... Now, we all bend our rules in some cases. I'll have some, PI-RADS 5, only Gleason 6, but it doesn't make sense. PSA is 8. This patient has a strong family history ... If I'm going to offer a prostatectomy or radiation in that setting, I think I have a reasonable argument to offer focal.
[Dr. Matt Cooperberg]:
... There are exceptions to every rule. The PI-RADS 5 or the Gleason 6, especially somebody very young with a strong family history ... sure, accepting some risks. ... The point is they should be uncommon.
[Dr. Aditya Bagrodia]:
Totally. I wholeheartedly agree ... Any experience, comments, issues, problems.
Focal Therapy Outcomes & Salvage Treatment Planning
Salvage treatment following focal therapy for prostate cancer presents unique challenges and considerations. Dr. Cooperberg and Dr. George explain the variability in fibrotic reactions, which can range from minimal to severe, affecting surgical complexity. While post-focal therapy surgery is generally more manageable than post-radiation surgery, specific modalities like cryoablation often induce significant desmoplastic reactions. Counseling patients before focal therapy is essential, highlighting recurrence risks, limitations of current long-term data, and the nature of potential salvage treatments. Clear communication helps set realistic expectations, ensuring patients understand the trade-offs and possible outcomes.
[Dr. Matt Cooperberg]:
I've done salvage prostatectomies after brachy, protons, IMRT, and a number after focal therapy. ... It's a truism that it is easier after focal than after radiation therapy in general. ... Fibrotic reactions can be very hard to predict after any of these modalities. ... Radiation, sometimes you go in and it seems like they forgot to turn the machine on ... other times it's like a bomb went off. ... Sometimes the fibrosis is minimal, sometimes it's terrible. Generally speaking, it seems to be easier after ablative therapy ... but that is a generalization. I think the data ... support that outcomes are better with post-focal therapy surgery than with post-radiation surgery.
...
[Dr. Arvin George]:
I've done a handful, maybe about 10 to 15 cases post ablation ... I think cryo probably has the most desmoplastic reaction post-ablation. ... The cases that I've done ... have been deceptively less complex than I anticipated. ... My advice to anybody doing post-focal cases is that your local stage of that MRI post-ablation is not going to be great. ... I go wide on the ipsilateral side of the prior ablation. If I can now spare on the contralateral side, I will. I do not do bladder neck sparing ... unless it was an apical tumor and I can see clearly the bladder neck. I'm very cautious about being aggressive in the resection now.
[Dr. Matt Cooperberg]:
I agree. The MR in general ... is not all that reliable post-ablation. ... I have still done bladder neck sparing, but we use frozen sections fairly liberally. ... Case selection is important. ... We had one ... who had bilateral cryoablation, recurrence by MR ... and the biopsy needle was bending trying to get into the prostate, which tells you something about fibrosis.
[Dr. Aditya Bagrodia]:
... First counseling ... recurrences in 20, 30% of patients in five years ... we don't expect to see the stressing constants or frequency urgency that are associated with surgery and radiation respectively. Does this sound about okay?
[Dr. Arvin George]:
Yes, that's about right. I do talk to them ... I say, this is not a standard of care treatment option. ... We don't have long-term or comparative data to prove it. ... I also do talk to them about salvage afterwards ... and plug their numbers into the Memorial Sloan Kettering Enogram ... Oftentimes, I surprise myself in that it may not be as far off as we think from focal treatments.
Modality Selection in Focal Therapy for Prostate Cancer
Choosing the appropriate modality for focal therapy in prostate cancer requires careful evaluation of lesion location, patient-specific factors, and technological strengths. Various treatment options include HIFU, cryoablation, IRE (NanoKnife), and newer techniques such as VAPOR2 water vapor ablation. Anterior lesions can be particularly challenging for HIFU due to energy attenuation, while cryoablation serves as a reliable and adaptable approach across different cases.
Adjusting treatment margins is critical to enhancing cancer control while maintaining functional outcomes. Imaging is fundamental to successful therapy, highlighting the need for urologists to develop expertise in interpreting both ultrasound and MRI for precise treatment planning. Proficiency in one or more patient-appropriate modalities and a strong focus on comprehensive imaging capabilities are key for achieving effective and consistent results.
[Dr. Aditya Bagrodia]:
All right. Let's talk a little bit about modalities here. This is an ever-expanding list. How do you think about this thermal, non-thermal, or maybe just run through the list? I think there's seven or eight that I can just fire off the top of my head. Maybe also a hypothetical. Actually, I'm curious, which one would you go with?
[Dr. Matt Cooperberg]:
We're doing occasional focal cryo, a lot of focal HIFU, starting to do IRE at UC, and the Tulsa folks have been around. We've played with other things over the years. That's our current menu.
[Dr. Arvin George]:
... We have irreversible electroporation or IRE, water vapor ablation on the VAPOR2 trial, high-intensity focused ultrasound or HIFU, and cryoablation. I've previously used focal laser ablation.
[Dr. Aditya Bagrodia]:
Calcifications ... HIFU, Tulsa, a little less feasible. Anterior lesions—any preferences?
[Dr. Arvin George]:
... HIFU for anterior lesions—I'm not a huge fan. The more tissue the HIFU beam has to travel through, the more energy attenuation ... I've had anterior persistent disease and transitioned to cryo, IRE, or percutaneous procedures, even Tulsa now …
[Dr. Matt Cooperberg]:
Focal radiation therapy is out there too ... focal SBRT or brachytherapy for lesions tough to reach with energy-directed treatments.
[Dr. Arvin George]:
Apex is a challenge for focal therapy. ... Dosimetry is a science; understanding placement of radiation doses is precise. For apex, I lean towards HIFU due to the smaller focal volumes. Technologies like vapor therapy may have advantages as they fill a space limited by anatomical boundaries.
[Dr. Matt Cooperberg]:
... Baseline QOL is crucial. Obstruction concerns arise when high doses are near the urethra ... Salvage outcomes differ significantly from de novo prostatectomy, especially for the apex.
[Dr. Aditya Bagrodia]:
I'm not an extended spectrum ablator ... We have Tulsa for anterior lesions, HIFU for posterior. Cryo is mostly for salvage. Do we need multiple tools or just focus on one?
[Dr. Arvin George]:
I don't think you can have just one ... HIFU is limiting for anterior tumors. I use cryo as a workhorse with good outcomes.
[Dr. Matt Cooperberg]:
Being proficient in your modality is key. ... Having various options can lead to over-treatment and selling modalities rather than oncologic care.
[Dr. Aditya Bagrodia]:
... For those with a deep interest and volume, multiple tools make sense.
[Dr. Matt Cooperberg]:
... Invest in imaging. Focal therapy's success hinges on knowing what you're treating ... Urologists should learn to read ultrasound and MRI and collaborate with high-volume, prostate-focused radiologists …
[Dr. Aditya Bagrodia]:
Tulsa's in-bore procedure with real-time imaging provides comfort—no mis-contouring ... Ablating the whole gland may sometimes be simpler.
[Dr. Arvin George]:
... I initially aimed for conservative margins but expanded them over time after seeing recurrences. Now, I aim for wider margins for better outcomes without adding risk.
Refining Follow-Up Strategies After Prostate Cancer Focal Therapy
Effective follow-up protocols after focal therapy for prostate cancer involve a combination of imaging, biopsy, and PSA monitoring. The initial year post-treatment typically requires frequent PSA testing, MRI at six months, and a biopsy at one year, regardless of MRI results. Long-term follow-up then shifts towards an active surveillance model, particularly for patients with untreated low-grade lesions.
Although MRI can aid in surveillance, it has limitations, particularly in detecting high-grade disease in initial confirmatory biopsies. Advances like PSMA PET and the use of secondary biomarkers show promise for more tailored follow-up strategies. This evolving approach to follow-up, including the possibility of reduced biopsy frequency supported by stable imaging and PSA trends, highlights the importance of personalized, data-driven decisions in post-focal therapy care.
[Dr. Matt Cooperberg]:
We typically follow the PSA every three to four months for the first year. We do an MRI at six months and an MRI with a biopsy at one year, pretty much no matter what the MR looks like. Then beyond that, they shift back into an active surveillance-type mode. We do follow the PSA. We'll follow with MR after that. If the biopsy was negative at a year and the MR stays stable, we're probably not going to do any more programmed biopsies, assuming the PSA is relatively stable.
...
I would argue neither is MR today. Maybe at some point, MR plus PSMA or next-generation MR with better AI, better experience with reading MR after focal therapy, we may get there but the biopsy to me is critical.
[Dr. Aditya Bagrodia]:
What do you think, Arvin?
[Dr. Arvin George]:
I actually have a question for Matt. Matt, what do you do in those patients with whom you have untreated Gleason 6, maybe on the contralateral side? You said you do allow for that. Now, do you feel compelled to do a protocol biopsy there with all other things being stable in those patients on surveillance?
[Dr. Matt Cooperberg]:
All right... even if we don't call it cancer, we absolutely still have to follow it... You call it something other than cancer, it still absolutely needs active surveillance but that's surveillance we're starting to tailor.
The more follow-up you have on the tumor or in a given lesion, the better we feel about the imaging... At the confirmatory biopsy... MR missed about 25% of upgrading events so it's even higher if the PSA density is high. On the other hand, once you've had the confirmatory, the downstream biopsies... the NPV is much higher, and if the PSA density is low, it's over 90%.
...
If the imaging is stable and the PSA has been stable, invariably we find nothing, or we find a little 3, 3 again. I'm getting more and more comfortable using imaging alone for these ones that have already declared themselves to be stable.
[Dr. Aditya Bagrodia]:
I think this is an area that's really exciting and ripe for further exploration... PSMA PET... secondary cancer screening biomarkers... I do think that this is going to be a bit of a shared decision-making, like surveillance... Maybe feel good about it.
...
Podcast Contributors
Dr. Matthew Cooperberg
Dr. Matthew Cooperberg is a professor at UCSF in San Francisco, California.
Dr. Arvin George
Dr. Arvin George is an associate professor of urology at the University of Michigan in Ann Arbor.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2024, May 28). Ep. 169 – Prostate Cancer: Navigating Focal Therapy Options [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
Evolving Guidelines on Focal Therapy for Prostate Cancer
The Modern Role of Genomics & Imaging in Prostate Cancer Diagnosis & Treatment
Active Surveillance for Prostate Cancer: A Tailored Approach
Tools for Prostate Cancer Screening & Risk Stratification