Historically, men with prostate cancer and favorable life expectancies only had 3 options to choose from: active surveillance, radical prostatectomy, or radiation therapy. Unfortunately, with all 3 management options, patients incurred an uncomfortable amount of worry or risk, whether it be of disease progression on active surveillance or posttreatment urinary and sexual dysfunction with whole-gland treatment with curative intent. The advent of prostatic multiparametric MRI (mpMRI) in conjunction with software-based or cognitive fusion biopsy has paved the way for a more targeted sampling for diagnosis and risk stratification, offering higher fidelity localization of cancer foci for patients affected with prostate cancer. This new approach to targeted, image-directed diagnosis now allows for more optimized localization of in-gland disease foci with the potential of more directed therapy.

Focal therapy is an alternative to whole-gland treatment, and thus far, it appears to provide similar oncologic control when compared to whole gland treatments yet incurs minimal risk of urinary incontinence or erectile dysfunction as a result of the treatment. A systematic review evaluated approximately 1,600 men who underwent focal cryoablation, the majority of whom had intermediate-risk prostate cancer. It found a posttreatment biopsy positivity rate of 8% to 25%, with no prostate cancer–related deaths.¹ To date, several focal ablation modalities have been successfully employed including cryotherapy, high-intensity focused ultrasound, irreversible electroporation, thermal laser ablation, and nanoparticle particle delivery with laser activation.

While focal therapy is a highly attractive option for patients and urologists alike, careful candidate selection and a thorough diagnostic workup are imperative to ensure optimal oncologic outcomes. Based upon the Göteborg trial, a screening PSA >1.8 ng/mL should trigger an mpMRI, and the presence of a PIRADS (Prostate Imaging Reporting & Data System) ≥3 lesion indicates need for an MRI-US fusion–guided prostate biopsy.² Ensuring patients obtain high-quality prostatic imaging is imperative, as the diagnostic precision of biopsy core placement and accurate focal treatment planning rests heavily upon the diagnostic image quality directing tissue sampling. It is important to note that despite the diagnostic capabilities of prostate mpMRIs at this current time, MRI-US fusion targeted biopsies do not obviate the need for the addition of the standard systematic biopsy sampling. A prospective, multicenter European trial evaluating the detection of clinically significant prostate cancer after targeted vs systematic prostate biopsy found that the combination of targeted and systematic biopsies had a higher detection rate than either method performed alone.³ The majority of studies evaluating the efficacy of focal prostate cancer ablation have evaluated men with Gleason Grade Group ≤ C3 and a corresponding isolated, MRI-visible lesion, without evidence of extraprostatic extension.

While specific guidelines as to the use of bioassays and genomics in determining optimal focal therapy candidates have not yet been defined, PSA <15 ng/mL, a PSA density <0.15 ng/mL², and favorable genomic markers are common thresholds to which most practitioners currently adhere. New imaging technologies such as the prostate-specific membrane antigen positron emission tomography (PET)–CT or PET-MRI significantly improve diagnostic accuracy and staging, especially for post-radiation failure salvage cases, allowing clinicians and patients alike to feel confident in their decision to avoid whole-gland therapies. The use of such instruments to aid in prostate cancer detection may allow for earlier intervention, perhaps one day eradicating the need for whole-gland therapy for prostate cancer and the complications that accompany it. Focal therapy for localized prostate cancer will likely become a more commonplace offering for men with low- to intermediate-risk prostate cancer in the near future. In this era in which obtaining high-quality prostate MRI ahead of biopsy and prostate-specific membrane antigen PET-CT scans in high-risk patients is standard-of-care, it is reasonable to believe that focal therapy may one day be considered an appropriate treatment approach for men with localized, high-risk disease.