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Identifying The Best Candidate for Focal Therapy: A Comprehensive Review - Beyond the Abstract

Focal therapy (FT) has gained recognition as a treatment option for the management of localized prostate cancer (PCa), aiming to minimize the side effects of more aggressive treatments while maintaining effective cancer control.1,2 Despite increasing evidence supporting the use of FT and its endorsement by guidelines,3 studies continue to demonstrate considerable variability in patient selection criteria and treatment planning.4 Over the past two decades, the identification of optimal candidates has evolved with advancing understanding and limitations of FT.

This systematic review aimed to evaluate the most recent evidence regarding optimal strategies for patient selection in FT for PCa.5 After eligibility and quality assessments, 11 studies were included in the qualitative analysis. Our review demonstrated that there is no level I evidence defining the optimal patient selection approach for FT in PCa. This process currently relies on international multidisciplinary consensus statements, which include the following recommendations.

  1. Lesion characterization and cancer features: mpMRI followed by MRI-targeted and systematic biopsy is recommended for all FT candidates. When mpMRI is unavailable, 3D mapping biopsies may serve as an alternative. As experience with its use in FT grows, the PSMA PET scan may become more commonly utilized in the future. After proper lesion characterization and mapping, FT may be considered in clinically localized, preferably unifocal, intermediate risk (Gleason grade group 2 and 3) disease. For those with Gleason grade group > 3 PCa, FT should be offered with caution and only if additional diagnostic evaluations have ruled out extra-prostatic disease.
  2. Patient features: Patients should have an acceptable life expectancy (8-10 years). While preserving erectile function is a key factor in choosing FT over radical treatments, the absence of erectile function at baseline should not disqualify a patient from undergoing FT. In addition, patients with a prostate volume greater than 50 ml and those with moderate to severe lower urinary tract symptoms should be counseled with caution. A history of previous PCa treatment is not a contraindication for FT and in some cases the only endorsed treatment option. However, salvage FT should preferably be performed at experienced centers as part of a clinical trial or a well-designed prospective cohort study.
  3. Biomarkers: PSA level of < 20 (ideally < 10) ng/mL is preferred when considering a patient for FT; however, the decision to proceed with this type of treatment should not rely solely on PSA levels. The utility of other molecular and genomic biomarkers in patient selection for FT remains unknown.

In conclusion, FT is currently recommended in well-selected patients with intermediate-risk PCa. Proper patient selection is essential for optimizing both functional and oncological outcomes. Ongoing trials and studies exploring new genomic and molecular biomarkers are expected to offer stronger evidence in this area.

Written by: Alireza Ghoreifi,1 Amir H. Lebastchi2

  1. SUO Fellow, Department of Urology, Duke University, Durham, NC, USA
  2. Assistant Professor of Urology, Department of Urology, University of Southern California, Los Angeles, CA, USA
References:

  1. Lebastchi AH, Gill IS, Abreu AL. A Focus on Focal Therapy for Prostate Cancer. JAMA Surg. 2021;156:881–2.
  2. Ghoreifi A, Kaneko M, Peretsman S, Iwata A, Brooks J, Shakir A, et al. Patient reported Satisfaction and Regret Following Focal Therapy for Prostate Cancer: A Prospective Multicenter Evaluation. Eur Urol Open Sci. 2023;50:10–6.
  3. Eastham JA, Auffenberg GB, Barocas DA, Chou R, Crispino T, Davis JW, et al. Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, Part II: Principles of Active Surveillance, Principles of Surgery, and Follow-Up. J Urol. 2022;208:19–25.
  4. Lebastchi AH, George AK, Polascik TJ, Coleman J, de la Rosette J, Turkbey B, et al. Standardized Nomenclature and Surveillance Methodologies After Focal Therapy and Partial Gland Ablation for Localized Prostate Cancer: An International Multidisciplinary Consensus. Eur Urol. 2020;78:371–8.
  5. Ghoreifi A, Gomella L, Hu JC, Konety B, Lunelli L, Rastinehad AR, et al. Identifying the best candidate for focal therapy: a comprehensive review. Prostate Cancer Prostatic Dis. 2024 Oct 23. Epub ahead of print.
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