World J Urol. 2021 Mar;39(3):719-728. doi: 10.1007/s00345-020-03303-y. Epub 2020 Jun 11.

Making a case "against" focal therapy for intermediate-risk prostate cancer.

World journal of urology

Paolo Gontero, Giancarlo Marra, Dogu Teber, Shahrokh Shariat, Selami Albayrak, Rafael Coelho, Simon Tanguay, Badrinath Konety

PMID: 32529451 DOI: 10.1007/s00345-020-03303-y

Abstract

INTRODUCTION: Focal therapy (FT) for localized prostate cancer (PCa) is a promising treatment strategy. Although, according to guidelines, it should be regarded as an experimental option, its introduction into clinical practice has occurred at an accelerated speed. It is, thus, crucial for Urologists to understand FT limitations and potential drawbacks that may derive from its use.

METHODS: We performed a literature search of peer-reviewed English language articles using Pubmed and the words "focal therapy" AND "prostate cancer" to identify relevant articles. Web search was complemented by manual search.

RESULTS: From a biological perspective, in contrast with the index lesion theory, which still needs to be better supported, PCa is a multifocal and multiclonal entity. Also, the effects of FT on PCa microenvironment are unclear. From a clinical perspective, patient selection is still not precisely defined. Even when all variables potentially decreasing mpMRI and biopsy accuracy are optimized, up to one out of two men may be incorrectly selected for FT, leaving a significant proportion of clinically significant PCa (csPCa) untreated. Underestimation of PCa volume and variant histologies are other additional mpMRI potential limitations. No RCTs have been performed against the standard of care to support FT. There is absence of long-term results and FT series reaching medium-term follow-up have non-optimal oncological control with significant re-treatment needs. When PCa recurs/persists after FT, little is known about the appropriate management strategies and their outcomes. Finally, the optimal follow-up scheme post-FT remains unclear.

CONCLUSIONS: Several arguments are present against the use of FT for localized PCa. Studies are needed to overcome current limitations and support FT before it can be included as part of the standard management of prostate cancer.

Keywords: Evidence; Focal therapy; Limitations; Oncological outcomes; Prostate cancer

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MeSH terms

• Ablation Techniques* / adverse effects
• Ablation Techniques* / methods
• Humans
• Male
• Organ Sparing Treatments
• Prostatic Neoplasms / surgery
• Risk Assessment

Publication Types

• Journal Article
• Review