Focal therapy for prostate cancer

What do you need to know? By Alan Doherty, consultant urologist

What is focal therapy?

The principle of focal therapy for prostate cancer is to target and selectively destroy the cancerous tissue within the prostate. The prostate is not removed; treatment is delivered using technology called HIFU (High Intensity Focused Ultrasound) or electroporation (NanoKnife), which uses heat or electricity to destroy the targeted cells. This is usually carried out using a general rather than local anaesthetic, with, in the case of HIFU, the ultrasound energy delivered via a probe. You will be able to go home on the same day as your procedure. It is normal for there to be a little swelling of the prostate, so you will be fitted with a catheter to ensure you empty your bladder fully. This will be removed within days and you can expect to immediately resume normal activities.

The importance of MRI and ongoing surveillance

Focal therapy for prostate cancer is dependent upon high quality MRI technology. Information from the MRI scan is used to plan and deliver treatment and to monitor patients on an ongoing basis. Normally, this means patients who have had focal therapy will have repeat PSA tests and an MRI scan every year to assess whether there is any evidence of untreated cancer, or indication that this might be the case (if PSA is rising). It is perhaps useful to think of focal therapy as a step between active monitoring (no treatment but regular surveillance) and a treatment like surgery. Ongoing surveillance is very important after focal therapy, so you need to be prepared for repeated MRI scans and may need further treatment.

What are the advantages of focal therapy?

The most evident advantage of focal therapy is how minimally invasive it is. In the short term, although you will have a catheter for the first few days, some soreness and debris in your urine, you will be able to resume normal activities, such as going back to work and physical activity very quickly (within one to two weeks).

In the longer term, the side-effects of prostate cancer treatment people are most concerned about are the impact on continence and erectile function. There is now an extensive body of evidence to support the theory behind focal therapy: that by selectively targeting treatment, healthy tissue is preserved and function (erectile and continence) is likely to be unaffected.

What are the disadvantages of focal therapy?

The key consideration to bear in mind is that choosing focal therapy is associated with a high likelihood of needing more treatment because the first treatment has not been successful. That is why you will need continued monitoring for prostate cancer after the first treatment. This is likely to involve clinic visits at least once a year, repeated MRI scans and repeat biopsies if there is any evidence of abnormality.

Failure to cure the cancer first time almost certainly will increase the likelihood of having to have hormone therapy and may have an impact on survival.  To compare this with surgery, if the cancer was indeed confined to the prostate gland, then cure is almost guaranteed. If the PSA blood results after surgery indicate cancer clearance, patients will have reviews at three months, 12 months, and then annually for five years before being discharged.

The other main consideration is that by choosing focal therapy, you may be reducing your future treatment options. For example, you may not be suitable for surgery, or suitable for nerve-sparing surgery (if the recurrent cancer has progressed and grown either close to the margins of your prostate gland or spread elsewhere, known as metastases).

How do I choose?

Developments in the prostate cancer field mean patients can have a wide choice of treatment (depending on their diagnosis). This choice can be challenging. Here are some questions that may help you weigh up focal therapy, compared with other prostate cancer treatments:

• How do you feel about repeated MRI scans and assessments and coming into hospital for routine monitoring? Some men are comfortable with this and for others, it can raise anxiety
• Is preservation of sexual function and continence a high priority for you? This can make focal therapy a more appealing treatment choice. Bear in mind, these outcomes vary according to individual surgeon: surgeons with high skill levels and volume have good rates of continence and erectile function after surgery
• Think about short term versus long term factors: focal therapy does have the benefit of very little disruption upon your life and you will get back to normal activities promptly. Surgery involves a longer period of recovery but affords the opportunity of full cancer clearance and “putting it behind you”

Discuss with us

We are unique as a clinic in offering high quality prostate cancer surgery, radiotherapy for prostate cancer and focal therapy. This means you can talk to us about the full range of options, including seeing several members of our team for their opinions and advice.