Focal Therapy for Prostate Cancer

What is focal therapy for prostate cancer?

Focal therapies are types of treatment for localized prostate cancer that target only the area of your prostate where the tumor is located. The tumor must be confined to your prostate (usually only on one side) without spreading to other tissue or organs around your prostate. Each type of focal therapy uses an energy source (like heat, cold or electric shock) to destroy tumor cells.

The goal of focal therapy is to destroy cancerous cells while leaving as much healthy tissue as possible, minimizing side effects and complications. It’s an alternative treatment to surgery or radiation, which treats the entire prostate, and active surveillance, where your provider periodically monitors and tests the tumor for signs of spreading. If you have favorable intermediate-risk prostate cancer (PSA between 10 and 20, grade 2 or 3, and less than 50% of biopsies are positive), focal therapy is a potential middle ground between active surveillance and surgery or radiation.

What types of focal therapy are there for prostate cancer?

Types of focal therapy include:

• Cryotherapy: A provider freezes the tumor with cold gases.
• Focal laser ablation (FLA): Heat from a laser destroys tumor cells.
• High-intensity focused ultrasound (HIFU): Heat from high-frequency sound waves destroys tumor cells.
• Irreversible electroporation (IRE): A provider uses electrodes around the tumor to deliver an electric shock that damages tumor cells.
• Transurethral ultrasound ablation of the prostate (TULSA): Heat from sound waves destroys tumor cells.

Who’s eligible for focal therapy?

Focal therapy treats cancer that has a low risk of spreading and is completely contained (localized) in your prostate. Ideally, the tumor is also not near your urinary sphincter (muscle that controls when pee is released from your bladder) or urethra (the tube that drains pee out of your body).

People with intermediate-risk prostate cancer are the best candidates for focal therapy. Low-risk cancers are better managed with active surveillance and high-risk cancers are better treated with whole-gland therapies (like surgery or radiation).

What happens before focal therapy?

Before focal therapy, you may need several tests and imaging studies to determine your treatment options. These include:

• MRI (magnetic resonance imagining).
• MRI-guided prostate biopsy (either transperineal or transrectal biopsy).
• Mapping biopsy. During a mapping biopsy, your provider will take several samples of tissue from your prostate to map the boundaries (margins) of the tumor.
• PSMA PET (positron emission tomography) scan. This is a type of PET scan (an imaging test that looks for cancer that’s spread to other parts of your body) that detects prostate-specific membrane antigen (PSMA) in your body.

How does focal therapy work?

Each focal therapy works a little differently. Your provider will tell you what to expect depending on which type of focal therapy you need. In general, a provider will:

1. Put you under anesthesia so you sleep through the procedure and don’t feel pain.
2. Insert the device into your prostate either through your rectum or urethra, or with a needle in your skin.
3. Target the tumor with an energy source that damages and destroys cells.

What are the advantages of focal therapy for prostate cancer?

Advantages of focal therapy include:

• Minimizing damage to healthy prostate tissue.
• A lower risk of side effects (including erectile dysfunction and urinary incontinence).
• Allowing you to manage prostate cancer while avoiding more invasive treatments.
• A more proactive alternative to active surveillance.

What are the downsides of focal therapy for prostate cancer?

The disadvantages of focal therapy may include:

• It might not get rid of all cancerous cells (focal therapies have a higher risk of recurrence).
• If the cancer returns, you might need additional treatments.
• Not everyone is a good candidate.
• While the risk is lower, it still might cause sexual and urinary side effects.
• Most are relatively new. This means we might not fully understand how beneficial they are compared to surgery, radiation or active surveillance.
• Focal therapies often require more thorough monitoring after treatment, such as MRIs and prostate biopsies.

What can I expect after focal therapy for prostate cancer?

After focal therapy, your provider will monitor you closely for months or years. This includes testing and looking for signs of cancer that:

• Didn’t show up on tests or imaging before.
• Wasn’t completely destroyed by focal therapy.
• Has come back (recurrence).
• Is spreading (metastasis).

You might need additional treatment — including surgery or radiation — if tests show that there’s still cancer in your prostate.

How effective is focal therapy for prostate cancer?

The effectiveness of focal therapy can vary widely (from about 30% to 96%). But these numbers aren’t apples-to-apples comparisons, and the quality of the studies vary. First, studies use different measurements to define effectiveness. They might look at the percentage of people who’ve been treated with focal therapy and:

• Who have negative biopsies.
• Who haven’t progressed (cancer hasn’t grown or spread) in a certain amount of time (usually 10 years).
• Whose PSA numbers have gone down.

Second, outcomes vary based on:

• Type of focal therapy.
• Tumor location.
• The likelihood that the tumor will spread.

Focal therapies are considered less effective than whole-gland therapies like surgery and radiation. Talk to your provider about the effectiveness, benefits and risks of different types of focal therapy to understand what might be right for you.

A note from Cleveland Clinic

Focal therapy treats prostate cancer while sparing healthy tissue. It can provide a less invasive alternative to radiation and surgery and might cause fewer side effects. It can also be a more proactive approach than active surveillance for some prostate cancers.

But it’s not an option for everyone — focal therapies haven’t been studied as much as traditional treatments and some are still considered investigational. Talk to your provider about the benefits and risks of available prostate cancer treatments. They can help you decide what’s right for your specific situation.