Introduction to focal therapies for prostate cancer

Overview by

Professor Iqbal Shergill
Consultant Urological Surgeon

Wrexham Maelor Hospital 

Focal therapies for prostate cancer are designed to treat patients with low to intermediate risk cancers. That is patients where the cancer is confined to part or bilateral parts of the prostate gland. These are relatively new technologies and currently not available in New Zealand.

• HIFU (high frequency ultrasound) to destroy cancer lesions in the posterior of the prostate
• Cryotherapy, freezing the cancer cells to destroy them. This is usually used to treat cancer lesions in the anterior of the prostate
• Nanoknife, also known as irreversible electroporation therapy, uses electrical pulses to destroy the cancer cells and can treat any part of the prostate. It is currently an experimental treatment.

There are several other focal treatments subject of trials and not clinically available  at the moment. They include, Francis Medical’s Transurethral thermal water vapour ablation, MR guided transurethral ultrasound ablation (TULSA -PRO) for cancer and BPH from Profound Medical and Focal Laser Ablation (FLA) of prostate cancer. For more information visit the innovations page. 

All these focal therapies for prostate cancer can be repeated if low to intermediate cancer reoccurs.

The treatments target significant prostate cancer lesions in the gland whilst leaving the rest of the prostate undamaged. The consequence is that there are very few side effects as compared to more radical treatments such as Radical Prostatectomy or Radiotherapy.

Specifically, erectile function is much more likely to be preserved, as is fertility, and there is far less chance of incontinence. Further, recovery time is much quicker.

Recently published research, the COMPARE study (Verity Watson et al Journal of Urology 2020) evaluated the trade offs men were prepared to make between the risks and benefits (minimum side effects) of different treatments.

The results:

Low to intermediate risk patients were:

• Willing to trade a 7% absolute decrease in survival in exchange for ‘conservative’ management or treatment ie active surveillance or focal treatments that minimise side effects.
• Were willing to trade:
  • 1% survival for one month earlier return to normal activities
  • 1% survival for 1% better urinary function
  • .4% survival for 1% improvement in sexual function

In fact, patients of all risks were willing to trade off cancer specific survival for improved quality of life.

There is an even more interesting study published by Imperial College last year.
The study is titled:
A comparison of cancer control outcomes at 5 years of Focal Therapy (using HIFU and Cryotherapy) to Radical Prostatectomy for clinically significant non-metastatic prostate cancer: propensity score matched analysis. Deepeka Reddy, Taimur Shah et al May 2019

The key conclusion was as follows:

Focal therapy provides comparable failure-free survival and better post-op function compared to radical prostatectomy.

That is to say, for low to intermediate risk cancer, focal therapy is just as good a treatment as radical prostatectomy but with better outcomes in terms of side effects including erectile function and incontinence in appropriately selected patients.

To learn more about these focal therapies, and where to get them, see the prostate cancer menu for links.

In conclusion, a quote from a recent presentation at UCLH

‘When the jury is out, we (Urological Surgeons) will be accused of committing two errors:

• Over estimating the risk (of death) in men with localised disease (and treating with Radiotherapy of radical prostatectomy)
• Under-estimating the utility that men place on maintaining both urinary continence and sexual function’

*the image below can be downloaded at the link