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Making a case “against” focal therapy for intermediate-risk prostate cancer

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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.

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Authors and Affiliations

  1. Department of Urology, San Giovanni Battista Hospital, Città della Salute e Della Scienza and University of Turin, C.so Bramante 88/90, 10100, Turin, Italy

    Paolo Gontero & Giancarlo Marra

  2. Institut Mutualiste Montsouris, Paris, France

    Giancarlo Marra

  3. Department of Urology, Stadtische Klinikum Karlsruhe, Karlsruhe, Germany

    Dogu Teber

  4. Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria

    Shahrokh Shariat

  5. Department of Urology, Istanbul Medipol University, Istanbul, Turkey

    Selami Albayrak

  6. Department of Urology, Instituto de Laparoscopia E Robotica, São Paulo, Brazil

    Rafael Coelho

  7. Department of Urology, McGill University, Montreal, Canada

    Simon Tanguay

  8. Department of Urology, University of Minnesota, Minneapolis, MN, USA

    Badrinath Konety

  9. Department of Urology, Weill Cornell Medical College, New York, NY, USA

    Shahrokh Shariat

  10. Department of Urology, University of Texas Southwestern, Dallas, TX, USA

    Shahrokh Shariat

  11. Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic

    Shahrokh Shariat

  12. Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia

    Shahrokh Shariat

  13. Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan

    Shahrokh Shariat

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  1. Paolo Gontero
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  2. Giancarlo Marra
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Contributions

Protocol/project development: PG and GM; Data collection or management: PG and GM; Data analysis: PG and GM; Manuscript writing: GM and PG; Manuscript editing: all authors; Revision for important intellectual contents: all authors.

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Correspondence to Giancarlo Marra.

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Gontero, P., Marra, G., Teber, D. et al. Making a case “against” focal therapy for intermediate-risk prostate cancer. World J Urol 39, 719–728 (2021). https://doi.org/10.1007/s00345-020-03303-y

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