Is focal therapy the future for prostate cancer?

Focal therapy aims to find a middle ground between surveillance and radical therapies by treating the cancer alone, with a margin, and preserving as much tissue as is practical. Early feasibility studies have demonstrated an absence of rectal toxicity and preservation of genitourinary function in 80-90% of men. The incidence of low- to intermediate-risk prostate cancer is rising owing to informal and formal prostate-specific antigen screening practices. The treatment burden from radical therapies is high with over 50% of men suffering genitourinary or rectal toxicity. Active surveillance, on the other hand, carries surveillance and psychological burden with risk of progression. A research strategy to evaluate focal therapy should be embedded within pragmatic designs using a broad patient group, using the available ablative technologies (cryotherapy, high-intensity focused ultrasound, brachytherapy and photodynamic therapy) with end points derived from biochemical, biopsy and imaging. Within this framework there exists a unique opportunity to undertake landmark diagnostic studies incorporating imaging techniques and biomarkers in addition to studies directed at the biology of prostate cancer over time.