Reference: August 2025 | Issue 8 | Vol 11 | Page 29
SUMMARY OF RECOMMENDATIONS
- For patients with localised prostate cancer, focal therapy is not routinely recommended due to the lack of long-term oncological data.
- Focal therapy may only be considered for patients with localised prostate cancer on a case-by-case basis following shared decision-making with the patient.
- Any patients undergoing focal therapy should be enrolled in a prospective registry or participate in a clinical trial.
Quality of evidence: Low
Grade of recommendation: Conditional
*Focal therapy refers to HIFU and cryotherapy
In addition to new recommendations on active surveillance of patients with prostate cancer, the National Cancer Control Programme (NCCP) has published a new guideline on the use of focal therapy in patients with prostate cancer.1
The guideline is based on evidence from seven prospective studies, one retrospective study and one randomised control trial, while also incorporating the latest international guidelines.2-14
The overall quality of the evidence was considered to be low and the recommendations relate to high-intensity focused ultrasound (HIFU) and/or cryotherapy only, as the Guideline Development Group found “insufficient data to discuss the other modalities in the management of localised prostate cancer”.
Studies have shown that some focal therapies have better functional outcomes for patients compared to radical treatments. Focal therapy had been associated with continence rates ranging from 95-100 per cent, although these studies were deemed to be of low quality due to multiple confounding factors.2,5,9 Men who receive focal therapy have shown higher rates of preserved ejaculation (67 per cent).5
The Guideline Development Group concluded that while there is sufficient evidence to support the safety of focal therapy with HIFU for localised prostate cancer, there is insufficient data to support its oncological efficacy.
Hence, focal therapy is not routinely recommended for patients with localised prostate cancer, due to the lack of long-term oncological data.
However, the guideline acknowledges that some patients may prefer focal therapy despite the lack of long-term oncological outcome data due to the better functional outcomes. In this instance, the document states that “by emphasising a patient-centred approach that includes clear communication, healthcare providers can ensure patients feel empowered to make informed decisions about their treatment”.
The guideline states that focal therapy may only be considered for patients with localised prostate cancer on a case-by-case basis following shared decision-making with the patient.
Furthermore, any patient being considered for focal therapy must be enrolled in a centralised prospective registry with a surveillance protocol or be a participant in a clinical trial.
References
- National Cancer Control Programme (2025) HSE National Clinical Guideline: The use of focal therapy in patients with prostate cancer. Available at: www2.healthservice.hse.ie/organisation/national-pppgs/.
- Guillaumier S, Peters M, Arya M, Afzal N, Charman S, Dudderidge T, et al. A multicentre study of five-year outcomes following focal therapy in treating clinically significant non-metastatic prostate cancer. Eur Urol. 2018 Oct;74(4):422-429. doi: 10.1016/j.eururo.2018.06.006.
- van Son MJ, Peters M, Reddy D, Shah TT, Hosking-Jervis F, Robinson S, Lagendijk JJW, et al. Conventional radical versus focal treatment for localised prostate cancer: A propensity score weighted comparison of six-year tumour control. Prostate Cancer Prostatic Dis. 2021 Dec;24(4):1120-1128. doi: 10.1038/s41391-021-00369-6.
- Marra G, Soeterik T, Oreggia D, Tourinho-Barbosa R, Moschini M, Filippini C, et al. Long-term outcomes of focal cryotherapy for low- to intermediate-risk prostate cancer: Results and matched pair analysis with active surveillance. Eur Urol Focus. 2022 May;8(3):701-709. doi: 10.1016/j.euf.2021.04.008.
- Matsuoka Y, Uehara S, Toda K, Fukushima H, Tanaka H, Yoshida S, et al. Focal brachytherapy for localised prostate cancer: 5.7-year clinical outcomes and a pair-matched study with radical prostatectomy. Urol Oncol. 2022 Apr;40(4):161.e15-161.e23. doi: 10.1016/j.urolonc.2021.11.009.
- Reddy D, Peters M, Shah TT, van Son M, Tanaka MB, Huber PM, Lomas D, Rakauskas A, Miah S, Eldred-Evans D, Guillaumier S, Hosking-Jervis F, Engle R, Dudderidge T, Hindley RG, Emara A, Nigam R, McCartan N, Valerio M, Afzal N, Lewi H, Orczyk C, Ogden C, Shergill I, Persad R, Virdi J, Moore CM, Arya M, Winkler M, Emberton M, Ahmed HU. Cancer control outcomes following focal therapy using high-intensity focused ultrasound in 1379 men with non-metastatic prostate cancer: A multi-institute 15-year experience. Eur Urol. 2022 Apr;81(4):407-413. doi: 10.1016/j.eururo.2022.01.005. Epub 2022 Feb 3. PMID: 35123819.
- Habashy D, Reddy D, Peters M, Shah TT, van Son M, van Rossum PSN, et al. Evaluation of outcomes following focal ablative therapy for treatment of localised clinically significant prostate cancer in patients >70 years: A multi-institute, multi-energy 15-year experience. J Urol. 2023 Jul;210(1):108-116. doi: 10.1097/JU.0000000000003443.
- Ladjevardi S, Ebner A, Femic A, Huebner NA, Shariat SF, Kraler S, et al. Focal high-intensity focused ultrasound therapy for localised prostate cancer: An interim analysis of the multinational FASST study. Eur J Clin Invest. 2024 Jun;54(6):e14192. doi: 10.1111/eci.14192.
- Bass R, Fleshner N, Finelli A, Barkin J, Zhang L, Klotz L. Oncologic and functional outcomes of partial gland ablation with high intensity focused ultrasound for localised prostate cancer. J Urol. 2019 Jan;201(1):113-119. doi: 10.1016/j.juro.2018.07.040.
- Zhang K, Teoh J, Laguna P, Dominguez-Escrig J, Barret E, Ramon-Borja JC, et al. Effect of focal vs Extended irreversible electroporation for the ablation of localised low- or intermediate-risk prostate cancer on early oncological control: A randomised clinical trial. JAMA Surg. 2023 Apr 1;158(4):343-349. doi: 10.1001/jamasurg.2022.7516. Erratum in: JAMA Surg. 2023 Aug 1;158(8):892. doi: 10.1001/jamasurg.2023.2669.
- Cornford P, van den Bergh RCN, Briers E, Van den Broeck T, Brunckhorst O, Darraugh J, et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG guidelines on prostate cancer – 2024 update. Part I: Screening, diagnosis, and local treatment with curative intent. Eur Urol. 2024 Aug;86(2):148-163. doi: 10.1016/j.eururo.2024.03.027.
- Eastham JA, Auffenberg GB, Barocas DA, Chou R, Crispino T, Davis JW, et al. Clinically localised prostate cancer: AUA/ASTRO guideline, Part I: Introduction, risk assessment, staging, and risk-based management. J Urol. 2022 Jul;208(1):10-18. doi: 10.1097/JU.0000000000002757.
- National Institute for Health and Care Excellence. Focal therapy using high-intensity focused ultrasound for localised prostate cancer: Interventional procedures guidance. Reference number:IPG756. Published April 2023. www.nice.org.uk/guidance/ipg756.
- Schaeffer EM, Srinivas S, Adra N, An Y, Bitting R, Chapin B, et al. NCCN Guidelines® Insights: Prostate Cancer, Version 3.2024. J Natl Compr Canc Netw. 2024 Apr;22(3):140-150. doi: 10.6004/jnccn.2024.0019.
