Focal therapy: what is really needed to move from investigational to valid therapeutic alternative?

Focal therapy for prostate cancer: what is really needed to move from investigational to valid therapeutic alternative?—a narrative review (2020, Review, Full Text)

"Background and Objective: The most widely accepted therapeutic alternatives for men with intermediate risk prostate cancer (PCa) are mainly represented by whole gland therapies such as surgery or radiotherapy. However, these treatments can carry in some cases profound functional side effects. With the improvement of risk assessment tools and imaging modalities, in particular with the introduction of multiparametric magnetic resonance imaging of the prostate, a fine topographic characterisation of PCa lesions within the prostatic gland is now possible. This has allowed the development of gland-sparing therapies such as focal therapy (FT) as a means to provide an even more tailored approach in order to safely reduce, where feasible, the harms carried by whole gland therapies. Unfortunately, adoption of FT has been considered so far investigational due to some unsolved issues that currently hamper the use of FT as a valid alternative. Here, we aim to identify the main aspects needed to move FT forward from investigational to a valid therapeutic alternative for clinically localized PCa.

Methods: The literature discussing the evolution of focal therapy in the years and its current landscape was broadly searched to identify the factors hindering FT adoption and possible solutions.

Key Content and Findings: There are three broad areas hindering FT as a valid therapeutic alternative: (I) Correct patient selection; (II) harmonising the different FT technologies; (III) the lack of oncological outcomes.

Conclusions: By targeting the three aforementioned weaknesses of FT, greater adoption is expected, finally making FT a valid therapeutic alternative, potentially reshaping prostate cancer treatment and functional outcomes."

From the Full Text:

"Conclusions and future directions

In conclusion, it appears that FT for PCa is in a transition phase, exiting from being an experimental treatment, albeit too premature to be considered an established treatment.

The shift from treating low-risk to intermediate-risk PCa patients is the correct direction, considering the effectiveness of current management in the former cohort. Moreover, the continuous improvement in imaging modalities should allow a better characterization of the index lesion, improving patient selection and further justifying treating solely the index lesion, ensuring optimal functional outcomes. Equally important, standardising and harmonising the different FT approaches will be important to allow comparability and promote widespread adoption of FT. Finally, the ultimate step in consolidating the transition and establishing FT as valid alternative is the generation of robust long-term oncological outcomes.

However, the need to wait several years for RCT data to be published might be overcome by providing solid data based on well-selected comparative series with standardized follow-up, in order to understand as soon as possible whether or not FT could be considered among the set of therapeutic alternatives and providing patients with a further option that is awaited in the field of treatment of clinically localized PCa."

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Djin