The face of prostate cancer has been dramatically changed since the late 1980s when PSA was introduced as a clinical screening tool. More men are diagnosed with localized prostate cancer [30
] and smaller volume, non-aggressive prostate cancers [31
]. It is unlikely that these cancers will adversely affect the individuals overall survival, thus expectant management or now focal therapy may be an excellent treatment modality for this very select cohort. A key remains the ability to identify candidates for focal therapy. The International Task Force on Prostate Cancer and the Focal Lesion Paradigm has proposed a clinical definition of suitable candidates for focal therapy (Table ) [32
]. But for those individuals opting for definitive therapy, perhaps focal therapy utilizing any of the modalities discussed above may be an option [33
]. It is noted that advancements in the delivery of external beam radiation and brachytherapy are enabling these therapies to be considered in the focal therapy armamentarium.
Ideal Candidates for Focal Therapy*
Though focal therapy of the prostate only treats a portion of the prostate it has been referred to as the 'male lumpectomy', but one must remember women who undergo lumpectomy usually will have other local or systemic therapies to ensure eradication of disease. Since men who are undergoing 'male lumpectomy' rarely undergo these addition therapies, comparison with women undergoing a lumpectomy should be limited. However, through rigorous clinical scrutiny the ideal treatment combinations were identified for breast cancer that successfully treated the cancer and limited the morbidity associated with more radical therapies. A strong push must be made in the Urologic community to rigorously scrutinize focal therapy in men with prostate cancer.
As previously stated, successfully adoption of focal therapy for the treatment of prostate cancer will hinge on two critical issues: 1) accurately identifying index lesions within the prostate, 2) reliably imaging cancers within the prostate, 3) long-term efficacy of the technology to eradicate cancer, 4) appropriate follow-up of patients treated with focal therapy, 5) limitations of PSA following therapy and how to detect recurrent/persistent disease. Solving these critical issues not only will assist with pretreatment counseling of these patients, but could be used as effective monitors for ideal end points in cancer therapy. In addition, optimal patient selection using pretreatment risk stratification must be developed to ensure the treatment of subjects who would gain the most out of focal therapy. Despite our limitations in identifying disease that can be treated by focal therapy, several clinical trials utilizing some of the promising therapeutic modalities mentioned above are on the horizon. Hopefully with careful monitoring and critical review of these trials we can better determine if focal therapy is an appropriate treatment option to offer patients with localized, low-grade prostate cancer.