Selection for focal therapy: is it too early to judge?

The advent of novel focal therapies theoretically opens up new treatment avenues for patients with localised prostate cancer (PCa). Presently, management is dichotomised between active surveillance and radical, whole-gland therapy, such as prostatectomy and radiotherapy. While the former burdens patients with the detrimental diagnosis of cancer without the reassurance of treatment, the latter is too often associated with long-term incontinence and/or impotence [1]. The ultimate aim in PCa treatment is effective cure with minimal morbidity and maintenance of quality of life. Through targeted treatment and resultant tissue preservation, focal therapy has been hypothesised to achieve this difficult goal in certain patients. However, the interminable challenge of patient selection remains. In this month’s issue of European Urology, Singh and colleagues report an interesting and important study that retrospectively looked at all patients who had undergone transperineal template prostate-mapping biopsies over a 4-yr period [2]. Their creditable aim was to estimate the proportion of patients with PCa who are appropriate for focal therapy. Their optimistic conclusion was that 92% of 239 patients (220 men) with PCa were potentially suitable for focal treatments. The presence of substantial selection bias in a population-based study must, however, be acknowledged, with the authors only analysing men who had been referred to their tertiary centre with a special interest in focal therapy. Furthermore, and crucially, how do we define suitability for what are currently evolving and experimental treatments? Singh et al. [2] used broad criteria for suitability, requiring the cancer to be (1) unifocal, (2) unilateral, (3) bilateral/ bifocal with at least one neurovascular bundle avoided, or (4) bilateral/multifocal with one dominant index lesion and secondary lesions with Gleason 3 + 3 and cancer core