10 questions to ask before choosing focal therapy for prostate cancer

Am I genuinely a suitable candidate?

"What is it about my cancer that makes focal therapy a reasonable option?"

Focal therapy works best for a particular kind of cancer: one that is significant enough to need treatment, but contained within the prostate and concentrated in one main area. In practice, that usually means:

• an intermediate-risk cancer, typically Grade Group 2 or 3
• a single main area of significant cancer, clearly visible on MRI
• no sign of spread outside the prostate
• a tumour in a position the chosen energy can reach safely

Very low-risk cancers are usually better monitored with active surveillance, because they may never need treatment at all. High-risk or widespread cancers usually need whole-gland treatment.

How has my cancer been mapped?

"Are we confident there is no significant cancer elsewhere in the prostate?"

Focal therapy treats only what it is aimed at, so everything depends on knowing exactly where the cancer is, and where it isn't. That requires a high-quality prostate MRI and a careful transperineal biopsy, with targeted samples from the MRI lesion and systematic samples from the rest of the gland.

If your diagnosis came from a limited biopsy, more detailed sampling may be advised before focal therapy can be considered. That can feel like a step backwards, but it is what makes the treatment safe.

Which type of focal therapy, and why that one?

"Why is this energy source the best fit for where my cancer sits?"

Focal therapy is a family of treatments rather than one procedure. The main options use different energy to destroy cancer cells:

• HIFU (high-intensity focused ultrasound) heats the target area from a probe in the back passage. Focal One HIFU explained
• Irreversible electroporation (NanoKnife) uses electrical pulses through fine needles. How NanoKnife works
• Cryotherapy freezes the target area through fine needles.

The position of the cancer, the size of the prostate and features such as calcification can make one option more suitable than another. Ask why a particular method has been chosen for you, and whether it is the method best suited to your cancer or simply the one available.

What are the chances I'll need more treatment?

"How likely is it that I'll need a second focal treatment, or surgery or radiotherapy later?"

Because the rest of the prostate is left in place, cancer can persist in the treated area or appear elsewhere in the gland. This is not a failure of the idea, but it is part of the deal, and you should go in knowing it.

The largest UK series to date followed 1,379 men treated with focal HIFU. Around 1 in 5 (18%) had a repeat focal treatment, and about 1 in 14 (7%) went on to whole-gland surgery or radiotherapy. Seven years after treatment, about 7 in 10 men remained free of treatment failure as the study defined it.

Worth knowing: for many men, the possibility of a second focal treatment is an acceptable trade for a lower risk of side effects. For others, the certainty of a single definitive treatment matters more. Neither view is wrong.

What side effects should I expect?

"What is realistic for my continence, erections and ejaculation?"

The main appeal of focal therapy is a lower risk of the side effects associated with whole-gland treatment. Most men keep good urinary control, and erections are more often preserved than after surgery or radiotherapy. Serious complications are uncommon.

But "fewer side effects" does not mean none. Many men have a catheter for a short time afterwards, urinary symptoms for a few weeks while the treated area heals, and some notice a change in ejaculation or erections. Urine infections can occur. Your own risk depends on where the treatment is and how good your function is beforehand.

What will my follow-up involve, and for how long?

"What tests will I need in the years after treatment, and who arranges them?"

This is the part men most often underestimate. After surgery, PSA should fall to an undetectable level, which makes follow-up simple. After focal therapy, the untreated part of the prostate continues to make PSA, so the numbers are interpreted differently and can be less clear-cut.

Follow-up therefore relies on a combination of tests over several years:

• Regular PSA tests, more often in the first years
• Repeat MRI scans to check the treated area and the rest of the gland
• A follow-up biopsy in many cases, either routinely or if anything looks concerning

If you value a treatment that you can largely put behind you, this is worth weighing carefully.

Can I still have surgery or radiotherapy later?

"If focal therapy doesn't work, what are my options, and are they any harder?"

Yes. Choosing focal therapy does not close the door on radical treatment. Robotic prostatectomy and radiotherapy are both possible afterwards, and are used for men who need further treatment.

It is fair to know, though, that surgery after focal therapy can be technically more demanding, because the treated area heals with scar tissue. That can make nerve-sparing harder and may affect continence and erectile outcomes compared with having surgery first. Ask how this would apply to you.

How strong is the long-term evidence?

"How does the evidence for focal therapy compare with surgery and radiotherapy?"

Surgery and radiotherapy have been studied for decades, including in randomised trials that followed men for more than fifteen years. Focal therapy is newer. Results from large series are encouraging, but there is not yet long-term randomised evidence comparing it directly with radical treatment.

That is reflected in NICE guidance. NICE considers focal HIFU and irreversible electroporation safe enough to use, but advises that they should only be used with special arrangements for clinical governance, consent, and audit or research, because evidence on long-term effectiveness is still limited. This is not a reason to rule focal therapy out. It is a reason to choose it with your eyes open, and ideally within a trial or registry.

Has my case been reviewed by a multidisciplinary team?

"Has the MDT looked at my scans and biopsy, and did they agree focal therapy is reasonable?"

NICE recommends that patients for focal therapy are selected by a multidisciplinary team (MDT): urologists, radiologists, pathologists and oncologists reviewing your results together. That protects you from being steered towards any single treatment because it is the one on offer.

It is also reasonable to ask to hear the case for each option from someone who does it: a surgeon about prostatectomy, an oncologist about radiotherapy, and a specialist in active surveillance where relevant. My article on prostatectomy versus radiotherapy explains how those two compare.

Is there a clinical trial I could join?

"Am I eligible for the PART trial?"

The question every man considering focal therapy wants answered is whether it controls cancer as well as surgery or radiotherapy over the long term. That is exactly what the PART trial (Partial prostate Ablation versus Radical Treatment) has been designed to find out.

PART is a national NHS randomised trial, led by the University of Oxford and funded by the NIHR, for men with intermediate-risk prostate cancer on one side of the prostate. Men who join are allocated by chance to either focal treatment or radical treatment, and are followed closely. Taking part gives you carefully supervised care while helping answer the question for the men who come after you.