Focal Therapy and Active Surveillance of Prostate Cancer: A European Perspective

In the era of overdiagnosis and overtreatment of clinically localized prostate cancer (PCa), novel approaches aimed at reducing the risk of treatment-related side effects typically associated with radical therapies have been proposed. Among those, active surveillance and focal therapy (FT) represent less-invasive options to treat the disease without exposing the patient to the risk of short- and long-term sequelae. Active surveillance aims at avoiding or delaying curative-intent treatments in men initially diagnosed with low- or favorable intermediate-risk PCa. On the other hand, FT is a minimally invasive treatment targeting specific areas of the prostate, thus avoiding potential side effects of whole-gland treatment modalities. Active surveillance has been recently recommended as the preferred option for the management of early-stage disease by international clinical guidelines. However, nearly half of the patients initially managed conservatively eventually undergo any form of curative-intent treatment (namely, radical prostatectomy or external beam radiation therapy), which is associated with relevant sequelae in terms of sexual, urinary, and bowel dysfunctions. FT uses different energy modalities locally delivered to the prostate, to achieve local cancer control without compromising functional outcomes by avoiding the typical side effects of radical prostatectomy and radiation therapy. To date, it is a matter of debate whether radical whole-gland treatments with curative intent may do more harm than good in patients with low- or intermediate-risk prostate cancer. Therefore, FT is a promising bridge between active surveillance and options for curative-intent treatments. A vast number of studies have been conducted in Europe with different forms of FT modalities, demonstrating satisfactory oncologic outcomes, with sometimes the need for additional treatments after the initial energy delivery. The field of FT and PCa is evolving, and according to the urological community in Europe, more evidence regarding the long-term ability of cancer control is warranted before its application in daily clinical practice.