Top Line: Let’s warm up for another week of healthy multidisciplinary collaboration by delving into everyone’s favorite subject: focal therapy for prostate cancer.
The Study: A large registry study looked at outcomes from 3,477 men treated with high-intensity-focused ultrasound (HIFU, n=2,897) or cryotherapy (n=580) across 14 UK centers from 2004–2024. The cohort was not exactly low-risk: 48% had favorable-intermediate, 23% unfavorable-intermediate, and 25% high-risk disease. At ten years reported prostate cancer–specific mortality was just 0.13%, metastases 3.3%, and use of androgen deprivation therapy 14%. The authors boldy conclude: “Focal therapy using up to two sessions of focal HIFU or cryotherapy could be considered as a first-line treatment for well-selected patients of nonmetastatic prostate cancer alongside radical treatment.” This reply cautions: not so fast. Despite 10-year proclamations, median follow-up was just over 3 years, with a mere 173 patients (5%) actually reaching a decade of data. And focal therapy was hardly a one-and-done affair—the intention-to-treat analysis informs 10-year cumulative incidence of local retreatment was 33% and of “radical treatment” (aka truly standard prostatectomy or whole-prostate radiotherapy) 30%. Consider this along with the paucity of baseline staging or understanding of what proportion of patients were eligible for active surveillance in the first place, questioning the attribution of very low prostate cancer mortality to focal therapy itself. Not to mention, “By comparison, only 1.5% of men treated with stereotactic body radiotherapy in the phase 3 PACE-B randomised trial required ADT by 5 years.”
TBL: Declaring a new “first-line treatment” for something as prevalent as prostate cancer generally calls for robust randomized trials with well-defined patient populations, validated patient-reported outcomes, and, at the very least, mature outcomes. | Light, Eur Urol 2026 & Van As, Eur Urol 2026
The Study: A large registry study looked at outcomes from 3,477 men treated with high-intensity-focused ultrasound (HIFU, n=2,897) or cryotherapy (n=580) across 14 UK centers from 2004–2024. The cohort was not exactly low-risk: 48% had favorable-intermediate, 23% unfavorable-intermediate, and 25% high-risk disease. At ten years reported prostate cancer–specific mortality was just 0.13%, metastases 3.3%, and use of androgen deprivation therapy 14%. The authors boldy conclude: “Focal therapy using up to two sessions of focal HIFU or cryotherapy could be considered as a first-line treatment for well-selected patients of nonmetastatic prostate cancer alongside radical treatment.” This reply cautions: not so fast. Despite 10-year proclamations, median follow-up was just over 3 years, with a mere 173 patients (5%) actually reaching a decade of data. And focal therapy was hardly a one-and-done affair—the intention-to-treat analysis informs 10-year cumulative incidence of local retreatment was 33% and of “radical treatment” (aka truly standard prostatectomy or whole-prostate radiotherapy) 30%. Consider this along with the paucity of baseline staging or understanding of what proportion of patients were eligible for active surveillance in the first place, questioning the attribution of very low prostate cancer mortality to focal therapy itself. Not to mention, “By comparison, only 1.5% of men treated with stereotactic body radiotherapy in the phase 3 PACE-B randomised trial required ADT by 5 years.”
TBL: Declaring a new “first-line treatment” for something as prevalent as prostate cancer generally calls for robust randomized trials with well-defined patient populations, validated patient-reported outcomes, and, at the very least, mature outcomes. | Light, Eur Urol 2026 & Van As, Eur Urol 2026