Focal therapy for management of prostate cancer

The Department of Urology at Cambridge University Hospitals (CUH) does not offer focal therapy but have prepared this fact sheet for men who have decided to have a treatment for early prostate cancer and are enquiring about focal therapy referral to other units.

What is focal therapy

Focal therapy for prostate cancer is a targeted, minimally invasive treatment approach that destroys specific areas of cancerous tissue within the prostate gland, leaving the healthy rest of the gland intact. However, because prostate cancer is often a multifocal disease, it does not eradicate all cancer cells like whole gland treatments (e.g. radiotherapy, brachytherapy or prostatectomy). Some areas of cancer (low-grade) may be left untreated.

It should therefore be considered a disease management option rather than a cure.

There are different types of focal therapy including:

High-Intensity Focused Ultrasound (HIFU): Uses targeted, high-frequency sound waves to heat and burn away cancer cells. It is highly effective for posterior (lower/back) tumours. You can read about it here on the HIFU section on the Cancer Research website (opens in a new tab).

Cryotherapy (Cryoablation): Uses metal probes inserted into the prostate to deliver cold gases (like argon), freezing and destroying the tumour cells. It is often preferred for anterior (front) lesions. You can read about it on the cyrotherapy section on the Cancer Research Website (opens in a new tab).

Irreversible Electroporation : Employs electrodes placed around the tumour to administer quick, high-voltage electrical pulses. This punches microscopic holes in the cancer cell membranes, causing cell death without thermal damage to surrounding tissue

Benefits

Disease suitable for focal therapy is primarily when there is predominantly one area of cancer and it is localised well within the prostate (stage T1-T2) - typically disease classed as Cambridge Prognostic Groups (CPG) 1 and 2 and some men with Cambridge Prognostic Group 3. Other factors like the location of the cancer and size of prostate may also affect suitability for focal therapy.

It is important to note that for men with Cambridge Prognostic Groups 1 and 2 prostate cancer, the National Institute for Health and Clinical Excellence (NICE) consider this type prostate cancer suitable for active surveillance as well as any form of treatment. All these options are also available for men with Cambridge Prognostic Group 3.

In other words, outcomes in terms of prostate cancer survival and risk from cancer death are similar whether or not men with CPG1&2 have active surveillance or any treatment including focal therapy.

• You can read about NICE recommendations - click here for the NICE recommendations (opens in a new tab).

For men with CPG1-2:

The 10-year risk of dying of prostate cancer regardless of whether they have active surveillance or any type of treatment is less than 0.5%

The 10-year risk of developing disease that has spread (metastatic) regardless of whether they have active surveillance or any type of treatment is around 3%

To see your own risks from early prostate cancer and likely benefits from a treatment you can access tools recommended and endorsed by the National Institute for Health and Clinical Excellence:

• Click here for Cancer Alliance - Prostate (opens in a new tab)
• Click here for Prostate Predict (opens in a new tab)

There have been no direct comparison studies between focal therapy and active surveillance nor has there been any direct comparisons with whole gland treatments like surgery or radiotherapy.

Focal therapy has therefore not been shown to have improved cancer outcomes compared to either active surveillance or to any other whole gland treatments.

Risks

Focal therapy, because it is only delivered to a part of the prostate, does result in less side effects compared to standard whole gland treatments particularly a much less chance of urinary incontinence and erectile dysfunction.

It is important however to note that the lower side effects reported for focal therapy are similarly low as those reported from modern forms of whole gland radiotherapy approaches.

e.g. Incontinence (not needing to wear a pad)

• Radiotherapy or Stereotactic ablative radiotherapy - less than 10%
• Brachytherapy - less than 5%
• Focal therapy - less than 5%

Focal therapy (just like any other treatment) will however have a higher risk of side effects compared to active surveillance.

Some other known side effects from focal therapy as reviewed by the National Institute for Health and Clinical Excellence (2023) may include:

• Acute urinary retention or temporarily unable to pass urine (7% to 27%)
• Urinary tract infections (5% to 18%)
• Fistula or damage to the wall between the urinary system and rectum (0.3% to 3%)
• Urethral stricture disease or narrowing of the urinary tube (2% to 4%)

Other reported outcomes after focal therapy

In a recent UK registry report of over 3400 men who had focal therapy with a median (average) follow-up of 3.5 years

• 1 in 3 men need to have 2 or more focal treatments
• 1 in 3 men eventually needed to have a definitive whole gland treatment ((e.g. radiotherapy, brachytherapy or prostatectomy)

In a national audit of focal therapy outcomes published by the National Prostate Cancer Audit of over 1300 men at 5 years follow up. Further treatment was needed in

• 17% of men with Grade Group 1 prostate cancer
• 23% of men with Grade Group 2 prostate cancer
• 28% of men with Grade Group 3 prostate cancer

Alternatives

Cambridge University Hospitals (CUH) does not offer focal therapy but does offer a range of other options for early prostate cancer.

These include:

Active Surveillance:

Risk stratified active surveillance with the view of considering definitive treatment in future if the disease progresses to a stage where it is warranted.

Treatments:

External beam radiotherapy including SABR - Stereotactic ablative radiotherapy (a way of giving radiotherapy to precisely target certain cancers over a shorter course and without antihormones).

Low dose rate brachytherapy (including option for focal MRI guided boosted therapy)

Robotic Radical Prostatectomy:

These options will be discussed with you by the clinical team if you wished to consider active treatment options in CUH.

Referral onwards for focal therapy

If you wish to be considered focal therapy we can refer you onto a centre that offers this treatment.

My Chart:

We would encourage you to sign up for MyChart. This is the electronic patient portal at Cambridge University Hospitals that enables patients to securely access parts of their health record held within the hospital’s electronic patient record system (Epic). It is available via your home computer or mobile device

More information is available on the My Chart section on our website.

Contacts / further information

• Prostate cancer nurse practitioner: 01223 216897
• Uro-oncology nurse specialist: 01223 586748

References/ Sources of evidence

1. NICE Prostate Cancer Guidelines (opens in a new tab)
2. NICE (2023) Focal therapy using high-intensity focused ultrasound for localised prostate cance (opens in a new tab)r
3. Parry MG, Sujenthiran A, Nossiter J, Morris M, Berry B, Nathan A, Aggarwal A, Payne H, van der Meulen J, Clarke NW. Prostate cancer outcomes following whole-gland and focal high-intensity focused ultrasound. BJU Int. 2023 Nov;132(5):568-574. doi: 10.1111/bju.16122.
4. Light A, Peters M, Gopalakrishnan A, Mayor N, Cullen E, Boaz RJ, Norris JM, Morris S, Arya M, Tanaka MB, Doherty A, Dudderidge T, Emara A, Emberton M, Grey A, Hindley R, Laniado M, McCraken S, Moore CM, Nigam R, Noureldin M, Orczyk C, Rakauskas A, Simmons L, Virdi J, Withington J, Zakikhani P, Ahmed HU, Shah TT. Oncological Outcomes Following Focal HIFU and Cryotherapy for Treatment of Nonmetastatic Prostate Cancer in the United Kingdom: An Updated Analysis of 3477 Patients from the Prospective HEAT and ICE Registries. Eur Urol. 2026 Jul 10:S0302-2838(26)02169-X.
5. Cooper S, Patel J, Moore C, Ostler P, van der Voet H, Loblaw A, Chu W, Ford D, Tolan S, Jain S, Camilleri P, Kancherla K, Frew J, Chan A, Naismith O, Armstrong J, Staffurth J, Martin A, Dayes I, Wells P, Price D, Pugh J, Manning G, Brown S, Burnett S, van As N, Hall E, Tree AC. Patient-reported Outcomes After Prostate Stereotactic Body Radiotherapy at 5 yr: Results from the PACE-B Trial. Eur Urol. 2026 Jul 20:S0302-2838(26)02212-8. doi: 10.1016/j.eururo.2026.05.034.
6. Leapman MS, Stone NN, Mock S, Stock RG, Hall SJ. Urinary Incontinence Following Prostate Brachytherapy. Urology. 2016 Sep;95:151-7.
7. Gnanapragasam VJ, Bratt O, Muir K, Lee LS, Huang HH, Stattin P, Lophatananon A. The Cambridge Prognostic Groups for improved prediction of disease mortality at diagnosis in primary non-metastatic prostate cancer: a validation study. BMC Med. 2018 Feb 28;16(1):31. doi: 10.1186/s12916-018-1019-5.
8. Thurtle, D., Bratt, O., Stattin, P. et al. Comparative performance and external validation of the multivariable PREDICT Prostate tool for non-metastatic prostate cancer: a study in 69,206 men from Prostate Cancer data Base Sweden (PCBaSe). BMC Med 18, 139 (2020) (opens in a new tab).