br Participant s responses to survey questions br
Participant’s responses to survey questions
Unilateral low risk (Gleason score 6) 68(66) Bilateral low risk as long as urethra and one neurovascular bundle are preserved (Gleason score 6) 27(26.2) Unilateral intermediate risk (Gleason score 7) 75(72.8) Bilateral intermediate risk as long as urethra and one neurovascular bundle are preserved (Gleason score 7) 11(10.7) Unilateral high risk (Gleason score >7) 22(21.4) If yes, how are CaP focal therapy candidate identified? (n = 103)
Based on systematic transrectal ultrasound (TRUS) biopsy only 11(10.7) Multiparametric MRI (mp-MRI) and systematic TRUS biopsy 33(32) Multiparametric MRI (mp-MRI) followed by MRI-TRUS fusion biopsy 33(32) Template prostate mapping biopsies with or without Multiparametric MRI 26(25.2) If yes, what modality?a (n = 103)
Urinary retention 43(67.2) Urethral stricture 8(12.5) Urinary incontinence 6(9.4) Erectile dysfunction 18(28.1) Rectal complications—perineal pain, rectal bleeding or rectourethral fistula 6(9.4) If yes, how do you follow-up a patient post focal therapy? (n = 102)
Prostate-specific antigen/ PSA kinetics 25(24.5) mp-MRI followed by targeted biopsy only if there is a suspicious lesion 31(30.4) Protocol biopsy at set intervals with or without prior mp-MRI 46(45.1) If yes, do you attempt focal therapy for biopsy proven recurrent prostate cancer post focal therapy? (n = 101)
CaP = prostate cancer. a Select all that apply question.
Logistic regression analysis for utilization of focal therapy
Use of focal therapy
Univariate OR [CI] P value Multivariate OR [CI] P value
Nonacademic (reference) 1 − 1 − Academic
CaP patients seen per month
Valerio et al.’s systemic review demonstrated that the majority of CaP patients treated with FT were men with low-risk and intermediate-risk disease . Physicians uti-lizing FT in our survey had very similar selection criteria and used it Paxilline most often for unilateral low- and intermediate-risk CaP patients.
In our survey, of the physicians utilizing FT, as much as two-thirds employed mp-MRI either followed by TRUS biopsy or MR targeted biopsy as prediagnostic interven-tions. Only a minority were selecting FT candidates based on TRUS biopsy alone. Prostate mp-MRI and MR-targeted biopsy have lately been recognized to precisely localize the index lesion [22,23]. Studies have proven mp-MRI’s excel-lent diagnostic utility especially in clinically significant CaP (>0.5 cm3 volume) [24−26]. Remarkably, Villers et al. demonstrated mp-MRI’s excellent cancer localizing capability and also negative predictive value as high as 95% for clinically significant CaP . An international Delphi consensus statement demonstrated a high level of agreement (92%) that mp-MRI is a standard imaging modality for patient selection for FT. Further, glucocorticoids described that patients with tumor foci <1.5 ml on mp-MRI of the prostate are advisable for FT [28,29]. The link between mp-MRI and FT may result in increased FT usage and confi-dence as the mp-MRI adoption increases. Though there is a clear link in these technologies, the most significant obsta-cle to FT adoption is a paucity of long-term beneficial evi-dence, as described by this survey. Indeed, large-scale favorable results and easier access to infrastructure looks to be critical for overall FT adoption. However, this is a rather tall order since FT must prove to have lower morbidity and noninferior oncologic outcomes than radical therapy.
In the last 2 decades, there has been a gradual increase in available therapy modalities. The application of each modality has been based on the tumor location. The 2 most common modalities used by the respondents were HIFU
and cryoablation. This trend is not surprising since these 2 technologies are relatively mature modalities and have the most longitudinal data available. Based on the existing lit-erature, focal cryotherapy seems to result in acceptable pre-liminary oncological outcomes with favorable morbidity profiles compared with radical treatment options [6,7]. Sim-ilarly, the efficacy rates for focal HIFU have been reported between 78% and 95% . Finally, there are several newer focal modalities (Laser ablation, photodynamic ther-apy, etc.) that have entered early-phase clinical trials and various are still under active investigation to be used clini-cally. No randomized trials have shown that one modality is superior to another.
The most common complications post-FT per respond-ents in our survey was urinary retention and erectile dys-function. To date, continence data and urinary symptoms after FT have not been reported universally. However, the limited evidence suggests that FT results in better urinary function compared to radical treatment options. Valerio et al.  identified complications like urinary retention and urinary infection in only 0% to 17% of total cases undergoing FT. Moreover, the limited literature suggests no significant difference between the complication rates between each of the FT modalities .