For men with localized prostate cancer, the standard approach often means removing the entire gland or delivering radiation, even when only a small tumor is present. A newer approach, called focal therapy, aims to treat just the visible lesion.
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A recent U.K. analysis followed patients for ten years after the procedure and found that only 0.1% died from the disease, a rate similar to that of radical surgery or external‑beam radiation. The same report noted higher satisfaction scores and fewer side‑effects among those who chose the approach.
Guidelines from the national urology association still label the technique experimental, recommending its use only within registries or prospective studies. Critics point out that about half of those treated fell outside the intermediate‑risk category that the guidelines deem appropriate for active surveillance.
“I’m super happy with it. I have zero side effects,” said Chris Brosseau, a 48‑year‑old from Denver with a family history of aggressive disease. He paid roughly $17,000 out of pocket because most commercial insurers do not cover the procedure, though Medicare does. “I realize it can come back because I didn’t treat my whole prostate,” he added.
Physicians Remain Divided Over Evidence
The method relies on FDA‑cleared technologies that destroy cancer cells by freezing, heating, or ablating tissue. In 2010, cryotherapy accounted for nearly 80% of such procedures; by 2023 its share fell to 20%, while laser ablation rose to 45% and high‑intensity focused ultrasound (HIFU) reached 35%.
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Eligibility estimates suggest that roughly 10%–20% of cases could qualify for the approach, yet recent U.S. data show only about 1.3% of men actually receive it.
Traditional removal surgery typically leads to temporary incontinence in almost all patients, with permanent loss affecting 5%–10%. More than half of men undergoing the operation report lasting erectile dysfunction. Radiation avoids a surgical incision but still carries risks of temporary urinary leakage and sexual side‑effects, and it requires daily sessions over several weeks.
“There are times you go and treat someone with the technique and you know with a pretty darn high likelihood there’s going to be close to zero chance of side effects,” said Scott Eggener, a professor of urology at UCLA. “But there’s other areas of the prostate near the nerves or the sphincter where … there’s a real risk of side effects that [patients] might encounter.”
In comparing this to the rollout of robotic prostatectomy two decades ago, the current debate mirrors earlier skepticism about minimally invasive surgery. Back then, limited long‑term data delayed broad acceptance, yet over time the technology proved comparable in cancer control while improving recovery times. The present situation may follow a similar path if robust trials emerge.
After treatment, patients are monitored with PSA blood tests, repeat MRI scans, and occasional biopsies. If cancer appears elsewhere in the gland, another focal session can be considered; recurrence at the treated site usually prompts a switch to radiation or surgery.
“Greater than 95% of the patients when they’re eligible for focal choose focal,” reported Abhinav Sidana, director of the program at the University of Chicago. “An average‑skilled surgeon doing focal will end up having better functional outcomes than sometimes even the most skilled prostatectomist.”
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Critics argue that the evidence base is thin. “The technique hasn’t been evaluated carefully and robustly,” said Tyler Seibert, an associate professor at UC San Diego. “The only way to know that is to do a head‑to‑head randomized trial, and that’s just what we’re missing.” He added that patients enthusiastic about the method often refuse random assignment, complicating study design.
“As far as which technology, there’s no direct comparisons, it’s all conjecture on which might be better than the other,” noted Eggener, highlighting the lack of head‑to‑head data among cryotherapy, laser and HIFU.
Registries currently group all modalities together, making it hard to tease out individual performance. “It’s focal therapy no matter how you did it,” said Samuel Peretsman, chief medical officer of a HIFU device maker. “We’re just going to call it all focal therapy so we can scale up the amount of data to analyze it.”
Some providers push back on the “experimental” label. “When they say that focal therapy is experimental, I say: ‘Which bit?’” remarked Mark Emberton, a professor of interventional oncology in London, who has performed the method for more than twenty years.
Sidana countered that many medical procedures were adopted on the basis of clinical judgment before large trials, citing robotic surgery and brachytherapy as examples. He said the only unknown is whether the technique shortens life expectancy compared with removal or radiation.
Data from the U.K. cohort showed ten‑year survival not inferior to radical surgery, while quality‑of‑life scores were markedly better. “When patients look at that data, they’re like, ‘OK, ten years is enough. I don’t care if twenty‑year outcomes of prostatectomy are going to be better,’” Sidana explained.
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“I’m relatively young and I get that there might be another spot that comes up someday, and I’m OK with that,” Brosseau said. “If it comes back on the other side, I wouldn’t hesitate to do this again.”
Opponents warn that the approach may lead to overtreatment. “The problem with focal is many of the people who do well would have done well with observation,” said Otis Brawley, professor of oncology at Johns Hopkins. He emphasized that active surveillance remains the guideline‑recommended path for low‑risk disease.
A recent JAMA analysis found that more than half of the procedures were performed on cancers outside the intermediate‑risk group, with 51% of cases being higher or lower risk than the guideline target. Low‑risk patients received the technique in only 4% of instances where surveillance would have been appropriate.
Peretsman noted that “surveillance fatigue” drives some men toward a quick fix: “I can take care of this anxiety and be out the door in 40 minutes, have sex in three days and never use a pad.” He said the balance of risk versus convenience is shifting for many.
At present, most commercial insurers continue to deny coverage, leaving patients to shoulder the cost or rely on Medicare. Ongoing registries and a handful of randomized studies in development aim to clarify whether the method will earn broader endorsement.