Focal Therapy (FT) is an emerging treatment modality for prostate cancer (PCa). Due to its novelty, the research exploring how patients should be followed-up after treatment is limited. There is currently no established role for non-prostate-specific-antigen (PSA) biomarkers and PSMA PET. However, a combination of PSA testing, multiparametric magnetic resonance imaging (mpMRI), and systematic and targeted biopsies should routinely be used for surveillance after FT. PSA values that rise 1.0 ng/mL over the nadir after twelve months or rise 1.5 ng/mL over nadir after twenty-four to thirty-six months should raise suspicion for recurrence. The standard imaging technique is mpMRI, but it can often be difficult to interpret after FT, so using a scoring system such as prostate imaging after focal ablation (PI-FAB) or the transatlantic recommendations for prostate gland evaluation with magnetic resonance imaging after focal therapy (TARGET) allows for greater consistency between readers. This review seeks to summarize the current literature regarding surveillance after FT as it relates to biomarkers, imaging, biopsies, and consensus statements.

Review Article A narrative clinical trials review in the realm of focal therapy for localized prostate cancer Alon Lazarovich, Vijay Viswanath, Aaron S. Dahmen, Abhinav Sidana

Introduction: Focal therapy (FT) is emerging as an alternative to radical treatment for prostate cancer (CaP). The purpose of this study is to assess the current perceptions of FT amongst urologists. Methods: A 22-item questionnaire was e-mailed to members of the American Urological Association. Multivariate logistic regression analysis was used to identify predictors of FT utilization. Results were compared to a previous survey from 2019. Results: Two hundred and sixty-four responses were recorded. Less than half (115/264, 43.6%) of respondents utilize FT; among them, 42% perform FT on more than 10 patients/year. Reasons for avoiding FT included: lack of experience (51.8%), belief that CaP is multifocal (46.0%), and lack of infrastructure (43.1%). The most common modalities for FT were high-intensity focused ultrasound (63.4%) and cryoablation (47.3%). Preferred patients for FT were primarily unilateral/anterior only Gleason Grade Group 2 (95/110, 86.4%). A fellowship training in urologic oncology (odds ratio [OR] = 2.86, P = 0.008) and seeing more than 10 CaP patients per month (OR = 2.46, P = 0.002) were associated with greater utilization of FT. Most respondents (85.4%) cited better imaging methods as a factor that has increased FT utilization. Compared to a previous survey, a higher number of respondents (43% vs. 24%) utilize FT and more respondents believe in the “index lesion theory.” Conclusions: Less than half of the respondents utilize FT in their practice. Fellowship training in urologic oncology and a higher volume of CaP patients were correlated with FT utilization. As urologists gain more experience, the trend of further utilization of FT for CaP may continue.

As the adoption of focal therapy (FT) for prostate cancer (PCa) grows, the demand for accurate post-treatment imaging to monitor outcomes and detect residual or recurrent cancer increases. Traditional diagnostic systems like the Prostate Imaging Reporting and Data System (PI-RADS) are ill-suited for post-FT evaluations due to treatment-induced tissue changes. MRI-based scoring systems specific for evaluation after FT have been developed to address these challenges and improve post-FT imaging accuracy by distinguishing benign alterations from recurrence. The currently developed scoring systems are Transatlantic Recommendations for Prostate Gland Evaluation with MRI after Focal Therapy (TARGET) and Prostate Imaging after Focal Ablation (PI-FAB). In this review, we describe and compare these two systems. These scoring systems standardize imaging assessments, enhance follow-up care, and support clinical decision-making. While promising, TARGET and PI-FAB require further large-scale validation to confirm their utility. Nevertheless, they represent critical advances in optimizing PCa management, particularly for patients undergoing FT, by improving diagnostic accuracy and guiding treatment decisions.