Con: Focal Therapy for Prostate Cancer – Another Unnecessary Tool

How to cite: Bagrodia A. Con: Focal Therapy for Prostate Cancer – Another Unnecessary Tool. Grand Rounds in Urology. November 13, 2025. Accessed Mar 2026. https://grandroundsinurology.com/con-focal-therapy-for-prostate-cancer-another-unnecessary-tool/

Summary

Aditya Bagrodia, MD, FACS, Professor of Urology, University of California, San Diego, San Diego, California, presents the “con” position in the point-counterpoint debate on focal therapy for prostate cancer, arguing that while focal therapy is appealing in concept, it currently lacks the evidence, consistency, and clarity needed to justify routine clinical use. He frames the discussion using classic principles from Willet F. Whitmore, emphasizing the enduring dilemma in prostate cancer care: determining not only whether treatment is possible, but also whether it is truly necessary.

Dr. Bagrodia begins by reviewing professional society guidelines, noting that for low-risk prostate cancer, active surveillance is the preferred strategy, and for high-risk disease, focal ablation should not be offered outside of a clinical trial. This leaves only a narrow subset of intermediate risk patients as potential candidates. He walks through detailed candidate criteria for focal therapy and demonstrates that, when applied rigorously, only a small percentage of patients qualify.

A central concern is oncologic efficacy. Dr. Bagrodia explains that there is no consensus definition of treatment success after focal therapy, with wide variability in prostate-specific antigen (PSA) based metrics, biopsy protocols, and imaging strategies. He highlights systematic review data showing retreatment rates of up to 67% with short-term follow-up, raising concerns about durability and patient counseling. He also emphasizes uncertainty surrounding outcomes after focal therapy failure, including both oncologic and functional consequences.

Dr. Bagrodia reviews functional and safety outcomes, challenging the notion that focal therapy is benign. He cites reported rates of erectile dysfunction, urinary symptoms, infection, retention, and need for secondary procedures that are not trivial. He further discusses the multifocal nature of prostate cancer, variability in magnetic resonance imaging (MRI) quality and interpretation, limitations in detecting adverse histologic features, and the steep learning curve associated with multiple focal therapy modalities.

He concludes that most patients considered for focal therapy are better served with active surveillance, that definitions of success and failure remain inadequate, and that widespread adoption risks reversing progress made in reducing overtreatment. While acknowledging ongoing trials, he argues that focal therapy should remain investigational until high-quality comparative data are available.

About the 32nd Annual Perspectives in Urology: Point Counterpoint conference: Presented by Program Chair and Grand Rounds in Urology Editor-in-Chief E. David Crawford, MD, this conference brought together leading experts in urology, medical oncology, and radiation oncology to discuss and debate the latest topics in genitourinary cancers, primarily prostate cancer and bladder cancer. This interactive conference offered topical lectures, pro/con debates, interesting-case presentations, interactive panel discussions, and interactive audience and faculty networking.