How to cite: Faiena I. Surveillance strategies after focal therapy. Grand Rounds in Urology. November 2025. Accessed January 2026. https://grandroundsinurology.com/surveillance-strategies-after-focal-therapy/
Summary
Izak Faiena, MD, MSCR, Assistant Professor of Clinical Urology, Columbia University Irving Medical Center, New York, New York, discusses the ongoing challenge of defining optimal surveillance strategies following focal therapy for prostate cancer. Although focal therapy is increasingly used, reported by about 40 percent of urologists, post-treatment monitoring lacks uniform guidelines.
He explains that most clinicians rely on prostate-specific antigen (PSA), magnetic resonance imaging (MRI), and biopsy as the core components of follow-up. A commonly used schedule includes PSA testing every three months, MRI every six months, and biopsy at six or twelve months. Yet no consensus exists on PSA recurrence thresholds because prostate volume and ablation extent vary.
MRI remains the standard imaging tool, but post-treatment interpretation can be challenging. Traditional prostate imaging reporting and data system (PI-RADS) scoring does not apply to ablated tissue. Two new systems, prostate imaging after focal ablation (PI-FAB) and transatlantic recommendations for prostate gland evaluation with MRI after focal therapy (TARGET), seek to standardize post-treatment MRI reading. Comparative studies suggest TARGET offers slightly greater specificity, whereas PI-FAB shows higher sensitivity.
Given the limitations of imaging and biomarkers, biopsy remains critical, typically performed at six and twelve months. Debate continues over targeted versus systematic biopsy and whether to perform per-protocol or for-cause sampling. Out-of-field recurrence rates of 8 to 20 percent support the continued use of systematic biopsy in many cases.
Dr. Faiena notes that no validated biomarkers yet exist for focal therapy surveillance. Genomic classifiers such as Decipher show promise, as higher scores before treatment may predict recurrence. His group is also investigating growth-rate (G-rate) modeling to evaluate tumor dynamics and potential recurrence risk.
Dr. Faiena argues that PSA, MRI, and biopsy remain the pillars of surveillance, but optimal thresholds and integration of new imaging and biomarkers require further study. Future directions include refining biopsy indications, developing predictive models, and incorporating PSMA and biomarker data into personalized follow-up.
ABOUT THE AUTHOR
Izak Faiena MD, MSCR, is an Assistant Professor of Clinical Urology and a Urologic Oncologist at Columbia University Irving Medical Center in New York, NY. Dr. Faiena specializes in prostate cancer diagnosis and treatment as well as in other urologic cancers. His expertise spans advanced diagnostic techniques, such as MRI fusion and transperineal biopsy, as well as cutting-edge treatments including focal therapy and robotic surgery.
