Abstract
Focal and differential therapy represent an approach to improve the therapeutic ratio of prostate cancer treatments. This concept is a shift from treating the whole gland to intensely treating the portion of the gland that contains significant tumor. However, there are many challenges in the move towards focal approaches. Defining which patients are suitable candidates for focal therapy approaches is an area of significant controversy, and it is likely that additional data from imaging or detailed biopsy methods is needed in addition to traditional risk factors. A number of methods have been suggested, and imaging with multiparametric MRI and transperineal template mapping biopsy have shown promise. The approach of differential therapy where the entire prostate is treated to a lower intensity and the tumor areas to high intensity is also discussed in detail. Radiation therapy is a well suited modality for the delivery of differential therapy. Data in the literature using external beam radiation, high dose rate brachytherapy, and low-dose rate brachytherapy for differential therapy are reviewed. Preliminary results are encouraging, and larger studies and randomized controlled trials are needed to validate this approach.
Highlights
Prostate cancer is the most common malignancy in men in the US, with an estimated 241,740 cases to be diagnosed in the US in 2012 [1]
There are many challenges in the move towards focal therapy including identifying appropriate candidates, methodology of identifying intraprostatic tumor, and whether the remaining prostate gland should receive some form of treatment
As newer methods of identifying intraprostatic tumor evolve, these will be incorporated into both patient selection and treatment planning for focal therapy
Summary
Prostate cancer is the most common malignancy in men in the US, with an estimated 241,740 cases to be diagnosed in the US in 2012 [1]. While many men with low-risk disease are well managed by surveillance [3], a large number of patients need or choose treatment Definitive treatments such as brachytherapy, external beam radiation therapy, or radical prostatectomy generally provide high success rates with biochemical control and disease specific survival of 80– 90% or higher for low-risk disease [4,5,6]. These procedures are associated with sexual, urinary, and rectal side effects that may impact patient quality of life and overall satisfaction of treatment outcome [7]. There are many challenges in the move towards focal therapy including identifying appropriate candidates, methodology of identifying intraprostatic tumor, and whether the remaining prostate gland should receive some form of treatment
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