Focal Therapy

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Focal Therapy

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What is focal therapy?

Focal therapies are also called local therapies because their goal is to target and destroy specific areas of your prostate that have cancer. Areas in your prostate that don’t have cancer are not treated.

The aim of focal therapies is to stop your cancer from progressing, while also:

  • Being minimally invasive
  • Preserving your surrounding healthy prostate tissue
  • Reducing your risk of side effects

Some focal therapies are established while others are emerging and experimental. There are ongoing clinical trials exploring how effective focal therapies are, their side effects and their benefits compared to current treatments, but more evidence is needed before they can be routinely used as mainstream therapies.

The aim of this section of your toolkit is to describe and explain some of the focal therapies being used or studied in prostate cancer. Talk to your specialist doctor or contact a PCFA nurse if you want to know more about these therapies and whether they are available or appropriate for you.

Who can have focal therapy?

Focal therapy may be offered when you have localised cancer and there is one small area of low to intermediate grade cancer. You may also be offered focal therapy after radiation to the prostate, surgery to remove your prostate or if initial focal therapy has not successfully treated the cancer. Other criteria for being eligible for focal therapy (these may vary according to the different type of focal therapy) include:

  • Be expected to live for longer than 5 years
  • Have a Gleason score (the grade of your cancer) between 6 and 8
  • Your cancer has a 3mm margin (border)

It’s important to be aware that you may have other small undetected areas of cancer in your prostate which would be missed by focal therapy.

Can you access focal therapies in Australia?

Only some focal therapies are available in Australia. You may be able to access these at specific private institutions, but they may not be covered by private health funds and are not reimbursed by Medicare.

You can also participate in clinical trials and receive this treatment for free if there are any trials available and you meet the strict criteria. Ask your doctor about the options available to you or reach out to a PCFA nurse on 1800 22 00 99.

What are the different types of focal therapy?

Focal therapy involves various techniques that use different types of energy to kill prostate cancer cells. The following are some of these techniques. Not all of these are available in Australia.

Irreversible electroporation (IRE)

Irreversible electroporation (IRE) is currently used for other cancers, such as renal (kidney), pancreatic and liver cancer. It’s minimally invasive and uses a system called Nanoknife® to deliver short and focused low-energy electrical currents to the cancer.

In this procedure, your cancer is separated by needles, using ultrasound for guidance. The electrical current damages and kills the cancer cells in your prostate that are between the needles but preserves the surrounding healthy tissue.

An Australian study was one of the first to trial IRE and found it was safe and had minimal side effects. But long-term research is needed before it can be recommended for widespread clinical use. IRE (Nanoknife®) is available in Australia.

Irreversible electroporation (IRE)

High intensity focused ultrasound (HIFU) delivers energy soundwaves to your cancer. An ultrasound probe is gently placed in your rectum, which provides a visual image of your prostate. The energy from the HIFU heats up the area and kills the cancer cells by causing bubbles to form inside them.

HIFU is challenging when there are many large cancers, and you may need to have further treatments. HIFU can be delivered to a small area, half or to the whole of your prostate gland. It’s been mainly used in research to treat the whole prostate gland, not just the cancerous area. HIFU is available in Australia.

3.5a HIFU

During HIFU, a transrectal probe emits ultrasound waves that heats and kills the cancerous tissue

Laser ablation

Ablation means to remove or destroy a body part or tissues. In laser ablation for prostate cancer, a laser probe is inserted into your prostate through your perineum. This probe is guided by a transrectal ultrasound (TRUS) or an MRI (magnetic resonance imaging scan). Cells in your cancer are killed by the heat from the laser. Early research results are promising, but effectiveness of laser ablation for improving long term outcomes is still being researched in clinical trials. Laser ablation therapy is available in Australia.

3.5b – laser ablation

In laser ablation, a laser probe is placed into the prostate that generates heat and destroys the tissue close by

Cryotherapy

Cryotherapy has been around for some time. It’s better understood than most other focal therapies and has been researched in several clinical trials. It’s a minimally invasive therapy.

During prostate cryotherapy, a freezing probe device (cryoprobe) is inserted into your prostate through your perineum with the guidance of a transrectal ultrasound (TRUS) or an MRI (magnetic resonance imaging scan). The cancer is snap-frozen and then thawed, which kills the cancer cells.

Clinical trials show cryotherapy has good short-term outcomes, but longer studies are needed to determine how well the treatment stops the cancer growing and what long term side effects there may be.

3.5c – cryotherapy

During cryotherapy, probes are instered into the prostate through your perineum, with the guidance of a transrectal ultrasound probe

The cancerous area is frozen and thawed, which kills the cells nearby

Cryotherapy may be offered if you are unable to have conventional treatments, such as radiation therapy or surgery, or if your prostate cancer has come back after external beam radiation therapy (EBRT). Prostate cryotherapy is available in Australia through private practice. It is not covered by Medicare. Ask your doctor if this therapy is suitable for you and what the costs will be.

Photodynamic therapy

Photodynamic therapy involves a light-activated drug. This drug is injected into a vein in your arm. Then a laser probe, with the guide of ultrasound, is inserted into your prostate through your perineum. The laser probe shines a light that activates the drug in the prostate area and kills the cells nearby.

More long-term research is needed before we know how effective this therapy is for treating prostate cancer. Photodynamic therapy for prostate cancer is available through a clinical trial in Australia.

3.5d – photodynamic therapy

In photodynamic therapy, a light-activated drug is injected into your vein and a light source is shone on your prostate – this light activates the drug and destroys the tissues nearby

A transrectal ultrasound probe provides guidance for the procedure

Focal brachytherapy

Brachytherapy is a common and effective conventional treatment for prostate cancer. It’s a special form of internal radiation therapy where a radioactive source is placed in your prostate gland to deliver radiation to small areas over time. However, this treatment can also damage surrounding tissues and organs leading to side effects. Follow the link to brachytherapy to learn more.

Focal brachytherapy uses the same technique, but the radioactive source (radioactive seeds) is placed directly into your cancer instead of the whole prostate gland. This preserves the rest of the healthy prostate and reduces the risk of side effects.

Another form of focal brachytherapy, called hemigland brachytherapy, is where the radioactive source is inserted into half of your prostate. This reduces the radiation dose to the nearby organs, reducing the risk of side effects, but still provides the appropriate dose.

There are ongoing clinical trials into focal brachytherapy. Focal brachytherapy requires a highly experienced healthcare team consisting of a urologist, radiation oncologist, radiologist and pathologist. Focal brachytherapy is available in Australia.

Radiofrequency ablation

Radiofrequency ablation is a new treatment being developed. Needles are inserted through your perineum to target the prostate cancer. Radio waves heat up your prostate cells to kill the cancer. Most studies of radiofrequency ablation have been done on animals, so it’s uncertain how effective this treatment is in humans.

Are there side effects or other issues to consider with focal therapy?

All treatments for prostate cancer have side effects, but many of the focal therapies have reduced side effects compared to conventional therapies. Follow the link to side effects to find out more details.

Further doctor consultations, scans, tests and biopsies may also be required to monitor your prostate cancer, as a PSA blood test alone may not be an effective strategy to monitor your progress. If you do require further treatment and follow up, you may incur further costs. There may also be limited options in finding a doctor who is experienced in managing cancers that have complications or have reoccurred after focal therapies. If you have any questions about focal therapies reach out to a PCFA nurse on 1800 22 00 99.

Key points

  • Focal therapies are emerging and experimental treatments for prostate cancer
  • More research and evidence is needed before these therapies can become conventional treatments
  • Focal therapy aims to treat the cancer within your prostate, not the whole prostate, to protect healthy tissue and minimise side effects
  • Only some focal therapies are available in Australia – those that are available may require upfront payments, as they may not be covered by private health insurance or Medicare
  • Further doctor consultations, scans, test and biopies may be required to monitor you prostate cancer as a PSA blood test may not be an effective strategy to monitor your progress This may result in further costs some of which may be not be covered by medicare reimbursement.
  • You may be able to access some focal therapies by enrolling in clinical trials, if they are available
  • You will need to meet particular criteria to be eligible for focal therapy
  • This toolkit discusses 7 types of focal therapy. Five of these treatments are available in Australia.
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