title: The role of focal therapy in the management of localised prostate cancer: a systematic review.
abstract: BACKGROUND
  The incidence of localised prostate cancer is increasing worldwide. In light of recent evidence, current, radical, whole-gland treatments for organ-confined disease have being questioned with respect to their side effects, cancer control, and cost. Focal therapy may be an effective alternative strategy.
  
  
  OBJECTIVE
  To systematically review the existing literature on baseline characteristics of the target population; preoperative evaluation to localise disease; and perioperative, functional, and disease control outcomes following focal therapy.
  
  
  METHODS
  Medline (through PubMed), Embase, Web of Science, and Cochrane Review databases were searched from inception to 31 October 2012. In addition, registered but not yet published trials were retrieved. Studies evaluating tissue-preserving therapies in men with biopsy-proven prostate cancer in the primary or salvage setting were included.
  
  
  RESULTS
  A total of 2350 cases were treated to date across 30 studies. Most studies were retrospective with variable standards of reporting, although there was an increasing number of prospective registered trials. Focal therapy was mainly delivered to men with low and intermediate disease, although some high-risk cases were treated that had known, unilateral, significant cancer. In most of the cases, biopsy findings were correlated to specific preoperative imaging, such as multiparametric magnetic resonance imaging or Doppler ultrasound to determine eligibility. Follow-up varied between 0 and 11.1 yr. In treatment-naïve prostates, pad-free continence ranged from 95% to 100%, erectile function ranged from 54% to 100%, and absence of clinically significant cancer ranged from 83% to 100%. In focal salvage cases for radiotherapy failure, the same outcomes were achieved in 87.2-100%, 29-40%, and 92% of cases, respectively. Biochemical disease-free survival was reported using a number of definitions that were not validated in the focal-therapy setting.
  
  
  CONCLUSIONS
  Our systematic review highlights that, when focal therapy is delivered with intention to treat, the perioperative, functional, and disease control outcomes are encouraging within a short- to medium-term follow-up. Focal therapy is a strategy by which the overtreatment burden of the current prostate cancer pathway could be reduced, but robust comparative effectiveness studies are now required.
authors.affiliation: Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College Hospitals NHS Foundation Trust, London, UK; Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. Electronic address: massimo.valerio@chuv.ch.
authors.forename: Massimo
authors.initials: M
authors.lastname: Valerio
authors.affiliation: Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College Hospitals NHS Foundation Trust, London, UK.
authors.forename: Hashim U
authors.initials: HU
authors.lastname: Ahmed
authors.affiliation: Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College Hospitals NHS Foundation Trust, London, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Emberton
authors.affiliation: Department of Surgery, University of Melbourne; and Ludwig Institute for Cancer Research, Austin Hospital, Melbourne, Australia.
authors.forename: Nathan
authors.initials: N
authors.lastname: Lawrentschuk
authors.affiliation: Department of Urology, Ospedale San Raffaele Turro, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Lazzeri
authors.affiliation: Section of Pathological Anatomy, Polytechnic University of the Marche Region, School of Medicine, United Hospitals, Ancona, Italy.
authors.forename: Rodolfo
authors.initials: R
authors.lastname: Montironi
authors.affiliation: Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Centre, Harvard Medical School, Boston, MA, USA.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Nguyen
authors.affiliation: Division of Urology, Department of Surgical Oncology, University Health Network; and Department of Surgery, University of Toronto, Toronto, ON, Canada.
authors.forename: John
authors.initials: J
authors.lastname: Trachtenberg
authors.affiliation: Division of Urology, Department of Surgery, and Duke Cancer Institute, Duke University Medical Centre, Durham, NC, USA.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Polascik
mesh_terms: D000368:Aged; D017679:Cryotherapy / Q000379:methods*; D018572:Disease-Free Survival; D019317:Evidence-Based Medicine; D006801:Humans; D053685:Laser Therapy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D018579:Patient Selection; D010778:Photochemotherapy / Q000379:methods; D011379:Prognosis; D011471:Prostatic Neoplasms / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D018570:Risk Assessment; D012380:Role; D016019:Survival Analysis; D016896:Treatment Outcome; D036761:Ultrasound, High-Intensity Focused, Transrectal / Q000379:methods*
keywords: Brachytherapy; Cryotherapy; High-intensity focused ultrasound; Laser therapy; Photodynamic therapy; Prostate cancer