title: Patient selection for prostate focal therapy in the era of active surveillance: an International Delphi Consensus Project.
abstract: Whole-gland extirpation or irradiation is considered the gold standard for curative oncological treatment for localized prostate cancer, but is often associated with sexual and urinary impairment that adversely affects quality of life. This has led to increased interest in developing therapies with effective cancer control but less morbidity. We aimed to provide details of physician consensus on patient selection for prostate focal therapy (FT) in the era of contemporary prostate cancer management.
  
  
  
  We undertook a four-stage Delphi consensus project among a panel of 47 international experts in prostate FT. Data on three main domains (role of biopsy/imaging, disease and patient factors) were collected in three iterative rounds of online questionnaires and feedback. Consensus was defined as agreement in ⩾80% of physicians. Finally, an in-person meeting was attended by a core group of 16 experts to review the data and formulate the consensus statement.
  
  
  
  Consensus was obtained in 16 of 18 subdomains. Multiparametric magnetic resonance imaging (mpMRI) is a standard imaging tool for patient selection for FT. In the presence of an mpMRI-suspicious lesion, histological confirmation is necessary prior to FT. In addition, systematic biopsy remains necessary to assess mpMRI-negative areas. However, adequate criteria for systematic biopsy remains indeterminate. FT can be recommended in D'Amico low-/intermediate-risk cancer including Gleason 4+3. Gleason 3+4 cancer, where localized, discrete and of favorable size represents the ideal case for FT. Tumor foci <1.5 ml on mpMRI or <20% of the prostate are suitable for FT, or up to 3 ml or 25% if localized to one hemi-gland. Gleason 3+3 at one core 1mm is acceptable in the untreated area. Preservation of sexual function is an important goal, but lack of erectile function should not exclude a patient from FT.
  
  
  
  This consensus provides a contemporary insight into expert opinion of patient selection for FT of clinically localized prostate cancer.
authors.affiliation: Duke Cancer Institute, Duke University, Durham, NC, USA.
authors.forename: K J
authors.initials: KJ
authors.lastname: Tay
authors.affiliation: Department of Urology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: M J
authors.initials: MJ
authors.lastname: Scheltema
authors.affiliation: Division of Surgery and Interventional Science, University College of London, London, UK.
authors.forename: H U
authors.initials: HU
authors.lastname: Ahmed
authors.affiliation: L'Institut Mutualiste Montsouris, Paris-Descartes University, Paris, France.
authors.forename: E
authors.initials: E
authors.lastname: Barret
authors.affiliation: Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: J A
authors.initials: JA
authors.lastname: Coleman
authors.affiliation: Servicio de Urología, Fundación Instituto Valenciano de Oncología (IVO), Valencia, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Dominguez-Escrig
authors.affiliation: University of Toronto, Toronto, ON, Canada.
authors.forename: S
authors.initials: S
authors.lastname: Ghai
authors.affiliation: Department of Pathology, Duke University, Durham, NC, USA.
authors.forename: J
authors.initials: J
authors.lastname: Huang
authors.affiliation: Cleveland Clinic, Cleveland, OH, USA.
authors.forename: J S
authors.initials: JS
authors.lastname: Jones
authors.affiliation: Sunnybrook Medical Center, Toronto, ON, Canada.
authors.forename: L H
authors.initials: LH
authors.lastname: Klotz
authors.affiliation: Duke Cancer Institute, Duke University, Durham, NC, USA.
authors.forename: C N
authors.initials: CN
authors.lastname: Robertson
authors.affiliation: L'Institut Mutualiste Montsouris, Paris-Descartes University, Paris, France.
authors.forename: R
authors.initials: R
authors.lastname: Sanchez-Salas
authors.affiliation: Saratosa Prostate Cancer Center, Sarasota, FL, USA.
authors.forename: S
authors.initials: S
authors.lastname: Scionti
authors.affiliation: L'Institut Mutualiste Montsouris, Paris-Descartes University, Paris, France.
authors.forename: A
authors.initials: A
authors.lastname: Sivaraman
authors.affiliation: Department of Urology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: J
authors.initials: J
authors.lastname: de la Rosette
authors.affiliation: Duke Cancer Institute, Duke University, Durham, NC, USA.
authors.forename: T J
authors.initials: TJ
authors.lastname: Polascik
mesh_terms: D006801:Humans; D008297:Male; D018579:Patient Selection; D011471:Prostatic Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy*