Salvage Focal Therapy Matches Surgery for Prostate Cancer Recurrence With Fewer Complications

For men with localized recurrence following prostate cancer radiotherapy, salvage treatment with either focal therapy or surgery may offer comparable long-term cancer control, but focal therapy comes with far fewer complications, according to an international cohort study published in JAMA Oncology. The study is the first to report survival data beyond 5 years with salvage focal therapy for radiorecurrent prostate cancer.

Researchers analyzed data from various centers in the UK and other countries, spanning the years 2000 to 2024. They included 923 patients with biopsy-confirmed, localized recurrent prostate cancer following radiotherapy with either external beam radiotherapy, brachytherapy, or both. Of the 419 patients undergoing salvage focal therapy, 78% received high-intensity focused ultrasound, and the rest got cryotherapy. Among 504 surgery patients, three quarters underwent open surgery, while the remainder had robot-assisted surgery.

The researchers created a matched cohort using variables such as tumor stage, grade group, prostate volume, and number of years between primary and salvage treatments. After matching, there were 277 patients in each treatment group.

Ten-year cancer-specific survival was 92% (95% CI, 86%-98%) for patients receiving focal therapy and 99% (95% CI, 97%-100%) for those undergoing radical prostatectomy. The restricted mean time lost was -0.09 years (95% CI, -0.22 to 0.03; P = 0.15). Five-year cancer-specific survival was 99% in both groups.

In the unmatched cohort, 69 patients died following focal therapy and 67 died following surgery. Ten-year overall survival was 57% (95% CI, 44%-70%) in the focal therapy group and 72% (95% CI, 61%-83%) in the surgery group, with no significant difference in restricted mean survival time (-0.13 years; 95% CI, -0.86 to 0.60; P = 0.72). In the matched cohort, the Kaplan-Meier curves for overall survival crossed at around 7 years after salvage treatment, with surgery associated with significantly worse survival up to 5 years but significantly better survival beyond 5 years.

The groups diverged substantially when it came to treatment complications. In the unmatched cohort, 24 patients (5.7%) experienced complications with focal therapy, compared with 302 (59.9%) undergoing surgery. For major complications, the percentages were 1.4% for focal therapy and 12.5% for surgery. In the matched cohort, patients who underwent salvage prostatectomy had greater odds of experiencing any complication (odds ratio [OR], 24.20; P < 0.001) or major complications (OR, 9.31; P < 0.001). The most common complications included vesicourethral anastomotic leak or stricture, rectal injury or fistula, hemorrhage, and urinary infection.

Between 10,000 and 15,000 men in the UK receive radiotherapy for prostate cancer every year. Around a quarter of them will have their cancer recur within ten years - up to 4,500 men every year. One of the treatments offered to these men includes surgical removal of the prostate (salvage radical prostatectomy) which comes with many side effects, such as long recovery, major complications, lifelong urinary incontinence and sexual dysfunction. Studies suggest that salvage radical prostatectomy can offer durable cancer control, but substantial side effects are common — including erectile dysfunction in up to 85% of patients and urinary incontinence requiring daily pad use in roughly 60%.

Currently, most men with radiorecurrent prostate cancer receive androgen-deprivation therapy, but the treatment has bothersome side effects and is not curative. Many opt to not have full surgery because of the side effects they might experience, so the outlook for these men is poor, with many not surviving beyond five years.

Salvage focal therapy, which targets just the cancerous area of the prostate using either heat (high intensity focused ultrasound HIFU) or cold (cryotherapy), has emerged as an alternative. Patients have a short procedure in hospital and can go home the same day. They are up walking, eating and in minimal discomfort and are generally able to get on with most of their normal activities.

Focal therapy is already available on the NHS and privately, with centres such as Charing Cross Hospital in London already offering the treatment alongside other centres in the capital and around the country (Southampton, Basingstoke, Brighton, Newcastle, Northampton, Bath, Kings Lynn). Patients can speak with their prostate doctor or GP for a referral to their nearest centre to get treatment.