Imperial College London investigators compared focal therapy with prostate removal surgery for men with prostate cancer that returned after radiotherapy. Matched analyses estimated 10-year cancer-specific survival at 92% after focal therapy and 99% after prostate removal surgery. Given sparse cancer-specific deaths and a small 10-year follow-up tail, the comparison was statistically inconclusive rather than confirming similar survival. Prostate removal surgery carried much higher odds of perioperative complications, although complication reporting came from different registries and eras.
Radiotherapy can deliver excellent long-term cancer-specific survival for prostate cancer, while disease recurrence still occurs in a quarter of patients within 10 to 15 years. Cancer-specific mortality following recurrence is 20% to 35% within 5 to 10 years.
Most men with prostate cancer recurrence after radiotherapy get androgen-deprivation therapy, a noncurative treatment with adverse effects. Hormone-resistant disease typically develops within 3 years. A substantial share of recurrences remain confined to the prostate, creating an opportunity for another localized treatment aimed at the tumor itself.
Prostate removal surgery after radiotherapy is technically challenging because radiation alters tissue structure and healing capabilities. Severe toxic effects are common, including high rates of erectile dysfunction and urinary incontinence.
Focal therapy offers a different strategy. Energy-based treatments such as high-intensity focused ultrasound or cryotherapy destroy only the region containing recurrent tumor, leaving the remaining prostate tissue untreated with the goal of reducing complications.
In the study, “Salvage Focal Therapy vs. Radical Prostatectomy for Localized Radiorecurrent Prostate Cancer,” published in JAMA Oncology, researchers conducted an international, multicenter cohort analysis with matched comparison data to compare cancer control and complications after focal therapy vs. radical prostatectomy.
A total of 923 men were eligible for matching, including 419 treated with focal therapy and 504 treated with prostate removal surgery. Researchers applied statistical matching to construct balanced treatment groups, pairing patients 1 to 1 based on radiotherapy type, time between treatments, recurrence risk group, age, prostate-specific antigen level, prostate volume, grade group, T stage, and androgen-deprivation therapy use.
Survival and complications tradeoff
Cancer-specific survival served as the primary outcome through 10 years, with overall survival and complications as secondary outcomes. Survival estimates focused on 5- and 10-year outcomes.
Cancer-specific survival at 5 years was 99% for both treatments in the matched cohort. Ten-year cancer-specific survival estimates were 92% following focal therapy and 99% following prostate removal surgery. Restricted mean time lost analysis did not identify a statistically reliable difference between treatments, although relatively few cancer-specific deaths contributed to these estimates.
Regression modeling produced a subdistribution hazard ratio of 0.45, with a 95% CI ranging from 0.05 to 4.00, indicating substantial uncertainty regarding the magnitude and direction of any survival difference.
Overall survival at 5 years was 90% following focal therapy and 83% following prostate removal surgery. Ten-year overall survival estimates were 57% following focal therapy and 72% following prostate removal surgery. Crossing survival outcomes suggest that estimated treatment effects were not stable over time, especially when including non-cancer-specific forms of death.
Perioperative complications were expectedly reported more frequently following prostate removal surgery. Any complication occurred in 5.7% of focal therapy patients and 59.9% of surgery patients. Major complications occurred in 1.4% and 12.5% of patients, respectively.
The findings position focal therapy and prostate removal surgery as competing treatment options with statistically inconclusive differences in long-term cancer outcomes and markedly different risk profiles. Treatment decisions require balancing uncertain survival differences against the known potential for treatment-related morbidity.
An Invited Commentary on the research was also released in JAMA Oncology.