Focal therapy (FT) in high-risk or very high-risk prostate cancer (CaP) is not guideline-recommended. However, it may be occasionally used, but its effect on cancer-specific mortality (CSM) relative to standard treatment options such as radical prostatectomy (RP) is unknown and was addressed in the present study.
In the Surveillance, Epidemiology, and End Results (SEER) database (2010-2022), high-risk or very high-risk CaP patients according to the National Comprehensive Cancer Network (NCCN) guidelines, treated with either FT or RP, were identified. A multivariable logistic regression (MLR) model assessed the associations between sociodemographic characteristics and receipt of FT. Multivariable competing risks regression (CRR) models, after 1:1 propensity score matching (PSM), tested for CSM differences after adjustment for other cause mortality (OCM).
Overall, 20,192 high-risk or very high-risk CaP patients treated with FT or RP were identified. Of those, 416 (2.0%) underwent FT and 19,776 (98.0%) RP. In the MLR model, rural area of residence and unmarried status predicted a 2.4-fold (P < 0.001) and 1.8-fold (P < 0.001) higher likelihood of receiving FT, respectively. In PSM analysis, 416 FT patients could only be matched with one RP control from 19,776 RP patients. After 1:1 PSM, at 120 months of follow-up, CSM after RP was 9.2 vs. 16.0% after FT. The corresponding OCM rates were 19.5 after RP vs. 31.5% after FT. In multivariable CRR models adjusted for OCM, FT increased CSM in a 2.0-fold fashion (mHR: 1.98; 95% CI: 1.17-3.34; P = 0.011).
Despite lack of guidelines endorsement, occasional high-risk or very high-risk CaP patients may be treated with FT. Specifically, rural and unmarried patients with high-risk or very high-risk CaP are more likely to receive guideline-discordant FT. Such practice doubles the risk of CSM relative to RP, and its use should therefore be discouraged in this patient population.
Urologic oncology. 2026 Aug 05 [Epub ahead of print]
Leonardo Quarta, Michele Petix, Maximilian Filzmayer, Filippo Orlandi, Jordan A Goyal, Matteo Ferro, Felix K H Chun, Salvatore Micali, Shahrokh F Shariat, Francesco Barletta, Armando Stabile, Giorgio Gandaglia, Francesco Montorsi, Fred Saad, Alberto Briganti, Pierre I Karakiewicz
Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Division of Experimental Oncology/Unit of Urology, Urological Research Institute (URI), IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy. Electronic address: ., Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, ASST Santi Paolo e Carlo, Milan, Italy; Università degli Studi di Milano, Milan, Italy., Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany., Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, AOU di Modena, University of Modena and Reggio Emilia, Italy., Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada., Department of Urology, ASST Santi Paolo e Carlo, Milan, Italy; Università degli Studi di Milano, Milan, Italy., Department of Urology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany., Department of Urology, AOU di Modena, University of Modena and Reggio Emilia, Italy., Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX,; Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan., Division of Experimental Oncology/Unit of Urology, Urological Research Institute (URI), IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.