11.16 PSA, two negative biopsies, queued up for a third

@ma740988
Not sure you saw my post about focal therapy. Here’s the information again.

At the 11/1/2025 PCRI conference the following was said by Matthew R. Cooperberg, MD, MPH Urologic Oncologist UCSF

What about focal therapy?
* The energy modality matters much less than the accuracy of the imaging - which is not there yet.
* Overall focal therapy is associated with minor side effects, but high rates of recurrence both in- and out-of-field.
* Focal therapy is not really a replacement for surgery or radiation; it is better considered an adjunct to active surveillance

Af the UCSF prostate cancer forum on 4-17-26 Dr. Cooperberg had slides with this information

UCSF Results: first 135 HIFU patients

• 54% recurrence (41% in-field)

• 4% progression by 1 year, 16% overall

• IPSS (urinary obstruction) 6 before, 6 after

• SHIM (erection function) 16 before, 13 after (p=0.11)

• Major drivers of recurrence: GG3, high Decipher

Trade-offs

• Overall focal therapy is associated with minor side effects, but high rates of recurrence

• Inadequate energy delivery?

• Inadequate field of treatment?

• New cancer development?

• Others?

• Understanding the high recurrence rates and trying to improve them is a major area of research focus.

• Focal therapy does not burn bridges: RP, RT, even additional focal therapy are possible if necessary

Summary thoughts

•Focal ablation has a growing role for very carefully selected cases.

• Side effects rates are low but recurrence rates are high. GG3 and high Decipher are warning signs, as are high PSAD and bilateral disease.

• Focal therapy is an adjunct to active surveillance; additional treatment may well be needed down the road, but these treatments are still possible after focal.

University of California Consensus

1 Focal therapy must be acknowledged to be investigational

2. Focal therapy should be done under trial or research protocols as much as possible

3. Candidates should have at least 10 year life expectancy, GG2 or low-volume GG3, stage T1 or 2, and PSA < 10 or PSA < 20 and PSAD
< 0.15

4. Candidates need an MRI-guided confirmatory biopsy before treatment

5. Follow-up biopsy at 12 months is essential

@ma740988 Read Wheel1 post and make sure you get a good surgeon if that is your choice for treatment since both technique and skill of surgeon will determine what side effects (ED, incontinence) you will suffer. A lot of younger patients chose surgery since it allows radiation if there is a recurrence.

Tests recommended by #2 are useful regardless of treatment chosen especially Decipher which gives you probability of recurrence based on the genetics of the tumor. Get Prostox if considering radiation since that will give you odds on negative long term side effects (separate genetic tests for IMRT and SBRT).

Tulsa Pro (form of HIFU) is now FDA approved and covered by Medicare. However, not covered by most work insurance along with other focal therapies. All (HIFU, laser, DC current, Cyro) have high recurrence rates but very low side effects. Usually chosen by younger patients where preservation of lifestyle is the priority. Even if no ED expect dry orgasms after surgery/radiation.