Incidence of ideal candidates for focal therapy: A scoping study following the FALCON Consensus Statements

Abstract

Introduction: Ideal candidates for focal therapy (FT) for prostate cancer (PCa) have mpMRI-visible ISUP Grade Group 2-3, localized disease. Transperineal (TP) prostate biopsies provide superior positional information of PCa in the transverse axis, and possibly higher PCa detection rates-important in choosing FT modalities. Here, we describe the frequency of optimal FT candidates among a large cohort of men with proven PCa identified from MRI-guided targeted and systematic TP biopsy.

Methods: We queried the Northwestern data warehouse for men with newly diagnosed PCa who had a positive mpMRI (PI-RADS 3-5) and a TP biopsy prior to diagnosis from January 2018 to June 2024. Patients with disease optimal for FT were determined using modified FALCON consensus guidelines with emphasis on mpMRI and biopsy findings. We also explored the disparity in FT candidacy when using only target cores compared to combined target and systematic cores.

Results: We identified 1342 men diagnosed with PCa on combined targeted and systematic TP biopsy after a positive mpMRI, of which 888 men had intermediate-risk PCa. Of these 888 men, 439 patients (49.4%) had unilateral-dominant disease, while 329 patients (37%) had unilateral-dominant and anterior (106; 11.9%) or posterior-dominant (223; 25.1%) disease. Up to half of the patients considered good candidates on target cores were considered FT-ineligible on review of systematic cores.

Conclusions: FT may be considered in up to 50% of patients with intermediate risk disease, while ideal candidates for functional preservation constitute a smaller number. Review of both targeted and systematic biopsy cores is crucial in determining FT candidacy.

Keywords: Focal Therapy; MRI; Prostate Cancer; Transperineal Biopsy.