Jul 17, 2026
YouTube 47:08
Video
Focal Therapy in Prostate Cancer Treatment w/ Dr. George R. Schade | BackTable Urology Ep. 317
Focal Therapy in Prostate Cancer Treatment w/ Dr. George R. Schade | BackTable Urology Ep. 317
Description
Overview
This episode of BackTable Urology features Dr. George Schade from the University of Washington discussing the role of focal therapy in prostate cancer treatment. Focal therapy aims to "thread the needle" between active surveillance and radical treatments by targeting only the cancerous portion of the prostate while preserving normal tissue. Dr. Schade explains the rationale, patient selection, technical approaches, and follow-up strategies for focal therapy, focusing on non-radiation energy modalities such as high-intensity focused ultrasound (HIFU), TULSA (high-intensity directional ultrasound), cryotherapy, and irreversible electroporation (IRE).
Focal Therapy Modalities and Selection
Dr. Schade compares focal therapy to a "lumpectomy" in breast cancer, contrasting it with whole-gland treatments like prostatectomy or radiation. The main energy sources discussed include:
- HIFU: Uses ultrasound waves from outside the prostate to heat and ablate tissue. It is the most widely used modality in Dr. Schade's practice.
- TULSA/HI-DU: Delivers ultrasound energy from inside the urethra outward, requiring MRI suite availability.
- Cryotherapy: Freezes prostate tissue to destroy cancer cells.
- Irreversible Electroporation (IRE): Uses electrical pulses to create pores in cell membranes, leading to cell death.
Choice of modality depends on provider preference, institutional resources, and patient-specific factors such as prostate size, tumor location, and presence of calcifications. For example, HIFU effectiveness can be limited by calcifications causing ultrasound shadowing, and anterior tumors in large glands may have higher failure rates with HIFU, making IRE a preferred option in those cases.
Evidence and Patient Counseling
While long-term randomized trials are still needed, Dr. Schade highlights recent studies supporting focal therapy. The Hi-Fi trial from France showed non-inferior cancer control for transrectal HIFU compared to prostatectomy in older men, with improved quality of life and fewer complications. The FARP trial from Oslo is expected to provide further comparative data. Early results from the TULSA captain trial also indicate favorable short-term quality of life outcomes.
In counseling patients, Dr. Schade emphasizes balancing cancer control with quality of life. He notes that focal therapy typically results in lower rates of urinary incontinence and better preservation of sexual function compared to surgery or radiation. Patients are informed about the possibility of slightly higher recurrence risk but often accept this trade-off for improved quality of life.
Implementing Focal Therapy in Practice
Dr. Schade shares his experience integrating focal therapy into his clinical practice, starting with institutional approval and equipment acquisition. He stresses the importance of identifying appropriate candidates, typically men with unilateral MRI-visible Gleason 7 tumors, and performing confirmatory biopsies to rule out significant contralateral disease. He also discusses the need for a structured patient counseling script to cover all treatment options and surveillance protocols.
Insurance and Financial Considerations
A major barrier to focal therapy is insurance coverage variability. Traditional Medicare generally covers focal therapy, but Medicare Advantage and private insurers often do not, requiring a time-consuming appeals process supported by device companies. Patients without coverage face high out-of-pocket costs, often in the mid to high $30,000 range, which can lead some to defer treatment until Medicare eligibility or choose active surveillance instead.
Preoperative and Intraoperative Considerations
Dr. Schade discusses factors influencing procedural planning, such as prostate size and median lobe presence. Large glands (e.g., >70-80 cc) may require pre-treatment with medications or bladder outlet procedures like TURP to reduce post-ablation urinary retention risk. Intraoperative workflow includes patient positioning, ultrasound imaging, MRI fusion or cognitive targeting, and contouring of the treatment region with appropriate margins. Treatment times typically range from one to two hours depending on ablation volume.
He also notes technical considerations such as avoiding nitrous oxide anesthesia during HIFU because it lowers the cavitation threshold, potentially affecting ablation quality. Deep muscle paralysis is important to prevent pelvic floor contractions that can displace electrodes during treatment.
Recovery and Surveillance
Post-ablation, patients usually have a catheter for about one week to reduce retention risk. Medications such as steroids, alpha blockers, and antispasmodics are used to manage inflammation and bladder spasms, which are the most common discomfort. Most patients pass voiding trials at one week, though a small percentage may require longer catheterization or intervention for urinary retention.
Follow-up includes PSA testing at 3 and 6 months, MRI at 11 months, and biopsy at 12 months. Surveillance protocols may vary, but confirmatory imaging and biopsy are essential to verify treatment success and detect recurrence.
Managing Recurrence and Repeat Treatments
Dr. Schade explains that focal therapy does not preclude future treatments. Approximately 10-15% of patients may require second-line therapy such as repeat ablation, surgery, or radiation. Repeat ablations can be challenging due to scarring, especially near the apex, and advanced imaging like PSMA PET scans can help localize recurrent disease. Surgery after focal therapy may be more complex but is generally feasible with careful dissection starting on the untreated side to identify correct planes.
He shares a rare case where a patient developed a new aggressive lesion after IRE ablation, illustrating that some recurrences may be unrelated to the original treated tumor. Overall, most patients remain candidates for multiple treatment options if needed.
Training and Resources for Providers
For urologists interested in adopting focal therapy, Dr. Schade recommends engaging with industry representatives, attending courses such as Focal One masterclasses, and networking with colleagues experienced in these techniques. Device companies provide technical support and training to facilitate the learning curve, which typically requires 5-10 cases to gain proficiency. He emphasizes persistence and collaboration with institutional leadership and radiology to establish focal therapy programs.
Key Considerations and Takeaways
Dr. Schade stresses that focal therapy is not suitable for every patient and must be carefully applied to avoid under-treatment or overuse. The goal is to balance effective cancer control with improved quality of life by preserving urinary and sexual function. He encourages thorough patient counseling using a structured script to cover all treatment options, risks, benefits, and surveillance requirements.
He also highlights the importance of respecting anatomical features such as the median lobe to avoid complications like urinary retention and the need for TURP. The evolving evidence base and ongoing trials may lead to guideline changes supporting focal therapy in the coming years.
Source Information
This detailed discussion is from the BackTable Urology podcast episode titled "Focal Therapy in Prostate Cancer Treatment w/ Dr. George R. Schade | BackTable Urology Ep. 317," published on YouTube. The transcript provides an in-depth exploration of focal therapy modalities, patient selection, procedural nuances, evidence base, insurance challenges, and clinical outcomes as shared by Dr. Schade, an associate professor of urology at the University of Washington. The content reflects current clinical perspectives and ongoing research without making definitive claims beyond the presented data.
