MRI and focal therapy may enable men on AS to safely delay surgery or radiation

A recent study published in Journal of Urology found that MRI and focal therapy may enable men with low- to favorable intermediate-risk prostate cancer to forego biopsy, extend active surveillance, and defer surgery or radiation.¹

Leonard S. Marks, MD

“This represents a major advancement in the management of prostate cancer,” said senior author Leonard S. Marks, MD, professor and deKernion endowed chair in urology at the David Geffen School of Medicine at the University of California, Los Angeles, in a news release on the findings.² “By combining MRI-guided diagnosis with selective focal therapy, we can offer men a more personalized approach. This strategy not only helps avoid unnecessary procedures, but also gives us a better way to predict who will benefit from extended surveillance, potentially improving quality of life and reducing [adverse] effects without compromising safety.”

In total, the study included 869 men with low- to favorable intermediate-risk prostate cancer who were on active surveillance. The cohort included 505 men with Grade Group (GG) 1disease, 174 men with GG2 disease, and 190 men with ‘GG0’ disease, defined as “those with prior diagnostic GG1 or 2, but negative baseline [MRI-guided biopsy],” according to the authors.

Among those who underwent serial MRI-guided biopsies (MRGB; n = 664), 7% with GG0, 19% with GG1, and 34% with GG2 progressed to GG3 or higher. The authors reported that “Men with GG2 at baseline were likely to progress to > GG3 (aHR, 3.8; 95% CI, 1.7 to 8.7).”

The median progression-free survival (PFS) time was 10.2 years (95% CI, NA) for men with GG0, 8.7 years (95% CI, 7.1 to 9.6) for men with GG1, and 5.8 years (95% CI, 3.8 to 10.9) for men with GG2. Further, PFS at 5 years following baseline MRGB was 89% in men with GG0, 68% in men with GG1, and 42% in men with GG2.

MRI demonstrated a negative predictive value of nearly 95% in those with baseline GG0, 90% of men with baseline GG1, and 70% in men with baseline GG2. This finding, the authors explained, suggests that routine follow-up biopsy may be avoided in men with baseline low-risk prostate cancer and a subsequent negative MRI.

Overall, 25% of eligible men (99 of 393) underwent focal therapy. According to the authors, prostate cancer characteristics between those who did and did not receive focal therapy were similar.

Data showed that focal therapy prolonged the duration of active surveillance.

At 5 years, the radical prostatectomy/radiation therapy (RP/RT)-free survival was 84% in those men that underwent focal therapy, compared with 46% among those who did not (P < .01). The median time to RP/RT-free survival was not reached among the men who underwent focal therapy and was 3.7 years among those who did not receive focal therapy.

“Although the numbers for the focal therapy group are small and the follow up was relatively brief, the near-term advantage of focal therapy in avoiding surgery or radiation is clear,” Marks added.² “This study offers some of the strongest evidence yet that active surveillance, when guided by modern imaging and minimally invasive treatments like focal therapy, can safely be expanded to more patients.”

Among the entire study cohort (n = 869), 21% (n = 181) underwent RP/RT over the 12-year duration of the study. Of those, 111 underwent radical prostatectomy and 70 received radiation therapy. The primary cause for receipt of RP/RT was disease progression to GG3 or higher.

Those who elected to undergo RP/RT without a progression to GG3 were marked as an “anxiety event.” The frequency of these events declined over the study period (P < .01).

According to the authors, “This change may have been related to the increasing acceptance of [active surveillance] generally, the overall safety data documented herein, the accuracy of MRGB, or to the management of lower urinary tract symptoms among patients in [active surveillance].”

Overall, they concluded, “[Active surveillance] has evolved over the past 30 years, at least partly because of 2 new technologies. The precision of [active surveillance] can be increased and its inclusiveness expanded by routine use of MRGB and, when appropriate, [focal therapy].”

REFERENCES

1. Martin SC, Gonzalez S, Kwan L, et al. Evolution of active surveillance of prostate cancer: Impact of magnetic resonance imaging, magnetic resonance imaging–guided biopsy, and focal therapy. J Urol. 2025:101097JU0000000000004559. doi:10.1097/JU.0000000000004559

2. Advanced imaging and targeted therapy help men with prostate cancer safely defer surgery and radiation therapy. News release. University of California, Los Angeles (UCLA), Health Sciences. May 8, 2025. Accessed May 13, 2025. https://www.newswise.com/articles/advanced-imaging-and-targeted-therapy-help-men-with-prostate-cancer-safely-defer-surgery-and-radiation-therapy