Prostate cancer treatment was a popular topic at this year's American Urological Association (AUA) meeting, as physicians discussed at length about several hot issues, including the use of active surveillance (and which patients are most amenable to it), and the role of focal therapy. At every turn we made, there seemed to be another meeting hall where a lively debate was happening about one of these topics.
Since May 2012, when the USPSTF changed its previous recommendation for prostate-specific antigen (PSA)-based screening for prostate cancer in men under the age of 75 to a recommendation against PSA screening in all age groups, there has been renewed interest in the incidence and treatment trends of prostate cancer. Not only has screening decreased overall as a result, but to combat against the overtreatment of prostate cancer, there has been a rise in the use of active surveillance in the context of low and intermediate risk cancers. For example, one poster that caught my attention was presented by Dr. Stacy Loeb who, using data from the National Prostate Cancer Register in Sweden, found increasing use of active surveillance. However, active surveillance should be chosen carefully and on a case-by-case basis; defining proper patient selection was therefore a main source of debate. One takeaway for physicians to keep in mind is the patient's perspective; some patients are very uncomfortable and anxious with the idea of knowing that they have any form of cancer?even if it is very low risk?and wish to have it treated immediately. For urologists, offering treatment is probably the easier task when compared to the task of addressing patient concern and guiding them towards a more informed understanding of active surveillance's benefits, which can be challenging and time-consuming. As Dr. Matt Rosenberg warned, primary care physicians are the ones who order the most PSA tests but are also more likely to follow USPSTF guidelines as opposed to the AUA guidelines, which continue to recommend screening; as a result, urologists will need to make themselves better heard in order to promote the best option, as opposed to being led by the popular option.
The increasing use of focal therapy was another recurring topic. The passion exhibited by both advocates and doubters of focal therapy illustrated its importance at this year's AUA meeting. Setting the pace for these discussions was a structured debate at the well-publicized Crossfire: Controversies in Urology session on the first day of the conference titled, ?Focal therapy for prostate cancer: Hope or hype?.  A dedicated panel of key opinion leaders in the field of prostate cancer treatment comprising Dr. Aaron Katz and Dr. Mark Emberton took the side for the use of focal therapy, while Dr. Eric Klein and Dr. Mark Gonzalgo countered with arguments against its use.
The ability to limit the extent of treatment to certain foci of the disease and to preserve healthy portions of the prostate is certainly the primary benefit of focal therapy. This is possible with the use of high-quality MRI that allows the cancer to be clearly detected. As MRI technology continues to improve and focal therapy's efficacy without compromise in oncologic control is supported by more data, focal therapy may indeed be a hopeful option (among others) in the urologist's toolkit.
On the other hand, there are reasons to see focal therapy as overhyped or faddish. What I found to be the most concise comment against its use was a statement made by Dr. Gonzalgo: simply put, focal therapy is inappropriate because prostate cancer is a multifocal disease. If there are several foci, then focal therapy may not be appropriate because a radical approach may be just as effective and less time-consuming. He presented evidence that targeting treatment to one visible focus of cancer based on MRI may allow other undetected foci to progress; a more radical initial treatment would limit the likelihood of this from occurring. However, medical discussions should avoid romanticizing the minority or the hypothetical at the risk of denying options for the general case. And although outliers do exist, disregarding focal therapy at this point in time is counterproductive to the advancement of individualized medicine, especially as patient candidacy continues to be an area of conversation and focal therapy techniques evolve. To that end, most physicians who spoke out about focal therapy at AUA, either for or against it, agreed that treatment selection should always be case-based and considerate of the patient.
While in my opinion there was no clear winner to the debate, it was clear that the success of focal therapy is fundamentally dependent on the quality of MRI, and one conclusion that can be made at this time is that focal therapy will largely be limited to developed countries where the best MRI systems exist.

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