A growing number of prostate cancer patients in the UK cannot access focal therapy on the NHS, raising concerns about long‑term quality of life and treatment equity
Topics covered
Prostate cancer debate shifts from survival to daily function
The discussion around prostate cancer care in the United Kingdom has moved beyond survival to include preservation of daily function and well‑being. At the centre of this debate is focal therapy, a minimally invasive approach that targets cancerous areas within the prostate while sparing healthy tissue.
Proponents present it as an intermediary between active surveillance and radical treatments such as prostatectomy or radiotherapy, aiming to control disease while reducing risks to urinary and sexual function.
Clinical advocates say many eligible men are not being offered this option through the NHS.
Treatment access appears uneven across regions and centres, according to specialists and patient groups.
In my Deutsche Bank experience, demands for less disruptive treatments often follow wider shifts in patient expectations and health‑care spending. The numbers speak clearly: interventions that preserve quality of life can reduce long‑term costs linked to rehabilitative care and lost productivity.
From a regulatory standpoint, adoption of focal therapy raises questions about standards for patient selection, long‑term outcome monitoring and commissioning decisions within the NHS. Anyone in the industry knows that robust evidence and clear pathways influence uptake across public systems.
Anyone in the industry knows that robust evidence and clear pathways influence uptake across public systems. Focal therapy sits at that intersection: promising clinical benefits but constrained by limited data, infrastructure and commissioning pathways.
What focal therapy is and why it matters
Focal therapy describes techniques that target only the tumour‑bearing portion of the prostate. Examples include high‑intensity focused ultrasound (HIFU), cryotherapy and focal laser ablation. The clinical aim is oncological control with less collateral damage to the neurovascular bundles, sphincter and bladder neck.
Compared with radical treatments, multiple case series and observational cohorts report lower rates of urinary incontinence and erectile dysfunction. Those outcomes underpin the description of focal approaches as quality‑of‑life preserving. The numbers speak clearly: many centres report meaningful reductions in functional morbidity while maintaining short‑term cancer control metrics.
Evidence, uncertainty and what clinicians tell patients
Randomised, long‑term evidence remains limited. Most published work comprises cohort studies and registry analyses. From a regulatory standpoint, that generates caution among guideline bodies and commissioners.
In my Deutsche Bank experience, clinical adoption follows a banker’s rule: evidence, infrastructure and predictable reimbursement. Who pays and how outcomes are measured determine scale. Anyone in the industry knows that without standardised endpoints and centralised data, due diligence is incomplete and spread across providers widens.
When clinicians discuss focal options, patients should expect detailed counselling on trade‑offs. Typical conversations include oncological uncertainty, need for intensive follow‑up, repeat treatments and potential functional gains. Shared decision‑making requires clear metrics for cancer control and validated patient‑reported outcome measures.
Real‑world barriers to broader access
Barriers are practical and systemic. Training and equipment costs limit service capacity. Commissioning bodies require robust cost‑effectiveness data. From a regulatory standpoint, compliance, audit and outcome reporting are prerequisites for wider roll‑out.
Liquidity of clinical expertise is uneven: only a minority of centres have multidisciplinary teams experienced in focal interventions. That creates geographic inequities in access and referral patterns.
Implications for patients and health services
For eligible patients, focal therapy may reduce the functional burden of treatment. Clinicians should present it as one option within a spectrum that ranges from active surveillance to radical therapy. The decision must rest on tumour characteristics, patient values and local pathway capacity.
The next steps are clear: larger comparative studies, harmonised outcome definitions and transparent commissioning criteria. Those developments would provide the evidence and infrastructure required to translate promise into practice.
Those developments would provide the evidence and infrastructure required to translate promise into practice. Evidence supporting focal therapy focuses on men with localized prostate cancer, where disease is confined to a discrete region of the gland rather than widespread bilateral involvement. Selection hinges on modern imaging and targeted biopsies, and treatment is frequently combined with active surveillance for untreated areas to balance disease control and functional outcomes.
Evidence and clinical outcomes
The clinical record for focal therapy comprises cohort studies, single-arm trials and early randomized comparisons rather than large phase III trials. Anyone in the industry knows that such data provide signals but not definitive proof of long-term oncological equivalence to whole-gland treatments.
Early reports show meaningful reductions in urinary and sexual morbidity compared with radical prostatectomy or whole-gland radiotherapy. The numbers speak clearly: studies consistently report lower rates of erectile dysfunction and urinary incontinence after focal treatment, with cancer control outcomes that appear encouraging at intermediate follow-up.
Patient selection remains the decisive variable. Accurate magnetic resonance imaging and targeted sampling reduce the risk of under-treating significant disease. In my Deutsche Bank experience, this resembles underwriting: rigorous due diligence at the start limits downstream surprises.
From a regulatory standpoint, authorities expect robust protocols for imaging, biopsy mapping, treatment delivery and follow-up. Compliance and standardized reporting are necessary for trust in outcomes and for scaling adoption across health systems.
Ongoing trials and registry efforts aim to address evidence gaps on long-term oncological outcomes and comparative effectiveness. Those results will determine whether focal therapy moves from an innovative option to a standard pathway for selected patients.
Randomised evidence for focal therapy remains limited compared with established treatments, though growing observational series and small trials report promising short‑ to mid‑term cancer control and favourable side‑effect profiles. Several centres have published data showing meaningful preservation of continence and potency while maintaining acceptable biochemical control in carefully selected patients. Specialist guidelines increasingly endorse focal therapy as an option within multidisciplinary care pathways, particularly where preservation of urinary and sexual function is a priority.
In my Deutsche Bank experience, translating a promising innovation into routine care requires the same disciplined due diligence we applied to complex asset classes. Anyone in the industry knows that early signals must be tested by robust comparative trials, clear selection criteria and consistent outcome metrics. The numbers speak clearly: without larger randomised studies and harmonised endpoints, regulators and commissioners will be cautious about broad adoption.
From a regulatory standpoint, focal therapy raises familiar issues of spread, liquidity of evidence and compliance with established standards of care. Clinicians and centres offering the treatment must demonstrate procedural reproducibility, reliable imaging and systematic follow‑up to satisfy payers and oversight bodies. Those requirements will shape whether focal therapy moves from an innovative option to a standard pathway for selected patients.
Key technical and diagnostic requirements
The numbers speak clearly: precise diagnostics determine whether focal therapy achieves cancer control while preserving function.
In my Deutsche Bank experience, robust systems separate successful innovation from costly experiments. Effective focal therapy requires a coordinated diagnostic pathway: multiparametric MRI, targeted transperineal biopsy and multidisciplinary case discussion including urology, radiology and pathology. These steps identify suitable candidates and reduce the risk of untreated significant disease. Without this infrastructure, clinical safety and treatment effectiveness are compromised.
Limitations of current data
Long‑term, head‑to‑head trials comparing focal therapy with radical prostatectomy or contemporary radiotherapy remain limited. Many clinicians therefore call for prospective, randomised studies that measure outcomes over decades rather than years. Anyone in the industry knows that short‑term registries and observational series cannot fully capture late recurrences, functional decline or the need for further treatment.
That uncertainty drives cautious adoption. Some specialists still offer focal therapy selectively, prioritising patients who place high value on urinary and sexual function while accepting stronger surveillance. The evidence gap affects informed consent, shared decision making and the design of follow‑up protocols.
Barriers to NHS access and practical implications
From a regulatory standpoint, NHS adoption faces multiple hurdles. Capacity constraints for high‑quality MRI and transperineal biopsy limit referral pathways. Variation in local expertise creates uneven access across trusts. Commissioning decisions hinge on cost‑effectiveness data and long‑term outcomes, not short‑term functional gains.
Anyone in the industry knows that implementing a new pathway requires investment in training, equipment and quality assurance. The spread between early adopter centres and general services reflects differences in liquidity of expertise and institutional due diligence. Without agreed standards for diagnostics, reporting and follow‑up, commissioners risk variable results and potential harms.
Practical implications include longer diagnostic timelines for patients and inconsistent eligibility assessments. From a compliance perspective, multidisciplinary case reviews are essential to ensure appropriate selection and documentation. Health systems must also plan for registry participation and data sharing to close the evidence gap.
The numbers speak clearly: expanding access will demand coordinated investment in imaging, biopsy services and multidisciplinary teams, alongside prospective data collection to inform commissioning and guideline updates.
Building on the need for sustained investment in imaging, biopsy services and multidisciplinary teams, patients face practical and policy barriers to accessing focal therapy.
What patients should ask their care team
In my Deutsche Bank experience, clarity on funding and pathways matters as much as clinical evidence. Ask whether focal therapy is routinely commissioned in the local health area and which criteria guide funding decisions.
Request details on diagnostic capabilities. Confirm availability of advanced imaging, targeted biopsy pathways and operators with documented experience in focal procedures.
Probe the data on outcomes. Ask for centre‑level metrics on cancer control, continence and sexual function, and the volume of cases managed each year. The numbers speak clearly: higher volumes usually correlate with more reliable outcomes.
Clarify follow‑up protocols and data collection. Ask whether the centre contributes to registries or prospective studies that can inform long‑term effectiveness and safety.
Discuss alternatives and trade‑offs. Seek a comparison of risks, benefits and quality‑of‑life implications between focal therapy, radical treatment and active surveillance.
From a regulatory standpoint, ask how local guidelines and commissioning policies influence treatment recommendations. Anyone in the industry knows that compliance and reimbursement shape clinical options.
Confirm practical matters: expected waiting times, out‑of‑pocket costs, and whether second opinions or transfers to specialist centres are supported.
Ask about multidisciplinary review. Ensure your case has been discussed in a prostate cancer multidisciplinary team that includes urology, radiology, oncology and pathology.
Finally, enquire about contingency plans. Ask what happens if focal therapy does not achieve the intended oncological control and which escalation pathways are in place.
Patients should discuss full treatment options and escalation pathways
Men diagnosed with localized prostate cancer should discuss the full spectrum of treatment options with their clinicians. Clinicians must place focal therapy within the wider pathway, including surveillance, radical treatment and salvage options. Ask what happens if focal therapy does not achieve the intended oncological control and which escalation pathways are in place.
Practical questions patients should raise
Useful questions include:
Am I a candidate for focal therapy? Clarify tumor size, location and risk category that determine eligibility.
What diagnostic tests are needed to confirm suitability? Request details on imaging, targeted biopsy and multidisciplinary review.
What outcomes can I expect for urinary and sexual function? Ask for real-world data from the treating centre, including complication and retreatment rates.
Are there local centres that offer this treatment, and will the NHS fund it? Confirm local availability and the centre’s commissioning or funding status.
When to seek further opinion and what to expect
Seeking a second opinion at a tertiary referral centre may be appropriate if local services are limited or outcomes data are scarce. Anyone in the industry knows that centralised expertise improves diagnostic precision and treatment selection. In my Deutsche Bank experience, concentration of complex care reduces variability in outcomes and supports robust data collection.
Regulatory and system implications
From a regulatory standpoint, clinicians and commissioners should align on evidence thresholds for funding. The numbers speak clearly: centres with structured audit and transparent outcome reporting provide the strongest justification for routine commissioning. Consider due diligence on provider experience, case volumes and surgeon or radiologist credentialing.
Patients should leave consultations with a clear plan for monitoring, defined criteria for escalation and contact points for rapid review. Health systems must clarify funding pathways and expand referral networks so patients can access appropriate care without undue delay.
Access and decision-making
Health systems must clarify funding pathways and expand referral networks so patients can access appropriate care without undue delay. In my Deutsche Bank experience, markets respond when governance and liquidity align; health services follow the same logic. Anyone in the industry knows that inconsistent commissioning and limited infrastructure create practical barriers to equitable care.
Focal therapy offers a tissue‑sparing option for selected men with localized prostate cancer. The evidence base remains incomplete, and that gap drives variability in local commissioning and clinical uptake. The numbers speak clearly: uneven evidence leads commissioners to prioritise established pathways over newer, specialist options.
Coordinated policy decisions, targeted investment in diagnostic pathways, and ongoing research are necessary to strengthen the evidence base and scale services. From a regulatory standpoint, clearer guidance and standardised outcome reporting would reduce regional variation and support robust due diligence.
Patients and clinicians should continue shared decision‑making, weighing risks and benefits and considering referral where appropriate. Expect incremental advances in trial recruitment and clearer commissioning frameworks as research accumulates and commissioning bodies respond to emerging data.
