Prostate cancer is a common diagnosis and men in the San Francisco Bay Area often seek multiple opinions to find the best treatment option for them. There are many innovative and less invasive treatment options available to men diagnosed with prostate cancer today than were available even five or ten years ago.. Among the emerging modalities, focal therapy, including High-Intensity Focused Ultrasound (HIFU) and Focal Prostate Brachytherapy, presents promising alternatives. While not yet considered the standard of care, these treatments can offer significant benefits for carefully selected patients. At Western Radiation Oncology/El Camino Hospital, Dr. Ankit Agarwal and Dr. Jonathan C. Hu are at the forefront of providing these advanced treatments, helping patients achieve optimal outcomes with minimal side effects.

The Rationale for Focal Therapy in Prostate Cancer

Focal therapy targets only the cancerous part of the prostate, sparing the surrounding healthy tissue. This approach aims to minimize the side effects associated with traditional treatments like radical prostatectomy or external beam radiation therapy, which can affect the entire prostate and nearby structures. The goal is to provide effective cancer control while preserving quality of life, including urinary and sexual function.

Benefits of Focal Therapy:

  • Reduced Side Effects: By focusing treatment just to the specific parts of the prostate where prostate cancer has been diagnosed, there’s less risk of damage to nerves and tissues involved in urinary and sexual function.
  • Shorter Recovery Time: Focal therapy is generally less invasive, leading to quicker recovery and fewer complications.
  • Personalized Treatment: Each patient’s treatment is tailored based on the size, location, and aggressiveness of the cancer.

However, it’s essential to note that focal therapy is not yet the standard of care and is best suited for specific patient profiles. Patients should discuss with their healthcare providers to understand if this approach is appropriate for their condition.

High-Intensity Focused Ultrasound (HIFU) for Prostate Cancer

High-Intensity Focused Ultrasound (HIFU) is a relatively non-invasive treatment that uses focused ultrasound waves to heat and destroy cancerous tissue in the prostate. Recently, results from a prospective trial (NCT04307056) were presented at the 2024 AUA Annual Meeting.

Clinical Trial Insights:

  • Patients Included: The study included over 3,000 men treated for prostate cancer between April 2015 and March 2022.
  • Outcomes: The trial reported a salvage treatment free survival rate (STFS) at 30 months of 89.6% in the HIFU-treated arm versus 86.2% in patients who underwent radical prostatectomy (RP)
  • Urinary Outcomes: Urinary incontinence rates were lower among patients who received HIFU. 
  • Sexual Outcomes: International Index of Erectile Function-5 (IIEF-5), a well validated measurement of erectile function, decreased significantly less after HIFU than after RP in patients 69 and older with a score of 15 or higher at baseline (median Δ = -8 vs -13 p < 0.001)

While we are still awaiting the final publication of these data, these initial presented results are quite promising. However, other studies, include a single-arm phase 2 trial published the World Journal of Urology has shown high progression rates of up to 40% for patients treated with HIFU. 

Focal Prostate Brachytherapy: A Targeted Approach

Focal Prostate Brachytherapy involves the placement of radioactive seeds directly into the cancerous area of the prostate. This localized treatment delivers high doses of radiation precisely where it is needed, minimizing exposure to healthy tissue. A recently published systematic review and meta-analysis looked at the published data for focal prostate brachytherapy.

Clinical Trial Insights:

  • Selection Criteria: Ten studies were identified and included a total of 315 patients. Of the total number of patients, 46.5% had Gleason score of 6 (Grade Group 1) and 53.5% had Gleason score of 7 (Grade Group 2) or higher
  • Outcomes: The overall control rate for prostate cancer was 91% at a median follow-up of 4 years post-treatment. This high success rate underscores the effectiveness of focal brachytherapy in managing localized prostate cancer.
  • Acute Side Effects: Acute side effects were minimal with acute Grade ≤ 2 GU and GI toxicities were reported in 22 (7%) and 11 (3.5%) patients, respectively. Essentially, most patients had fairly minimal short term changes in their urinary and gastrointestinal quality of life.
  • Long Term Side Effects: Late Grade ≤ 2 GU and GI toxicity were reported in 6 (2%) and 14 (4.4%) patients, respectively. The overall long term quality of life of patients was quite good.
  • Gastrointestinal (GI) Outcomes: GI side effects were almost nonexistent, with less than 1% of patients reporting any significant bowel symptoms. This is a significant advantage, as it allows patients to maintain a high quality of life without dealing with the common bowel complications associated with other forms of radiation therapy.
  • Sexual Outcomes: While difficult to ascertain the rates of erectile dysfunction as a result of brachytherapy in non-randomized single arm studies, the absolute rates of erectile dysfunction over time appeared to be similar to similar aged people who did not receive brachytherapy. Other studies of whole-gland prostate brachytherapy have shown erectile dysfunction rates of 10-15%, which are lower than just about any other modality of treatment for prostate cancer. For a more extensive discussion of the impact of prostate brachytherapy on sexual outcomes, see this article here.

Studies have shown that focal brachytherapy can effectively control cancer with a low incidence of significant side effects, making it a viable option for patients who prioritize quality of life. 


The Challenge of Treating Multi-Focal Prostate Cancer with Focal Therapy

While focal therapy offers many benefits, one of the significant challenges it faces is the nature of prostate cancer itself. Prostate cancer is often a multi-focal disease, meaning that multiple areas of the prostate may be affected by cancerous growths. This presents a critical limitation for focal therapy.

Limitation of Focal Therapy:

  • Prevalence of Multi-Focal Disease: Studies have shown that up to 80% of men with prostate cancer have multiple cancerous lesions within the prostate. This complicates the ability to target and treat all areas effectively with focal therapy alone.
  • Incomplete Treatment: Focal therapy targets only the visible or most significant tumor areas. However, it may miss smaller, undetectable lesions that can progress over time.
  • Potential for Recurrence: Because focal therapy does not treat the entire prostate, there’s a higher risk of cancer recurrence in untreated areas. Patients may require additional treatments if new cancerous areas are identified later.

Some advocate for focal therapy to be done only in the context of prospective clinical trials given these limitations. Regardless, patients should be well informed of the limitations of focal therapy before choosing any type of focal therapy.


Meet Our Experts: Dr. Ankit Agarwal and Dr. Jonathan C. Hu

At Western Radiation Oncology/El Camino Hospital, we pride ourselves on offering cutting-edge treatments for prostate cancer. Dr. Ankit Agarwal, a leading radiation oncologist, and Dr. Jonathan C. Hu, a renowned urologist, are dedicated to providing personalized care tailored to each patient’s unique needs. Our team is committed to exploring the latest advances in focal therapy to offer our patients the best possible outcomes.

Dr. Agarwal and Dr. Hu are highly experienced in the administration of HIFU and focal brachytherapy, making them the ideal team for patients seeking advanced prostate cancer treatment options in the San Francisco Bay Area.

Schedule a Consultation

If you or a loved one are considering focal therapy for prostate cancer, we invite you to schedule a consultation with Dr. Ankit Agarwal and Dr. Jonathan C. Hu. Our team is here to guide you through your treatment options and help you make an informed decision. Visit us at Silicon Valley Oncology to learn more and book your appointment.


Focal therapy represents a promising advance in the treatment of localized prostate cancer, offering patients in the San Francisco Bay Area new options for effective and less invasive care. At Western Radiation Oncology, Dr. Ankit Agarwal and Dr. Jonathan C. Hu are leading the way in providing these innovative treatments, ensuring that our patients receive the highest standard of care.


  1. HIFU Study on Prostate Cancer
  2. HIFU Effectiveness
  3. Focal Prostate Brachytherapy