Focal Ablation of Prostate Cancer.

Prior to the era of prostate-specific antigen (PSA) screening, at the time of diagnosis most prostate cancers were locally advanced or metastatic. The most common treatment for prostate cancer was androgen deprivation achieved via medical or surgical castration. The rare man diagnosed with a prostate nodule confined to the gland underwent radical prostatectomy (RP) or radiation therapy (RT) with the intent of curing the disease. In fact, between 1951 and 1963, Hugh Jewitt, MD, the preeminent prostate cancer surgeon at the Johns Hopkins Hospital, performed only 53 RPs.1 Prostatectomy provided durable cancer control for most men with these “early” prostate cancers.2 The clinical challenge was to develop a screening strategy that could identify a greater proportion of men with localized prostate cancer amenable to cure. The only cases managed by active surveillance (AS) in the pre–PSA screening era were men with stage A1 prostate cancer (low-grade and low-volume disease) diagnosed at the time of transurethral resection of the prostate.3 In the 1980s, there were several advances that contributed to the widespread acceptance of PSA screening. A major disincentive for detecting early disease was the significant morbidity associated with both RP and RT. The description of the anatomic nerve-sparing radical prostatectomy4 and more precise delivery of radiation therapy5 greatly reduced the morbidity of whole-gland curative interventions. Around this time, both transrectal ultrasonography (TRUS)6 and serum PSA7,8 were being independently explored as tools for early detection of prostate cancer. Ultimately, PSA testing became the primary screening tool for identifying men at risk for harboring prostate cancer. Diagnostic confirmation ultimately relied upon TRUS-guided biopsy (SB). Due to the limitations of TRUS, biopsy approaches evolved into systematic, random sampling.9