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Conventional radical versus focal treatment for localised prostate cancer: a propensity score weighted comparison of 6-year tumour control



For localised prostate cancer, focal therapy offers an organ-sparing alternative to radical treatments (radiotherapy or prostatectomy). Currently, there is no randomised comparative effectiveness data evaluating cancer control of both strategies.


Following the eligibility criteria PSA < 20 ng/mL, Gleason score ≤ 7 and T-stage ≤ T2c, we included 830 radical (440 radiotherapy, 390 prostatectomy) and 530 focal therapy (cryotherapy, high-intensity focused ultrasound or high-dose-rate brachytherapy) patients treated between 2005 and 2018 from multicentre registries in the Netherlands and the UK. A propensity score weighted (PSW) analysis was performed to compare failure-free survival (FFS), with failure defined as salvage treatment, metastatic disease, systemic treatment (androgen deprivation therapy or chemotherapy), or progression to watchful waiting. The secondary outcome was overall survival (OS). Median (IQR) follow-up in each cohort was 55 (28–83) and 62 (42–83) months, respectively.


At baseline, radical patients had higher PSA (10.3 versus 7.9) and higher-grade disease (31% ISUP 3 versus 11%) compared to focal patients. After PSW, all covariates were balanced (SMD < 0.1). 6-year weighted FFS was higher after radical therapy (80.3%, 95% CI 73.9–87.3) than after focal therapy (72.8%, 95% CI 66.8–79.8) although not statistically significant (p = 0.1). 6-year weighted OS was significantly lower after radical therapy (93.4%, 95% CI 90.1–95.2 versus 97.5%, 95% CI 94–99.9; p = 0.02). When compared in a three-way analysis, focal and LRP patients had a higher risk of treatment failure than EBRT patients (p < 0.001), but EBRT patients had a higher risk of mortality than focal patients (p = 0.008).


Within the limitations of a cohort-based analysis in which residual confounders are likely to exist, we found no clinically relevant difference in cancer control conferred by focal therapy compared to radical therapy at 6 years.

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Fig. 1: Two-way propensity weighted failure-free survival (FFS) and overall survival (OS).
Fig. 2: Three-way propensity weighted failure-free survival (FFS) and overall survival (OS).

Data availability

De-identified participant data that underlie the results reported in this article are stored in an institutional repository and may be shared upon request to the corresponding author.


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Author information




M.J.v.S. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: M.J.v.S., M.P., D.R., T.T.S., H.U.A. and A.F. Drafting of the manuscript: M.J.v.S. Critical revision of the manuscript for important intellectual content: M.P., D.R., T.T.S., J.J.W.L., S.M., T.D., S.M., R.G.H., A.E., R.N., R.P., J.V., H.L., C.M., C.O., M.E., M.A., H.U.A., J.R.N.v.d.V.v.Z., M.W. and A.F. Statistical analysis: M.J.v.S. and M.P. Obtaining funding: not applicable. Administrative, technical, or material support: S.R., F.H.-J. Supervision: H.U.A., J.R.N.v.d.V.v.Z., M.W. and A.F.

Corresponding author

Correspondence to Marieke J. van Son.

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Conflict of interest

Dr Peters and Dr van der Voort van Zyp received a research grant from the Dutch Cancer Society. Dr Reddy received a research grant from Prostate Cancer UK and received travel grants from Imperial Health Charity and Sonacare. Dr Shah received funding from Prostate Cancer UK and the St Peters Trust and has received funding in the past for conference attendance from Astellas, Ferring and Galil Medical. Professor Moore receives funding from the National Institute for Health Research, The European Association of Urology Research Foundation, MRC, Cancer Research UK, Prostate Cancer UK, Movember and the Cancer Vaccine Institute for clinical prostate cancer research. She has received advisory board fees for Genomic Health. Professor Emberton’s research is supported by core funding from the United Kingdom’s National Institute of Health Research (NIHR) UCLH/UCL Biomedical Research Centre. He was awarded NIHR Senior Investigator in 2015. He receives funding from NIHR-i4i, MRC (UK), Cancer Research UK, Sonacare Inc., Trod Medical, Cancer Vaccine Institute and Sophiris Biocorp for trials in prostate cancer. He is a medical consultant to Sonacare Inc., Sophiris Biocorp, Steba Biotech, Exact Imaging and Profound Medical. Professor Ahmed’s research is supported by core funding from the United Kingdom’s National Institute of Health Research (NIHR) Imperial Biomedical Research Centre. He currently receives funding from the Wellcome Trust, Medical Research Council (UK), Prostate Cancer UK, Cancer Research UK, The BMA Foundation, The Urology Foundation, The Imperial Health Charity, Sonacare Inc., Trod Medical and Sophiris Biocorp for trials and studies in prostate cancer. He was a paid medical consultant for Sophiris Biocorp and is still a paid proctor for HIFU, cryotherapy and Rezum water vapour therapy. Dr Winkler received a travel grant and a loan of device from Zicom Biobot. The remaining authors declare no competing interests.

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van Son, M.J., Peters, M., Reddy, D. et al. Conventional radical versus focal treatment for localised prostate cancer: a propensity score weighted comparison of 6-year tumour control. Prostate Cancer Prostatic Dis 24, 1120–1128 (2021).

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