Focal vs Prostatectomy

Your dad is much younger than I was (aged 74) when diagnosed, also with Gleason 3+4, and his PSA level at 4 is very low so certainly no rush to make decisions.

Gleason 3+4 is regarded as favourable intermediate PCa. I would ask what his MRI scan showed, ie PI-RADS or Likert score was? How many cores in the biopsy were taken and how many contained cancer? A Gleason score of 3+4 means that the majority of the cancer seen is pattern 3 which is very slow-growing, if at all.

The question is, how much pattern 4 is contained? If this is less than 5% then, as in my own case, this is generally regarded as 3+3 so active surveillance could come into the mix, although I appreciate at your dad's age and life expectancy he would prefer treatment. However, and sorry if this sounds pessimistic or alarmist, those who have undergone treatment need to be monitored for many years afterwards because of the risk of recurrance so the worry never really goes away anyway.

The usual NHS treatments are RT (with unpleasant HT for months), brachatherapy or radical prostacetomy, all of which have pretty ugly long-term side effects.

You mentioned focal therapy (HIFU, cryotherapy or in some situations nano-knife) and he is indeed fortunate to get an NHS rereferral as it's mostly only available privately for patients with insurance or self-paying many thousands. I certainly wouldn't rule it out as the side-effects are much less severe than the other options and it's usually done as a day case.

I checked this out thoroughly for myself and found I was eligible and it would be my treatment of choice if my own cancer changed after over four years on active surveillance. It's true that HIFU is relatively new, although statistics over 20 years or so have proved it's success. The only proviso is that it sometimes, in a minority of cases, it needs to be repeated which isn't generally a problem.

Hope that's helpful and with all good wishes, Julian

Lucy,
The risk of biochemical failure after Prostatectomy is about 25% to 40%. This varies depending on the grade, position and extent of an individual's case, the skill of the surgeon and to a lesser extent whether there are other factors, such as the surgeon causing some cancer cells to break away during removal of the Prostate leading to seeding. So Prostatectomy is not necessarily an end to treatment.

You make no reference to radiotherapy, this being the usual alternative offered, so there must be some reason for this, I would think.

I had HIFU, in my case as a salvage treatment for failed Radiotherapy, although it can be given as a primary treatment. It took two sessions to put me into remission, which I still am. A couple or so hours after my second HIFU, I was driven 200+ miles home. It's a very easy procedure with milder side effects than Prostatectomy, so lower risk of incontinence or Erectile Dysfunction. (The latter in my case had suffered due to the Radiotherapy). Where the HIFU probe cannot reach to focus on the tumour, Cryotherapy is the usual alternative, although Nanoknife, Irreversible Electroporation, is a more recent treatment that can be used more widely in the Prostate. The objective with Focal Treatment, is to treat only significant tumour(s) preferably, but not essentially, on one side of the Prostate so the Prostate retains as much function as possible. Where Focal is not successful, Radiotherapy or Prostatectomy can be done after it.

Dad has been diagnosed at any early stage so he can take his time in considering his options. He may find it helpful to take a look at 'The Tool Kit' https://shop.prostatecanceruk.org/our-publications/all-publications/tool-kit?limit=100&_ga=2.206109653.795867346.1564408880-1013787081.1564408880

Whichever, treatment is given - they all have their pros and cons - the man will be monitored for years to come by way of PSA and MRI at increasingly longer intervals.

Edited by member 28 Aug 2026 at 01:05  | Reason: to highlight link

Thanks Julian for taking the time to reply! You’re right, the news was shocking but as you say, it’s early and he’s lucky to have these options in front of him. I think we’re so used to taking advice from medical professionals that it’s hard when the choice is suddenly with you. 

The PI-RADs was a 4 and I believe there were 6/17 cores that came back as problematic, all within the left side I think.

You raise a good point about the worry never fully going away. Thank you for your thoughts on the focal therapy. 

I  wish you all the best with your active surveillance. 

Lucy