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  • br Conclusions Only a quarter


    Conclusions: Only a quarter of our respondents utilize FT in their practice with surgeon’s experience being the important independent predictor for using FT. Majority of respondents though consider FT to be beneficial in CaP management, would use it more often if provided more reliable and cost-effective options. Over time, experience and accessibility to reliable methods to perform FT may lead to further utili-zation of this novel treatment strategy. 2018 Elsevier Inc. All rights reserved.
    Keywords: Prostate cancer; Focal therapy; Multiparametric MRI; Survey
    Funding: This research was supported by the Intramural Research Pro-gram of the National Institutes of Health (NIH), National Cancer Institute, Center for Cancer Research, and the Center for Interventional Oncology. NIH and Philips Healthcare have a cooperative research and development agreement. NIH and Philips share intellectual property in the field.
    E-mail addresses: [email protected], [email protected] (A.L. Jain). 1Equal contribution.
    1. Introduction
    The widespread use of prostate-specific antigen screen-ing has led to an earlier and increased diagnosis of low-risk prostate cancer (CaP) [1,2]. While urologists have increas-ingly been using active surveillance for very low-risk and low-risk disease, whole gland treatment (WGT) by means of radical prostatectomy and radiation therapy is still
    widely used for high volume low-risk and low volume intermediate-risk CaP. However, the risk of CaP mortality in these populations is low [3,4]. These patients may ulti-mately receive WGT because of several reasons, including, but not limited to, concerns of the patient and physician, young patient age, and strong family history [3,5]. The radi-cal treatment strategy in such patients has the potential of overtreatment and can lead to treatment related morbidity such as urinary and erectile issues.
    Focal therapy (FT) for localized CaP is a treatment strat-egy which aims to destroy only the cancerous areas in pros-tate while preserving rest of the prostate with the aim of maintaining genitourinary function. It has been shown to have encouraging short-term oncological outcomes, excel-lent preservation of functional outcomes and is increasing in popularity in urologic Ruxolitinib (INCB018424) [6−8].
    FT is based on the principle of targeting the “index lesion.” The “index lesion” is defined as the most signifi-cant focus of tumor in the gland with the highest Gleason score and has been shown to be responsible for the cancer progression, and hence, treating this particular lesion may have the potential of accomplishing oncological outcomes similar to WGT [9,10]. FT in the oncological world has shown promising results in other various solid malignan-cies, but its use is limited in CaP due to inadequate results. In the kidney, there has been a transition from radical nephrectomy to nephron preserving surgery. Foreseeing a similar shift in CaP, FT is meticulously evaluated.
    In our previous survey regarding multiparametric mag-netic resonance imaging (MRI) and magnetic resonance (MR)-targeted biopsy, 27% of respondents utilized MR-tar-geted biopsy for localizing disease in FT candidates [11]. As there is debate surrounding the use of FT in CaP, we hope to evaluate the current status of FT in the urologic community further. To our knowledge, no previous study has gauged the utilization of FT in physicians’ practice for CaP. In this study, we aim to evaluate the current beliefs, practice patterns, and viewpoints among urologists regard-ing utilization of FT for localized CaP.
    2. Materials and methods
    2.1. Survey instrument
    A 20-item questionnaire was designed to collect demo-graphic information and data on urologists’ beliefs, practice patterns, and experience with using FT for localized CaP. The questionnaire was designed in a branching fashion such that respondents were taken to different follow-up questions based on how they responded to the previous question. Also, some questions allowed respondents to “select all that apply” in response to the question. Informa-tion was obtained on the respondents’ age, practice type, geographical location, years in practice, fellowship training in urologic oncology, urological societies, number of CaP patients seen in a month, and use of FT for CaP in clinical 
    practice. Respondents were also asked if they believed in index lesion theory as the basis for FT. Index lesion theory was defined “in the multifocal CaP, only the index lesion, Ruxolitinib (INCB018424) the largest tumor focus with the highest grade, determines the prognosis.”
    A link to the survey was sent through e-mail to the members of Endourological Society (ES) and the American Urological Association (AUA). Approximately 3,000 members of AUA and 2,800 members of ES received requests for the study. As both the societies have heterogeneous member population (practicing physicians, research scientist, etc.), an unknown number of recipients qualified for the study, and therefore the response rate could not be accurately calculated. The responses were automatically and anonymously collected in a spreadsheet. The study was determined to be exempt from review by institutional review board by the Office of Human Subjects Research Protection at the National Institutes of Health.