Despite two decades of technological progress in prostate-cancer treatment, many Canadian men are still not informed about less invasive, tissue-sparing options that could preserve urinary and sexual function while effectively treating localized disease.
Prostate cancer is the most common cancer among Canadian men. One in eight will be diagnosed in their lifetime; for many, the barrier to early detection isn’t lack of access to screening – it’s fear of what the diagnosis will mean for their lives afterward. Incontinence, erectile dysfunction and long recoveries are widely perceived as unavoidable outcomes of treatment. These fears are not abstract; they are based on the experiences of men who underwent the dominant interventions offered in Canada: surgery or radiation.
Yet, for a significant portion of patients, those are not the only options.
Since 2006, when Health Canada approved High-Intensity Focused Ultrasound (HIFU) for prostate cancer – nearly a decade before the U.S. – a category of approaches known collectively as focal therapies has existed. These treatments target only the cancerous region of the prostate rather than the entire gland. The goal is simple but transformative: destroy the tumour while preserving nearby structures that control urinary and sexual function.
Focal therapy is not one single procedure. It includes energy-based approaches such as High Intensity Focused Ultrasound (HIFU) and, more recently, Irreversible Electroporation (IRE) – also known as NanoKnife – which uses electrical pulses to ablate tumours with millimetre-level precision. IRE has been used internationally for several cancers and was recently recognized by TIME as one of the year’s Best Inventions for its tissue-sparing potential.
These developments have expanded the treatment landscape. For appropriately selected patients – those with small or moderate-sized MRI-visible tumours confined to the prostate – studies now show that focal therapy can achieve oncologic control comparable to traditional treatment while significantly reducing the complications that men fear most.
The issue is not scientific legitimacy.
The issue is awareness – or lack of it.
Across much of Canada, men are never told that focal therapy exists. Family physicians may be unfamiliar with it. Referral pathways tend to guide patients toward centres that provide only surgery or radiation. And because the technology is available in only a limited number of locations, even some specialists lack experience with it.
As a result, men are often presented with a narrowed set of options that do not reflect the full spectrum of evidence-based choices.
This information gap has consequences beyond individual decision-making. It affects whether men seek screening at all. If the main narrative is that prostate cancer inevitably leads to incontinence or loss of sexual function, some will delay PSA testing or avoid it entirely. For a disease in which early detection is critical, this represents a preventable barrier to care.
The public’s understanding is shaped not only by physicians but by media and culture. A recent example illustrates the point. In the Sex and the City reboot And Just Like That, the character Harry Goldenblatt is diagnosed with prostate cancer and offered only surgery or radiation. The storyline was emotionally resonant, but medically limited. It reflected a version of care from decades past – not the evolving reality of today.
“Shows like that shape what people think medicine can do,” says Jack Barkin, a Toronto urologist with more than 40 years of experience. “If even a fictional upper-middle class family in Manhattan isn’t told about focal therapy, how would the average Canadian man know to ask?”
Barkin was the first surgeon in North America to perform HIFU for localized prostate cancer nearly 20 years ago. From his perspective, the problem is not whether focal therapy works – the evidence continues to build – but that most men never hear about it during the decision-making process.
“This isn’t for everyone,” he says. “But for the right patient, it changes the equation from ‘survival versus function’ to ‘both.’ Men deserve to hear that option.”
What Canada lacks is not scientific consensus but system-level integration:
- No national guidelines that formally incorporate focal therapy into the shared decision-making framework.
- Uneven provincial access, with some regions having no providers at all.
- Inconsistent clinician familiarity, especially at the primary-care level.
- Limited public-health messaging, leaving patients reliant on outdated assumptions or online research.
Bridging this gap does not require replacing existing treatments but expanding the conversation. Surgery and radiation will continue to be essential options with strong evidence behind them. But they should not be presented as the only viable paths for every man with localized disease.
A modern approach would include:
- Clear referral pathways to specialists experienced in focal therapy.
- Standardized criteria for patient selection.
- Updated educational resources for physicians and patients.
- National guidelines reflecting current evidence and technological capabilities.
- Public-health messaging that acknowledges patients’ fears around quality of life and addresses them with facts, not omissions
For many men, prostate cancer is not just a question of survival. It is a question of how they will live afterward – their continence, their sexual function, their confidence, their relationships. When the system fails to offer a full picture of the options available, it limits not only their choices but their long-term well-being.
