Shifting tides: A survey analysis of urologists’ evolving attitudes toward focal therapy for prostate cancer

ABSTRACT

Introduction:

Focal therapy (FT) is emerging as an alternative to radical treatment for prostate cancer (CaP). The purpose of this study is to assess the current perceptions of FT amongst urologists.

Methods:

A 22-item questionnaire was e-mailed to members of the American Urological Association. Multivariate logistic regression analysis was used to identify predictors of FT utilization. Results were compared to a previous survey from 2019.

Results:

Two hundred and sixty-four responses were recorded. Less than half (115/264, 43.6%) of respondents utilize FT; among them, 42% perform FT on more than 10 patients/year. Reasons for avoiding FT included: lack of experience (51.8%), belief that CaP is multifocal (46.0%), and lack of infrastructure (43.1%). The most common modalities for FT were high-intensity focused ultrasound (63.4%) and cryoablation (47.3%). Preferred patients for FT were primarily unilateral/anterior only Gleason Grade Group 2 (95/110, 86.4%). A fellowship training in urologic oncology (odds ratio [OR] = 2.86, P = 0.008) and seeing more than 10 CaP patients per month (OR = 2.46, P = 0.002) were associated with greater utilization of FT. Most respondents (85.4%) cited better imaging methods as a factor that has increased FT utilization. Compared to a previous survey, a higher number of respondents (43% vs. 24%) utilize FT and more respondents believe in the “index lesion theory.”

Conclusions:

Less than half of the respondents utilize FT in their practice. Fellowship training in urologic oncology and a higher volume of CaP patients were correlated with FT utilization. As urologists gain more experience, the trend of further utilization of FT for CaP may continue.

INTRODUCTION

Radical treatments (surgery or radiation) are considered the gold standard for localized prostate cancer (CaP).[1] However, radical treatments significantly impact patients’ quality of life (QoL) and genitourinary function and have been shown to be accompanied by a significant degree of treatment choice regret.[2] The increasing use of diagnostic tools to localize and stratify CaP patients, such as multiparametric magnetic resonance imaging (mpMRI), has led to the opportunity and desire for innovative focal treatments.[3] In the past decade, focal therapy (FT) has emerged as a viable treatment option for selected men with biopsy-proven clinically significant CaP confined to a section of the prostate and is associated with decreased morbidity compared to radical treatments.[4] FT considers the spatial distribution of CaP within the prostate and treats the region of interest, thus minimizing the impact on QoL.[5] Cryoablation, high-intensity focused ultrasound (HIFU), laser ablation, and irreversible electroporation (IRE) are the more commonly used energy modalities utilized in FT.[6,7]

A previous survey in 2019 addressing urologists’ views and utilization of FT found that 50.8% of respondents believed FT to be moderately to extremely beneficial in the management of CaP.[8] The same survey indicated that only 24.2% of the respondents utilized FT in their clinical practice.[8] Research continues to emerge, indicating that FT carries a low risk of side effects and moderate efficacy in preventing CaP recurrence.[9,10] Considering the continuing adoption of FT, this study aims to provide an updated assessment of the views and practices of urologists regarding the use of FT in managing CaP.

METHODS

Survey instrument

The survey instrument used in the previous study was adapted to a 22-item questionnaire with four questions added and the elimination of one question. The instrument was designed to collect demographic information and data on urologists’ perception and utilization of FT for localized CaP. Information obtained included age, sex, practice type, geographical location, years in practice, fellowship training in urologic oncology, 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 the index lesion theory as the basis for FT. The questionnaire was designed in a branching fashion so that respondents answered different follow-up questions based on how they answered the question regarding the utilization of FT. Furthermore, some questions allowed respondents to “select all that apply” in response to a question. The survery instrument and changes made to the previous survey instrument can be found in supplementary files and Supplementary Table 1, respectively.

Supplementary Table 1.

Questions added/removed from a survey in 2019 and rationale

Question	Reason
Added – Gender	We wanted to better understand the demographics of respondents
Added – If a patient’s CaP can be treated with FT, which age demographic(s) would you recommend FT for?	Patient selection is an important aspect of FT that needed to be captured in this survey
Removed – What complications are commonly encountered?	While complications are important, clinical trials likely would capture a more objective evaluation of side effects
Added – Do you believe that FT will be a standard-of-care option for CaP treatment in future?	We wanted to assess the opinions of urologists regarding what they believe to be the future of FT
Added – In your opinion, which factor(s) led to increased utilization of FT in the last 5 years? (check all that apply)	This question may help us evaluate why FT has increased in popularity.

CaP=Prostate cancer, FT=Focal therapy

Study design

A link to the survey was e-mailed to 22,415 members of the American Urological Association (AUA) in November of 2023. As the AUA has a heterogeneous member population (practicing physicians, research scientists, etc.), an unknown number of recipients qualified for the study, and therefore the response rate could not be accurately calculated. The responses were anonymously collected.

Statistics

All statistical analyses were performed using SAS software (V9.4, SAS Institute Inc., Cary, NC). Univariate and multivariate logistic regression models were utilized to assess predictors of FT use. Respondents’ age, practice type, years in practice, fellowship training in urologic oncology, number of newly diagnosed CaP patients per month, and whether the practice is based in the US were used in the regression analysis. Odds ratio (OR) and 95% confidence intervals were reported. The Chi-square test of independence was used to compare the results of three questions to the previous survey.[8] The compared questions addressed the benefits of FT, belief in index lesion theory, and utilization of FT. All tests of significance were two sided, and P < 0.05 was deemed statistically significant.

RESULTS

Respondent characteristics

A total of 264 responses were collected. The mean age of respondents was 52.9 years. Most of the respondents practice in the United States (181/257, 70.4%) and 55.3% have practiced for more than 15 years (141/255). 36.5% of respondents (93/255) were fellowship trained in urologic oncology and 38.1% (98/257) practiced in academic centers [Table 1].

Table 1.

Responses to survey questions

Variable	Mean (SD) or n (%)
Age (n=264), mean (SD)	52.94 (14.4)
Gender (n=262)
Female	21 (8.0)
Male	240 (91.6)
Other	1 (0.4)
Society (check all that apply) (n=256)
AUA	237 (92.6)
The Endourological Society	46 (18.0)
SUO	43 (16.8)
EAU	62 (24.2)
FTS	33 (12.9)
Other	43 (16.8)
Practice type (n=257)
Academic	98 (38.1)
Hybrid	50 (19.5)
Nonacademic	109 (42.4)
Practice based in the United States (n=257)
No	76 (29.6)
Yes	181 (70.4)
Years in practice (n=255)
0–5	41 (16.1)
6–10	44 (17.2)
11–15	29 (11.4)
>15	141 (55.3)
Fellowship trained in urologic oncology (n=255)
No	162 (63.5)
Yes	93 (36.5)
Number of patents seen monthly with newly diagnosed CaP (n=258)
1–10	133 (51.5)
10–20	80 (31.0)
20–30	27 (10.5)
>30	18 (7.0)
Questions only for those who use FT
What set of CaP patients are preferred (check all that apply)? (n=110)
Unilateral/anterior only Grade Group 1	53 (48.2)
Bilateral Grade Group 1 (as long as the urethra and one neurovascular bundle are preserved)	24 (21.8)
Unilateral/anterior only Grade Group 2	95 (86.4)
Bilateral Grade Group 2 (as long as the urethra and one neurovascular bundle are preserved)	27 (24.6)
Unilateral/anterior only Grade Group 3	52 (47.3)
Bilateral Grade Group 3 (as long as the urethra and one neurovascular bundle are preserved)	11 (10.0)
Unilateral/anterior only Grade Group 4 or 5	12 (10.9)
How are CaP FT candidates identified? (check all that apply) (n=111)
Ultrasound-guided systematic biopsy only (transperineal or transrectal)	13 (11.7)
mpMRI and systematic biopsy only (transperineal or transrectal)	17 (15.3)
mpMRI and targeted biopsy only (transperineal or transrectal)	13 (11.7)
mpMRI and a combination of targeted and systematic biopsy (transperineal or transrectal)	89 (80.2)
Template mapping biopsies with or without MRI	7 (6.3)
If a patient’s CaP can be treated with FT, which age demographic (s) would you recommend FT for? (check all that apply) (n=112)
40–49	53 (47.3)
50–59	79 (70.5)
60–69	97 (86.6)
70–80	94 (83.9)
>80	58 (51.8)
What modality? (check all that apply) (n=112)
Cryoablation	53 (47.3)
Laser ablation	9 (8.0)
HIFU	71 (63.4)
IRE	32 (28.6)
Photodynamic therapy	3 (2.7)
WVA	13 (11.6)
Radiofrequency ablation	2 (1.8)
Focal brachytherapy	13 (11.6)
Transurethral ultrasound ablation	4 (3.6)
Microwave ablation	1 (0.9)
On average how often do you perform FT for CaP? (n=113)
1–5 patients per year	36 (31.9)
6–10 patients per year	29 (25.7)
11–15 patients per year	16 (14.2)
>15 patients per year	32 (28.3)
How do you follow your patient’s status post-FT? (check all that apply) (n=111)
PSA kinetics only	28 (25.2)
PSA plus mpMRI followed by targeted biopsy only if there is a suspicious lesion	75 (67.6)
PSA plus protocol biopsy at set intervals with or without prior mpMRI	44 (39.6)
Do you attempt repeat FT for biopsy-proven recurrent CaP post FT? (n=111)
No	43 (38.7)
Yes	68 (61.3)
Which of the following should be part of the follow-up after FT for CaP? (check all that apply) (n=111)
Biopsies	83 (74.8)
PSA	108 (97.3)
Imaging	106 (95.5)
IPSS	79 (71.2)
SHIM	77 (69.4)
QoL questionnaire	60 (54.1)
Assessment of incontinence by the number of pads	45 (40.5)
Would you use FT more often if it could be performed effectively in an office or outpatient setting? (n=110)
No	53 (48.2)
Yes	57 (51.8)
Do you believe that navigation tools and treatment planning tools can improve FT outcomes? (n=111)
No	4 (3.6)
Yes	87 (78.4)
Maybe	20 (18.0)
Questions only for those who do not use FT
Reasons for not using FT (check all that apply) (n=137)
Lack of evidence	52 (38.0)
Believe CaP is multifocal	63 (46.0)
Index lesion theory is not established	40 (29.2)
Lack of infrastructure	59 (43.1)
Cost is prohibitive	40 (29.2)
Lack of experience	71 (51.8)
Higher risk of CaP recurrence	51 (37.2)
Salvage treatment is challenging in case of recurrence	30 (21.9)
How likely are you to consider FT in future in your own practice (assuming you have access to all the resources)? (n=146)
Very likely	23 (15.8)
Likely	33 (22.6)
Neither likely nor unlikely	32 (21.9)
Unlikely	35 (24.0)
Very unlikely	23 (15.8)

FT=Focal therapy, AUA=American Urological Association, SUO=Society of Urologic Oncology, EAU=European Association of Urology, FTS=FT Society, MRI=Magnetic resonance imaging, mpMRI=Multiparametric MRI, HIFU=High-Intensity focal ultrasound, PSA=Prostate-specific antigen, IPSS=International Prostate Symptom Score, SHIM=Sexual Health Inventory of Men, QoL=Quality of life, CaP=Prostate cancer, IRE=Irreversible electroporation, WVA=Water vapor therapy, SD=Standard deviation

Survey responses

In response to whether or not they used FT in their practice, 43.6% (115/264) of respondents answered yes. 68% (175/257) of respondents answered that FT is moderately, very, or extremely beneficial. Almost 60% (152/256) of respondents held belief in index lesion theory. Better imaging methods for localization of CaP was selected by 85.4% (217/254) of respondents as a factor that has increased the use of FT in the last 5 years. Most respondents (215/259, 83%) believe that FT will be a standard-of-care option in future. Responses to survey questions are summarized in Figure 1.

Figure 1.

Responses to survey questions given to all respondents

Preferred candidates for FT were unilateral/anterior only Grade Group 2 for 86.4% of (95/110) respondents. The vast majority (89/111, 80.2%) of FT patients are selected through mpMRI and a combination of targeted and systematic biopsy. The three most common modalities utilized for FT were HIFU (71/112, 63.4%), cryoablation (53/112, 47.3%), and IRE (32/112, 28.6%). Most (68/111, 61.3%) of FT users attempt to repeat FT for a biopsy-proven CaP recurrence after FT. About half (57/110, 51.8%) of respondents using FT would utilize it more frequently if it could be performed in an office or outpatient setting [Table 1]. Of the respondents that do not utilize FT, lack of experience (71/137, 51.8%) was the most cited reason for FT avoidance [Figure 2].

Figure 2.

Responses from those who do not use focal therapy

Prediction of focal therapy utilization

Fellowship training in urologic oncology (OR = 2.86, 95% CI: 1.57–5.22, P = 0.001) and seeing more than ten newly diagnosed CaP patients per month (OR = 2.46, 95% CI: 1.40–4.31, P = 0.002) were independently associated with FT use. A practice based in the United States was associated with an increase in FT use on multivariate analysis (OR = 2.44, 95% CI: 1.27–4.67, P = 0.008) [Table 2].

Table 2.

Univariate and multiple logistic regression analysis for utilization of focal therapy

Variable	Univariate		Multiple
	OR (95% CI)	P	OR (95% CI)	P
Age	1.00 (0.98–1.02)	0.876	1.01 (0.98–1.04)	0.692
Practice type
Nonacademic (reference)	-	-	-	-
Academic	0.97 (0.56–1.68)	0.517	0.67 (0.35–1.28)	0.080
Hybrid	1.32 (0.67–2.58)	0.352	1.30 (0.61–2.75)	0.187
Fellowship trained in urologic oncology (yes)	2.50 (1.48–4.22)	0.0006	2.86 (1.57–5.22)	0.001
US-based practice (yes)	1.43 (0.83–2.48)	0.198	2.44 (1.27–4.67)	0.008
Years in practice
0–15 (reference)	-	-	-	-
>15	1.04 (0.64–1.71)	0.871	1.10 (0.45–2.71)	0.830
Number of newly diagnosed CaP patients seen per month
1–10 (reference)	-	-	-	-
>10	2.51 (1.51–4.16)	0.0004	2.46 (1.40–4.31)	0.002

OR=Odds ratio, 95% CI=95% confidence interval, CaP=Prostate cancer

Comparison to the previous survey

A higher number of respondents in the current survey believe in the “index lesion theory” and more respondents answered that FT is very and extremely beneficial [Table 3]. Moreover, urologists are steadily increasing their adoption of FT; 43.6% (115/264) of respondents in this survey are using FT compared to only 24.2% (103/425) from the previous survey (P < 0.0001) [Table 3].[8]

Table 3.

Responses compared to the previous survey

Question	Current survey, n (%)	Previous survey8, n (%)	P
How beneficial is FT for CaP?	n=257	n=421
No benefit at all	16 (6.2)	63 (15.0)	0.0001
Slightly beneficial	66 (25.7)	144 (34.2)
Moderately beneficial	82 (31.9)	130 (30.9)
Very beneficial	69 (26.9)	68 (16.1)
Extremely beneficial	24 (9.3)	16 (3.8)
Belief in “index lesion theory”	n=256	n=424
No	104 (40.6)	232 (54.7)	0.0004
Yes	152 (59.4)	192 (45.3)
Use FT for CaP?	n=264	n=425
No	149 (56.4)	322 (75.8)	<0.0001
Yes	115 (43.6)	103 (24.2)

CaP=Prostate cancer, FT=Focal therapy

DISCUSSION

As the technology for localizing CaP has emerged, opportunities for the growth of FT seem ripe, and this optimism is reflected in the confidence of urologists regarding FT captured in this survey.

The most important difference between the current survey and the previous one is the higher rate of FT utilization among respondents (43.6% vs. 24.2%). While this is an indication of overall increased use, this is not proven from this survey since different respondents likely answered this survey compared to the previous one. The indicated increase in adoption of FT might be related to newly graduated, fellowship-trained urologists embracing this modality. Another important aspect possibly contributing to an increase in FT utilization is the slowly growing favor among urological societies’ guidelines. For example, the EAU CaP guidelines from 2016 recommended not offering FT except for clinical trials.[11] The new guidelines in 2024 recommend offering FT in the case of clinical trials as well as registries.[12] In addition, the National Institute for Health and Care Excellence guidelines in 2012 for cryoablation stated the distinct lack of safety and efficacy data for FT.[13] However, their newest FT guidelines in 2023 for HIFU stated that there is sufficient evidence for the safety of FT, but it is still lacking sufficient data for efficacy.[14] While urological society guidelines do not as yet widely recommend FT, they are slowly upgrading their stance on FT, which could be encouraging more urologists to incorporate it into their practice.

In the previous survey, years of practice (>15 years) was a significant predictor of the use of FT. In the current survey, fellowship training now significantly predicted FT utilization. Newly trained urologic oncologists may be driving increased adoption. In addition, increased utilization may be due to strong acceptance of the index lesion theory, as belief has significantly increased as compared to the previous survey.[15,16,17] Recent research could be contributing to this increase in acceptance of index lesion theory. One study in 2019 analyzed the genome sequences of CaP lesions and local metastases and found that 76.7% were clonal, indicating that index lesion theory likely has some merit.[18] However, it remains to be seen if stronger belief in the index lesion theory is driving increased adoption rates, or if the emerging success of FT and viable short- and intermediate-term oncological outcomes are increasing support of the index lesion theory.[4,19] Regardless, much like the previous survey, belief that CaP is multifocal remains one of the top deterrents against the adoption of FT utilization.

Furthermore, this survey reflects the growing interest in FT modalities beyond HIFU, cryoablation, and IRE including water vapor therapy (WVA) and focal brachytherapy. In contrast, the previous survey results showed laser ablation and photodynamic therapy as the next two most popular modalities after cryoablation, HIFU, and IRE. Nascent research for WVA and focal brachytherapy may have peaked new interest within the urological community. In the world of WVA, the VAPOR 1[20] trial showed effective cancer control (albeit in a small sample size of 15), and the ongoing VAPOR 2 (NCT05683691) may be poised to show effective long-term control in a more substantive sample size. Furthermore, Matsuoka et al. found that focal brachytherapy offered far better control of genitourinary symptoms including continence and preserved ejaculation with similar salvage therapy-free rates at 5 years compared to radical prostatectomy.[21] As some FT modalities have demonstrated favorable oncological outcomes while causing minimal impact on genitourinary function and overall QoL,[22] new FT modalities are likely to emerge and enhance interest and adoption.

In multivariate logistics regression, having a US-based practice is an independent significant predictor for the utilization of FT. This likely reflects a predominance of research on FT occurring in the US, with strong academic fellowships offering opportunities for graduating urologists to engage with FT. However, there is a large urology community studying and using FT outside of the US, especially in Europe. This survey only includes 76 individuals (29.6%) outside of the US. Therefore, the limited sample size may contribute to trends seen here regarding global differences in use. In a survey from 2018 regarding the use of FT in the European urological community (with 88.4% of responses coming from European countries), 52% of survey respondents indicated they would recommend FT to a patient, with 70.8% believing FT will become a standard therapy option after certain refinements take place.[23] There may be broader support for FT across both the United States and Europe, although this may not be accurately captured in this current survey.

Furthermore, although much research has gone into the patient selection awnd efficacy of FT, there is still confusion and debate on best practices for follow-up of FT patients. While most urologists sampled use a combination of prostate-specific antigen (PSA), mpMRI, and biopsy, a quarter (25.2%) are content with only using PSA trends. Lebastchi et al. published consensus guidelines in 2020 that call for a systematic biopsy (along with targeted biopsy) at 6–12 months post-FT, although they do not call for an extended 5-year timeframe sample.[24] Furthermore, there is less agreement on the necessity of including functional and QoL metrics (SHIM score, AUA-SS, and QoL questionnaires) on urologists polled in this survey. In contrast, Lebastchi et al. called for the necessity of investigating functional outcomes 3–6 months after FT and until the resolution of noted symptoms.[24] A lack of universal guidelines for follow-up after FT may make new providers hesitant to begin using FT and provide a major hindrance in comparing FT outcomes in patients across varying centers.

This survey was limited by a small sample size, which hinders the ability to draw generalizable conclusions on the attitude of urologists toward FT. Other limitations include the inability to calculate an accurate response rate and the unknown characteristics of those who chose not to respond. Presumably, there could be a considerable amount of respondent bias, as those who are more familiar with FT could be more likely to respond to a FT survey. Nonetheless, this survey still gives a glimpse into the changing landscape of the CaP field regarding FT.

CONCLUSIONS

While only a small number of urologists responded, there is increasing confidence and adoption of FT by the responding urologists, with fellowship training significantly predicting the use of this modality. There is still considerable debate over the merit of the index lesion theory, and although belief is growing, it still heavily contributes to resistance to FT adoption. To continue to increase adoption of FT, there needs to be ongoing positive long-term data, as well as more opportunities for experience in performing FT.

Conflicts of interest

There are no conflicts of interest.

SUPPLEMENTARY FILES

What is your age?

  _____

What is your sex?

  Male

  Female

  Other

Type of Practice?

  Academic

  Nonacademic

  Hybrid

How many years have you been practicing Urology (post-residency)?

  0–5 years

  6–10 years

  11–15 years

  Greater than 15 years

What society do you belong to? (check all that apply)

  AUA

  The Endourological society

  Society of Urologic Oncology

  European Association of Urology

  Focal Therapy Society

On average how many patients do you see per month with newly diagnosed prostate cancer?

  1–10 patients

  10–20 patients

  20–30 patients

  Greater than 30 patients.

Do you believe in the INDEX LESION theory as a basis for the focal therapy in prostate cancer? (In the multifocal prostate cancer, only the index lesion, the largest tumor focus with the highest grade, determines the prognosis)

  Yes

  No

How beneficial do you think focal therapy is in the management of prostate cancer?

  No benefit at all

  Slightly beneficial

  Moderately beneficial

  Very beneficial

  Extremely beneficial

Do you utilize focal therapy in the management of prostate cancer in your practice?

  Yes

  No

What modality do you utilize for prostate focal therapy? (check all that apply)

  Cryoablation

  Laser ablation

  High-Intensity Focal Ultrasound (HIFU)

  Irreversible electroporation

  Photodynamic therapy

  Water vapor therapy

  Radiofrequency Ablation

  Focal Brachytherapy

  Other

On average how often do you perform focal therapy for prostate cancer?

  1–5 patients per year

  6–10 patients per year

  11–15 patients per year

  >15 patients per year

Which set of prostate cancer patients do you prefer for focal therapy? (check all that apply)

  Unilateral low-risk-Gleason score 6

  Bilateral low-risk-Gleason score 6 (as long as urethra and one neurovascular bundle are preserved)

  Unilateral intermediate risk-Gleason score 7

  Bilateral intermediate risk-Gleason score 7 (as long as urethra and one neurovascular bundle are preserved)

  Unilateral high risk (Gleason score > 7)

How do you identify prostate cancer focal therapy candidates? (select all that apply)

  Based on systematic transrectal ultrasound (TRUS) biopsy only

  Multiparametric MRI and systematic TRUS biopsy

  Multiparametric MRI followed by MRI-TRUS fusion biopsy

  Template prostate mapping biopsies with or without multiparametric MRI

If the patient's prostate cancer is an adequate candidate for focal therapy, which age demographic would you recommend focal therapy for? (check all that apply)

  40–49

  50–59

  60–69

  70–80

  >80

How do you follow your patient's status postfocal therapy? (check all that apply)

  Prostate-specific antigen/PSA kinetics only

  PSA plus MpMRI followed by targeted biopsy only if there is a suspicious lesion

  PSA plus protocol Biopsy at set intervals with or without prior MpMRI

Which of the following should be part of the follow-up after focal therapy for prostate cancer? (check all that apply)

  Biopsies

  PSA

  Imaging

  International Prostate Symptom Score (IPSS)

  Sexual Health Inventory of Men (SHIM)

  QoL questionnaire

  Assessment of incontinence by # of pads

  Other

Do you attempt to repeat focal therapy for biopsy-proven recurrent prostate cancer postfocal therapy?

  Yes

  No

If you had access to a reliable and cost-effective way to perform focal therapy in an office or outpatient setting, would you use it more often?

  Yes

  No

Do you believe that navigation tools and treatment planning tools can improve focal therapy outcomes?

  Yes

  No

  Maybe

  (The following are only for those who answered no to using focal therapy)

Reasons for not performing focal Therapy?

  Free Response

If you don't utilize focal therapy in your practice what is the reason? (check all that apply)

  Lack of evidence

  Believe prostate cancer is multifocal

  Index lesion theory is not established

  Lack of infrastructure

  Cost is prohibitive

  Lack of experience

  Higher risk of prostate cancer recurrence

  Salvage treatment is challenging in case of recurrence

How likely are you to consider focal therapy in future in your own practice (Assuming you have access to all the resources)?

  Very likely

  Likely

  Neither likely nor unlikely

  Unlikely

  Very unlikely

Funding Statement

Nil.