The European Society for Medical Oncology (ESMO) released the 2015 edition of its clinical practice guidelines for the diagnosis, treatment and follow-up of prostate cancer online in the journal Annals of Oncology on July 22. I would like to compile the main updates of the latest edition of ESMO prostate cancer here, hoping to bring insight and reference to your clinical practice.
The guidelines use the Infectious Diseases Society of America’s Public Health Service rating system, with levels of evidence ranging from I to V, with I being the strongest, followed by II, II and IV in that order. Recommendation levels include A to E, with A: strongly recommended; E: not recommended under any circumstances; and B, C, and D ranked in between in terms of recommendation strength.
Screening and early diagnosis
Although population-based PSA screening can reduce prostate cancer mortality, it is also associated with overdiagnosis and overtreatment and is therefore not recommended. [I, C]
Laboratory testing for prostate cancer should not be performed in asymptomatic men over 70 years of age. [I, B]
Diagnosis and pathology
A single elevated PSA value should not be followed by a prostate biopsy and should be confirmed by retesting. [IV, B]
The decision to biopsy the prostate should be based on the patient’s rectal examination (DRE), race, age, comorbidities, PSA value, free/total (f/t) PSA ratio, biopsy history, and patient preference. [II, B]
Transrectal ultrasound-guided prostate biopsy should be performed with antibiotics and local anesthesia, and tissue samples should be obtained from at least 10 to 12 sites. [II, B]
MRI-guided or MRI-transrectal prostate ultrasonography (TRUS)-fused biopsies should be performed using multiparametric MRI prior to repeat biopsies. [III, B]
The extent of involvement and the most common and worst Gleason grades should be reported for each sampling. [II, A]
Tumor staging and risk assessment
Locoregional prostate cancer should be classified into low, intermediate and high risk groups based on serum PSA, Gleason score and clinical staging to guide prognosis and treatment. Patients in the intermediate or high risk group should be staged by lymph node staging using CT , MRI, choline PET/CT or pelvic lymph node dissection. [III, B]
Patients in the intermediate-risk group or high-risk group should be staged for cancer metastasis using technetium bone scan, chest-abdomen CT or whole-body MRI or choline PET/CT scan. [III, B]
Treatment of limited prostate cancer
There is no consensus on the best option for managing limited disease.
Patients in the low-risk group may opt for watchful waiting while delaying hormonal treatment options.
Patients with limited or locally advanced prostate cancer may choose watchful waiting and defer hormonal therapy when radical treatment is not appropriate, or not desired. [I, A]
For patients in the low-risk group, active surveillance is an option. [II, A]
Radical prostatectomy (RP) or radiotherapy (external or brachytherapy) is an option for patients in the low- or intermediate-risk group. [I, B]
Androgen depot therapy (ADT) alone is not recommended as an initial standard regimen for non-metastatic disease. [III, B]
External radiation radiotherapy (RT) + hormone therapy [I, B] or RP + pelvic lymph node dissection [III, B] is an option for patients in the high-risk group or for patients with locally advanced prostate cancer.
Neoadjuvant and adjuvant hormonal therapy
Four to six months of neoadjuvant and concurrent ADT is recommended for high-risk patients undergoing radical RT, and this regimen may also be considered for intermediate-risk patients. [I, A]
Adjuvant ADT for 2 to 3 years is recommended for prostate cancer patients at high risk of mortality who have received neoadjuvant hormonal therapy and radical RT.[I, A]
Postoperative radiotherapy
Immediate radiotherapy after RP is not routinely recommended. Patients with positive surgical margins or excess-capsular extension (extra-capsular extension) after RP and a PSA below the detection threshold should be explained the advantages and disadvantages of adjuvant RT. [I, A]
Recurrence after radical treatment
At follow-up after RP, patients should be tested for PSA levels. When PSA has failed, salvage RT to the prostate base is recommended. salvage RT should be performed as early as possible (e.g. PSA < 0.5 ng/ml). [III, B]
Early ADT is not routinely recommended for patients with biochemical index recurrence unless there is symptomatic local disease, or confirmed metastasis, or a two-fold rise in PSA in less than 3 months. [IV, B]
Intermittent ADT is recommended for patients with biochemical relapse who start ADT therapy after RT. [I, B]
Treatment of advanced/metastatic prostate cancer
Continuous ADT is recommended as a first-line treatment option for patients with metastatic, untreated hormonal therapy. [I, A]
Patients initiated on ADT should be advised to exercise routinely to reduce fatigue and improve quality of life. [I, A]
ADT + docetaxel is recommended as a first-line treatment option for metastatic, hormone-naïve patients in patients who are in a better condition for chemotherapy. [I, A]
Treatment of destructive resistant prostate cancer (CRPC)
Abiraterone or enzalutamide is recommended for the treatment of asymptomatic/mildly symptomatic chemotherapy-naïve metastatic CRPC. [I, A]
Radium-223 is recommended for CRPC without visceral metastases and with predominantly metastatic bone symptoms.[I, A]
Docetaxel is recommended for patients with metastatic CRPC. [I, A]
For asymptomatic/mildly symptomatic metastatic, chemotherapy-naive patients, Sipuleucel-T is one of the options. [II, B]
Abiraterone, enzalutamide, cabazitaxel, and radium-223 (in patients without visceral metastases) are recommended for patients with metastatic CRPC after docetaxel treatment. [I, A]
Palliative care
Single-split external irradiation RT is recommended for palliative metastatic bone pain treatment. [I, A]
Denosumab or zoledronic acid may be recommended for CRPC with bone metastases, and for patients at high risk for skeletal events. [I, B]
For patients with CRPC with spinal metastases, MRI of the spine is recommended to detect subclinical spinal cord compression. [III, B]
For patients with CRPC with spinal metastases and neurological symptoms, urgent MRI of the spine is strongly recommended to detect clinical spinal cord compression in a timely manner. [III, A]
Individualized treatment
Patients with prostate cancer with evidence of neuroendocrine changes should receive chemotherapy in addition to ADT. [IV, B]
Follow-up and long-term effects
Routine DRE is not required for locally treated patients who are asymptomatic and whose PSA is controlled. [II, B]
Biopsy in patients with prostate cancer after RT should only be performed if local salvage therapy is contemplated. [V, C]
Symptoms of chronic bowel disease after RT should be managed by a gastroenterologist for investigation. [V, B]
Patients treated with long-term ADT should be monitored for adverse effects, including osteoporosis (using optical density analysis), metabolic syndrome, etc. [IV, B]
For patients with CRPC treated with systemic therapy, disease response/progression should be monitored regularly using imaging. [V, B]