CARCINOMA PROSTATE

Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline

Part I: Risk Stratification, Shared Decision Making, and Care Options

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The AUA (American Urological Association), ASTRO, and SUO (Society of Urologic Oncology) have formulated an evidence-based guideline based on a risk stratified clinical framework for the management of localized prostate cancer. Part 1 focuses on risk stratification, shared decision making, and care options.

The guideline appears in the recent issue of Journal of Urology, the official journal of AUA. It is structured to provide a clinical framework stratified by cancer severity to facilitate care decisions and guide the specifics of implementing the selected management options.

RISK STRATIFICATION

CARE OPTIONS BY CANCER SEVERITY/RISK GROUP

Very Low Risk and Low risk Prostate Cancer

• Clinicians should not perform abdominopelvic CT or routine bone scans in the staging of asymptomatic very low or low risk localized prostate cancer patients (Strong Recommendation; Evidence Level: Grade C)

• Clinicians should recommend active surveillance as the best available care option for very low risk localized prostate cancer patients (Strong Recommendation; Evidence Level: Grade A)

• Clinicians should recommend active surveillance as the preferable care option for most low risk localized prostate cancer patients (Moderate Recommendation; Evidence Level: Grade B) 

• Clinicians may offer definitive treatment (i.e. radical prostatectomy or radiotherapy) to select low risk localized prostate cancer patients who may have a high probability of progression on active surveillance (Conditional Recommendation; Evidence Level: Grade B)

• Clinicians should not add androgen deprivation therapy (ADT) along with radiotherapy for low risk localized prostate cancer with the exception of reducing the size of the prostate for brachytherapy (Strong Recommendation; Evidence Level: Grade B) 

• Clinicians should inform low risk prostate cancer patients considering whole gland cryosurgery that consequent side effects are considerable and survival benefit has not been shown in comparison to active surveillance (Conditional Recommendation; Evidence Level: Grade C)

• Clinicians should inform low risk prostate cancer patients who are considering focal therapy or HIFU that these interventions are not standard care options because comparative outcome evidence is lacking (Expert Opinion)

• Clinicians should recommend observation or watchful waiting for men with a life expectancy  ≤5 years with low risk localized prostate cancer (Strong Recommendation; Evidence Level: Grade B) 

• Among most low risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance (Expert Opinion)

Intermediate Risk Prostate Cancer

• Clinicians should consider staging unfavorable intermediate risk localized prostate cancer patients with cross-sectional imaging (CT or MRI) and bone scan (Expert Opinion)

• Clinicians should recommend radical prostatectomy or radiotherapy plus ADT as standard treatment options for patients with intermediate risk localized prostate cancer (Strong Recommendation; Evidence Level: Grade A) 

• Clinicians should inform patients that favorable intermediate risk prostate cancer can be treated with radiation alone, but the evidence basis is less robust than for combining radiotherapy with ADT (Moderate Recommendation; Evidence Level: Grade B)

• In select patients with intermediate risk localized prostate cancer, clinicians may consider other treatment options such as cryosurgery (Conditional Recommendation; Evidence Level: Grade C)

• Active surveillance may be offered to select patients with favorable intermediate risk localized prostate cancer; however, patients should be informed that this comes with a higher risk of developing metastases compared to definitive treatment (Conditional Recommendation; Evidence Level: Grade C) 

• Clinicians should recommend observation or watchful waiting for men with a life expectancy ≤5 years with intermediate risk localized prostate cancer (Strong Recommendation; Evidence Level: Grade A)

• Clinicians should inform intermediate risk prostate cancer patients who are considering focal therapy or HIFU that these interventions are not standard care options because comparative outcome evidence is lacking (Expert Opinion)

High Risk Prostate Cancer

• Clinicians should stage high risk localized prostate cancer patients with crosssectional imaging (CT or MRI) and bone scan (Clinical Principle)

• Clinicians should recommend radical prostatectomy or radiotherapy plus ADT as standard treatment options for patients with high risk localized prostate cancer (Strong Recommendation; Evidence Level: Grade A) 

• Clinicians should not recommend active surveillance for patients with high risk localized prostate cancer. Watchful waiting should only be considered in asymptomatic men with limited life expectancy (≤5 years) (Moderate Recommendation; Evidence Level: Grade C) 

• Cryosurgery, focal therapy, and HIFU treatments are not recommended for men with high-risk localized prostate cancer outside of a clinical trial (Expert Opinion) 

• Clinicians should not recommend primary ADT for patients with high risk localized prostate cancer unless the patient has both limited life expectancy and local symptoms (Strong Recommendation; Evidence Level: Grade A) 

• Clinicians may consider referral for genetic counseling for patients (and their families) with high risk localized prostate cancer and a strong family history of specific cancers (e.g., breast, ovarian, pancreatic, other gastrointestinal tumors, lymphoma) (Expert Opinion)

About AUA/ASTRO/SUO
Founded in 1902, the AUA (American Urological Association) is a premier urologic association, providing invaluable support to the urologic community. The AUA is committed to supporting urologic research through funding, advocacy and scholarly exchange. ASTRO (the American Society for Radiation Oncology) is a leading professional association in radiation oncology that is dedicated to improving patient care through professional education and training, support for clinical practice and health policy standards, advancement of science and research, and advocacy. The SUO (Society of Urologic Oncology) was found in 1984, its mission is to enable qualified members primarily interested in the care of patients with malignant GU diseases to meet for the purpose of discussion, development and implementation of ideas to improve care.

Note: This list is a brief compilation of some of the key recommendations included in the Guidelines and is not exhaustive and does not constitute medical advice. Kindly refer to the original publication here: https://goo.gl/NboS9R

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ABOUT AUTHOR

Dr. Prachi Chhimwal

Research Analyst at PlexusMD

Dr. Prachi Chhimwal is a Research analyst at PlexusMD and is a part of the Editorial Team. She curates the Technical Content posted daily on the news feed. She graduated from Army College of Dental Sciences (B.D.S) and went on to pursue her post-graduation (M.D.S) in Oral & Maxillofacial Pathology. After a decade in the field of dentistry she took a leap of faith and joined PlexusMD. A badminton enthusiast, when not working you can find her reading, Netflixing or enjoying stand-up comedy shows.

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