New NCCN prostate cancer guide allows for individualized choices

Key Points

Among the updates are the recommended use of life expectancy tables to guide treatment decisions, a more complete discussion of active surveillance, and recognition of laparoscopic and robotic techniques as appropriate surgical approaches.

The interdisciplinary committee responsible for updating the guidelines aims to gather a broad perspective on prostate cancer treatment and comprises urologists, medical oncologists, radiation oncologists, advocates, and a population scientist.

"In the consensus meeting that led to the development of the 2007 guidelines, there were some rousing debates, reflecting the fact that so much having to do with prostate cancer management is very controversial," Dr. Mohler told Urology Times.

New to the 2007 guidelines is a section on Principles of Life Expectancy Estimation. For the first time, the guidelines re-commend using the Social Security Administration's life expectancy tables and then further modifying that information based on a global assessment of the patient's comorbidities.

"Comparing the threat to a patient's life expectancy from other diseases and age with the threat to life from prostate cancer is important for framing the discussion about treatment choices. We know many men diagnosed with prostate cancer are appropriate candidates for active surveillance, and the decision to undergo treatment and the choice of treatment type depend greatly on life expectancy and overall health," Dr. Mohler explained.

The section on active surveillance has also been updated to incorporate recent developments in the knowledge base about that management approach. As a result, the new algorithm and discussion section on the choice of active surveillance are more complete. The algorithm on radiation therapy as a choice for clinically localized prostate cancer has been improved; it has been simplified to make it more straightforward.

Biochemical failure definition

The 2007 guidelines also contain revised definitions for biochemical treatment failure after radiation therapy and radical prostatectomy. The new American Society for Therapeutic Radiation Oncology Phoenix definition has replaced that group's previous definition for biochemical failure after radiation therapy. The Phoenix definition is equally useful after brachytherapy and neoadjuvant and/or adjuvant androgen deprivation therapy. The post-radical prostatectomy definition no longer has an absolute cutoff, and is thus independent of the type of assay used. New criterion for postsurgical biochemical failure requires an increase in PSA on two subsequent measurements performed at least 3 months apart.

"We believe these new definitions will assist urologists and radiation oncologists in appropriately recognizing treatment failures so that they can consider additional treatment using another modality," Dr. Mohler said.

Laparoscopic and robot-assisted techniques for radical prostatectomy are now recognized as acceptable surgical alternatives in the new guidelines.

"This was an area of debate in the previous guideline, but in 2006, an estimated one-third of all radical prostatectomies were done laparoscopically or robotically. The consensus of the committee was that there are enough data on those techniques in the peer-reviewed literature that their use should be recognized as appropriate," Dr. Mohler said.

Guidelines relating to treatment with androgen deprivation therapy and che-motherapy for men with advanced prostate cancer have been simplified and made more accurate based on new evidence from clinical trials. In addition, recommendations for bisphosphonate therapy have been clarified as a result of expanding data. According to the 2007 guidelines, bisphosphonates are appropriate in men who are receiving long-term androgen deprivation therapy and to prevent secondary metastasis in men on androgen deprivation therapy for metastatic disease.

"The Cancer and Leukemia Group B 20202 trial is now under way to examine the efficacy and safety of bisphosphonates in men with newly diagnosed metastatic prostate cancer. However, at this time, there is no evidence to suggest the benefits outweigh the risks in that group," Dr. Mohler said.