Updated prostate cancer guidelines stress low-risk surveillance

Buffalo, NY-Recent updates to the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology-Prostate Cancer include new recommendations on active surveillance, a new requirement for external beam radiation therapy, and revisions to the entire section on chemotherapy, said guidelines panel chair James L. Mohler, MD.

The very low-risk subset represents a modification of the Epstein criteria for clinically insignificant prostate cancer from Johns Hopkins University, Baltimore, explained Dr. Mohler, who is chair of the department of urology at Roswell Park Cancer Institute, Buffalo, NY.

"The recommendations for active surveillance in very low-risk and low-risk prostate cancer do not derive from level I evidence, but rather represent level 2b recommendations," Dr. Mohler said. "They are based on accumulating evidence about active surveillance in the literature, which comes predominantly from Sunnybrook Health Sciences Centre, Johns Hopkins, and the University of California, San Francisco.

"Also driving these recommendations was concern about overtreatment, generated in part by the prostate cancer-specific mortality results from the American and European randomized screening studies published in the New England Journal of Medicine [2009; 360:1310-9 and 2009; 360:1320-8]. The panel believes a consensus is developing that there are many men diagnosed with low-risk prostate cancer for whom the survival benefit of treatment is low and may be lower than the risk to quality of life from treatment side effects."

Dr. Mohler explained that accumulating data from institutional and multi-institutional studies provide the basis for creating the very low-risk category.

"The panel is sensitive to the fact that prostate biopsy uncovers many incidental prostate cancers that would not impact survival. What is needed is some type of molecular or clinical indicator of the lethal phenotype of prostate cancer. Until such a tool is available, physicians need to discuss all of the treatment options with patients, and now especially active surveillance for appropriate men in the low-risk and very low-risk prostate cancer categories, to enable patients to make the best decision about their own prostate cancer."

RT and chemotherapy updates

In 2009, the guidelines for external beam radiation therapy were modified to require intensity-modulated radiation therapy. Now, the 2010 update also requires daily image guidance. These revisions aim to increase the efficacy and safety of external beam radiation therapy, explained Dr. Mohler.

"There is level I evidence for using a high dose of radiation in treating moderate and high-risk prostate cancer to improve cancer control. However, such doses put the adjacent tissues at risk, and without precise localization of the prostate, they may also cause increased side effects. Therefore, the guidelines now require IMRT and image guidance," he said.

Changes in the section on chemotherapy include updating and simplification of the algorithms and the principles of chemotherapy along with particular attention to making the ensuing discussion more thorough and fully referenced. Specifically, docetaxel (Taxotere) is now the only chemotherapy recommended for castration-recurrent metastatic prostate cancer based on level I evidence that it improves both quality of life and survival.

The guidelines panel represents a multidisciplinary group consisting of urologists, radiation oncologists, medical oncologists, experts in quality of life, and patient advocates. It will continue to meet at least annually in order to modify the guidelines as new information emerges, Dr. Mohler said.

The guidelines may be accessed online at http://www.nccn.org/. In addition, the February issue of the Journal of the National Comprehensive Cancer Network features three articles that will help urologists understand the underlying rationale for many of the guideline changes, especially the need for increasing use of nomograms for informing decisions when conducting treatment discussions, Dr. Mohler said.