The American Urological Association (AUA), American Society for Radiation Oncology (ASTRO), and Society of Urologic Oncology (SUO) have released new guidelines for the diagnosis and treatment of advanced prostate cancer, the associations announced.
These guidelines were developed by a panel of experts that a patient advocate. In addition to their own expertise and experience, panel members assessed data from 264 prostate cancer studies in developing these recommendations for clinical practice.
“For the past several years, the prostate cancer landscape has been rapidly evolving due to changes in PSA (prostate-specific antigen) screening standards, as well as the approval of new classes of treatment options for use in various prostate cancer disease states,” William Lowrance, MD, MPH, chair of the guideline panel and a professor at the University of Utah, said in a press release.
“This guideline is comprised of clinical recommendations based on this new evidence and aims to further support the medical community and patients as they navigate through the various stages of this disease,” Lowrance added.
In total, the panel released 38 individual guidelines, grouped into six overarching themes. These are early evaluation and counseling, recurrence without metastatic disease (local treatment exhausted), metastatic hormone-sensitive cancer, non-metastatic castration-resistant disease, metastatic castration-resistant cancer, and bone health.
The first three guidelines concern early evaluation and counseling for people diagnosed with prostate cancer. They stress the importance of interdisciplinary care, and the management of pain and other symptoms for patients, noting they should be included in decisions about their care. The guidelines also note the importance of obtaining tumor biopsies where possible.
After local treatment (treatment directed at the prostate itself), a predictor of recurrence is rising levels of PSA, a protein made by prostate cells that can be detected in the blood. Five guidelines concerned care for people who have exhausted available local treatments, and show an increase in PSA but without evidence of metastasis (cancer that has spread from the prostate). They stress the importance of routine observation (e.g., imaging assessments), but advise against use of androgen deprivation therapy (ADT) with these patients.
For some prostate cancers, tumor cell growth is driven by signaling from hormones called androgens. Lowering androgen production — the goal of ADT — can slow these tumors’ growth, so they are said to be “hormone-sensitive.” Other tumors do not depend on androgens for their growth and, as such, are not typically sensitive to ADT; these tumors are referred to as “castration-resistant.”
Ten guidelines concern the prognosis and treatment of metastatic hormone-sensitive prostate cancer. In terms of prognosis, the guidelines stress the importance of gathering data, such as using imaging to determine all sites of metastases, measuring PSA levels regularly so changes can be detected, and inquiring about a patient’s symptoms.
In terms of treatment for these patients, the guidelines recommend ADT in combination with other androgen therapies or chemotherapy, with radiation therapy recommended if disease load is relatively low. The guidelines offer specific recommendations about things like which types of ADT or androgen therapies to use, and what combinations of treatments to avoid.
Five guidelines concern prostate cancer that has not metastasized, but is also castration-resistant. These guidelines again emphasized the importance of data gathering, including imaging and regular PSA measurements. The guidelines recommend treatment with ADT or other anti-androgen therapies; they advise against systemic chemotherapy or immunotherapy.
Eleven guidelines focus on prostate cancer that is both metastatic and castration-resistant. Again, imaging and PSA measurements are advised; the guidelines also recommend certain genetic testing, which can provide information relevant to possible targeted treatments. In such individuals, treatment decisions typically require the consideration of many factors — most notably, prior treatment and responses — in determining a best approach. The guidelines offer specific recommendations for specific scenarios, such as people with newly diagnosed cancer and those with prior lines of chemotherapy.
Four final recommendations concern bone health, as bones are a common site of metastasis in prostate cancer. The guidelines highlight the importance of discussing bone-related risks, like osteoporosis and fractures, associated with ADT. They recommend preventative measures, such as vitamin supplements or medications, for people with a high likelihood of developing bone problems.
In addition to offering guidance, the guidelines also highlight several areas of prostate cancer care that could be improved. For instance, they note room for improvement in making prostate cancer treatment more individualized, with treatment decisions based on predictive markers that are specific to each person.
“As we move forward as a field, we need to focus on the biologic make-up of tumors and how these can be better leveraged to identify treatment options for patients,” the panelists wrote.