The European Association of Urology (EAU) has just updated its guideline document “EAU guidelines on prostate cancer. Part 1: Screening, diagnosis, and local treatment with curative intent”.
According to a paper by Heidenreich et al. in European Urology, the key factors to be noted in the revised guidelines are as follows:
- Current evidence is insufficient to warrant widespread, population-based screening for risk of prostate cancer using the PSA test.
- Systematic prostate biopsies under ultrasound guidance and local anesthesia remain the preferred diagnostic method.
- Active surveillance is a viable management option in men with low-risk prostate cancer and a long life expectancy.
- Biopsy progression while on active surveillance indicates the need for active intervention, but the role of PSA doubling time in initiation of active treatment is controversial.
- For those patients with locally advanced prostate cancer for whom local therapy is not mandatory, watchful waiting (as opposed to active surveillance) is an appropriate alternative to androgen-deprivation therapy (ADT), with equivalent oncologic efficacy.
- Active treatment is recommended primarily for patients with localized disease and a long life expectancy, and radical prostatectomy has been shown to be superior to watchful waiting in prospective randomized trials.
- Nerve-sparing radical prostatectomy is the approach of choice in organ-confined disease; neoadjuvant ADT provides no improvement in outcome variables.
- When radiation therapy is the recommended form of treatment, it should be performed with ≥ 74 Gy in men with low-risk prostate cancer and 78 Gy in men with intermediate- or high-risk prostate cancer.
- In the treatment of men with locally advanced disease, adjuvant ADT for 3 years results in superior rates for disease-specific and overall survival and is the treatment of choice.
- Follow-up after local therapy is largely based on PSA and a disease-specific history, with imaging indicated only when symptoms occur.
Let us be clear that not everyone is going to agree with all of these recommendations. This is a document written, in large part, by European urologists for European urologists. It is possible to quibble with several of these recommendations, and some European urologists would certainly argue that what they are doing today (e.g., MRI/TRUS fusion biopsies, focal therapy) are a significant improvement over some of the processes recommended here for appropriately identified patients.
The complete text of the full guidance document can be found on the EAU web site. To find this document, first click here; then click on the link to the prostate cancer guidelines; then open the “full guideline – 2013”.