NCCN updates prostate cancer management guidance


In a media release issued earlier today, the National Comprehensive Cancer Network (NCCN) has announced updates to the NCCN Clinical Practice Guidelines for Oncology™ for Prostate Cancer, and has placed a new emphasis on the value of active surveillance in management of men with low and very low risk of clinically significant disease.

The revised NCCN clinical guidelines now include an explicit recommendation for active surveillance and only active surveillance for many men diagnosed with prostate cancer. In particular, they state that:

  • Men with low-risk prostate cancer who have a life expectancy of less than 10 years should be offered and recommended active surveillance.
  • A new “very low-risk” category has been added to the guidelines using a modification of the so-called “Epstein criteria” for clinically insignificant prostate cancer.
  • Only active surveillance should be offered and recommended for men with very low-risk prostate cancer when life expectancy is less than 20 years.

This new guidance may be considered controversial by many in the patient and the physician community, given the lack of established outcome data from randomized clinical trials comparing active surveillance to immediate interventional therapy. However, The “New” Prostate Cancer InfoLink would emphasize that active surveillance is not “no treatment.”

Active surveillance is a “deferred treatment” strategy, whereby the patient and his doctor set out to give necessary treatment only if and when it is needed. The intent is to be able to offer curative therapy to patients who need curative therapy before the disease spreads but to avoid over-treatment of patients who are likely to have greater risk of harm than benefit from immediate curative treatment. And in the case of many patients this means that treatment may be deferred indefinitely or even forever.

According to James L. Mohler, MD, of Roswell Park Cancer Institute, who is the current chair of the NCCN Guidelines Panel for Prostate Cancer, “The NCCN Prostate Cancer Guideline Panel and the NCCN Prostate Cancer Early Detection Panel remain concerned about over-diagnosis and over-treatment of prostate cancer. Growing evidence suggests that over-treatment of prostate cancer commits too many men to side effects that outweigh a very small risk of prostate cancer death.”

“Although the NCCN Guidelines Panel stresses the importance of considering active surveillance, ultimately this decision must be based on careful individualized weighting of a number of factors including life expectancy, disease characteristics, general health condition, potential side effects of treatment, and patient preference,” notes Dr. Mohler. “It is an option that needs to be thoroughly discussed with the patient and all of his physicians which may include his urologist, radiation oncologist, medical oncologist, and primary care physician.”

It will be interesting to see how the urology and the radiation oncology communities react to these guidelines. Even though respected urologists and radiation oncologists are members of this guideline committee, that does not necessarily mean that the rest of the urology and radiation oncology community are going to rush to endorse this guidance. For the “New” Prostate Cancer InfoLink, we believe that the emphasis needs to be placed on the “thorough discussion” that needs to take place between the patient and his physicians.

7 Responses

  1. I believe I can predict with a good deal of accuracy the howls of anger that will eminate from those in the prostate cancer industry who stand to lose a significant amount fo their income if these guidelines concerning AS gain acceptance and are followed.

    Activists will no doubt also join the chorus, as will the men who realize that their “cure” may not have been necessary. And as for the over 70s! … Well, when they realize that, if the age expectancy calculations are followed, none of them is expected to live longer than 20 years, so all 70 and overs with the “low risk” diagnosis will be recommended to follow the AS route ….

  2. I was diagnosed with low grade prostate cancer a year ago at age 70. Because my prostate is very enlarged (130 cc), any form of radiation should not be considered. My Gleason score was 3 + 3 with a PSA of 8, but the PSA has gone down to 4 over the past year due to taking finasteride to reduce the size of prostate.
    My urologist and medical oncologist said I was a good candidate for surgery or active surveillance. I am doing AS, so I was happy to read this NCCN guideline.

    Norm

  3. I agree with the findings completely. Since I am well past 70 and my prostate cancer was of the low risk variety I become very upset when I think of the surgery and radiation I have endured. My quality of life has been horrible. One thing for sure though is that the urologists and oncologists will probably will take their time in changing their direction toward any new guidelines.

  4. Where can I find what NCCN is defining as “low risk” diagnosis.

    Bill

  5. Dear Bill:

    Together with the relevant life expectancy materials, this information is all provided in great detail within the NCCN guidelines, which anyone can sign up to use. However, the actual criteria defined by the NCCN are as follows:

    Very low risk patients: T1a; Gleason score < or = 6; PSA < 10 ng/ml; fewer than 3 biopsy cores positive; < or = 50% of cancer in any positive biopsy core; PSA density < 0.15 ng/ml.

    Low risk patients: T1-T2a; Gleason score 2-6; PSA < 10 ng/ml.

  6. I am 48 and a recent biopsy found 1 core of 9 was 5% positive and Gleason score of 6. Is active surveillance recommended for men with greater than a 20-year life expectancy?

  7. For younger men, active surveillance can be thought of as a way to “defer” treatment decisions for at least a while. Thus, given your age, and your presumed concern about things like loss of sexual function as a consequence of treatment, active surveillance would be an option (but not a recommendation). If this is something you are interested in, we would suggest that you consult with a physician group that has considerable experience in the management of prostate cancer patients on active surveillance protocols before you made a decision. Should you go down this path, it is possible that: (a) you might never need treatment at all; (b) you might not need treatment for years; (c) you might need treatment 6 months from now. It would certainly appear — on the basis of the data you have provided — that you meet even the most stringent criteria for low-risk disease.

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