New guidelines for management of advanced prostate cancer

The American Urological Association (AUA), together with the American Society for Radiation Oncology (ASTRO) and the Society for Urologic Oncology (SUO), has just issued a new set of guidelines for the management of advanced prostate cancer (see here).

The full set of guidelines developed by Lowrance et al. offers 38 recommendations under six headings, as follows:

Prostate Cancer International would still find it more appropriate if we could get rid of terms like “hormone sensitive” and “castration resistant” disease in the discussions of management of advanced prostate cancer. In our opinion the preferred terms ought to be more like “androgen suppressed” and “androgen suppression refractory” forms of the disease. However, that is an ongoing issue for discussion.

It will be interesting to see whether the American Society for Clinical Oncology (ASCO) is going to be willing to endorse most or all of this new set of guidelines for the management of advanced prostate cancer. They were willing to do this not so long ago with regard to the management of localized prostate cancer.

We note that a patient representative is once again a named author to the current set of guidelines. We are unsure the degree to which Mr. Crispino may have been able to influence the guideline-writers as a group, but we have no doubt that he will have let them know if he thought they were “off track” from a patient perspective.

8 Responses

  1. There is no definition of “Exhaustion of Local Treatment Options”. Some say it is the second BCR after SRT (see Tumati et al.), but there are reports about multiple prostate re-irradiation for locally recurrent prostate cancer (see Volpe et al.).

  2. Dear Valeriy:

    My suspicion is that the reason no precise definition of “exhaustion of local treatment options” is given in this guideline is that this is highly case dependent. Perhaps the correct way to think about this is that “exhaustion of local treatment options” is when both the patient and his physician consider that no additional local treatment option is likely to have a significant clinical benefit compared to the risks involved.

    You are correct in stating that there may well be case-dependent local treatment options after standard biochemical recurrence following either first-line radiation therapy or surgery with adjuvant radiation therapy (RT) or surgery followed by salvage RT. However, all those additional local options depend on the precise clinical evaluation and work-up of carefully selected patients. The further options for localized treatment can (at least hypothetically) include: additional, targeted forms of radiation therapy; salvage cryotherapy; and even salvage HIFU. However, these options will probably not be appropriate for the majority of patients with standard biochemical recurrence as described above.

  3. I started bicalutamide monotherapy (no ADT) — which is widely used in Europe — after progressing from oligometastatic disease. I have had a complete response (200 to 0.1 ng/ml) in 9 weeks with no side effects.

    I find it very interesting the US continues to not recommend antiandrogen monotherapy. Seems like we are shutting the door on what can be an effective and less side effect-laden treatment.

  4. No mention of testosterone measurement during ADT for metastatic hormone-sensitive disease (MHS) — see #12

    No direction re somatic testing? Cell-free DNA, biopsy tissue from primary or metastasis — if uncertain, say so — see #26

    Difficult to accept the “may” advice for sipuleucel-T (Provenge) vs the”should” advice for radium-223 (Xofigo) — see #28 and # 29

  5. Dear bullet33912:

    The basic problem is that the US Food and Drug Administration here in the US has never approved antiandrogen monotherapy with a drug like bicalutamide for the treatment of progressive or metastatic prostate cancer (either at a standard dose of 50 mg once daily or at a high dose of 150 mg once daily. It is the latter dose that is often used in Europe.

    I should point out that because you have only been treated for a few weeks with this type of therapy, it is unlikely that you would have had any of the side effects yet, but these do occur and in some men they can become quite serious.

  6. Thank you for these comments Dr. Schellhammer. (For readers who don’t know this, Dr. Paul Schellhammer is a highly experienced urologic oncologist and a former President of the AUA who has advanced prostate cancer himself.)

  7. Mike thanks for the mention. The science in these statements came from the multidisciplinary panel being divided into subpanels and scrubbing through the relevant studies. There were minimal times for me to bring up the patients perspective because they were fantastic physicians and they were always on top of that. Interestingly, the panelists do require me to study through each potential statement as these are consensus statements based upon the facts we had. My biggest contributions, I think, were helping in getting the verbiage of the statements themselves into better/more clearer statements. The physicians were very respectful of my input and were excellent teachers too. This is my fifth guideline, third with the AUA. I have always been made to feel a welcome contributor in each of them. I’m absolutely happy they keep asking me to do them because I really enjoy it and feel these guidelines make for better patient care.

  8. Response to Valeriy,

    Great point. Our panel specifically talked about when local therapy was considered exhausted and salvage radiation after radical prostatectomy was discussed. It is still in the clinically localized guideline published in 2017.

    It was in that spirit that this guideline was silent on it. I read your reference to Volpe et al. and while I find it interesting in and of itself to re-irradiate, I don’t think that paper is strong enough to make it a standard of care. But if they are doing so, then I would still consider this still to be localized therapy in the same consideration I gave above for radiation after surgery.

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