NCCN guidance on initial management of low-risk, localized prostate cancer (redux)


In late October, we had commented on the then-latest revision of the National Comprehensive Cancer Network (NCCN)’s guidelines on the initial management of men with low-risk forms of localized prostate cancer. Specifically we had protested the removal of any suggestion that this form of prostate cancer should — preferably — be managed using active surveillance. The NCCN has now released a new revision to the guidelines that has modified the prior suggestion.

Specifically, in this new set of guidelines (Version 2.2022 — November 30, 2021), the NCCN has made a very important change to its guidance regarding the first-line management of patients with a confirmed diagnosis of low-risk prostate cancer who have a life expectancy of 10 or more years (see p. PROS-4). Please note that you do have to register yourself with the NCCN to be able to access these guidelines, but there is no charge for doing this.

  • In immediately preceding versions of Version 1.2022, the guideline had stated that active surveillance was the “preferred” option for all such patients (the other two options being EBRT or brachytherapy and radical prostatectomy).
  • In Version 1.2022 — October 20, 2021, the guideline stated that active surveillance was one of three reasonable options for all such patients (the other two being EBRT or brachytherapy and radical prostatectomy).
  • In Version 2.2022 — November 30, 2021, the guideline has been revised to state that active surveillance is the option “preferred for most patients” (the other two options still remaining as EBRT or brachytherapy and radical prostatectomy).

Prostate Cancer International and The “New” Prostate Cancer InfoLink are very satisfied by this revision to the most recent version the the NCCN’s guidance. We were far from being the only organization or set of individuals that had expressed serious concerns about the removal of the term “preferred” in relation to active surveillance as a first-line treatment for men clearly and accurately diagnosed as having low-risk forms of prostate cancer. We recognize that this may not be the most appropriate form of first-line care for every man diagnosed with low-risk prostate cancer. We also agree completely with the NCCN that there is still serious research needed into how to best identify — with high accuracy — men with very low-, low-, favorable intermediate-, and unfavorable intermediate-risk forms of localized prostate cancer and how to best monitor those patients over time.

Having said that, we still believe that the term “recommended” is a more accurate word than “preferred” in the actual presentation of the individual guidelines, since we feel that the word “preferred” is open to inappropriate interpretation. But the revision is a very reasonable compromise and we thank the NCCN prostate cancer guidelines committee for their decision to make the most recent revision highlighted above.

We should note that in this latest version of the guideline document, the use of active surveillance remains

  • The “preferred” form of first-line management for all patients with a confirmed diagnosis of very low-risk prostate cancer and a life expectancy of 20 or more years (see page PROS-3)
  • The only form of first-line management suggested for all patients with a confirmed diagnosis of very low-risk prostate cancer and a life expectancy of 10 to 20 years (see page PROS-3)
  • One of three options for the first-line management for all patients with a confirmed diagnosis of favorable intermediate-risk prostate cancer and a life expectancy of 10 or more years (see page PROS-5)

In addition, we should point out that the NCCN has still to complete revisions to the “Discussion” section of this revised document (see pages MS1 to MS68). This is the section that includes all of the very detailed information supporting the rationale for guidance offered.

4 Responses

  1. You seem to not publish my comments anymore. I commented yesterday about this.

  2. Dear Allen:

    Unfortunately the sitemaster is not able to check all comments every day. Some days there are other things he has to do as priorities.

  3. Why is HIFU not an option?

  4. Dear Mike:

    If you read all of the detailed comments in the most recent update to the NCCN guidelines, what you will find is a statement that many other forms of treatment are accessible for the treatment of prostate cancer but they are not formally recommended. In the case of HIFU, this because it has never been proven in a randomized, controlled trial to be effective and safe in the treatment of localized prostate cancer. It has only been approved for use in the ablation of prostate tissue (e.g., for the treatment of benign prostatic hyperplasia or BPH), which is not the same thing as prostate cancer.

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