Justification For A New Guideline
Clinicians treating men with advanced prostate cancer are challenged with the rapidly evolving prostate cancer landscape given the approval of new classes of agents for use in various prostate cancer disease states. The increasing complexity of advanced prostate cancer management underscores the need for the current clinical practice guideline, developed to provide a rational basis for treatment of patients with advanced disease, based on currently available published data. To assist in clinical decision-making, guideline recommendations are furnished according to disease state across the entire continuum of advanced prostate cancer.
Prostate Cancer Treatment Options
The treatment approach required for prostate cancer depends on a number of factors, namely the stage of the disease, the risk of recurrence, your age, and your overall health. If yours is low-grade prostate cancer, you may not need any treatment at all. Instead, your urologist may recommend active surveillance with regular rectal exams, follow-up blood work, and prostate biopsies to monitor the progression of your condition.
If you belong to the immediate-risk group , your urologist may recommend partial gland ablation, radiation therapy, or radical prostatectomy .
If youre a high-risk prostate cancer patient, you also have an increased likelihood of disease recurrence and death. Your care team may recommend local treatment strategies, which could include radical prostate removal, with or without adjuvant or salvage radiation therapy
Stages Of Prostate Cancer
In order to determine the stage of a patients prostate cancer, most doctors start by using the TNM staging system, which helps describe different aspects of the cancers growth.
- T the T category measures the size and extent of the Tumor
- N the N category measures whether and how far the cancer has spread to the Lymph Nodes
- M the M category whether the cancer has spread to other organs in the body (a process called Metastasis
The score for each of these categories is determined based on a pre-determined set of criteria. Your doctor cannot feel or see the tumor with a score of T1. A score of T3 means that the tumor has begun to grow outside of the prostate.
After calculating the TNM categories, doctors will combine the TNM score with the patients Gleason score and PSA levels assigning of a specific stage to the patients cancer.
Prostate cancer prognosis and survival rates can help give patients an idea of their chances of surviving the disease based on the stage and time of diagnosis. While some patients may find this information helpful, others may not want to know.
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Outlook For Men With Localised Prostate Cancer
Most localised prostate cancer is slow-growing and may not need treatment or shorten a mans life. For many men who have treatment for localised prostate cancer, the treatment will get rid of the cancer. For others, treatment may be less successful and the cancer may come back. If this happens, you might need further treatment.
Standard Treatment Options For Stage Ii Prostate Cancer
Standard treatment options for patients with stage II prostate cancer include the following:
Watchful waiting or active surveillance/active monitoring
Asymptomatic patients of advanced age or with concomitant illness may warrant consideration of careful observation without immediate active treatment. Watch and wait, observation, expectant management, and active surveillance/active monitoring are terms indicating a strategy that does not employ immediate therapy with curative intent. .
Evidence :
Radical prostatectomy
Radical prostatectomy, usually with pelvic lymphadenectomy is the most commonly applied therapy with curative intent. Radical prostatectomy may be difficult after a transurethral resection of the prostate .
Evidence :
Evidence :
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What Type Of Hormone Therapy Works Best
Unfortunately, understanding the details of hormone therapy for prostate cancer can be difficult. Which drug or combination of drugs works best? In what order should they be tried? Research hasnt answered these questions yet.
Right now, theres a level of art to figuring out which agents to use, says Durado Brooks, MD, MPH, director of prostate cancer programs at the American Cancer Society. We dont have clear evidence yet.
LHRH agonists remain the usual first treatment. But in some cases, doctors are trying anti-androgens first. Anti-androgens may be especially appealing to younger men who are still sexually active, since these drugs dont completely shut down sex drive. When anti-androgens stop working based on PSA tests a person then might shift onto an LHRH agonist.
Other doctors prefer to begin therapy with a combination of two or even three drugs, especially for patients with symptoms or advanced disease, says Holden.
Researchers originally hoped that combined androgen blockade would significantly add to the benefits of LHRH agonists. However, the results, to date, have been mixed. Some studies have shown slightly longer survival with combined androgen blockade, but the results havent been as dramatic as many experts had hoped. Other studies have shown no benefit. A possible explanation may be the type of anti-androgen used, but further studies are needed to answer this question.
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Prostate Cancer Risk Groups
Prostate cancer can be categorised into one of 5 risk groups in the Cambridge Prognostic Group .
Doctors will look at the Grade Group , prostate specific antigen level and tumour stage to decide which CPG group the prostate cancer is.
The risk group of the cancer will help determine which types of treatments will be necessary.
If prostate cancer is diagnosed at an early stage, the chances of survival are generally good.
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Focused Care For Men At High Risk For Prostate Cancer And Those With Advanced Disease
Prostate cancer is one of the most common and deadly cancers for American men. To better assist men at risk for the disease, we created the University of Chicago Medicine High-Risk and Advanced Prostate Cancer Clinic . The program provides a comprehensive genetic evaluation and multifaceted screening plan for men with an increased prostate cancer risk. If youve been recently diagnosed with aggressive forms of prostate cancer, our team also offers novel treatment strategies as well as access to leading-edge clinical trials.
What Factors Determine Life Expectancy For Metastatic Prostate Cancer
The life expectancy of someone with cancer depends on the extent of metastasis and which organs are involved. Metastatic prostate cancer is designated as stage IV:
- Stage IVA: Cancer has progressed to surrounding lymph nodes but not to distant locations.
- Stage IVB: Cancer has progressed to distant tissues and organs, such as the bones or smooth muscles.
Generally, prostate cancers do not spread rapidly to other areas of the body. Most prostate tumors grow slowly and may not cause symptoms or complications for years, if at all.
Even when prostate cancer has spread to other regions of the body, it is usually treatable for an extended period. As a result, even men with advanced prostate cancer can enjoy good health for many years. However, if not properly treated, prostate cancer can cause serious symptoms and even turn fatal.
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What Is Bone Metastasis
The bone is a common site for metastasis. Bone metastasis or âbone metsâ occurs when cancer cells from the primary tumor relocate to the bone. Prostate, breast, and lung cancers are most likely to spread to the bone. However, other cancers are not excluded. Bone metastases do not begin from the bones but move there from the primary tumor site. On the other hand, primary bone cancers are rare cancers where the primary tumor actually starts in the bone. Therefore, bone cancer and bone metastases are not the same.
As an example, consider a patient with prostate cancer. Prostate cancer cells from the primary tumor can break away and get into the bloodstream. Once in the blood, the cancer cell can travel to the bone and form a new tumor. It is important to remember that this secondary tumor is made up of abnormal prostate cancer cells, not abnormal bone cells. The result of this process is referred to as prostate cancer that has metastasized to the bone or metastatic prostate cancer. This is otherwise known as bone metastasis.
When cancer cells metastasize to the bone, they can cause changes to the bone. The process by which portions of the bone are damaged is called osteolysis. Oftentimes, small holes result from osteolysis. These holes in the bone are referred to as osteolytic lesions or lytic lesions. Lytic lesions can weaken the bones and increase the risk of breakage or other problems. It is also common for bone metastasis patients to experience pain with lesions.
What Types Of Hormone Therapy Are There
There are two basic kinds of hormone therapy for prostate cancer. One class of drugs stops the body from making certain hormones. The other allows the body to make these hormones, but prevents them from attaching to the cancer cells. Some doctors start treatment with both drugs in an effort to achieve a total androgen block. This approach goes by several names: combined androgen blockade, complete androgen blockade, or total androgen blockade.
Hereâs a rundown of the techniques.
Hormone therapy for prostate cancer can cause bone thinning osteoporosis, which can lead to broken bones. However, treatment with bisphosphonates â like Aredia, Fosamax, and Zometaâ may help prevent this condition from developing, says Holden.
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Survival By Disease Progression
The extent prostate cancer has progressed can influence survival rates.
Prostate-specific antigen is a protein produced by cells of the prostate gland by normal and malignant cells. In men with prostate cancer, blood levels of PSA are often elevated.
Doctors can use PSA as a marker to better understand the progression of prostate cancer and the resulting prognosis.
One way doctors assess the progression of the disease is through PSA doubling time. This refers to the number of months it takes for PSA to double.
One study suggests a short doubling time means a poorer prognosis for patients with stage IV prostate cancer. Median survival was 16.5 months for those with a PSA doubling time lower than 45 days compared with 26 months for patients with a longer PSA doubling time.
Whether or not the cancer has metastasized and spread to other areas of the body outside the prostate can also influence survival. In distant or stage IV prostate cancer, when cancer has spread from the prostate to other organs like the liver or lungs, the five-year survival rate is 31% compared with localized cancer, which has a five-year survival rate of nearly 100%.
Multidisciplinary Nature Of Treatment In Todays Advanced Prostate Cancer Care Paradigm
As the therapeutic landscape evolves to include increasingly complex combinations of systemic therapies with or without local therapies, advances in imaging, and germline and somatic genetic testing, treating men with advanced prostate cancer is increasingly one that must embrace multidisciplinary management approaches. Team members should include urologists, medical oncologists, and radiation oncologists at a minimum when supporting treatment decisions for advanced disease. Additional specialists may also include genitourinary pathology, genetic counseling, palliative care, and holistic specialists, as appropriate, in addition to primary care. Best practices must also include clinicians comfortable describing the use of germline and somatic genetic testing, and when advanced imaging techniques could be optimally used or avoided. Radiologists and nuclear medicine specialists are valuable in helping to accurately interpret scans. Palliative care team members may also play a key role when treating men with symptomatic metastatic disease. Palliative care itself is an interdisciplinary, holistic approach to managing an advanced disease such as prostate cancer with a guarded prognosis. It can include controlling symptoms that are physical, psychological, spiritual, and social. The goal of palliation is to prevent and relieve suffering and to support the best possible QOL for the patient and family.
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The Frequency Of Bcr Cp Crd And Rates Of Bpfs Cpfs Css
Median time of follow-up after RP was 64 months. Over this time, 207 men experienced BCR. One hundred twenty-seven men had BCR in the following year after RP, 27 in the second year, 16 in the third, 14 in the fourth, 7 in the fifth, and 16 patients had BCR after 5 years . Of 207 men, 181 received salvage radiotherapy or hormone therapy or both sRT + HT due to BCR.
Figure 1. Risk of biochemical recurrence by the following year after radical prostatectomy .
CP was diagnosed in 49 cases. Median time from BCR to CP was 17 months. Twelve men had metastases in lymph nodes, 11 had metastases in bones, 19 had metastases in lymph nodes and bones, 1 had visceral metastases, and 6 had local recurrence in the surgical bed. During the follow-up, 72 patients died. In 24 cases PCa was the cause of death.
According to the DAmico risk classification, the 5-year BPFS rate after RP of patients with one risk factor was 57.7%, and that with two factors was 34.4%. All patients with three risk factors had BCR in the first 5 years after RP .
In all study cohorts, 5- and 10-year BPFS rate was 49.2 and 34.2%, respectively. CPFS rate was 89.2 and 81% and CSS rate was 95.6 and 90.1%, respectively.
Staging Of Prostate Cancer
- Stage I : The Gleason score is 6 or less, and the PSA level is less than 10. Cancer at this stage is normally not detectable in an ultrasound test or in a DRE test, as the tumor is very small. It is within the prostate and has not spread to nearby lymph nodes. It is usually discovered accidentally during a surgery carried out for another purpose. Prostate ultrasound and biopsy can be performed after detection of elevated blood PSA levels.
- Stage II : From this stage onwards, the Gleason score and the PSA level may vary from person to person. As the tumor grows in size, it can be detected in a DRE test or sonogram, but the tumor is still confined to the prostate gland. It is in one half or less of only one side of the prostate. It hasnt spread to lymph nodes and nearby organs, or it has spread to nearby lymph nodes, but has not invaded nearby organs.
- Stage III : The cancerous cells spread out from the original site and invade the seminal vesicles. They do not spread to nearby lymph nodes or to nearby organs in the body.
- Stage IV : The cancer moves out of the seminal vesicles and invades the lymph nodes. The size and number of tumors increase, and the cancerous cells spread into the nearby organs, such as the bladder and the rectum. In stage four prostate cancer, even bones and other parts of the body like lungs and liver are likely to be invaded by the cancerous cells.
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Neoadjuvant And Adjuvant Hormonal Therapy With Rt
A consideration of the role of adjuvant therapy with RT is useful before examining the treatment choices in the setting of BCR after RT. The combination of RT with gonadotrophin-releasing hormone ADT is proven to be superior to RT alone followed by deferred ADT upon BCR . Use of adjuvant or neoadjuvant ADT with RT in patients with locally advanced PCa is now standard practice.
A meta-analysis showed that for localised and locally advanced PCa, neoadjuvant ADT before RT significantly improved biochemical disease-free survival and clinical disease-free survival . For patients with a Gleason score of 26, neoadjuvant ADT before RT significantly improved OS, and a short duration of neoadjuvant ADT should therefore be considered in such patients .
While the evidence strongly favours neoadjuvant/adjuvant therapy in patients with locally advanced PCa , the value of this approach in intermediate- or high-risk localised PCa is less clear . Rates of BCR may be reduced with adjuvant or neoadjuvant ADT in carefully selected patients with intermediate- or high-risk localised PCa , and the decision to use adjuvant or neoadjuvant ADT with RT in such patients should therefore be based upon individualised assessment.
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Searches And Article Selection
A research librarian conducted searches in Ovid MEDLINE , Cochrane Central Register of Controlled Trials , and Cochrane Database of Systematic Reviews . An updated search was conducted prior to publication through January 20, 2020. The methodology team supplemented searches of electronic databases with the studies included in the prior AUA review and by reviewing reference lists of relevant articles.
The methodology team developed criteria for inclusion and exclusion of studies based on the Key Questions and the populations, interventions, comparators, outcomes, and settings of interest. The population was patients with advanced prostate cancer as described in Table 3. Treatments included first and second line antiandrogens, immunotherapy, chemotherapy, radiation therapy, surgery, radiopharmaceuticals, and surveillance strategies. Comparisons were against placebo, no therapy, or another active intervention and intermittent versus continuous therapy. Outcomes included overall survival , prostate cancer mortality, progression-free survival , prostate-specific antigen progression-free survival , failure-free survival, metastases-free survival, time to metastases, time to progression, skeletal events, and adverse events.
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Stage Iv Prostate Cancer Prognosis
Prostate cancers detected at the distant stage have an average five-year survival rate of 28 percent, which is much lower than local and regional cancers of the prostate. This average survival rate represents stage IV prostate cancers that have metastasized beyond nearby areas to lymph nodes, organs or bones in other parts of the body.