ESMO Minimum Clinical Recommendations for diagnosis, treatment and follow-up of prostate cancer
V. V. Kataja
Department of Oncology, University Hospital of Kuopio, Kuopio, Finland
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Incidence
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- The age-standardized incidence of prostate cancer in the European Union is 65/100 000, and mortality 26/100 000 per year. It is the most common male cancer in Western Europe and the Nordic countries. The mean diagnostic age is 71 years. Latent sub-clinical prostate cancer is very common in men >80 years. Only 1 in 10 latent cancers will eventually become clinical cancers.
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Early diagnosis
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- Early diagnosis (screening) of asymptomatic men with prostate specific antigen (PSA) testing, digital rectal examination and/or rectal ultrasound has not yet been proven to prolong survival [II, B]. Serum PSA should be measured for patients presenting with urinary symptoms. If serum total PSA is 02 µg/l, the probability of prostate cancer is 1%. If it is >10 µg/l the probability is >50% [II, B]. Pathological diagnosis should be made from a histological specimen obtained by ultrasound-guided core-needle biopsy. The pathologist should report the grading using either the WHO or the Gleason classification.
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Staging
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- Routine staging should include full blood count, alkaline phosphatase, creatinine and serum PSA. Clinical assessment should be done by digital rectal examination. Radiological examinations should include rectal ultrasound to assess the size, form, glandular structure and possible capsular and/or seminal vesicle involvement [III, C] and a chest X-ray. Pelvic lymph node involvement can reliably be assessed only by laparoscopic biopsy or in open surgery. Bone scintigraphy should be performed if bone metastases are suspected clinically or PSA is >10 µg/l [II, B]. TNM staging system should be used (Table 1).
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Treatment of localized prostate cancer (T14NXM0)
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- There is no general consensus as to what is the best treatment. If the tumor is well-differentiated and intracapsular, the 10-year survival rate is 9094% with all treatment modalities [II, B]. The decision upon the treatment should be based on the clinical stage and histopathological classification as well as on the patients age and general physical condition and co-morbidity. The patient should be informed of the potential benefits and harms of the different treatment options before the final decision. Treatment options are (Table 2):
External radiotherapy and brachytherapy are alternatives to radical prostatectomy in T12 tumors.
To achieve local control the target dose in external radiotherapy should be 6672 Gy given in 1.82.0 Gy fractions in 67 weeks.
Androgen suppression before and during radiotherapy or following it significantly improves local control, reduces disease progression and improves overall survival in T2T4 tumors [II, A].
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Treatment of metastatic prostate cancer
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- Treatment is primarily hormonal. Treatment options are (Table 3):
Medical castration with luteinizing hormone-releasing hormone (LHRH) analogs should be accompanied by an antiandrogen for 4 weeks. There is no proven benefit for continuing total androgen blockade beyond this.
Chemotherapy (mitoxantrone, estramustine, possibly docetaxel) may palliate pain, but has not been proven to prolong survival.
Palliation of pain with anti-inflammatory drugs and opiates is important, and palliation of bone pain with external radiotherapy or radioisotopes.
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Follow-up
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- Following curative radical prostatectomy, serum PSA should be below detection level after 2 months. Following curative external radiotherapy, serum PSA should reach 1 µg/l within 16 months [II, B]. The first follow-up visit after radical treatment should be at 3 months.
In addition to measuring PSA value, digital rectal examination should be performed and all symptoms, especially treatment related, checked. Yearly visits are recommended after this.
No recommendation can be given on the timing of second-line treatment of asymptomatic patients.
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Note
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Levels of Evidence [IV] and Grades of Recommendation [AD] as used by the American Society of Clinical Oncology are given in square brackets. Statements without grading were considered justified standard clinical practice by the expert authors and the ESMO faculty.
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Literature
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Coordinating author for the ESMO Guidelines Task Force: V. V. Kataja, Department of Oncology, University Hospital of Kuopio, Kuopio, Finland.
Approved by the ESMO Guidelines Task Force: August 2002.
Correspondence to:
ESMO Guidelines Task Force
ESMO Head Office
Via La Santa 7
CH-6962 Viganello-Lugano
Switzerland
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References
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