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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 Treatment of metastatic prostate...
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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.


    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 0–2 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.


    Staging
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 Treatment of metastatic prostate...
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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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Table 1.
 

    Treatment of localized prostate cancer (T1–4NXM0)
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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 90–94% 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 patient’s 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 T1–2 tumors.
To achieve local control the target dose in external radiotherapy should be 66–72 Gy given in 1.8–2.0 Gy fractions in 6–7 weeks.
Androgen suppression before and during radiotherapy or following it significantly improves local control, reduces disease progression and improves overall survival in T2–T4 tumors [II, A].


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Table 2.
 

    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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Table 3.
 

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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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 Treatment of metastatic prostate...
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Levels of Evidence [I–V] and Grades of Recommendation [A–D] 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.


    Literature
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 Treatment of metastatic prostate...
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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


    References
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1. Catalona WJ, Richiek JP, Ahmann FR et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6639 men. J Urol 1994; 151: 1283–1290.[ISI][Medline]

2. Kramer BS, Gohagan JK, Prorok PC. Clinical oncology update: prostate cancer. is screening for prostate cancer the current gold standard? ‘No’. Eur J Cancer 1997; 33: 348–353.[Medline]

3. Keetch DW, Catalona WJ, Smith DS. Serial prostatic biopsies in men with persistently elevated serum prostate specific antigen values. J Urol 1994; 151: 1571–1574.[ISI][Medline]

4. Gleave ME, Coupland D, Drachenberg D et al. Ability of serum prostate-specific antigen levels to predict normal bone scans in patients with newly diagnosed prostate cancer. Urology 1996; 47: 708–712.[CrossRef][ISI][Medline]

5. Lu Yao GL, Yao S-L. Population based study of long-term survival in patients with clinically localised prostate cancer. Lancet 1997; 349: 906–910.[CrossRef][ISI][Medline]

6. Robinson MR, Smith PH, Richards B et al. The final analysis of the EORTC Genito-Urinary Tract Cancer Co-Operative Group phase III clinical trial (protocol 30805) comparing orchidectomy, orchidectomy plus cyproterone acetate and low dose stilboestrol in the management of metastatic carcinoma of the prostate. Eur Urol 1995; 28: 273–283.[ISI][Medline]

7. Tannock IF, Osoba D, Stockler MR et al. Chemotherapy with mitoxantrone plus prednisone or prednisone alone for symptomatic hormone-resistant prostate cancer: a Canadian randomized trial with palliative end points. J Clin Oncol 1996; 14: 1756–1764.[Abstract]

8. Boccon-Gibod L. Monitoring and treating the patient after radical treatment of localized prostatic cancer. Eur Urol 1994; 20: 154–159.

9. Zagars GK. Serum PSA as a tumor marker for patients undergoing definitive radiation therapy. Urol Clin North Am 1993; 20: 737–747.[ISI][Medline]

10. Lawton CA, Winter K, Murray K et al. Updated results of the phase III Radiation Therapy Oncology Group (RTOG) trial 85-31 evaluating the potential benefit of androgen suppression following standard radiation therapy for unfavourable prognosis carcinoma of the prostate. Int J Radiat Oncol Biol Phys 2001; 49: 937–946.[ISI][Medline]

11. Pilepich MV, Winter K, John MJ et al. Phase III Radiation Therapy Oncology Group (RTOG) trial 86-10 of androgen deprivation adjunct to definitive radiotherapy in locally advanced carcinoma of the prostate. Int J Radiat Oncol Biol Phys 2001; 50: 1243–1252.[ISI][Medline]