2016 NCCN Prostate Cancer Physician Guidelines

NCCN has released their annual update of physician guidelines for prostate cancer (they usually come out with their more user-friendly patient guidelines a little later.) Arguably, this represents the standard of care for PC, as many of the top PC docs in the US reach a consensus.

What's new this year? The major updates were:

• New risk groups: as expected, they subdivided intermediate risk PC into "favorable" and "unfavorable" categories. "Favorable intermediate risk" is defined as intermediate risk with Gleason score of 3+4 and % positive biopsy cores<50% and no more than one intermediate risk factor (Gleason score, stage or PSA). NCCN endorses active surveillance as an option for favorable intermediate risk men but not for unfavorable intermediate risk.

• Docetaxel +ADT has been added as an initial treatment option for all high risk or very high risk men, regardless of metastases. It has also been added for all hormone-sensitive men with distant mets, although they note the benefit is less certain for low volume mets.

• Intermittent ADT is an option for hormone-sensitive men regardless of metastatic status.

• EBRT+ADT has been elevated to the preferred initial treatment option (over just ADT) for men diagnosed with lymph node but no distant mets.

• Estrogen has been added as an option for metastatic castrate-resistant men

NCCN Prostate Cancer Physician Guidelines v.1.2016

Andrew, well we did hear champagne was helpful in another recent post. Maybe it will be make it into next year's guidelines.

So the favorable/unfavorable intermediate risk distinction had not had the blessing of the NCCN up until now? I hadn't realized that...

With respect to PROS-4, the page mapping out Intermediate-risk cases, they should have made the "favorable" and "unfavorable" distinctions more than footnotes...they really should have broken this page into two different pages--one page for 3+4 and another page for 4+3--so that their endorsement of AS for 3+4 cases was more clear. It is, I recognize, very clear in the PROS-C section (Principles of AS & Observation), but is buried in the more visible PROS-4. The lumping of 3+4 and 4+3s together is one of the biggest weaknesses of the otherwise outstanding NCCN Guidelines.

When the NCCN guidelines eventually gets updated to encompass the new Epstein grading system (we are still probably a few years of adoption away from this), this point will probably become more clear...

OK, where do you find a decoder ring for the acronyms.
T

Check the sticky:
Long-Running Threads and Prostate Cancer Abbreviations

But these guidelines are designed for physicians rather than patients. The National Comprehensive Cancer Network (NCCN) also puts out more patient-friendly guidelines. You can see the last year's version for patients at the following link:

www.nccn.org/patients/guidelines/prostate/index.html

- Allen

"> Docetaxel +ADT has been added as an initial treatment option for all high risk or very high risk men, regardless of metastases. It has also been added for all hormone-sensitive men with distant mets, although they note the benefit is less certain for low volume mets.

> Intermittent ADT is an option for hormone-sensitive men regardless of metastatic status."

While a fan of E3805, I question the data that proves either category. We just do not have enough data to prove a non-metastatic case will benefit from early Chemo. And we know that metastatic cases that are hormone sensitive better benefit with continuous HT.

That stated one of the E3805 trial designers is my oncologist. He says he wished he talked me into docetaxel in 2007. I haven't decided to agree or not agree. Still good at year 9...

Tall Allen ...

Thanks for the update ... good to see the advances being made

Ray

Great point, ASAdvocate...times are changing.

But shockingly, even though we can now readily identify the harmless cancers, the problem of rampant PC overtreatment continues.

Despite rising up to nearly 40%, as you reported, in 2015 another 50,000 men underwent unnecessary radical treatment. It used to be closer to 100,000 per year, leading to over a million men in the US living with impotence and incontinence for no justifiable reason. We are making progress, but still a disaster of gargantuan proportions.

I have to say, our (wife incl.) first response to the PC diagnosis, was totally based on "emotion" - Take it Out now.

Because, the urologist would not accept a treatment selection until weeks later. I had the time to hit the web for information.

Thank God I did, HW members opened my eyes to the reality of my condition. Information/Knowledge, is the true survival element of life.
____________________________________________________________________________________________
OCTOBER 2015
Age: 59
PSA: 3.0 elevated to 3.5 in (6) months
3T-MRI: (1) lesion identified
Fusion Biopsy Results: Lesion cores benign, additional (12) cores = (1) positive, cancer <5%
Pathology Summary: Grade 1 (GS6:3+3), 2nd pathology verification
Clinical Stage: T1c
Cancer DNA Profile: DNA risk status unknown (Oncotype DX test cannot be performed, <1mm)
High Grade Biological Score: 27% aggressive risk (Mi-Prostate Score)
Other Health Conditions: Diabetes Type II (DX 2000), on meds & insulin

PC Treatment: "Active Surveillance"
Risk: Undetected Cancer Progression
Risk Likelihood: LOW

My Story: https://www.healingwell.com/community/default.aspx?f=35&m=3528051

RCS, I recently received an annual publication on prostate diseases from Johns Hopkins.

In this edition, Dr. Ballentine Carter, who is the godfather of Active Surveillance (at least at JH), addressed the issue of Gleason 6 being termed a cancer. He was strongly opposed to changing it to be something less. His reason was that patients would not follow up, where he believes that they must certainly do so.

I suppose I would say that....IF the patient is counseled to wait for something to happen (or not)--in other words is encouraged into AS...and chooses treatment anyway...then they aren't being "overtreated". Would you tell women who had the 'breast cancer gene' and underwent mastectomy as a preventive measure (Angelina Jolie for example) that THEY were overtreated and got railroaded into unnecessary surgery?

People go against their physician's advice all the time, and choose dangerous or unnecessary treatments all the time. And, they will continue to do so, for all manner of reasons. The only patient, however, who's treatment decisions I am responsible for, is me.

RCS said...
Halbert,

I feel that as long as G6 is considered cancerous, there will continue to be a diminishing tendency for guys to seek active (non AS) treatment.

Once G6 is relegated to the status of a G5 or G4, I feel active treatments will crater .... much to the chagrin of those you term "money-grubbers", as well as all-stars trying to earn a buck. Therefore, I do not see the AMA endorsing the reclassification of G6 anytime soon.

RCS, regarding the first paragraph, and first sentence of the second paragraph, i think you are 100% spot on. And thats a very good thing.
Regarding the bolded comment, i'm afraid you are right again, GENERALLY SPEAKING, money makes the world go round, whether its three card monte on the streets of Manhattan, or a Professional organization like the AMA, trying to protect their interests.

With that said, i emphasize generally speaking. My experience with MOST of the Drs i've dealt with has been nothing but exemplary. My surgeon encouraged me to consult a radiation oncologist before making a decision. The radiation oncologist stated to me, in pretty much these words "surgery and radiaton will both give you an equally high probability of cure. I'm going to go through your options along with the pluses and minuses of each, but while i do, i want you to make sure you keep in mind, that I'm a radiation oncologist and i have a natural bias towards radiation." And the urologist i went to at Columbia Presbyterian in NYC, when i was told i needed (my first) biopsy, told me before the biopsy - "if it does come back positive, unless its aggressive, remember that we do a lot more Active Surviellance than we used to"

So its important to remember that there are good people practicing medicine, that truly want to do whats best for the patient.
Just had to get that out

Halbert, you too, make a good analogy, to the patient with Breast Cancer.
If someone is told they have a G6. There is risk. Period. If for no other reason, than because 30-40% of G6 biopsies turn into G7 after surgery (ref you and I). And even with 3T MRI able to detect THE VAST MAJORITY of higher grades, it is, from all I've read, 95% accurate. This is different, for those not as proficient in math, as Mel, our resident Mathematician, than 100%.

So in view of this, it seems to me that a patient biopsied at G6, clearly has some level of risk. He shouldn't be misled to think he doesn't, and doesn't need treatment. The choice in just how much risk a man must accept, should be his own decision.