New AUA Guidelines for treating prostate cancer are out

Well it's official! The new AUA/ASTRO/SUO Clinical Guidelines for treating localized cancer of the prostate are now posted publicly. I am a co-authored of this document. This was truly and honor to be a part of. It was 18 months ago I was approached to be on this panel. It involved dozens of phone calls, emails, a trip to AUA headquarters in Virginia, and will be a main discussion during the Plenary session at AUA2017 in Boston this coming Friday. The physicians were multidisciplinary and terrific to work with. As was our coordinator. I was made to feel a part of this team right from the get go.

/www.auanet.org/guidelines/clinically-localized-prostate-cancer-new-(aua/astro/suo-guideline-2017)

LOL, so let the second guessing begin!

***IMPORTANT NOTE***
Each statement is shown two locations. First there is a straight list of all 68 statements. Later in the guidelines each statement has a discussion "button" that provides additional information on the reasoning behind each guideline statement. I highly recommend reading the entire document including the discussions provided.

Thanks for the link. It's interesting reading, particularly the discussion section about each point.

Also, the huge number of reference links is quite valuable. Those links carry more weight, since they're given extra credence by inclusion after review by this knowledgeable panel.

Thanks for your ongoing support of the PCa community!

Allen,
I look forward to our discussion on this. My only need is to honor my non-disclosure agreement of the behind the scenes discussions at this time. But I am certain with all of these physicians I have a good communication channel with. But also with the other stakeholders like the AUA/ASTRO/SUO... I can say this was a multi-disciplinary effort. The RO's are very well known. That was important in their effort in the authorship.

It speaks very well for the folks at AUA/ASTRO/SUO that they included someone with personal experience of PCa.

Thanks for sharing.

I was dismayed to see that according to this report I am an unfavorable risk and should have been offered ADT as part of my treatment. Here is how my RO described it:

Primary Site: Favorable Intermediate Risk, clinical stage T1cN0M0 adenocarcinoma of the prostate, Gleason score 3+4 with a pretreatment PSA of 11.19.

Furthermore, he and I discussed ADT and he said not recommended in my case.

Hi Jim, and all,
I just want to point out that this was not just AUA that sat on the panel. This was a multidiscipline panel with ASTRO and SUO having sitting members.

As far as radiation modalities. The AHRQ data still shows that there are still far more IMRT procedures for PCa last year than all other modalities combined. Though trends show upticks in HDR, PBT, and SBRT, there are still a limited number of facilities that have these techniques available. IMRT is pretty much available at all clinics. I will say that it's pretty obvious looking at the authors list that Howard Sandler, George Rodrigues, and Ronald Chen were intently involved with what was stated concerning radiation. They are all radiation oncologists that are well known in the ranks and file.

I can't comment on the elephant in the room because that will be discussed this weekend at AUA. I was attending entire discussions of each statement. When I can comment I will. I hope it's not for the entire year my NDA on private panel discussions is in effect. The start date of that NDA is effectively today as the AUA is announcing the new guidelines at the plenary session AUA2017. But as comments are made publicly I am free to regurgitate them. I've requested some liberties and they will probably grant it soon enough.

Tony,

That's disingenuous, and doesn't reflect how decisions are made in the real world. Once information is public, it is public to patients and clinicians alike. We don't have one set of facts for patients and another set for doctors - there are no alternative facts.

If you truly believed that, you would not have posted this thread on HW.

I just modified the original post adding:

"***IMPORTANT NOTE***
Each statement is shown two locations. First there is a straight list of all 68 statements. Later in the guidelines each statement has a discussion "button" that provides additional information on the reasoning behind each guideline statement. I highly recommend reading the entire document including the discussions provided."

I am thinking that some only read the statements and not the discussions. It's reminded me of a time a member of my support group asked for the NCCN Treatment Guidelines a few years ago. I sent them and two years later he mentioned he thought they were useless. I ask him why and he stated that he printed them all out and they were very difficult to follow. Of course the file is an interactive document with click points to keep you following along nicely. So you need to read it on a computer because page by page in a printout they will make little sense. Same with our statements here. If you don't read the discussion points you might make up your own mind what the statement actually means.

Post Edited (Tony Crispino) : 5/12/2017 4:19:46 PM (GMT-6)

I just posted some detailed comments on InfoLink that I will copy and paste here too:

On the whole, it was fair and balanced. I think it does a great job of dispelling many of the half-truths and myths that patients hear. A few reactions I had:

• I was particularly impressed by the first section on shared decision-making, and the section on active surveillance. (BTW -What happened to the links for statements 6-27?)

I would like to have seen a statement that active surveillance is appropriate for low risk men regardless of age.

• Statement 40 should have mentioned other morbidities associated with PLND: thromboembolisms and permanent lymphedema.

There was no mention of treatment of men newly diagnosed with N1M0 from STAMPEDE and other data analyses.

• Statements 23 and 41 should have included strong guidance that cancer control was significantly increased by the addition of a brachy boost to EBRT in unfavorable risk patients. This has been proved in a large RCT for LDR brachy boost (ASCENDE-RT), and 3 RCTs for HDR brachy boost. There is now Level 2 evidence that cancer control is vastly improved in high risk patients compared to surgery ± salvage radiation.

• Statement 41: They should mention the benefit of allowing urinary and sexual symptoms to improve with early salvage rather than adjuvant radiation, and the possible use of adjuvant ADT to prevent progression while waiting for continence to be restored.

• While there was a lot of space devoted to focal therapies (guidelines 50-60 et al.), there was little (a brief mention in #42) devoted to HDR-BT or SBRT - a glaring omission imho.

• For consistency, they should have adopted the NCCN (Zumsteg) definitions for favorable and unfavorable intermediate risk. The unfavorable category should include those with >50% positive cores even with GS3+4, even though the data are "less robust."

• Statement 61 (about ED): once again (as in the PROSTQA study), they hid the important distinctions by not breaking it down by age groups. Among 60-69 yo men, potency preservation 2+ years post-treatment was 27% for RP, 39% for EBRT and 44% for BT. They also ignore that in some studies they reference, men receiving EBRT were 10 years older than men receiving surgery.

I like that they finally mentioned climacturia and anorgasmia, but they did not mention perceived penile shrinkage or Peyronie's.

They should have recommended early penile rehab after RP, and prophylactic ED meds with RT.

• Statement 64 (about bother with incontinence and ED) bothers me a lot. The fact is, people are adaptive, and unless symptoms worsen, "bother" scores will naturally lessen over time. The ProtecT RCT showed that about 20% had lasting incontinence. They were also wrong to draw an equivalence with the irritative effects after radiation - at 6 years post-treatment, urinary irritation/obstruction EPIC scores were virtually identical and back to baseline for both RP and EBRT. The same holds true for bowel function EPIC scores.

• Statement 66: I'm disappointed that they did not recommend ultrasensitive PSA for monitoring after RP. They should also have recommended referral to a radiation oncologist at the earliest indication of uPSA recurrence.

• There should have been separate statements in the decision-making section about informing patients about the potential for salvage therapies if primary treatment should fail. This is included in the explanation of statement 66, but merits a guideline statement of its own. This should include a discussion that the probabilities of primary treatment failure with RP or RT are similarly small for favorable risk patients, so salvage should not be a key decision factor for them.

• There should be some mention made of the biggest benefits of RP: the patient gets a pathology report and, if successful, the PSA becomes immediately undetectable.

• Possibly statements about the low risk of secondary cancers from radiation, and the low risk of spreading the cancer with surgical instrumentation.

It's easy to pick at it, but it was a great step towards a collaborative effort to assure that patients don't hear different "truths" from different therapists. Tony is to be congratulated for keeping it all so patient-centric.

Addendum- I see there is a statement about the low risk of secondary cancers after radiation in the back-up to statement #4.

I would also like to see a statement in this section that the patient should be informed that he has plenty of time to meet with experts and make an informed choice. Even high risk patients who waited more than 3 months before getting treatment did no worse than patients waiting less than 3 months. That has been shown whether the choice was ultimately surgery and radiation. In fact, I hope the statement would be worded more strongly - that clinicians should not act on any decision until at least a month has passed. Decisions made in the emotional period of diagnosis may be different from a more considered opinion.

Tony -

One more question. I notice there is only the briefest of mentions of ART and none of SRT - both of which are potentially curative treatments for localized prostate cancer. Was that intentional because there is already a joint AUA/ASTRO guideline?/www.auanet.org/guidelines/radiation-after-prostatectomy-(astro/aua-guideline-2013)

If so, it could use a touch-up - it was last done in 2013 and is showing its age.

These are guidelines for members of the American Urological Association and the American Society of Radiation Oncologists. They do not apply to any other country- if counterpart professional associations want to use these recommendations, they are certainly free to do so. By defining a standard of care, they help Medicare and American insurance companies decide what they will cover.

I hope it will be updated every few years, and we don't have to wait ten years for the next one.