MUST READ: New Guidelines for Localized Prostate Cancer

The American Urological Association and the American Society for Radiation Oncology (AUA/ASTRO) just issued new guidelines for the treatment of localized prostate cancer.

There are major changes for active surveillance, being the preferred treatment for all low risk cases. Also, AS can now be considered for select favorable intermediate risk men.

There are cautions about the lack of high quality data for focal ablation, and a statement that proton has not been shown to be superior to other radiation choices in outcomes and toxicities. Lots of good information here that patients, especially those deciding treatment, should be aware of.

These new guidelines are the result of studies and discussions of new findings since the last publication five years ago.

https://www.auanet.org/guidelines/guidelines/clinically-localized-prostate-cancer-aua/astro-guideline-2022?fbclid=IwAR0puAJC0ROsyY_04pbG0B8CAw jXKdGDbn7pbIRCuD6HYV2ruF4ywGEVXJc

What is the exact definition of "low risk" they are using for AS especially with regard to biopsies?

Djin

I'm not sure how to interpret these two statements together:

"Risk Assessment

2. Clinicians may selectively use tissue-based genomic biomarkers when added risk stratification may alter clinical decision-making. (Expert Opinion)

3. Clinicians should not routinely use tissue-based genomic biomarkers for risk stratification or clinical decision-making. (Moderate Recommendation; Evidence Level: Grade B)"

So should a G6 biopsy result with lesions limited to less than half the prostate and an acceptable PSA have genomic testing or not before embarking on AS?

Djin

Post Edited (DjinTonic) : 5/11/2022 5:47:48 PM (GMT-6)

ASAdvocate said...
A Gleason 6 with a high PSA is not low risk. Actually, PSA Density is more definitive than total PSA. But, if those are not low risk, then point 2. would indicate that the clinician could selectively order a genomics test.

I'm talking about low PSA, not high. Since published Decipher data indicates that 1 in 10 G6 men test high-risk for progressing to higher-grade lesions and metastases within 5 years, I, for one, would want to know where I stand when making a decision about AS (even more so if told I'm an AS eligible G7). Some high-Decipher G6 men might feel comfortablel that AS monitoring will alert them about progression in time to be safely treated; some may choose to forego AS for treatment instead. I think we'll see adoption of genomic testing for AS eligibility for low-risk G7; I'm not sure about G6.

Djin

Could someone decode number 41 in the link. Did they come to the conclusion that it doesn’t matter when you start ADT, as long as you do start it. It looks like with a normal prostate size and contained PC at high risk, you can start ADT at any time with the same outcome. If that is the case, why start before RA? Thanks a bunch.
Jack

Thanks central, it looks like current practice will continue until a more studies are done. I would think that regardless of the outcome of new studies, that it certainly doesn’t hurt to get started before RA if you have to wait to get the treatment.
On the same subject, but some after treatment questions? Why do those with high risk only get six months ADT after surgery? Those of us who have elected RA need 18 months of ADT or longer. If there is any suspicion after the prostate is removed that PC still exists, why the shorter duration of ADT? The choice between surgery or RA continues. For high risk, it would seem that if RA is going to be needed after surgery anyway for high risk, why not go with RA to begin with? It would seem that a lot of SEs could be avoided by choosing RA and ADT over surgery. Again thanks a bunch for the clarification on the link. My best to all.
Jack

Here's a better link.
https://www.auanet.org/guidelines/guidelines/clinically-localized-prostate-cancer-aua/astro-guideline-2022

I recommend the Unabridged version though. That's a link here.

The new Guidelines discuss the ART vs SRT issue for those men who choose surgery and have positive local node(s); however, I don't see the ART vs SRT discussion for high- and very high-risk men with other adverse pathology (e.g., SM, SVI) revealed by surgery. The three recent studies that will probably sway the pendulum from ART to early SRT for most men suffered the usual problem of having relatively small numbers of Gleason 9-10 men, since very-high Gleason scores are much less common. The studies I've seen conclude that too few G9-10 men with adverse post-op pathology get advised adjuvant therapy.

A meta-analysis on the use of radiotherapy after prostatectomy: adjuvant versus early salvage radiation (Review, Full Text, June 2022)

"Abstract
To determine which method of radiotherapy proves more effective after prostatectomy: Adjuvant (ART) or early salvage (ESRT), we observed the pathologic and adverse risk factors of patients and their results from both treatments, looking specifically at biochemical-free survival rates, metastasis-free survival rates, and overall survival rates. Peer review articles containing their own data collected between 1986 and 2022 were reviewed. We reviewed 67 peer review articles and included 33 that met criteria. Studies focused on the adverse risk factors and the results of patients either before/after receiving adjuvant or early salvage/salvage radiotherapy were included in the analysis. Patient characteristics had an effect on what treatment a patient would receive; if a patient had more than one adverse risk factor such as a high Gleason score, prostate-specific antigen (PSA) level, T-stage, or positive margins, they would receive immediate radiation after prostatectomy, which would classify as ART. If the patient had no adverse risk factors after surgery, they would be placed in an observation period to follow their PSA and overall health, and only if necessary, undergo ESRT. Of the 33 studies, ART was proven to be only slightly more beneficial when relating to biochemical recurrence-free survival while ART and ESRT results were similar in metastasis-free survival and overall survival. ART and ESRT are overall comparable in their patient outcomes, despite their own unique pros and cons. The use of ESRT reduces overtreatment in men who may not experience biochemical recurrence. However, in those with very high-risk pathologic features, a multi-disciplinary approach should be utilized to best determine which mode of radiation therapy after surgery is recommended."

Post Edited (DjinTonic) : 5/14/2022 9:20:47 AM (GMT-6)