NCCN Prostate Cancer Guidelines Update: To Screen and Treat or Not?

A prostate cancer diagnosis is made every 3 minutes in the United States, and every 18 minutes an American succumbs to this disease—a 6-fold difference. At the National Comprehensive Cancer Network (NCCN) 15th Annual Meeting, James L. Mohler, MD, Roswell Park Cancer Institute, presented updates to the NCCN Prostate Cancer Guidelines, noting that prostate cancer is a complex disease with considerable controversy surrounding its management. Because there is a paucity of sound data to support most recommendations, the NCCN Guidelines strive to provide an evidence-based framework on which healthcare providers can base screening and treatment decisions.

Screening

The Guidelines recommend annual prostate cancer screening using prostate specific antigen (PSA) and digital rectal examination starting at 40 years in men at higher risk of prostate cancer, such as African-American men and those with a family history of prostate cancer. Other men should be screened starting at age 50 and examined annually until their life expectancy is less than 10 years. “When men get to age 65, we should become more casual. If physiological age is greater than 75, we need to stop,” said Mohler, noting that prostate specific antigen (PSA) screening is so controversial because 70% of men with an elevated PSA have negative biopsies and PSA levels are known to fluctuate up to 36% daily.

Biopsy can also prove challenging, identifying only 75% of prostate cancers on a first biopsy, 91% on a second biopsy, and 97% on a third biopsy, though Mohler noted that you would probably find any clinical meaningful prostate cancer with a 12-core biopsy. He also stressed the importance of conducting a digital rectal exam, noting that while PSA tests identify more prostate cancers than digital rectal exams, they do not detect bulky tumors, which are imperative to catch due to their more aggressive nature.

Active Surveillance

The Guidelines have been updated to include a very low risk prostate cancer category, which includes the following criteria: stage T1c; Gleason Score (GS), 2-6; prostate specific antigen (PSA) <10; <3 cores positive; <50% cancer in any core; and PSA density <0.15. Patients who fall into this category and have a life expectancy of less than 20 years may be monitored through PSA screenings as often as every 6 months and digital rectal examinations as often as every 12 months. Those considered low risk (T1-T2a; GS, 2-6; PSA <10) and with a life expectancy of approximately 10 years may also be monitored, but surveillance in these patients may include biopsy as often as every 12 months if their life expectancy is 10 years or more.

Treatment

According to Mohler, patients are being over-treated based on their PSA levels. “If we biopsied everyone with a PSA over 2.5, we would find 775,000 cases of prostate cancer. We do not need to find and treat all the prostate cancer we can,” he said. While he cautioned that medicine should not move backwards, approximately 10% of US men have received an unnecessary prostatectomy and 45% have been over-treated with radiotherapy based on SEER data.

While some patients may prefer treatment over expectant management, Mohler noted that many patients are treated because of anxiety. “I will put to you that a lot of that is physician-generated anxiety," he said, noting that while disease progression may occur, the chances of this are small, and if disease progression results, it will likely preclude nerve-sparing surgery, which may increase the risk of erectile dysfunction but likely won’t affect outcomes. Mohler noted that those in good health and with long life expectancy should be treated whereas those with poor health and a short life expectancy should not. As for those with a median life expectancy, treatment route will remain the patient’s decision for now.

In patients selecting or requiring treatment, radical prostatectomy can be performed using an open, laparoscopic, or robotic approach. Mohler noted that the majority of men undergoing radical prostatectomy should regain urinary continence and erectile function postoperatively. When radiation is employed, dose-escalation should be used when appropriate, and daily localization is imperative to preventing long-term side effects.

To review the full NCCN Guidelines, including Prostate Cancer, visit the NCCN website.