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Four current clinical practice guidelines on prostate cancer provide urologists with valuable, evidence-based decision points about diagnosis and treatment while raising questions that will likely be addressed by future research.
|Neal D. Shore, MD||Dr. Shore|
This special supplement to Urology Times provides expert commentary and take-away messages from four current clinical practice guidelines on prostate cancer. The guidelines provide urologists with valuable, evidence-based decision points about diagnosis and treatment while raising questions that will likely be addressed by future research.
Early detection. From the inception of PSA development and utilization in the early 1980s through the present, there is consensus that urology has not efficiently utilized PSA as a screening test, resulting in unnecessary patient morbidity and costs. Still, most urologists would concur that the U.S. Preventive Services Task Force’s draconian recommendations are detrimental not only because they lacked input from urology leadership but also because they largely were policy driven and failed to account for patient-physician shared decision-making.
In light of the USPSTF edict, as well as the responses from organized medicine and the evidence-based research, the urologic community was already transforming to an awareness of the option of active surveillance (AS). Certainly, binary decision-making for a biopsy based on PSA alone is not acceptable. Moreover, the traditional clinical parameters, as well as newer biomarker assays and imaging advances, should further improve biopsy decision-making.
Challenges still facing the busy clinician are many: How can I best actuarially calculate 10- to 20-year life expectancy; how do I most appropriately discuss quality of life versus survival extension in the “shared decision-making process”; and, importantly, with the looming shift from volume-based to value-based care and the unrelenting medicolegal risk, how will future discussions between physician and patient best ensue?
Next: Active surveillance
Active surveillance. The NCCN multidisciplinary panel recommendations are valuable for urologists, not only for their review of the most recent data but also because of the scrutiny paid to them by third-party payers. Expanding the spectrum of inclusion for newly diagnosed patients with favorable intermediate-risk disease is beneficial for shared decision-making with the urologist, should he or she be hesitant to delay/avoid an intervention.
Forgoing a discussion of cost considerations, the borderline candidate for AS or the patient who misinterprets or is apprehensive about the cancer diagnosis can derive further information in addition to the traditional parameters with currently available genomic assays (ie, Prolaris, Oncotype DX). These tests and potentially new markers and imaging tests may optimally determine who should have AS versus intervention.
The field still awaits consensus on the ideal AS protocol, with capabilities for individualized flexibility-important for the clinician and patient in order to recognize the “one-third progressor” group, and thus not miss the window of opportunity for cure.
Radiation after prostatectomy. Both the AUA/ASTRO guideline recommendations and the subsequent ASCO endorsement with additional specifications are important in assisting the shared decision between physician and patient regarding both adjuvant and salvage radiation therapy options after prostatectomy. The historical evidence suggests significant underutilization of the option for radiation therapy, with a presumed overutilization of subsequent androgen deprivation therapy as the second-line treatment. As both the guideline and endorsement emphasize, individualized assessment of multiple variables is key: evaluating not only the PSA in a vacuum, but the timing of PSA recurrence, rate of rise, histopathology, comorbidities, risk-benefit ratio of radiation, and approved genomic markers (ie, Prolaris, Decipher).
Next: Castration-resistant disease
Castration-resistant disease. The AUA CRPC guideline committee has performed an invaluable task, and continues to do so with annual updates, assisting with the education of clinicians dedicated to managing CRPC. A key facet to appreciating the AUA guidelines, as well as NCCN, ASCO, EAU, and the St. Gallen Consensus recommendations, is to recognize the complexity of this field, as we traverse the therapeutic “embarrassment of riches” and the near-term addition of immunologic and oncolytic options as well as diagnostics that will better inform our decisions.
Importantly, the guidelines are not dogma, but provide recommendations for the most appropriate care based on meta-analysis of the evidence-based data. There are still unmet questions: What is the ideal testosterone level of suppression; what do we offer the patient with M0CRPC; when do we stop an approved agent; and, of course, how do we maximally combine agents and/or sequence most beneficially for patient care?
In an advanced prostate cancer clinic, understanding the balance between volume of care for these very expensive antineoplastic agents and the efficiency of costs is required. Moreover, the champions of that care should be fully dedicated to the ongoing management of CRPC patients.
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