Updated prostate cancer guidelines stress risk stratification

September 1, 2007

A panel of urologists, oncologists, research specialists, and a statistician began meeting 5 years ago with the goal of updating the AUA guidelines for treating localized prostate cancer, last issued in 1995. After reviewing thousands of papers, the group released the updated guidelines at the AUA annual meeting in May.

The most important difference between the 1995 guidelines and the 2007 guidelines is the concept of risk stratification, according to Ian M. Thompson, MD, professor of urology at the University of Texas Health Sciences Center, and chair of the panel.

"The patient's expectations are important, and the physician should examine whether the tumor is a low-, intermediate-, or high-risk tumor," Dr. Thompson said. "All four treatment options-active surveillance, radiation seeds, radiation beam, or surgery-should be explained to patients to include the likelihood of cure and side effects, and the concept that no one treatment is the optimal treatment for all patients."

Rather than just help urologists tell their patients what to do, the guidelines will help them work with their patients.

"These data give us that much better insight in trying to draw out what a patient's expectations are, and on the basis of those expectations, try to make the decision as to what his best treatment option is," Dr. Thompson said.

A significant change that influenced the direction of the guidelines is the debate over the importance of PSA. There is now evidence that screening too widely or too early could be problematic for patients. Men today present at a younger age, with a lower PSA, less-aggressive cancers, and less biochemical recurrence after primary therapy. Among those with biochemical recurrence, they tend to have a less lethal type of cancer, according to panel member Anthony V. D'Amico, MD, PhD, professor of radiation oncology at Brigham and Women's Hospital, Boston.

"None of that is proof that PSA screening will reduce mortality," Dr. D'Amico said. "But what we do have is stage migration as a necessary but not sufficient first step for proof."

The panel members pointed out that while they feel that these guidelines offer the best information available from a large body of knowledge, they cannot definitively say that one treatment is the best for all patients, or even compared to another treatment.

"If there are huge differences between [surgical and non-surgical] treatments, they have not become apparent from any of the retrospective studies that have been done," Dr. D'Amico said.

For this reason, all the members of the panel encouraged physicians to enroll their patients in clinical trials, citing spouse and nurse education as keys to trial accrual.

"There needs to be a groundswell of interest from patients themselves," Dr. Thompson said. "If you look at what women and breast cancer researchers have done, they're miles ahead of us."

The updated guidelines have been published in the Journal of Urology (2007; 177:2106-31). Also, to view a complete copy of the guidelines, visit http:// http://www.auanet.org/guidelines/proscan07.cfm.