This week, the American Urological Association released its updated guidelines on how to treat localized prostate cancer during its annual meeting in Anaheim, Calif.
Decision making can be difficult partly due to the variety of options and the lack of clear-cut studies directly comparing one treatment to another.
Localized prostate cancer, in which the cancer is still confined to the prostate gland, accounts for about 91 percent of all prostate cancers at diagnosis.
The new guidelines update the previous ones, issued in 1995.
Over the last 12 years, more solid scientific research has emerged about
treatments, says Ian Thompson, M.D., chairman of the panel creating the new
"We now can make some recommendations based on high-quality evidence," he tells WebMD.
"Look on it as a patchwork quilt," Thompson says of the decision
process about treatment for the cancer. "There are many patches that are
now complete." Even so, he and other experts acknowledge, the
treatment decisions are not easy for the patient nor his doctor.
The new guidelines take into account "the biology of the tumor, the life
expectancy of the patient, and the patient's expectations," says Thompson,
professor and chairman of urology at The University of Texas Health Science
Center at San Antonio.
In the new guidelines the panel includes statements described as
"standards," which have the strongest evidence and the least
flexibility as a treatment policy, "recommendations," which are not as
strong, and "options," the most flexible of the statements. Among the
standards in the updated guidelines:
- Before treatment decisions are made, the patient's life expectancy, overall health status, and tumor characteristics should be assessed. Patients should be classified as low-risk, intermediate, or high. The criteria used to categorize the risk include the results of the PSA, or prostate-specific antigen, blood test (which looks for a protein produced by the prostate gland and can help detect cancer), tumor aggressiveness, and the clinical stage of the tumor.
- All men with localized prostate cancer should be told about the most common initial treatments, including active surveillance (in which the tumor is observed and exams and tests are scheduled to determine if treatment should be started), radiotherapy (including external beam and implanted "seeds"), surgery, and radical prostatectomy or removal of the gland.
- Men should be informed that in comparing options of "watchful
waiting" and surgery, surgery may reduce the risk of cancer recurrence and
improve survival. (In watchful waiting, the decision is made to hold off on
treatment but to closely monitor the cancer to see if it progresses and then
decide on treatment.)
- Men at intermediate risk who choose external beam radiation as their
treatment should be informed that adding hormone therapy improves
- Men at high risk should know that adding hormone therapy to external beam radiation may prolong their life.
Among the recommendations:
- Men should know that for localized prostate cancer, using hormone therapy as an initial treatment is seldom indicated.
- Patients with localized cancer should be offered the chance to enroll in clinical trials if they qualify.
Among the options:
- High-risk men should be told that recurrence rates are high even with treatments.
Developing the updated guidelines required more than five years of work,
Thompson tells WebMD. The panel included physicians from radiology, oncology, urology, sexual medicine, and other specialties. "We reviewed 13,888 published papers," he says. Many did not meet their rigid criteria for inclusion. The final papers evaluated totaled 436.
Clinical trials that have aimed to compare different types of prostate
cancer treatments have been beset with problems, Thompson says. Problems have included not getting enough men to participate or men who wanted to pick the treatment rather than be randomized to one of two or more (crucial to the science of the study).
Patients with localized prostate cancer need to know that "no one treatment is right for all," Thompson says. "Two patients with precisely the same tumor may come to two different conclusions (about treatment) based on the evidence."
The updated guidelines are stronger than the previous version, Thompson
By Kathleen Doheny
Reviewed by Louise Chang
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