Review – Prostate CancerEAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer—2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent
Section snippets
Epidemiology and risk factors
The most recent summary of the European Association of Urology (EAU)-European Society for Radiotherapy and Oncology (ESTRO)-International Society of Geriatric Oncology (SIOG) guidelines on prostate cancer (PCa) was published in 2017 [1]. In view of the volume of new data, there was a need for an updated summary. The present summary is based on the latest guidelines published in April 2020 [2]. This update is based on structured annual literature reviews and systematic reviews, as a continuous
Classification and staging
The 2017 TNM classification of the American Joint Committee on Cancer (AJCC) for staging of PCa should be used [17], where the cT stage is based on digital rectal examination (DRE) only. Compared with the 2009 version, the main difference is the lack of pT2 substage differentiation. The EAU risk group classification (Table 1) is based on grouping patients with a similar risk of biochemical recurrence after local treatment. However, emerging clinical data support this distinction between
Screening and early detection
Population or mass screening is defined as the “systematic examination of asymptomatic men (at risk)” and is usually initiated by health authorities. The coprimary objectives are a reduction in disease-specific mortality and a maintained QoL. Screening for PCa remains one of the most controversial topics in the urologic literature, and it is currently not recommended in most countries worldwide. A Cochrane review suggested that prostate-specific antigen (PSA) screening is associated with an
Diagnosis
Definitive diagnosis depends on histopathological verification. In order to avoid unnecessary biopsies, a further risk assessment should be offered (Table 5).
An abnormal DRE is an indication for biopsy, but as an independent variable, PSA is a better predictor of cancer than either DRE or transrectal ultrasound (TRUS). PSA is a continuous parameter, with higher levels indicating a greater likelihood of PCa, precluding an optimal PSA threshold for detecting nonpalpable but csPCa. A limited PSA
Prostate biopsy
TRUS-guided or transperineal ultrasound–guided biopsy using an 18 G biopsy needle and a periprostatic block is the standard of care. When the same numbers of cores are taken, both transrectal and transperineal approaches, when performed without prior imaging with MRI, have comparable detection rates [50]; however, some evidence suggests a reduced risk of infection with the transperineal route [51]. Where mpMRI has shown a suspicious lesion, MR-TBx can be obtained through cognitive guidance,
Staging of PCa
The decision to proceed with a further staging work-up is guided by which treatment options are available, taking into account the patient’s preference and comorbidity. A summary of the guidelines is presented in Table 8. The field of noninvasive nodal and metastatic staging of PCa is evolving very rapidly.
Evaluating life expectancy and health status
Older men with a high incidence of PCa may be undertreated. In the USA, only 41% of patients aged >75 yr with intermediate- and high-risk disease receive curative treatment compared with 88% of patients aged 65–74 yr [77].
Evaluation of life expectancy and health status is important in clinical decision making on screening, diagnosis, and treatment of PCa. In localised disease, >10 yr life expectancy is considered mandatory for any survival benefit from local treatment. Country-specific life
Primary local treatment
Management decisions should be made after all options have been discussed with a multidisciplinary team (including urologists, radiation oncologists, medical oncologists, pathologists, and radiologists), and after the balance of benefits and side effects of each therapy modality has been considered together with the patient.
Comparing various local therapies
The ProtecT trial is the only available RCT comparing three treatment modalities. A total of 1643 patients were randomised between active treatment (RP or EBRT + 6 mo of ADT) and active monitoring (AM) [175]. In this AM schedule, only patients with a PSA rise of >50% in 12 mo underwent a repeat biopsy. Of the patients, 56% had low-risk disease, with 90% having a PSA level of <10 ng/mL, 77% having ISUP grade 1 (20% ISUP grade 2–3), and 76% having T1c, whilst the other patients were mainly of
Alternative local treatment options
Besides RP, EBRT, and BT, other modalities have emerged as possible therapeutic options in patients with clinically localised PCa. However, patients with life expectancy of >10 yr should be informed fully that there are limited data on the long-term outcome for cancer control beyond 10 yr [180].
A systematic review compared cryotherapy versus RP and EBRT [181]. Data from 3995 patients across 19 studies were included. In the short term, there was conflicting evidence relating to cancer-specific
Conclusions
The present text represents a summary of the 2020 EAU-EANM-ESTRO-ESUR-SIOG PCa guidelines. A summary of recommendations is presented in Table 13. For more detailed information and a full list of references, refer to the full-text version available at the EAU web site (http://uroweb.org/guideline/prostate-cancer/).
Author contributions: Nicolas Mottet had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study
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