GuidelinesEAU Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent—Update 2013
Introduction
The most recent summary of the European Association of Urology (EAU) guidelines on prostate cancer (PCa) was published in 2011 [1]. The aim of this paper is to present a summary of the 2013 update of the EAU guidelines on PCa. To facilitate evaluating the quality of the information provided, level of evidence (LE) and grade of recommendation (GR) have been inserted according to the general principles of evidence-based medicine [2].
Section snippets
Epidemiology
In Europe, PCa is the most common solid neoplasm, with an incidence rate of 214 cases per 1000 men, outnumbering lung and colorectal cancer [3]. PCa affects elderly men more often and therefore is a bigger health concern in developed countries. Approximately 15% of male cancers are PCa in developed countries, compared with 4% of male cancers in developing countries [4]. There are large regional differences in incidence rates of PCa, with a range from 68.8 per 1000 in Malta to 182 per 1000 in
Risk factors
The factors that determine the risk of developing clinical PCa are not well known, although three well-established risk factors have been identified: increasing age, ethnic origin, and heredity. If one first-line relative has the disease, the risk is at least doubled. If two or more first-line relatives are affected, the risk increases by 5–11 times [5]. Approximately 9% of individuals with PCa have true hereditary PCa, defined as three or more relatives affected or at least two relatives who
Classifications
The Union Internationale Contre le Cancer 2010 TNM classification is used throughout these guidelines [8].
The Gleason score is the recommended methodology for grading PCa. According to current international convention, the (modified) Gleason score of cancers detected in a prostate biopsy consists of the Gleason grade of the dominant (most extensive) carcinoma component plus the highest grade, regardless of its extent—there is no 5% rule [9]. In radical prostatectomy (RP) specimens, both the
Prostate cancer screening
There is currently no evidence for introducing widespread population-based screening programs for early PCa detection in all men [10] (LE: 2). To evaluate the efficacy of PCa screening, two large randomized trials have been published: the Prostate, Lung, Colorectal and Ovary (PLCO) trial in the United States and the European Randomized Study of Screening for Prostate Cancer (ERSPC) in Europe [11], [12] (LE: 1b).
The PLCO cancer-screening trial randomly assigned 76 693 men to receive either annual
Diagnosis and staging of prostate cancer
The main tools to diagnose PCa include DRE, serum concentration of PSA, and transrectal ultrasound (TRUS)-guided biopsy. In approximately18% of all patients, PCa is detected by a PCa-suggestive finding on DRE alone, regardless of the PSA level [17] (LE: 2a). A suspect DRE in patients with a PSA level of ≤2 ng/ml has a positive predictive value of 5–30% [18] (LE: 2a). A PSA cut-off of 3 or 3.1 μg/l should be considered for World Health Organization–calibrated assays to achieve the same
Primary local treatment of prostate cancer
The therapeutic management of PCa, even clinically localized disease, has become increasingly complex because of the various stage-specific therapeutic options available. It is therefore advisable to do the following:
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Counsel patients with low-risk PCa (PSA <10 ng/ml and biopsy Gleason score 6 and cT1c–cT2a) or intermediate-risk PCa (PSA 10.1–20 ng/ml or biopsy Gleason score 7 or cT2b–c) in an interdisciplinary setting with a urologist and a radiation oncologist.
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Discuss neoadjuvant and adjuvant
Irradiation to the pelvic lymph nodes
There is no firm evidence base for prophylactic whole-pelvic irradiation (46–50 Gy), since randomized trials have failed to show a benefit in high-risk cases [104], [105], [106], [107]. The use of ePLND may be needed to improve the selection of patients who may be able to benefit from pelvic lymph node irradiation. The results of pelvic lymphadenectomy, particularly in young patients, will enable radiation oncologists to tailor both the planning target volume and the duration of
Proton-beam and carbon ion–beam therapy
Proton-beam therapy is a promising but costly treatment for PCa. Although there are theoretical physical advantages, this therapy has so far been shown to be only comparably safe and effective when compared with the alternatives and not necessarily superior [108].
The Proton Radiation Oncology Group 9509 trial randomly assigned 393 men with clinically localized PCa to receive EBRT with 70.2 Gy compared with 79.2 Gy of combined photon and proton radiation [109] in a dose-escalation trial. At a
Follow-up of prostate cancer patients
Patients diagnosed with PCa who undergo local treatment with curative intent are usually followed for ≥10 yr or until high age makes follow-up superfluous. Determination of serum PSA, together with a disease-specific history, is supplemented by DRE and by imaging studies if locally recurrent disease is suspected.
Alternative local treatment options for prostate cancer
Besides RP, EBRT, and/or brachytherapy, cryosurgical ablation of the prostate (CSAP) and high-intensity focused ultrasound (HIFU) have emerged as alternative therapeutic options in patients with clinically localized PCa who are not suitable for RP [110], [111], [112].
Crouzet et al. [111] analyzed the oncologic and functional outcomes of the largest patient cohort, which included 803 patients with low-, intermediate-, and high-risk PCa in 40.2%, 46.3%, and 13.5% of patients, respectively. Mean
Summary
The present text represents a summary. For more detailed information and a full list of references, refer to the full-text version. These EAU guidelines (ISBN 978–90–79754–71–7) are available at the EAU Web site (http://www.uroweb.org/guidelines/online-guidelines/).
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