National Comprehensive Cancer Network

In 2009, an estimated 192,280 new cases of prostate cancer were diagnosed. The disease was expected to account for 25% of new cancer cases in men and 27,360 deaths. Fortunately, the age‑adjusted death rates from prostate cancer have declined, suggesting that, unless prostate cancer is becoming biologically less aggressive, increased public awareness with earlier detection and treatment of prostate cancer has begun to affect mortality from this prevalent cancer. However, early detection and treatment of prostate cancers that do not threaten life expectancy result in unnecessary side effects, which impair quality of life, and increased health care expenses, and decrease the value of prostate-specific antigen and digital rectal examination as early detection tests. The intention of these guidelines is to provide a framework on which to base treatment decisions. Prostate cancer is a complex disease, with many controversial aspects of management and a dearth of sound data to support treatment recommendations. Several variables (including life expectancy, disease characteristics, predicted outcomes, and patient preferences) must be considered by patients and physicians when tailoring prostate cancer therapy to the individual patient.

Prostate Cancer Early Detection

Since the early 1990s, many variants of the serum total prostate-specific antigen assay have been introduced to increase the sensitivity of screening programs (cancer detection) while maintaining specificity (elimination of unnecessary biopsies). These guidelines recommend ways that individuals and their physicians can use these new techniques rationally for early detection of prostate cancer, and were not designed to provide an argument for using population screening programs for prostate cancer. Rather, they were developed for men who have elected to participate in prostate cancer screening and to provide a set of sequential recommendations detailing a screening and subsequent workup strategy for maximizing the detection of prostate cancer in an early, organ‑confined state and attempting to minimize unnecessary procedures.

Special Feature

A Method for Using Life Tables to Estimate Lifetime Risk for Prostate Cancer Death
Hyung L. Kim, MD; Marvin R. Puymon, FSA, MAAA; Maochun Qin, MD; Khurshid Guru, MD; James L. Mohler, MD

Prostate cancer can have a long and indolent course, and management without curative therapy should be considered in select patients. When counseling patients, a useful way to convey the risk for death from competing causes is to estimate the lifetime risk for dying of prostate cancer. Double-decrement life tables were constructed to calculate age-specific death rates using the death probabilities from the Social Security Administration life tables and Gleason score–specific mortality rates reported from a pre–prostate specific antigen (PSA) cohort study. The life tables provided life expectancy and risk for prostate cancer death based on age at diagnosis. For example, a 60-year-old patient with a tumor of Gleason score of 6, 7, or 8 had an overall life expectancy of 14.4, 10.2, or 6.6 years, respectively, and a 33%, 49%, or 57% risk for prostate cancer death during the expected years of life, respectively. If a 10-year lead-time bias was assumed for PSA detection, the risks for death from prostate cancer decreased to 16%, 26%, or 37%, respectively. If the patient was in the bottom quartile for overall health and disease was detected by prostate examination, the risk for death from prostate cancer was 21%, 32%, or 40%, respectively. A Web-based tool for performing these calculations is available. Life tables can be created to estimate overall life expectancy and risk for prostate cancer death, and to assist with decision-making when considering management without curative therapy.

Featured Articles

Appropriate Use of Nomograms to Guide Prostate Cancer Treatment Selection
Andrew K. Lee, MD, MPH, and Christopher L. Amling, MD

For decades physicians have attempted to accurately predict post-treatment outcomes before performing prostate cancer interventions. Use of basic clinical factors, such as clinical T-stage, biopsy Gleason sum, and pretreatment prostate specific antigen, has allowed some level of prediction of pathologic and clinical outcomes. However, these basic tables and risk stratification schema provide a broad range of potential outcomes. The rapid growth of retrospective research in prostate cancer has yielded an abundance of additional potential prognostic factors that may influence outcomes of interest; however, incorporating and understanding the significance of these ever-expanding factors is difficult. Nomograms incorporate these factors (including treatment-specific) and assign them relative weights to provide a probability of the outcome of interest on a graphical scale. They distill large numbers of data into a manageable format and provide the probability of outcomes on a continuous scale rather than in categoric groups. However, because they require a computation to generate a probability, they are not amenable to memorization, which decreases ease of use. Furthermore, these numbers still have associated confidence intervals and the models are largely derived from retrospective data, which have inherent drawbacks. Clinicians and patients should still exercise due diligence when interpreting the results of these nomograms, and these prediction tools should not serve as a stand-alone substitute for clinical decision-making.

Adverse Effects of Androgen Deprivation Therapy: Defining the Problem and Promoting Health among Men with Prostate Cancer
Philip J. Saylor, MD, and Matthew R. Smith, MD, PhD

Androgen deprivation therapy (ADT) plays a central role in the management of men with locally advanced, recurrent, and metastatic prostate cancer. Because most men diagnosed with prostate cancer will die of something other than their cancer, treatment-related adverse effects are highly relevant to their long-term health. Benefits of ADT in each clinical setting must be weighed against ADT-related adverse effects. ADT is detrimental to several metabolic end points and bone health. ADT has been prospectively shown to cause decreased lean muscle mass, increased fat mass, weight gain, increased cholesterol and triglycerides, insulin resistance, and loss of bone mineral density. In population-based analyses it has been associated with an increased incidence of diabetes, clinical fractures, and cardiovascular disease. Data-driven recommendations for managing these adverse effects are needed. Currently the authors advocate the use of adapted practice guidelines developed to prevent diabetes, fractures, and coronary heart disease in the general population.

Salvage or Adjuvant Radiation Therapy: Counseling Patients on the Benefits
Matthew E. Nielsen, MD; Bruce J. Trock, PhD; and Patrick C. Walsh, MD

Recent developments in urologic oncology literature suggest that residual local disease—as opposed to the presence of occult metastases at surgery—may characterize a more substantial component of the natural history of the recurrence and progression of initially clinically localized prostate cancer than previously appreciated. These important studies have illuminated the extent to which postoperative radiotherapy (RT) may provide benefit to patients with adverse pathologic features (extraprostatic extension, seminal vesicle invasion, or positive surgical margins) or biochemical recurrence after radical prostatectomy. Nevertheless, the question of whether all patients with the aforementioned adverse features should undergo immediate adjuvant RT versus initial observation with more selective, but early, salvage RT in the event of biochemical failure remains the subject of heated controversy. This article reviews salient recent studies in this field to address important questions relevant to counseling patients on the use of postprostatectomy RT. Discussion points include data supporting benefit (efficacy), questions of generalizability of benefit (effectiveness) and risks, and important questions for further study.

Prostate Cancer Screening and Determining the Appropriate Prostate-Specific Antigen Cutoff Values
William J. Catalona, MD, and Stacy Loeb, MD

Prostate-specific antigen (PSA) in combination with digital rectal examination forms the basis for current prostate cancer (CaP) screening programs. Although PSA screening was recently shown to reduce CaP-specific mortality in a European randomized trial, its limitations include the risk of unnecessary prostate biopsy, as well as the diagnosis and treatment of some CaP that might never have caused suffering or death. A potential way to minimize these pitfalls is through the use of derivatives of PSA, particularly PSA kinetics, to increase the specificity for clinically relevant CaP. CaP is the second-leading cause of cancer death in men in the United States and many other westernized countries; accordingly, judicious screening of healthy men allows the diagnosis to be made early enough that all options (i.e., treatment or surveillance) are still available in most cases.

Use of Nomograms for Early Detection of Prostate Cancer
Devon C. Snow, MD, and Eric A. Klein, MD

Since the introduction of prostate specific antigen (PSA) as a screening tool in the 1980s, accurate diagnoses of clinically significant prostate cancer remains a challenge. Analysis of a correlation between PSA levels and prostate biopsies of men with PSA 3 ng/mL or less in the placebo group of a prostate cancer prevention trial suggested that no “normal” PSA level exists. With the acknowledgement that PSA level is considered a continuum rather than a dichotomous marker, accurately diagnosing clinically significant prostate cancer is even more challenging. Nomograms are increasingly being used as tools in the clinical setting to address this challenge. Through incorporating multiple clinical factors, such as PSA, digital rectal examination, age, race, prostate volume, family history, and previous negative biopsy, risk calculators can improve sensitivity of diagnosis over using a PSA cutoff alone. This article discusses the rational for the use of nomograms and the advantages and limitations for the most commonly used nomograms.

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National Comprehensive Cancer Network

NCCN Guidelines® & Clinical Resources

JNCCN – The Journal of the National Comprehensive Cancer Network

Table of Contents - Volume 8, Number 2: February 2010

NCCN Clinical Practice Guidelines in Oncology™

Special Feature

Featured Articles

NCCN Guidelines^® & Clinical Resources