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NCCN Guidelines for Patients


Prostate Cancer, Version 1.2016


Treatment guide: Initial treatment

Very low risk

Active surveillance

Active surveillance is advised if you are likely to live

more than 10 years. Active surveillance consists of

testing on a regular basis so that treatment can be

started when needed. Treatment is given when there

is still an excellent chance for a cure.

Active surveillance consists of multiple tests. In

general, PSA testing should occur no more often than

every 6 months. DRE should occur no more often

than every 12 months.

Doctors don’t agree on the need for and frequency

of repeat biopsies. Some doctors do repeat biopsies

each year and others do them based on test results.

Examples of such test results include a rise in PSA

level or change in DRE.

A decision to do a repeat biopsy should balance the

potential benefits and risks. Risks include infection

and other side effects. If 10 or more cores were

removed, the next biopsy may be done within 18 to

24 months of diagnosis. If you’re likely to live less

than 10 years or are older than 75 years of age,

repeat prostate biopsies are rarely needed.

A prostate biopsy may be done under the guidance

of MRI images combined with real-time ultrasound

images. This type of biopsy is called an MRI-US

fusion biopsy. It may help detect higher-grade

cancers. Higher-grade cancers include those with

Gleason score 7 through 10.

The use of mpMRI may help to assess whether the

cancer is still very low risk. Your doctor may suspect

that the cancer is in the front part of your prostate

that can’t be felt during DRE. This is called anterior

prostate cancer. Your doctor may also or instead

suspect that an aggressive cancer is now present.

mpMRI may help stage and grade the cancer when

the PSA level increases but no cancer was found in

biopsy samples.

MRI may still miss small but aggressive cancers.

Thus, biopsies may still be helpful if MRI doesn’t

detect cancer. Likewise, biopsies done with

ultrasound may miss high-grade tumors. MRI may

better assist in finding these tumors than a standard

prostate biopsy.

There is debate over which events during active

surveillance should signal the start of treatment. The

decision to start treatment should be based on your

doctor’s judgment and your personal wishes. NCCN

experts suggest the following triggering events:

• Cancer from the repeat biopsy has a Gleason

grade of 4 or 5, or

• There is a larger amount of cancer within

biopsy samples or a greater number of biopsy

samples have cancer.

Radiation therapy

If you will likely live more than 20 years, you may

want treatment now instead of active surveillance.

In time, the cancer may grow outside your prostate,

cause symptoms, or both. In this case, radiation

therapy is an option. Very-low-risk cancers can be

treated with EBRT to the prostate and maybe the

seminal vesicles but not to the pelvic lymph nodes.

They can also be treated with LDR brachytherapy


Surgical treatment

Surgical treatment is another option if you will likely

live more than 20 years. It should consist of a radical

prostatectomy. Your pelvic lymph nodes may also be

removed if your risk for them having cancer is 2% or

higher. Your doctor will determine your risk using a

nomogram, which was described in Part 3.