NCCN Guidelines for Patients
Prostate Cancer, Version 1.2016
Treatment guide: Initial treatment
Very low risk
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
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
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.
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 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.