Guidelines for prostate cancer disease staging and treatment

This study summarized updated guidelines for risk assessment and appropriate management approaches for prostate cancer. 

Treatment options for prostate cancer require careful assignment of patients to risk groups. The tumor stage (extant of disease) is determined by rectal examinations and imaging results. A Gleason score refers to the aggressiveness of the cancer cells as measured from prostate biopsies (tissue samples). Higher Gleason scores indicate more aggressive cancers. Biopsies also indicate the extent of cancer (number of samples positive for cancer cells). Together with PSA levels (prostate specific antigen; a protein elevated in the blood in prostate cancer), these values help determine the risk of cancer recurrence for patients. This review by the National Comprehensive Cancer Network was conducted to update guidelines and recommendations for disease staging and treatment options for each risk group.

Men assigned to the very low or low risk group have a tumor stage of 1 or 2, low Gleason scores (6 or less), fewer than 3 positive biopsy cores, and low PSA levels (under 10 ng/ml). If the predicted life expectancy is 20 years or more, surgery or radiation are recommended. In other cases, active surveillance (delayed treatment with regular screening to monitor disease progression) is recommended.

Men in the intermediate risk group have a tumor stage of 2b or 2c, a Gleason score of 7, or PSA levels between 10 and 20 ng/ml. Prostate surgery (with or without lymph node removal) is recommended for those with life expectancies of 10 or more years. Other possible therapies include external beam radiation therapy (EBRT) and androgen deprivation therapy (ADT; standard hormone therapy). If life expectancy is less than 10 years, brachytherapy (radiation source placed inside the prostate) can be administered alone or combined with EBRT and short-term ADT (4 to 6 months). Alternatively, patients may choose to undergo observation only.

The high risk group has a prostate tumor stage of 3a, Gleason score of 8 to 10, or PSA levels more than 20 ng/ml. In the very high risk group, the tumor extends into nearby tissue (locally advanced, stage 3b to 4). EBRT with long-term ADT (2 to 3 years), with or without brachytherapy, and prostate surgery with lymph node removal are the recommended primary therapies. Another option is long-term ADT with additional docetaxel (Taxotere) after EBRT for patients fit for chemotherapy. Men with very high risk prostate cancer who are not candidates for radiation or surgery may undergo ADT alone as a primary therapy. Secondary therapies typically involve a combination of EBRT and ADT or observation, if cancer spreads to the lymph nodes.

The standard treatment for metastatic prostate cancer (spread beyond the prostate) is ADT. Men with lymph node involvement only may consider observation. In cases of cancer spread to distant organs, men may undergo continuous ADT combined with docetaxel with or without prednisone (steroid drug) for 6 cycles. Patients with smaller tumors may benefit less from additional docetaxel treatment. If cancer progresses despite ADT, patients may consider secondary therapies depending on symptoms present. 

Authors updated guidelines in an effort to better define risk for men with prostate cancer to help optimize treatment decisions.