Clinical Practice Guidelines for the management of locally advanced ...

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Side effects (toxicity) As these radioisotopes are taken up by bone, they have the potential to suppress the bone marrow and result in low red and white blood cell and platelet counts which can then lead to dependence on blood transfusions, increased risk of infections and easy bruising. Patients who have low blood counts at the outset would generally be regarded as being unsuitable and ineligible for this treatment. All the strontium 89 and samarium 153 trials reported toxicity outcomes. Thrombocytopenia and/or leucopenia were observed to some extent in all studies. strontium 89 tends to show a similar or worse effect on thrombocytopenia and leucopenia than hemibody and local irradiation 48, 49 , more effect than ‘best supportive care’ 46, 47 , and statistically significantly more effect when added to localised radiation. 52-54 There is no good evidence that strontium 89 causes significant adverse effects other than haematological. All the samarium trials demonstrate a reduction in platelets and white cell count with samarium 153. In one trial this effect is statistically significant for white blood cell toxicity. 56 However, the development of grade III or IV neutropaenia is uncommon (
Recommendation Unsealed radioisotopes alone may be associated with higher haematological adverse events compared with supportive care or localised radiation, although overall these rates are low. Unsealed radioisotopes in combination with other treatments such as radiotherapy have higher rates of serious toxicity than radiotherapy alone. The toxicity of unsealed radioisotopes in combination with modern chemotherapy (taxanes) has not yet been defined and caution should be exercised if such combinations are considered. Grade C 6.5 Chemotherapy Metastatic prostate cancer refers to patients in whom the cancer has spread beyond the primary site. This chapter deals with adenocarcinoma only. Most commonly, metastatic disease involves bone and lymph nodes and less commonly, viscera such as the lungs and liver. Patients with metastatic prostate cancer may be considered as hormone naïve or castration-resistant. 6.5.1 Hormone-naïve metastatic prostate cancer Hormone-naïve patients are treated with hormone deprivation therapies including gonadotrophin releasing hormone (GnRH) agonists, orchidectomy and anti-androgens. The response rate is high and the median duration of response is approximately 18–24 months 60 , with 20% of patients living five years or more. Small, non-informative RCTs performed over the past 20 years using minimally active chemotherapy demonstrated no benefit from the use of cytotoxic agents in the hormone-naïve setting. 61 Continuing large phase III studies are currently examining the role of chemotherapy, which is active in the castrate-resistant setting, in combination with androgen deprivation therapy in the hormone-naïve setting. 6.5.2 Castration-resistant prostate cancer Castration-resistant prostate cancer (CRPC) includes patients with evidence of disease progression despite castrate levels of testosterone. About 20% of these patients may initially respond to secondline hormone manipulations, but almost all ultimately progress. At least three clinical states exist: patients with a rising PSA who are asymptomatic and have no objective radiologic evidence of metastatic disease patients with a rising PSA who are asymptomatic but who do have objective radiologic evidence of metastatic disease patients with a rising PSA who have objective radiologic evidence of metastatic disease and symptoms. In general, the first group of patients (asymptomatic rising PSA) are not treated with chemotherapy but may be suitable candidates for clinical trials and/or second-line hormone manipulations. The second and third groups are candidates for the use of systemic chemotherapy as discussed below or as part of a trial. Old studies examined a variety of chemotherapy agents in combination or as monotherapy. These studies were generally of poor quality, had limited patient numbers, used agents with low efficacy and were constrained by difficulties in evaluating efficacy in this patient population. Modern chemotherapy for CRPC was established by the studies of Tannock et al and Kantoff et al. 62, 63 Both studies examined the efficacy of mitoxantrone against a control arm of prednisolone or Clinical practice guidelines for the management of locally advanced and metastatic prostate cancer 88
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Clinical Practice Guidelines for th
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4 Biochemical relapse .............
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FOREWORD The management of prostate
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SUMMARY OF CLINICAL PRACTICE RECOMM
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SUMMARY OF RECOMMENDATIONS Chapter
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Chapter Recommendations Grade Refs
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1 INTRODUCTION 1.1 Natural history
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2 PSYCHOSOCIAL CARE The diagnosis a
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2.2 Effect of psychological and cog
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Evidence summary Level References T
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Recommendation Men with advanced pr
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An Australian cross-sectional study
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10. Dunn J, et al. A review of peer
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41. Sharpley CF, Christie DRH. An a
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different treatments from different
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Evidence summary Level References I
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Evidence summary Level References F
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Despite these reservations and the
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For non-metastatic disease there we
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Evidence summary Level References T
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monotherapy for low-to-intermediate
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Evidence summary Level References M
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for surgery, suggesting that surger
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Microscopic fully resected node pos
Page 56 and 57: All three trials demonstrated impro
Page 58 and 59: Evidence summary Level References B
Page 60 and 61: of an international multicentre ran
Page 62 and 63: 45. Melton LJ, III, Alothman KI, Kh
Page 64 and 65: 76. Little DJ, Kuban DA, Levy LB, Z
Page 66 and 67: 105. Thompson IM, Tangen CM, Parade
Page 68 and 69: 4.2 Androgen deprivation therapy (e
Page 70 and 71: Evidence summary Level References F
Page 72 and 73: therapy since such studies would be
Page 74 and 75: apparent in trials comparing CAB wi
Page 76 and 77: QLQ instrument published by Cleary
Page 78 and 79: Note: Larger well-powered studies h
Page 80 and 81: Eight trials examined acute toxicit
Page 82 and 83: half of patients experienced pain r
Page 84 and 85: olus) in addition to radiotherapy a
Page 86 and 87: References 1. Seidenfeld J, Samson
Page 88 and 89: Cooperative Group. Scandinavian Jou
Page 90 and 91: Oncology Group, TROG 96.05). Radiot
Page 92 and 93: trial. European Journal of Cancer 1
Page 94 and 95: 6 CASTRATION-RESISTANT PROSTATE CAN
Page 96 and 97: the median overall survival for pat
Page 98 and 99: There are two points regarding bisp
Page 100 and 101: with bone pain at study entry. At n
Page 102 and 103: Recently, there have been reports o
Page 104 and 105: of these studies 56, 58 and in the
Page 108 and 109: hydrocortisone respectively. Tannoc
Page 110 and 111: 5. Manikandan R, Srirangam SJ, Pear
Page 112 and 113: 33. Elomaa I, Kylmala T, Tammela T
Page 114 and 115: 60. Janknegt RA, Abbou CC, Bartolet
Page 116 and 117: physiotherapists, occupational ther
Page 118 and 119: 7.5 Q2: Symptom control There was e
Page 120 and 121: Informal or family caregivers deriv
Page 122 and 123: 8. Hughes SL, Weaver FM, Giobbie-Hu
Page 124 and 125: 8 COMPLEMENTARY AND ALTERNATIVE (UN
Page 126 and 127: corresponding benefit in obstructiv
Page 128 and 129: 3. Eisenberg DM, Kessler RC, Van Ro
Page 130 and 131: areas of the state were more likely
Page 132 and 133: 8 Miller DC, Litwin MS, Bergman J,
Page 134 and 135: 10 EMERGING THERAPIES It is impossi
Page 136 and 137: APPENDIX 1 GUIDELINE DEVELOPMENT PR
Page 138 and 139: study type. Studies published befor
Page 140 and 141: Grade of recommendation Description
Page 142 and 143: 2. National Health and Research Cou
Page 144 and 145: Dr Carole Pinnock AM Principal rese
Page 146 and 147: Surgery Professor Villis Marshall A
Page 148 and 149: APPENDIX 3 TNM CLASSIFICATION OF PR
Page 150 and 151: Summary Prostate T1 T2 T3 T4 N1 M1a
Page 152 and 153: APPENDIX 4 ABBREVIATIONS AND GLOSSA
Page 154 and 155: Glossary Actuarial survival A metho
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Effectiveness The extent to which a
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Lymph nodes Small, generally pea-si
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Each stage is divided into subgroup
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APPENDIX 6 - ORGANISATIONS WHICH PR
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Consultant Urologist, Royal Brisban
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No conflict of interest to declare.
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Index to Clinical practice guidelin
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cardiovascular mortality 19, 54, 55
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androgen deprivation therapy (ADT)
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and surgery 32-34 survival 18 toxic
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and chemotherapy 89-90 see also bon
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spinal cord compression 62-63 see a
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systemic 141 Tasmania Association f
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