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

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Chapter Recommendations Grade Refs Effects on bone health and fracture risk Before commencing patients on androgen deprivation therapy, consider the likely duration of that treatment and the risk–benefit analysis for the indication for treatment, and take into account the effects on bone mineral density and risks of pathological fractures from osteoporosis. Effects on quality of life Toxicities should be considered in the context of what is important to each individual patient, as for some patients impairment of sexual function may have a significant impact on their quality of life and overall adjustment, as well as affecting adversely those close to them. 3.1.2 Radiotherapy Definitive external beam radiotherapy techniques for locally advanced disease When radiation therapy alone is used, limited field radiotherapy has similar efficacy and has less toxicity than whole pelvis and therefore is recommended. The role of whole pelvis radiation is yet to be defined. Consideration should be given to dose escalation (74Gy or higher) if it can be delivered safely. Patients with locally advanced prostate cancer should receive 3D conformal radiation to minimise toxicity. External beam radiotherapy and other treatments for local control Based on randomised trial evidence, it is not possible to quantify the degree of benefit provided by radiotherapy alone for locally advanced prostate cancer. The role of surgery or hormonal therapy alone in this group of patients remains to be defined. Radiation in addition to hormone therapy improves survival and is recommended. Brachytherapy 3D conformal dose escalated external beam radiotherapy alone, or reduced dose external beam radiation treatment in combination with high dose-rate brachytherapy, are well-recognised radical treatments for locally advanced disease. There is no randomised evidence to suggest superiority or to recommend one modality over the other. xii C C C D B D 88 Clinical practice guidelines for the management of locally advanced and metastatic prostate cancer 24, 25, 36 37, 38, 39 40, 41, 42 43, 44, 45 46, 47, 49 50, 51, 56 11, 21, 57, 58, 59 62-64, 66, 71-76, 78- 82 8, 9, 83, 84, 86
Chapter Recommendations Grade Refs 3.1.3 Radiotherapy and androgen deprivation therapy (ADT) Long term androgen deprivation It is recommended that patients with locally advanced prostate cancer who are receiving treatment with radical radiotherapy receive long-term androgen deprivation (at least two years). Short-term androgen deprivation Short-term neoadjuvant androgen deprivation therapy can be considered for patients with locally advanced prostate cancer. The optimal sequencing and duration of androgen deprivation in relation to radiotherapy is yet to be defined. Effect of androgen deprivation therapy on radiotherapy toxicities Androgen deprivation therapy can be used in combination with radiotherapy without additional radiotherapy toxicities (urinary and gastrointestinal). Effect on sexual functioning has not been defined. B C C 6, 28, 31, 32, 68, 89, 90, 91 C 26, 27, 29 30, 92, 93 94, 97, 98 3.1.4 Surgery There is insufficient evidence to support the use of surgery in the management of advanced prostate cancer, with the possible exception of a transurethral resection of the prostate in men who are unable to void after androgen deprivation therapy. C 100 3.1.5 Surgery plus androgen deprivation therapy Androgen deprivation for locally advanced disease For locally advanced prostate cancer, anti-androgens as an adjuvant monotherapy to radical prostatectomy are not recommended. Androgen deprivation therapy for fully resected microscopic node positive disease For node-positive disease androgen deprivation therapy (ADT) should be considered. For patients with fully resected node-positive disease (prostatectomy and lymphadenectomy), it is strongly recommended that patients be counselled on the overall survival benefit of ADT and weighed against the short- and long-term toxicities of androgen deprivation. It is further recommended that patients be counselled on the ‘benefit’ of improved survival in relation to the ‘risk’ of therapy – namely the impact of ADT on quality of life. 3.2 Pathologic T3/T4 disease post radical surgery 3.2.1 Adjuvant external beam radiotherapy It is recommended that patients with extracapsular extension, seminal vesicle involvement or positive surgical margins receive postoperative EBRT within four months of surgery. The role of active surveillance and early salvage radiotherapy has not been defined. B 6, 23 C 18 B 102, 103, 106, 107, 110 Summary of clinical practice recommendations xiii
Page 1: Clinical Practice Guidelines for th
Page 4 and 5: 4 Biochemical relapse .............
Page 6 and 7: FOREWORD The management of prostate
Page 8 and 9: SUMMARY OF CLINICAL PRACTICE RECOMM
Page 10 and 11: SUMMARY OF RECOMMENDATIONS Chapter
Page 14 and 15: Chapter Recommendations Grade Refs
Page 20 and 21: 1 INTRODUCTION 1.1 Natural history
Page 22 and 23: 2 PSYCHOSOCIAL CARE The diagnosis a
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Page 28 and 29: Recommendation Men with advanced pr
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Page 42 and 43: Despite these reservations and the
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Page 52 and 53: for surgery, suggesting that surger
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Page 56 and 57: All three trials demonstrated impro
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45. Melton LJ, III, Alothman KI, Kh
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76. Little DJ, Kuban DA, Levy LB, Z
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105. Thompson IM, Tangen CM, Parade
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4.2 Androgen deprivation therapy (e
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Evidence summary Level References F
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therapy since such studies would be
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apparent in trials comparing CAB wi
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QLQ instrument published by Cleary
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Note: Larger well-powered studies h
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Eight trials examined acute toxicit
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half of patients experienced pain r
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olus) in addition to radiotherapy a
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References 1. Seidenfeld J, Samson
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Cooperative Group. Scandinavian Jou
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Oncology Group, TROG 96.05). Radiot
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trial. European Journal of Cancer 1
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6 CASTRATION-RESISTANT PROSTATE CAN
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the median overall survival for pat
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There are two points regarding bisp
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with bone pain at study entry. At n
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Recently, there have been reports o
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of these studies 56, 58 and in the
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Side effects (toxicity) As these ra
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hydrocortisone respectively. Tannoc
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5. Manikandan R, Srirangam SJ, Pear
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33. Elomaa I, Kylmala T, Tammela T
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60. Janknegt RA, Abbou CC, Bartolet
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physiotherapists, occupational ther
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7.5 Q2: Symptom control There was e
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Informal or family caregivers deriv
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8. Hughes SL, Weaver FM, Giobbie-Hu
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8 COMPLEMENTARY AND ALTERNATIVE (UN
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corresponding benefit in obstructiv
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3. Eisenberg DM, Kessler RC, Van Ro
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areas of the state were more likely
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8 Miller DC, Litwin MS, Bergman J,
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10 EMERGING THERAPIES It is impossi
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APPENDIX 1 GUIDELINE DEVELOPMENT PR
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study type. Studies published befor
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Grade of recommendation Description
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2. National Health and Research Cou
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Dr Carole Pinnock AM Principal rese
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Surgery Professor Villis Marshall A
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APPENDIX 3 TNM CLASSIFICATION OF PR
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Summary Prostate T1 T2 T3 T4 N1 M1a
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APPENDIX 4 ABBREVIATIONS AND GLOSSA
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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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