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

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Chapter Recommendations Grade Refs 3.3 Node-positive disease 3.3.1 Radiotherapy and adjuvant androgen deprivation therapy If radical radiotherapy is given to patients with node-positive disease it is reasonable to offer long-term androgen deprivation in addition to radiotherapy. 3.3.2 External beam radiotherapy There is insufficient evidence to make a recommendation for the use of external beam radiation as alternative or adjuvant to hormone therapies in node positive patients. 4. BIOCHEMICAL RELAPSE 4.2 Early versus delayed androgen deprivation therapy The optimal timing of androgen deprivation therapy in patients with biochemical relapse of disease without evidence of overt metastatic disease is not defined. Eligible patients should be informed about the current TROG Trial (www.ranzcr.edu.au/affiliatedgroups/trog/healthprofessionals/hptrial s/open/TROG_0306.cf) comparing early versus delayed hormonal therapy in this group. D 112-114 N/A 62, 63, 116,117 N/A 6 5. OVERT METASTATIC DISEASE AND/OR LOCO-REGIONAL PROGRESSIVE DISEASE 5.1 Androgen deprivation therapy 5.1.1 Choice of androgen deprivation therapy Patients with metastatic prostate cancer can be treated with either orchidectomy or LHRH agonist based on patient preference. Antiandrogen monotherapy should be avoided as the data indicate this is probably associated with a shorter overall survival. 5.1.2 Single agent versus total androgen blockade Patients with metastatic prostate cancer may be treated with a nonsteroidal anti-androgen combined with androgen deprivation therapy as a continuing strategy (beyond the period of LHRHinduced surge [flare] of testosterone) if they are prepared to accept the greater likelihood of unwanted effects from combination therapy. It is recommended that patients with high–volume disease or disease where urgent tumour debulking is required (eg impending spinal canal compression or urinary outflow obstruction) be commenced on combined androgen blockade to prevent flare reactions. This required period is approximately one month for an LHRH agonist and covers the time it takes for testosterone levels to reach a castrate state. Continuation of combined therapy beyond that period may be considered if the patient is prepared to accept the greater likelihood of unwanted side effects from combination therapy. xiv C 1-5 B 6-14 Clinical practice guidelines for the management of locally advanced and metastatic prostate cancer
Chapter Recommendations Grade Refs 5.1.3 Early versus delayed androgen deprivation Androgen deprivation therapy is indicated for metastatic prostate cancer. Immediate therapy is warranted for symptomatic metastases. The evidence for immediate therapy for asymptomatic metastases is unclear, but it is definitely warranted if delay may result in complications (e.g. spinal cord compression from vertebral metastases). 5.1.4 Toxicity The benefits of androgen deprivation therapy in controlling a patient’s cancer outweigh the ADT adverse-event profile. However, given the clinically relevant and quality-of-life impairing litany of unwanted effects of ADT, the timing of commencement of ADT as a palliative treatment needs to be considered carefully. Assessment of liver function tests, risk of osteoporosis and bone density measurements as required is recommended. Baseline information on what is important to each individual patient should be ascertained (refer chapter 3, p20). This will permit the commencement and nature of treatment to be tailored and allow an assessment of the cause of adverse effects if they emerge. The common side effects need to be discussed with the patient before commencing any ADT. All patients taking anti-androgens should have their liver function monitored. 5.1.5 Quality of life Toxicities in the context of what is important to each individual patient should be considered, as decrements in highly valued faculties for some patients may have a significant impact on the quality of life and overall adjustment of those individuals and those close to them. 5.1.6 Intermittent or continuous androgen deprivation therapy No formal recommendation on intermittent or continuous androgen deprivation therapy can be made based on the lack of definitive data. However, it would appear that there may be a quality of life benefit. Intermittent androgen deprivation therapy can be considered for men who (i) achieve a good remission, (ii) are destined to be on ADT for a prolonged period, and (iii) are having intolerable side effects from long-term androgen deprivation. C 15,16, 18, 19 C 4, 5, 9, 10,21-34, 35, 36-40 C 23, 24, 26, 27, 30, 43 C 44, 46, 48, 49, 51 Summary of clinical practice recommendations xv
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 12 and 13: Chapter Recommendations Grade Refs
Page 20 and 21: 1 INTRODUCTION 1.1 Natural history
Page 22 and 23: 2 PSYCHOSOCIAL CARE The diagnosis a
Page 24 and 25: 2.2 Effect of psychological and cog
Page 26 and 27: Evidence summary Level References T
Page 28 and 29: Recommendation Men with advanced pr
Page 30 and 31: An Australian cross-sectional study
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Page 36 and 37: different treatments from different
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Page 42 and 43: Despite these reservations and the
Page 44 and 45: For non-metastatic disease there we
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Page 48 and 49: monotherapy for low-to-intermediate
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Page 52 and 53: for surgery, suggesting that surger
Page 54 and 55: Microscopic fully resected node pos
Page 56 and 57: All three trials demonstrated impro
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Page 60 and 61: of an international multicentre ran
Page 62 and 63: 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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