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

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Chapter Recommendations Grade Refs 5.2 Radiotherapy 5.2.1 External beam radiotherapy (conventional) for the treatment of Bone pain Radiotherapy is an effective and well-tolerated treatment for metastatic bone pain. A single dose of 8Gy is as effective as higher fractionated doses (e.g. 20–30Gy) in reducing bone pain. The higher incidence of re-treatment with lower-dose single fraction regimens should be considered as part of the decision-making process. Loco-regionally progressive disease (lymph and prostate) Radiotherapy can be considered for palliation of symptoms secondary to locally progressive disease. Spinal cord compression/nerve root compression (with or without surgery) For patients with malignant spinal cord compression the use of radiation is recommended. The optimal fractionation schedule of radiotherapy is unknown. Patients being treated with radiation for spinal cord compression should be given dexamethasone at time of diagnosis. For highly selected patients with malignant spinal cord compression vertebrectomy with spinal stabilisation prior to radiotherapy should be considered. The role of decompression laminectomy prior to radiotherapy is unknown. Patients being treated with radiotherapy for malignant spinal cord compression should also receive dexamethasone. C D D 82 B 82 58, 60 52-57,59, 62, 63, 65, 66 71-79 C 83, 84 C 85 The optimal dose of dexamethasone remains to be defined. D 87 6. CASTRATION-RESISTANT PROSTATE CANCER (CRPC) 6.2 Hormone manipulations 6.2.1 Second-line hormone manipulation There is a sequence of actions that should be followed when a patient is shown to have progressive cancer on androgen deprivation therapy. First, confirm that the patient has a castrate level of testosterone if on an LHRH agonist therapy. If the patient is also on a non-steroidal anti-androgen, this agent could be withdrawn and observed for the possibility of an anti-androgen withdrawal phenomenon. It is reasonable to trial further hormone manipulations if the patient is asymptomatic or minimally symptomatic prior to use of chemotherapy (e.g. docetaxel). xvi Clinical practice guidelines for the management of locally advanced and metastatic prostate cancer C 2-11, 15- 17
Chapter Recommendations Grade Refs 6.2.2 Continuing LHRH agonists after the patient has become hormone refractory There is insufficient evidence to make a recommendation as to whether a patient should continue LHRH agonist therapy once his disease has progressed while on androgen deprivation. 6.3 Bisphophonates 6.3.1 Bisphosphonates and the prevention of skeletal related events Zoledronic acid may be considered for the prevention of skeletalrelated events in men with asymptomatic or mildly symptomatic hormone-resistant or castrate-resistant metastatic prostate cancer. Men, as part of the informed consent process, should be made aware that nine men will need to be treated for one to achieve a benefit, and that there is a risk of osteonecrosis of the jaw occurring during treatment. Dental review is advised and be sought before commencing treatment. Renal function needs to be monitored during treatment. Ideally treatment should be confined to men whose serum creatinine is less than 265umol/L at the time of starting treatment. 6.3.2 Bisphosphonates in the management of bone pain associated with metastatic prostate cancer On the basis of the available evidence, bisphosphonates are not recommended for routine palliation of symptomatic bone disease in men, with hormone-resistant prostate cancer with a possible exception of zoledronic acid, where there is some evidence of a benefit in castrate-resistant men. 6.4 Radiotherapy 6.4.2 Radioisotopes Unsealed radioisotopes may be considered for the management of multifocal bone pain alongside other options of treatment in patients with hormone refractory prostate cancer. The impact of unsealed radioisotopes on overall survival in men with castrate-resistant metastatic prostate cancer is undefined. The relative roles of unsealed radioisotopes and the newer chemotherapeutic agents (e.g. taxanes) and bisphosphonates have also not been defined. It is not known what effect unsealed radioisotopes have on quality of life for men with metastatic prostate cancer. D B 28-31 C 29-31, 33- 35, 37, 39-41 C 46-48, 52, 53, 56-59 D 46, 48, 49 52, 53, 57 58 C 47-49, 52, 53 Summary of clinical practice recommendations xvii
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
Page 32 and 33: 10. Dunn J, et al. A review of peer
Page 34 and 35: 41. Sharpley CF, Christie DRH. An a
Page 36 and 37: different treatments from different
Page 38 and 39: Evidence summary Level References I
Page 40 and 41: Evidence summary Level References F
Page 42 and 43: Despite these reservations and the
Page 44 and 45: For non-metastatic disease there we
Page 46 and 47: Evidence summary Level References T
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
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
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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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