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

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41. Sharpley CF, Christie DRH. An analysis of the psychometric profile and frequency of anxiety and depression in Australian men with prostate cancer. Psycho-Oncology 2007;(16):660-667. 42. Nelson C, Weinberger M, Balk E, Holland J, Breitbart W, Roth A. The chronology of distress, anxiety and depression in older prostate cancer patients. The Oncologist 2009;(14):891-899. 43. Pirl WF, Greer JA, Goode M, Smith MR. Prospective study of depression and fatigue in men with advanced prostate cancer receiving hormone therapy. Psycho-Oncology 2008;(17):148- 153. 44. Smith EM, Gomm JA, Dickens CM. Assessing the independent contribution to quality of life from anxiety and depression in patients with advanced cancer. Palliative Medicine 2003;(17):509-513. 45. Lloyd-Williams M, Dennis M, Taylor F. A prospective study to determine the associate between physical symptoms and depression in patients with advanced cancer. Palliative Medicine 2004;(18):558-563. 46. Katon W, Lin E, Kroenke K. The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. General Hospital Psychiatry 2007;(29):147-155. 47. Di Matteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Archives of Internal Medicine 2000;(160):2102-2107. 15 Psychosocial care
3 LOCALLY ADVANCED DISEASE (Locally advanced/high-risk prostate cancer—de novo presentation (clinical stage T3–4, and/or early-stage disease with PSA>20) 3.1 Introduction In these guidelines locally advanced/high risk prostate cancer is usually defined by clinical stage T3-4 and or early stage disease with PSA>20. However, to establish with certainty that it is locally advanced can be difficult and apart from clinical staging and the level of PSA, MRI scans can sometimes be of assistance as well as CT pelvis but both have low sensitivity. The presence of positive margins in the surgically resected specimen also points to the potential for locally advanced disease as does an early rise in the PSA, the rate of rise prior to localised treatment has also been suggested as a potential indicator of metastatic disease. However, in most cases it is the persistent rise in the PSA that has become a surrogate marker for advanced or metastatic disease after surgical resection of the prostate. Post radiotherapy if the PSA reaches its nadir and then starts to rise this is usually used as a surrogate marker of advanced disease. A measurable PSA after radical prostatectomy does not always indicate residual disease, as it could be due rarely to residual benign tissue. Biopsy of the prostatic bed can be performed to try to obtain tissue and /or monitoring of the rate of rise of the PSA in conjunction with knowledge of the Gleason score and presence of positive or negative margins may provide a means of determining whether the rise is due to a small remnant of benign tissue rather than metastatic disease. Androgen Deprivation can be achieved in a number of ways. Testicular androgen production can be prevented by surgical castration, by chemical castration through the use of LHRH agonists, or by suppression of androgen production by oestrogens although because of undesirable cardiac side effects oral oestrogens are now rarely used. The other strategy is to use steroidal and non steroidal anti-androgens that compete with both testicular and andrenal androgens for the androgen receptor binding sites. These agents can be used singly and or in combination. It is important to note that there are some restrictions regarding the prescribing of these agents. LHRH agonists are available on the RPBS and anti androgens are only available on the PBS (authority) in combination with ADT. The non steroidal anti-androgens, bicalutamide and flutamide are approved only for use for stage D (metastatic) disease in combination with LHRH agonist therapy whereas the non-steroidal antiandrogen , nilutamide, is approved for use in combination with LHRH agonists or orchidectomy for the treatment of stage C (locally advanced) or D (metastatic prostate cancer). In contrast, the steroidal anti-androgen ,cyproterone acetate is approved for the treatment of “advanced” prostate cancer. 3.1.1 Androgen deprivation therapy (ADT) Early versus delayed androgen deprivation therapy Some patients may not be suitable for definitive local therapy because of co-morbidities or advanced age. Data are emerging to provide guidance on the timing of ADT for patients with locally advanced disease and for those with locally advanced disease who decline surgery or radiotherapy. The question for these patients with no evidence of metastases on imaging is whether to start ADT immediately or wait until clinical progression (localised or metastatic). There is an extensive amount of data addressing this issue, covering the period from the 1970s to 2006. This complicates the analysis because of: issues of stage migration and stage detection with pre bone scan and pre PSA era incorporated with studies involving patients who are more accurately staged in modern era Clinical practice guidelines for the management of locally advanced and metastatic prostate cancer 16
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 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
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
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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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