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

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Evidence summary Level References Both of the two larger RCT subgroup analyses for biopsy proven node-positive disease that were examined showed that castration, either LHRH agonist until progression or orchidectomy, resulted in significant overall and cancer-specific survival benefits when combined with radiotherapy Recommendation II 112-114 If radical radiotherapy is given to patients with node-positive disease it is reasonable to offer long-term androgen deprivation in addition to radiotherapy. Grade D 3.3.2 External beam radiotherapy There are three randomised control trials examining radiotherapy alone as a treatment option for node-positive disease. Two of the three trials compared prostate and pelvic irradiation to para-aortic and pelvic and prostate irradiation. 62, 63, 116 The Bagshaw trial included 18 patients and the Pilepich trial, a subgroup analysis, included 134 patients. The third trial was also small, with 77 patients. It compared extended field radiation in pelvic lymphadenectomy patients with observation followed by delayed hormonal therapy. 117 None of the trials was blinded. There were no RCTs comparing conformal modern radiotherapy techniques with immediate hormone therapies. The trials examining extended field with a more limited pelvic field were consistent, showing no overall survival or disease-free survival benefit when comparing extended para-aortic irradiation to pelvic and prostate irradiation. There was only one trial comparing radiotherapy with no radiotherapy. 117 At five years median disease-free survival was statistically significantly improved in the radiotherapy arm. However, the overall survival benefit with radiotherapy was not statistically significant. The lack of statistical significance may be due to limited follow-up. Evidence summary Level References The role of external beam radiotherapy in node-positive patients has not yet been defined. Recommendation II 62, 63, 116, 117 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. Grade N/A 39 Locally advanced disease
References 1. Jordan WP, Jr., Blackard CE, Byar DP. Reconsideration of orchiectomy in the treatment of advanced prostatic carcinoma. Southern Medical Journal 70(12):1411-3, 1977. 2. Immediate versus deferred treatment for advanced prostatic cancer: initial results of the Medical Research Council Trial. The Medical Research Council Prostate Cancer Working Party Investigators Group. British Journal of Urology 79(2):235-46, 1997. 3. Schroder FH, Kurth KH, Fossa SD et al. Early versus delayed endocrine treatment of pN1-3 M0 prostate cancer without local treatment of the primary tumor: results of European Organisation for the Research and Treatment of Cancer 30846--a phase III study. Journal of Urology 172(3):923-7, 2004. 4. Schroder FH, Kurth KH, Fossa SD et al. Members of the European Organisation for the Research and Treatment of Cancer Genito-urinary Grup (2008) Early versus delayed endrocrine treatment of pN1-3 M0 prostate cancer without local treatmetn of the primary tumor: results of European Organsiation for the Research and Treatment of Cancer 30846 after 13 years followup - A phase III study. American Society of Clinical Oncology 2008 Genitourinary Cancers Symposium, February 14-16, San Franscisco www asco org/ accessed 29 February 2008 . 5. Studer UE, Whelan P, Albrecht W et al. Immediate or deferred androgen deprivation for patients with prostate cancer not suitable for local treatment with curative intent: European Organisation for Research and Treatment of Cancer (EORTC) Trial 30891. Journal of Clinical Oncology 24(12):1868-76, 2006. 6. McLeod DG, Iversen P, See WA et al. Bicalutamide 150 mg plus standard care vs standard care alone for early prostate cancer. BJU International 97(2):247-54, 2006. 7. Byar DP. Proceedings: The Veterans Administration Cooperative Urological Research Group's studies of cancer of the prostate. Cancer 1973;32(5):1126-1130. 8. Aro J, Haapiainen R, Kajanti M, Rannikko S, Alfthan O. Comparison of endocrine and radiation therapy in locally advanced prostatic cancer. European Urology 15(3-4):182-6, 1988. 9. Aro J, Haapiainen R, Kajanti M, Rannikko S, Alfthan O. Orchiectomy, estrogen therapy and radiotherapy in locally advanced (T3-4 M0) prostatic cancer. Scandinavian Journal of Urology & Nephrology Supplementum 110:103-7, 1988. 10. Johansson JE, Andersson SO, Holmberg L, Bergstrom R. Primary orchiectomy versus estrogen therapy in advanced prostatic cancer--a randomized study: results after 7 to 10 years of followup. Journal of Urology 145(3):519-22; discussion 522-3, 1991. 11. Iversen P, Tyrrell CJ, Kaisary AV et al. Bicalutamide monotherapy compared with castration in patients with nonmetastatic locally advanced prostate cancer: 6.3 years of followup. Journal of Urology 164(5):1579-82, 2000. 12. Boccardo F, Barichello M, Battaglia M et al. Bicalutamide monotherapy versus flutamide plus goserelin in prostate cancer: updated results of a multicentric trial. European Urology 42(5):481-90, 2002. 13. Prostate Cancer Trialists' Collaborative Group. Maximum androgen blockade in advanced prostate cancer: An overview of the randomised trials. Lancet 2000;355(9214):1491-1498. 14. Boccardo F, Pace M, Rubagotti A et al. Goserelin acetate with or without flutamide in the treatment of patients with locally advanced or metastatic prostate cancer. The Italian Prostatic Cancer Project (PONCAP) Study Group. European Journal of Cancer 29A(8):1088-93, 1993. 15. Tyrrell CJ, Altwein JE, Klippel F et al. Comparison of an LH-RH analogue (Goeserelin acetate, 'Zoladex') with combined androgen blockade in advanced prostate cancer: final survival results Clinical practice guidelines for the management of locally advanced and metastatic prostate cancer 40
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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
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
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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
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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
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Page 62 and 63: 45. Melton LJ, III, Alothman KI, Kh
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Page 66 and 67: 105. Thompson IM, Tangen CM, Parade
Page 68 and 69: 4.2 Androgen deprivation therapy (e
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Page 72 and 73: therapy since such studies would be
Page 74 and 75: apparent in trials comparing CAB wi
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Page 80 and 81: Eight trials examined acute toxicit
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Page 84 and 85: olus) in addition to radiotherapy a
Page 86 and 87: References 1. Seidenfeld J, Samson
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Page 94 and 95: 6 CASTRATION-RESISTANT PROSTATE CAN
Page 96 and 97: the median overall survival for pat
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Page 100 and 101: with bone pain at study entry. At n
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Page 104 and 105: of these studies 56, 58 and in the
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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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