HOLLYWOOD, FLA. — Updated National Comprehensive Cancer Network guidelines stress expectant management—surveillance only with no other treatment—for low- and intermediate-risk prostate cancer.
“We think it is more prudent to take into account a man's life expectancy than just to look at his prostate cancer when it comes to devising a treatment strategy,” Dr. James L. Mohler, chairman of the department of urologic oncology at Roswell Park Cancer Institute, Buffalo, N.Y., said at the NCCN's annual conference.
The NCCN prostate cancer guidelines now recommend that men with low-risk prostate cancer (stage T1-T2a, Gleason score 2–6, and prostate specific antigen (PSA) levels less than 10 ng/mL) consider expectant management, regardless of whether their life expectancy is more or less than 10 years.
If these low-risk men decline expectant management, the NCCN recommends radiation therapy with three-dimensional conformal radiation, intensity-modulated radiation, or brachytherapy if their life expectancy is less than 10 years. If their life expectancy is more than 10 years, the guidelines stipulate an additional option: radical prostatectomy with or without pelvic lymph node dissection if the predicted probability of lymph node metastasis is 7% or greater.
Expectant management is also an option for men with intermediate-risk prostate cancer (stage 2b-T2c, Gleason score 7, and PSA levels of 10–20 ng/mL).
“Increased emphasis on expectant management as an appropriate option … is the most interesting change in the [guidelines],” said Dr. Mohler, who chaired the NCCN prostate cancer guidelines committee.
Also new is a warning against the use of neoadjuvant androgen deprivation therapy before radical prostatectomy. “It does not work, and it makes the operation more difficult,” he said.
The panel also stated that radical prostatectomy may be performed as an open procedure, laparoscopically, or as a robot-assisted procedure. In addition, patients should consider high-volume surgeons and high-volume centers when opting for radical prostatectomy, “because, in general, the procedures will be performed better.”
Robot-assisted prostatectomy was added to the new guidelines, Dr. Mohler said, because it offers the same results as open or laparoscopically performed surgery with faster recovery times. Any dangerous movements are recognized as “not allowed” by the robot. In addition, complex maneuvers such as suturing and tying knots also can be performed easily. “The patients I do every Monday go home Tuesday at 2 o'clock.”
Dr. Mohler said he had no conflicts of interest to declare.
The patient shown here has undergone a radical prostatectomy using robotic surgery, which Dr. Mohler referred to as 'the new look of the surgical urologic oncology patient.' Courtesy Roswell Park Cancer Institute
The guidelines now include robotic prostatectomy because it issafer, faster, easier, and has good outcomes. DR. MOHLER