Guideline of guidelines: primary monotherapies for localised or locally advanced prostate cancer

Abstract

Decisions regarding the primary treatment of prostate cancer depend on several patient- and disease-specific factors. Several international guidelines regarding the primary treatment of prostate cancer exist; however, they have not been formally compared. As guidelines often contradict each other, we aimed to systematically compare recommendations regarding the different primary treatment modalities of prostate cancer between guidelines. We searched Medline, the National Guidelines Clearinghouse, the library of the Guidelines International Network, and the websites of major urological associations for prostate cancer treatment guidelines. In total, 14 guidelines from 12 organisations were included in the present article. One of the main discrepancies concerned the definition of 'localised' prostate cancer. Localised prostate cancer was defined as cT1-cT3 in most guidelines; however, this disease stage was defined in other guidelines as cT1-cT2, or as any T-stage as long as there is no lymph node involvement (N0) or metastases (M0). In addition, the risk stratification of localised cancer differed considerably between guidelines. Recommendations regarding radical prostatectomy and hormonal therapy were largely consistent between the guidelines. However, recommendations regarding active surveillance, brachytherapy, and external beam radiotherapy varied, mainly as a result of the inconsistencies in the risk stratification. The differences in year of publication and the methodology (i.e. consensus-based or evidence-based) for developing the guidelines might partly explain the differences in recommendations. It can be assumed that the observed variation in international clinical practice regarding the primary treatment of prostate cancer might be partly due to the inconsistent recommendations in different guidelines.

The pathological upgrading after radical prostatectomy in low‐risk prostate cancer patients who are eligible for active surveillance: How safe is it to depend on bioptic pathology?

“…However, overdiagnosis and overtreatment were frequently discussed in the last decade. Active surveillance (AS) is offered for suitable patients who have a very low or low‐risk disease to prevent overtreatment in the management of PCa …”

“…Active surveillance (AS) is offered for suitable patients who have a very low or low-risk disease to prevent overtreatment in the management of PCa. 3 Despite the improvements such as multiparametric prostate MRI (mp-MRI), and molecular technologies in PCa diagnostic tools, AS is also a controversial topic. 4 This controversy might be based on several factors including the tumor heterogenity, multifocality, and the biopsy undersampling which are associated with Gleason upgrading (GU) after RP.…”

Current Treatment for Low-Risk Prostate Cancer in China: A National Network Survey

“…Another study on PCa followed-up for 20 years also showed that RP does not significantly reduce all-cause mortality or tumor-specific mortality compared with AS, and RP results in associated complications11. Nearly 30% of patients require other treatments, such as surgery and radiotherapy, within 5 years of AS12, but AS is still widely used and recommended for patients with LRPC 1, 8. The 2014 edition of the CUA guidelines proposed an indication of AS for PCa confirmed by prostate biopsy, which was similar to other indications 4-6.…”

“…All guidelines except the Chinese Urological Association(CUA), including the American Urological Association, the European Association of Urology (EAU), the Japanese Urological Association, and the Canadian Urological Association currently have clear recommendations for treating low-risk prostate cancer (LRPC). Among them, active monitoring or surveillance (AS) is the most widely advised treatment 1. If LRPC is treated with radical prostatectomy (RP) or radiotherapy, it may be overtreated, which has no benefit to the patient and increases the complication rate2, 3 and wastes limited medical resources, leading to delayed treatment opportunities for those who have more aggressive prostate cancer (PCa).…”

Treatment outcomes of 125I low-dose-rate brachytherapy vs radical prostatectomy for patients with intermediate-risk prostate cancer

“…Radical prostatectomy (RP), low-dose-rate brachytherapy (LDR), and external beam radiation therapy (EBRT) are the three major de nitive treatment options for localized prostate cancer. Established clinical guidelines recommend that treatment decisions should be made based on tumor features, baseline prostate speci c antigen (PSA) levels, patient age, comorbidity, life expectancy, and quality of life (3)(4)(5). However, which of these treatments is the best for patients with localized prostate cancer remains a subject of debate.…”