Prostate Cancer

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

To access the pdfs & translations of individual guidelines, please log in as EAU member.
Non-EAU members can view the web versions.
To become an EAU member, click here.

N. Mottet (Chair), J. Bellmunt, E. Briers (Patient Representative), M. Bolla, L. Bourke, P. Cornford (Vice-chair), M. De Santis, A.M. Henry, S. Joniau, T.B. Lam, M.D. Mason, H.G. van der Poel, T.H. van der Kwast, O. Rouvière, T. Wiegel
Guidelines Associates: N. Arfi, R.C.N.. van den Bergh, T. van den Broeck, M. Cumberbatch, N. Fossati, T. Gross, M. Lardas, M. Liew, P. Moldovan, I.G. Schoots, P.M. Willemse

1.INTRODUCTION

1.1.Aims and scope

The Prostate Cancer (PCa) Guidelines Panel have prepared this guidelines document to assist medical professionals in the evidence-based management of PCa.

It must be emphasised that clinical guidelines present the best evidence available to the experts but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account.

Guidelines are not mandates and do not purport to be a legal standard of care.

1.2.Panel composition

The PCa Guidelines Panel consists of an international multidisciplinary group of urologists, radiation oncologists, medical oncologists, radiologists, a pathologist and a patient representative.

All imaging sections in the text have been developed, jointly with the European Society of Urogenital Radiology (ESUR). Representatives of ESUR in the PCa Guidelines Panel are (in alphabetical order): Prof.Dr. O Rouvière and Dr. I.G. Schoots.

Section 6.3: Treatment - Definitive Radiotherapy, has been developed jointly with the European Society for Radiotherapy & Oncology (ESTRO). Representatives of ESTRO in the PCa Guidelines Panel are (in alphabetical order): Prof.Dr. M. Bolla, Prof.Dr. A.M. Henry, Prof.Dr. M.D. Mason and Prof.Dr. T. Wiegel.

All experts involved in the production of this document have submitted potential conflict of interest statements which can be viewed on the EAU website Uroweb: http://uroweb.org/guideline/prostatecancer/?type=panel.

1.2.1.Acknowledgement

The PCa Guidelines Panel are most grateful for the support and considerable expertise provided by
Prof.Dr. J-P. Droz, Emeritus Professor of Medical Oncology (Lyon, France) on the topic of ‘Management of PCa in senior adults’. As a leading expert in this field, and prominent member of the International Society of Geriatric Oncology, his contribution has been invaluable.

1.3.Available publications

A quick reference document (Pocket guidelines) is available, both in print and in a number of versions for mobile devices. These are abridged versions which may require consultation together with the full text version. Several scientific publications are available [1,2] as are a number of translations of all versions of the PCa Guidelines. All documents can be accessed on the EAU website: http://uroweb.org/guideline/prostate-cancer/.

1.4.Publication history and summary of changes

1.4.1.Publication history

The EAU PCa Guidelines were first published in 2001. This 2017 document presents a full update of the 2016 full text document.

1.4.2.Summary of changes

New and relevant evidence has been identified, collated and appraised through a structured assessment of the literature and incorporated in all chapters of the 2017 EAU PCa Guidelines.

Key changes for the 2017 print:

  • Chapter 3 - Epidemiology and aetiology. This section has been completely renewed.
  • Chapter 4 - Classification and staging systems. This chapter has been expanded with a new section (4.3 Prognostic relevance of stratification). Additional information on the International Society of Urological Pathology Gleason grading has been included in Table 4.2.2 (EAU risk groups for biochemical recurrence of localised and locally advanced prostate cancer).
  • Section 6.6.8 - Imaging as marker of response in metastatic prostate cancer. This is a new section.
  • Chapter 6.7 - Management of PCa in older men. Two new figures have been included.
  • Chapter 8 - Quality of life outcomes in prostate cancer. This chapter is partly based on the findings of a new systematic review (SR) (see below). A second review is ongoing, the findings of which will be incorporated in the 2018 print of these Guidelines.

Changes in the summaries of evidence and recommendations can be found in sections:

3.2.3 Summary of evidence and guidelines for epidemiology and aetiology

Summary of evidence

Prostate cancer is a major health issue in men, the incidence mainly dependent on age.

Genetic factors are associated with risk of (aggressive) PCa but ongoing trials will need to define the clinical applicability of screening for genetic susceptibility of PCa.

A variety of exogenous/environmental factors may have an impact on the risk of progression.

5-ARIs are not EMA-approved for PCa prevention.

Selenium or vitamin-E supplements have no beneficial effect in preventing PCa.

In hypogonadal men, testosterone supplementation does not increase the risk of PCa.

Recommendation

No definitive recommendation can be provided for specific preventive or dietary measures to reduce the risk of developing prostate cancer.

Table 4.2.2: EAU risk groups for biochemical recurrence of localised and locally advanced prostate
cancer

Definition

Low-risk

Intermediate-risk

High-risk

PSA < 10 ng/mL

and GS < 7 (ISUP Grade 1)

and cT1-2a

PSA 10-20 ng/mL

or GS 7 (ISUP Grade 2/3)

or cT2b

PSA > 20 ng/mL

or GS > 7 (ISUP Grade 4/5)

or cT2c

any PSA

any GS cT3-4

or cN+

Any ISUP Grade

Localised

Locally advanced

GS=Gleason score; ISUP=International Society for Urologcal Pathology; PSA=prostate-specific antigen.

6.1.5 Guidelines for active surveillance and watchful waiting

Recommendations - active surveillance

LE

GR

Perform multiparametric magnetic resonance imaging before a confirmatory biopsy.

2b

B

During confirmatory biopsy include systematic and targeted biopsies.

2a

B

6.2.7.5 Guidelines for eLND in prostate cancer and pN+ patients

Recommendation

LE

GR

Do not perform a frozen section of nodes during radical prostatectomy to decide whether to proceed with, or abandon, the procedure.

2a

A

6.2.10 Guidelines for radical prostatectomy

Recommendations

LE

GR

Offer both radical prostatectomy and radiotherapy in patients with low- and intermediate-risk disease and a life expectancy > 10 years.

1b

A

Offer active surveillance as an alternative to surgery in patients with low-risk disease and a life expectancy of > 10 years.

1b

A

6.3.8 Summary of evidence and guidelines for definitive radiotherapy

Summary of evidence

LE

The optimum duration of androgen deprivation therapy (ADT) with external beam radiation therapy (EBRT) is well established in the literature. There is no evidence that these durations should change when using brachytherapy boost with EBRT.

1b

Limited data, from experienced centres only, are available for the use of fractionated high-dose-rate brachytherapy as monotherapy in patients with low and intermediate-risk PCa.

2a

Recommendations

LE

GR

Moderate hypofractionation (HFX) with IMRT including image-guided radiation therapy (IGRT) to the prostate only can be offered to carefully selected patients with localised disease (as discussed in the text).

1a

A

Moderate HFX should adhere to radiotherapy-protocols from trials with equivalent outcome and toxicity, i.e. 60 Gy/20 fractions in four weeks or 70 Gy/28 fractions in six weeks.

1a

A

6.9.4.6 Guidelines for imaging in patients with biochemical recurrence

Prostate-specific antigen (PSA) recurrence after radical prostatectomy

LE

GR

PSA > 1 ng/mL: positon emission tomography (PET)/computed tomography (CT) imaging is recommended using choline or prostate-specific membrane antigen (PMSA).

2b

A

8.3.1.1Guidelines for long term quality of life in men with localised disease

Recommendations

LE

GR

Advise eligible patients for active surveillance, that global quality of life is equivalent for up to five years compared to radical prostatectomy or radiotherapy.

1b

A

Discuss the negative impact of surgery on urinary and sexual function, as well as the negative impact of radiotherapy on bowel function with patients.

1b

A

Advise patients treated with brachytherapy of the negative impact on irritative urinary symptomatology at one year but not after five years.

1b

C

8.3.2.1 Guidelines on improving quality of life in men who have been diagnosed with prostate cancer

Recommendations

LE

GR

Offer men on androgen deprivation therapy, twelve weeks of supervised (by trained exercise specialists) combined aerobic and resistance exercise.

1a

A

Offer men with T1-T3 disease specialist nurse led, multi-disciplinary rehabilitation based on the patients’ personal goals addressing incontinence, sexuality, depression and fear of recurrence, social support and positive lifestyle changes after any radical treatment.

1b

A