Clinical practice guidelines for the management of locally advanced and metastatic prostate cancer
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Management of locally advanced and metastatic prostate cancer
This resource has been developed, reviewed or revised more than five years ago. It may no longer reflect current evidence or best practice.
Published: 2010
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Foreword
Preface
Summary of recommendations
Introduction
Psychosocial care
- In men with prostate cancer, do interventions improve decision satisfaction, risk comprehension, knowledge about prostate cancer and understanding of their prognosis?
- In men with prostate cancer, do psychological and cognitive interventions improve psychological adjustment?
- In men with prostate cancer, do diet and lifestyle interventions improve quality of life?
- In men with prostate cancer, do interventions improve sexual functioning?
- In men with prostate cancer, do interventions alleviating partner distress improve quality of life?
- What are the levels of psycho-social distress in men with advanced prostate cancer, including that related to PSA anxiety?
Locally advanced disease
Androgen deprivation therapy (ADT)
- What should be done for patients with locally advanced disease who are not suitable candidates for surgery or radiotherapy – primary androgen deprivation at diagnosis or wait until clinical progression (localized or metastatic) - Timing?
- What should be done for patients with locally advanced disease who are not suitable candidates for surgery or radiotherapy – primary androgen deprivation at diagnosis or wait until clinical progression (localized or metastatic)?
- Are there differences between the different hormone therapy methods in the pattern and severity of toxicity effects, specifically symptoms such as hot flushes, gynecomastia, liver function and gastrointestinal, effect on sexual function and cognitive function and possible long term side effects such as changes in body composition and metabolic syndrome for non metastatic disease?
- What is the incidence of osteoporosis and reduction in bone mineral density at 2, 5 and 10 years and what is the risk of osteoporotic bone fracture due to bilateral orchidectomy (or orchidectomy), LHRH agonist or long term androgen deficiency?
- What is the effect on Quality of Life as measured by validated questionnaires due to androgen ablation (deprivation or blockade) treatment?
Radiotherapy
- What is the efficacy of external beam radiotherapy techniques for locally advanced disease?
- What is the efficacy of external beam radiotherapy compared with other treatments for local control for locally advanced disease?
- What is the efficacy of brachytherapy for locally advanced disease?
Radiotherapy and androgen deprivation therapy (ADT)
- Is there any survival advantage for androgen blockade (androgen ablation, deprivation) when used as first line therapy in the adjuvant or neoadjuvant setting with radiotherapy for locally advanced prostate cancer?
- Are cumulative treatment toxicities different when androgen blockade (androgen ablation, deprivation) is used as first line therapy in the adjuvant or neoadjuvant setting with radiotherapy for locally advanced prostate cancer in locally advanced disease?
Surgery
Surgery plus androgen deprivation therapy
Chemotherapy
Bisphosphonates
Pathologic T3/T4 disease post radical surgery (Patients with extra capsular extension, seminal vesicle involvement or positive surgical margins)
Node-positive disease
- Is there any survival advantage for androgen blockade (androgen ablation, deprivation) when used as first line therapy in the adjuvant or neoadjuvant setting with radiotherapy for locally advanced, node-positive prostate cancer?
- What is the efficacy of radiation for locally advanced node positive disease?
Biochemical relapse
Overt metastatic disease and/or loco-regional progressive disease
Androgen deprivation therapy
- Is any one hormone therapy (androgen ablation) superior to another when given in the first line setting in terms of survival in metastatic disease?
- Is there any survival advantage for maximum androgen blockade (or combined hormone therapy) compared with single agent androgen blockade when used as first line therapy in metastatic disease?
- For patients with radiologically detectable but asymptomatic disease should hormone therapy be started immediately or should it be started at the onset of symptoms?
- Are there differences between the different hormone therapy methods in the pattern and severity of toxicity effects, specifically symptoms such as hot flushes, gynecomastia, liver function and gastrointestinal, effect on sexual function and cognitive function and possible long term side effects such as changes in body composition and metabolic syndrome in metastatic disease?
- What is the effect on Quality of Life as measured by validated questionnaires due to androgen ablation (deprivation or blockade) treatment in metastatic disease?
- Is there a difference in survival for intermittent androgen deprivation compared to continuous androgen deprivation?
Radiotherapy
- What is the effectiveness of local external beam radiotherapy (EBRT) in the palliation of uncomplicated bone pain?
- What is the evidence for the effect of radiotherapy in palliation of soft tissue disease of EBRT to the prostate for symptom treatment in locally advanced disease and to local metastases such as the lymph nodes for symptom treatment such as lymphoedema and painful lymph nodes?
- What is the benefit of EBRT alone given for malignant spinal cord compression?
- What is the role of surgery in the treatment of malignant spinal cord compression?
- What is the efficacy of steroids for the treatment of malignant spinal cord compression?
- What is the efficacy of Hemibody (widefield) external beam radiotherapy in the palliation of uncomplicated bone pain?
Bisphosphonates
Chemotherapy
Castration-resistant prostate cancer
- Is any one hormone therapy (androgen ablation) superior to another when given in the second-line setting (after relapse from first-line androgen ablation) in terms of response, progression-free survival or survival?
- Should LHRH agonist be continued when the patient is hormone refractory?
Bisphosphonates
- What is the evidence for the use of bisphosphonates in the prevention of skeletal related events?
- What is the evidence for the use of bisphosphonates in the treatment of bone pain?
Radioisotopes
- What is the effectiveness of unsealed radioisotopes in the management of bone pain from prostate cancer?
- Do unsealed radioisotopes improve survival in metastatic prostate cancer?
- What is the evidence that quality of life is improved with unsealed radioisotopes in prostate cancer?
- What is the toxicity of unsealed radioisotopes for treatment of metastatic prostate cancer?
Chemotherapy
Palliative care
- In men with advanced prostate cancer, what is the evidence that referral to specialist palliative care can assist in supporting a patient’s decision making and treatment planning processes?
- In men with advanced prostate cancer, what is the evidence that referral to specialist palliative care can assist with symptom control?
- In men with advanced prostate cancer what palliative interventions (including use of analgesics and co-analgesics) can assist in pain control?
- In men with advanced prostate cancer, what interventions may ameliorate or minimise the symptoms of fatigue?
- In men with advanced prostate cancer, what is the evidence that specialist palliative care can assist patients and families in providing effective end of life care?
Complementary and alternative therapies
Socio-economic aspects of advanced prostate cancer
Emerging therapies
Appendices
- Guideline development process
- Working party members and contributors
- TNM classification of prostate tumours
- Further references
- Organisations which provide information and/or support for men with advanced prostate cancer
- Conflict of interest summary
- Abbreviations
- Glossary
Information for consumers
Advanced Prostate Cancer: a guide for men and their families 2009