Elsevier

European Urology

Volume 53, Issue 1, January 2008, Pages 68-80
European Urology

Guidelines
EAU Guidelines on Prostate Cancer

https://doi.org/10.1016/j.eururo.2007.09.002Get rights and content

Abstract

Objectives

To present a summary of the 2007 version of the European Association of Urology (EAU) guidelines on prostate cancer (PCa).

Methods

A literature review of the new data emerging from 2004 to 2007 was performed by the working panel. The guidelines have been updated, and the level of evidence/grade of recommendation was added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

Results

A full version is available at the EAU Office or at www.uroweb.org. Systemic prostate biopsy under ultrasound guidance is the preferred diagnostic method. Active treatment is mostly recommended for patients with localized disease and a long life expectancy, with radical prostatectomy being shown to be superior to watchful waiting in a prospective randomized trial. Nerve-sparing radical prostatectomy represents the approach of choice in organ-confined disease; neoadjuvant androgen deprivation demonstrates no improvement of outcome variables. Radiation therapy should be performed with at least 72 and 78 Gy in low-risk and intermediate- to high-risk PCa, respectively. Monotherapeutic androgen deprivation is the standard of care in metastatic PCa; intermittent androgen deprivation might be an alternative treatment option for selected patients. Follow-up is largely based on prostate-specific antigen and a disease-specific history with imaging only indicated when symptoms occur. Cytotoxic therapy with docetaxel has emerged as the reference treatment for metastatic hormone-refractory PCa.

Conclusions

The knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarize the most recent findings and put them into clinical practice.

Introduction

The most recent summary of the European Association of Urology (EAU) guidelines on prostate cancer (PCa) was published in 2005 [1]. The long version of these guidelines has been continuously updated because many important changes affecting the clinical management of PCa have occurred over the past few years. The aim of this paper is to present a summary of the 2007 update of the EAU guidelines on PCa. To facilitate evaluating the quality of the information provided, evidence levels and grade of recommendation have been inserted according to the general principles of evidence-based medicine [2].

Section snippets

Epidemiology

PCa is recognized as one of the major medical problems facing the male population. In Europe, an estimated 2.6 million new cases of cancer are diagnosed each year. PCa constitutes about 11% of all male cancers in Europe [3], and accounts for 9% of all cancer deaths among men within the European Union [4].

Risk factors

Hereditary factors are important in determining the risk of developing clinical PCa, and exogenous factors may have an important impact on this risk. The key question is whether there is enough evidence to recommend lifestyle changes in order to decrease the risk. There is some evidence for this, and such information could be given to male relatives of PCa patients who ask about the impact of diet (level of evidence: 3–4).

If one first-line relative has the disease, the risk is at least doubled.

Classifications

The Union International Contra Cancer 2002 tumour, node, metastasis (TNM) classification is used throughout these guidelines [7]. The most commonly used system for grading of adenocarcinoma of the prostate is the Gleason score [8]. The system describes a score between 2 and 10, with 2 being the least aggressive and 10 the most aggressive. This score is the sum of the two most common patterns (grades 1–5) of tumour growth found. To be counted, a pattern (grade) needs to occupy more than 5% of

Prostate cancer screening

Population or mass screening is defined as the systematic examination of asymptomatic men (at risk). Usually, screening takes place within the framework of a trial or study and is initiated by a screener. In contrast, opportunistic screening aims at early detection of PCa in individual cases, and it is initiated by the patient and/or his physician. To evaluate the efficacy of PCa screening, two large randomized trials are underway, the Prostate, Lung, Colorectal, and Ovary Trial in the United

Diagnosis and staging of prostate cancer

The main diagnostic tools used to look for evidence of PCa include digital rectal examination, serum concentration of PSA, and transrectal ultrasound-guided biopsies [11]. Diagnosis depends on the presence of adenocarcinoma in operative specimens and prostate biopsy cores.

A threshold level of PSA that indicates the highest risk of PCa needs to be defined [10]. Extrapolating data from the curves, the cumulative 7-yr risk of being diagnosed with PCa in a screening programme based on PSA

Primary local treatment of prostate cancer

It is not possible to state that one therapy is clearly superior over another, as randomized controlled trials are lacking in this field. However, based on the available literature, some recommendations can be made. A summary, subdivided by stage at diagnosis, is provided in Table 2; below a few suggestions are made with regard to the different treatment options available. In general, it is recommended to integrate recently developed and validated nomograms into the counselling process.

Alternative local treatment options of prostate cancer

Besides RP, external beam radiation therapy, and/or brachytherapy, cryosurgical ablation of the prostate and high-intensity focused ultrasound have emerged as alternative therapeutic options in patients with clinically localized PCa who are not suitable for RP [38]. Patients ideally suitable for cryosurgical ablation of the prostate are those with organ-confined PCa, prostate size ≤ 40 ml, PSA serum level < 20 ng/ml, and a biopsy Gleason score < 7. Because there are only very few data on the

Hormonal therapy

Today, luteinising hormone-releasing hormone (LHRH) agonists have become the standard of care in hormonal therapy because they avoid the physical and psychological discomfort associated with orchiectomy and lack the potential cardiotoxicity associated with DES [39], [40]. As primary anti-androgen monotherapy, bicalutamide 150 mg/d has been compared to medical or surgical castration in two large prospective randomized trials with an identical study design, including a total of 1435 patients with

Follow-up of prostate cancer patients

Patients diagnosed with PCa are usually followed lifelong or until advancing age makes follow-up superfluous. Determination of serum PSA, disease-specific history, and digital rectal examination are the cornerstones in the follow-up of PCa patients. Routine imaging procedures in stable patients are not recommended and should only be used in specific situations. The follow-up intervals and which tests are needed have not been well studied, and often these need to be individualized. Table 4

Treatment of relapse after curative therapies

Following RP, PSA values > 0.2 ng/ml represent recurrent cancer [45]. Following radiation therapy, a PSA value 2 ng/ml above the nadir after radiation therapy represents recurrent cancer [46].

An effort should be made to distinguish between the probability of local failure only versus distant and/or local failure. Initial pathology, how long after primary therapy the PSA-relapse occurs, and how fast the PSA value is rising can all aid in the distinction between local and distant failure (Table 6).

Treatment of relapse after hormonal therapy

Patients experiencing relapse after hormonal therapy are usually in a more advanced disease stage and will generally become symptomatic within a relatively short time after the onset of the PSA rise. In most cases the decision to treat or not to treat is made based on counselling of the individual patient, which limits the role of guidelines. However, there are some therapeutic algorithms available that have emerged based on the data of prospective clinical trials. The recommendations for

Summary

The present text represents a summary of the EAU guidelines on PCa; for more detailed information and a full list of references, we refer readers to the full text version. These EAU guidelines (ISBN 90-70244-27-6) are available at the website of the European Association of Urology (http://www.uroweb.org).

Conflicts of interest

Dr. Axel Heidenreich has financial relationships as a lecturer, consultant, and Advisory Board Member at Sanofi-Aventis, Novartis, Hoffmann-La Roche, Centocor.

During the EAU meeting in Berlin, 2007, Prof. Gunnar Aus has been taking part in a symposium related to High Intensity Focused Ultrasound (HIFU) for the treatment of prostate cancer. For chairing this symposium, he received financial compensation from EDAP, Lyon, France.

There are no financial disclosures to be made for Prof. M. Bolla, Dr.

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