Elsevier

European Urology

Volume 65, Issue 1, January 2014, Pages 124-137
European Urology

Guidelines
EAU Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent—Update 2013

https://doi.org/10.1016/j.eururo.2013.09.046Get rights and content

Abstract

Context

The most recent summary of the European Association of Urology (EAU) guidelines on prostate cancer (PCa) was published in 2011.

Objective

To present a summary of the 2013 version of the EAU guidelines on screening, diagnosis, and local treatment with curative intent of clinically organ-confined PCa.

Evidence acquisition

A literature review of the new data emerging from 2011 to 2013 has been performed by the EAU PCa guideline group. The guidelines have been updated, and levels of evidence and grades of recommendation have been added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

Evidence synthesis

A full version of the guidelines is available at the EAU office or online (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. Systematic prostate biopsies under ultrasound guidance and local anesthesia are the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. A biopsy progression indicates the need for active intervention, whereas the role of PSA doubling time is controversial. In men with locally advanced PCa for whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT), with equivalent oncologic efficacy. Active treatment is recommended mostly for patients with localized disease and a long life expectancy, with radical prostatectomy (RP) shown to be superior to WW in prospective randomized trials. Nerve-sparing RP is the approach of choice in organ-confined disease, while neoadjuvant ADT provides no improvement in outcome variables. Radiation therapy should be performed with ≥74 Gy in low-risk PCa and 78 Gy in intermediate- or high-risk PCa. For locally advanced disease, adjuvant ADT for 3 yr results in superior rates for disease-specific and overall survival and is the treatment of choice. Follow-up after local therapy is largely based on PSA and a disease-specific history, with imaging indicated only when symptoms occur.

Conclusions

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.

Patient summary

A summary is presented of the 2013 EAU guidelines on screening, diagnosis, and local treatment with curative intent of clinically organ-confined prostate cancer (PCa). Screening continues to be done on an individual basis, in consultation with a physician. Diagnosis is by prostate biopsy. Active surveillance is an option in low-risk PCa and watchful waiting is an alternative to androgen-deprivation therapy in locally advanced PCa not requiring immediate local treatment. Radical prostatectomy is the only surgical option. Radiation therapy can be external or delivered by way of prostate implants. Treatment follow-up is based on the PSA level.

Introduction

The most recent summary of the European Association of Urology (EAU) guidelines on prostate cancer (PCa) was published in 2011 [1]. The aim of this paper is to present a summary of the 2013 update of the EAU guidelines on PCa. To facilitate evaluating the quality of the information provided, level of evidence (LE) and grade of recommendation (GR) have been inserted according to the general principles of evidence-based medicine [2].

Section snippets

Epidemiology

In Europe, PCa is the most common solid neoplasm, with an incidence rate of 214 cases per 1000 men, outnumbering lung and colorectal cancer [3]. PCa affects elderly men more often and therefore is a bigger health concern in developed countries. Approximately 15% of male cancers are PCa in developed countries, compared with 4% of male cancers in developing countries [4]. There are large regional differences in incidence rates of PCa, with a range from 68.8 per 1000 in Malta to 182 per 1000 in

Risk factors

The factors that determine the risk of developing clinical PCa are not well known, although three well-established risk factors have been identified: increasing age, ethnic origin, and heredity. If one first-line relative has the disease, the risk is at least doubled. If two or more first-line relatives are affected, the risk increases by 5–11 times [5]. Approximately 9% of individuals with PCa have true hereditary PCa, defined as three or more relatives affected or at least two relatives who

Classifications

The Union Internationale Contre le Cancer 2010 TNM classification is used throughout these guidelines [8].

The Gleason score is the recommended methodology for grading PCa. According to current international convention, the (modified) Gleason score of cancers detected in a prostate biopsy consists of the Gleason grade of the dominant (most extensive) carcinoma component plus the highest grade, regardless of its extent—there is no 5% rule [9]. In radical prostatectomy (RP) specimens, both the

Prostate cancer screening

There is currently no evidence for introducing widespread population-based screening programs for early PCa detection in all men [10] (LE: 2). To evaluate the efficacy of PCa screening, two large randomized trials have been published: the Prostate, Lung, Colorectal and Ovary (PLCO) trial in the United States and the European Randomized Study of Screening for Prostate Cancer (ERSPC) in Europe [11], [12] (LE: 1b).

The PLCO cancer-screening trial randomly assigned 76 693 men to receive either annual

Diagnosis and staging of prostate cancer

The main tools to diagnose PCa include DRE, serum concentration of PSA, and transrectal ultrasound (TRUS)-guided biopsy. In approximately18% of all patients, PCa is detected by a PCa-suggestive finding on DRE alone, regardless of the PSA level [17] (LE: 2a). A suspect DRE in patients with a PSA level of ≤2 ng/ml has a positive predictive value of 5–30% [18] (LE: 2a). A PSA cut-off of 3 or 3.1 μg/l should be considered for World Health Organization–calibrated assays to achieve the same

Primary local treatment of prostate cancer

The therapeutic management of PCa, even clinically localized disease, has become increasingly complex because of the various stage-specific therapeutic options available. It is therefore advisable to do the following:

  • Counsel patients with low-risk PCa (PSA <10 ng/ml and biopsy Gleason score 6 and cT1c–cT2a) or intermediate-risk PCa (PSA 10.1–20 ng/ml or biopsy Gleason score 7 or cT2b–c) in an interdisciplinary setting with a urologist and a radiation oncologist.

  • Discuss neoadjuvant and adjuvant

Irradiation to the pelvic lymph nodes

There is no firm evidence base for prophylactic whole-pelvic irradiation (46–50 Gy), since randomized trials have failed to show a benefit in high-risk cases [104], [105], [106], [107]. The use of ePLND may be needed to improve the selection of patients who may be able to benefit from pelvic lymph node irradiation. The results of pelvic lymphadenectomy, particularly in young patients, will enable radiation oncologists to tailor both the planning target volume and the duration of

Proton-beam and carbon ion–beam therapy

Proton-beam therapy is a promising but costly treatment for PCa. Although there are theoretical physical advantages, this therapy has so far been shown to be only comparably safe and effective when compared with the alternatives and not necessarily superior [108].

The Proton Radiation Oncology Group 9509 trial randomly assigned 393 men with clinically localized PCa to receive EBRT with 70.2 Gy compared with 79.2 Gy of combined photon and proton radiation [109] in a dose-escalation trial. At a

Follow-up of prostate cancer patients

Patients diagnosed with PCa who undergo local treatment with curative intent are usually followed for ≥10 yr or until high age makes follow-up superfluous. Determination of serum PSA, together with a disease-specific history, is supplemented by DRE and by imaging studies if locally recurrent disease is suspected.

Alternative local treatment options for prostate cancer

Besides RP, EBRT, and/or brachytherapy, cryosurgical ablation of the prostate (CSAP) and high-intensity focused ultrasound (HIFU) have emerged as alternative therapeutic options in patients with clinically localized PCa who are not suitable for RP [110], [111], [112].

Crouzet et al. [111] analyzed the oncologic and functional outcomes of the largest patient cohort, which included 803 patients with low-, intermediate-, and high-risk PCa in 40.2%, 46.3%, and 13.5% of patients, respectively. Mean

Summary

The present text represents a summary. For more detailed information and a full list of references, refer to the full-text version. These EAU guidelines (ISBN 978–90–79754–71–7) are available at the EAU Web site (http://www.uroweb.org/guidelines/online-guidelines/).

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