Elsevier

European Urology

Volume 79, Issue 2, February 2021, Pages 243-262
European Urology

Review – Prostate Cancer
EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer—2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent

https://doi.org/10.1016/j.eururo.2020.09.042Get rights and content

Abstract

Objective

To present a summary of the 2020 version of the European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Geriatric Oncology (SIOG) guidelines on screening, diagnosis, and local treatment of clinically localised prostate cancer (PCa).

Evidence acquisition

The panel performed a literature review of new data, covering the time frame between 2016 and 2020. The guidelines were updated and a strength rating for each recommendation was added based on a systematic review of the evidence.

Evidence synthesis

A risk-adapted strategy for identifying men who may develop PCa is advised, generally commencing at 50 yr of age and based on individualised life expectancy. Risk-adapted screening should be offered to men at increased risk from the age of 45 yr and to breast cancer susceptibility gene (BRCA) mutation carriers, who have been confirmed to be at risk of early and aggressive disease (mainly BRAC2), from around 40 yr of age. The use of multiparametric magnetic resonance imaging in order to avoid unnecessary biopsies is recommended. When a biopsy is performed, a combination of targeted and systematic biopsies must be offered. There is currently no place for the routine use of tissue-based biomarkers. Whilst prostate-specific membrane antigen positron emission tomography computed tomography is the most sensitive staging procedure, the lack of outcome benefit remains a major limitation. Active surveillance (AS) should always be discussed with low-risk patients, as well as with selected intermediate-risk patients with favourable International Society of Urological Pathology (ISUP) 2 lesions. Local therapies are addressed, as well as the AS journey and the management of persistent prostate-specific antigen after surgery. A strong recommendation to consider moderate hypofractionation in intermediate-risk patients is provided. Patients with cN1 PCa should be offered a local treatment combined with long-term hormonal treatment.

Conclusions

The evidence in the field of diagnosis, staging, and treatment of localised PCa is evolving rapidly. The 2020 EAU-EANM-ESTRO-ESUR-SIOG guidelines on PCa summarise the most recent findings and advice for their use in clinical practice. These PCa guidelines reflect the multidisciplinary nature of PCa management.

Patient summary

Updated prostate cancer guidelines are presented, addressing screening, diagnosis, and local treatment with curative intent. These guidelines rely on the available scientific evidence, and new insights will need to be considered and included on a regular basis. In some cases, the supporting evidence for new treatment options is not yet strong enough to provide a recommendation, which is why continuous updating is important. Patients must be fully informed of all relevant options and, together with their treating physicians, decide on the most optimal management for them.

Section snippets

Epidemiology and risk factors

The most recent summary of the European Association of Urology (EAU)-European Society for Radiotherapy and Oncology (ESTRO)-International Society of Geriatric Oncology (SIOG) guidelines on prostate cancer (PCa) was published in 2017 [1]. In view of the volume of new data, there was a need for an updated summary. The present summary is based on the latest guidelines published in April 2020 [2]. This update is based on structured annual literature reviews and systematic reviews, as a continuous

Classification and staging

The 2017 TNM classification of the American Joint Committee on Cancer (AJCC) for staging of PCa should be used [17], where the cT stage is based on digital rectal examination (DRE) only. Compared with the 2009 version, the main difference is the lack of pT2 substage differentiation. The EAU risk group classification (Table 1) is based on grouping patients with a similar risk of biochemical recurrence after local treatment. However, emerging clinical data support this distinction between

Screening and early detection

Population or mass screening is defined as the “systematic examination of asymptomatic men (at risk)” and is usually initiated by health authorities. The coprimary objectives are a reduction in disease-specific mortality and a maintained QoL. Screening for PCa remains one of the most controversial topics in the urologic literature, and it is currently not recommended in most countries worldwide. A Cochrane review suggested that prostate-specific antigen (PSA) screening is associated with an

Diagnosis

Definitive diagnosis depends on histopathological verification. In order to avoid unnecessary biopsies, a further risk assessment should be offered (Table 5).

An abnormal DRE is an indication for biopsy, but as an independent variable, PSA is a better predictor of cancer than either DRE or transrectal ultrasound (TRUS). PSA is a continuous parameter, with higher levels indicating a greater likelihood of PCa, precluding an optimal PSA threshold for detecting nonpalpable but csPCa. A limited PSA

Prostate biopsy

TRUS-guided or transperineal ultrasound–guided biopsy using an 18 G biopsy needle and a periprostatic block is the standard of care. When the same numbers of cores are taken, both transrectal and transperineal approaches, when performed without prior imaging with MRI, have comparable detection rates [50]; however, some evidence suggests a reduced risk of infection with the transperineal route [51]. Where mpMRI has shown a suspicious lesion, MR-TBx can be obtained through cognitive guidance,

Staging of PCa

The decision to proceed with a further staging work-up is guided by which treatment options are available, taking into account the patient’s preference and comorbidity. A summary of the guidelines is presented in Table 8. The field of noninvasive nodal and metastatic staging of PCa is evolving very rapidly.

Evaluating life expectancy and health status

Older men with a high incidence of PCa may be undertreated. In the USA, only 41% of patients aged >75 yr with intermediate- and high-risk disease receive curative treatment compared with 88% of patients aged 65–74 yr [77].

Evaluation of life expectancy and health status is important in clinical decision making on screening, diagnosis, and treatment of PCa. In localised disease, >10 yr life expectancy is considered mandatory for any survival benefit from local treatment. Country-specific life

Primary local treatment

Management decisions should be made after all options have been discussed with a multidisciplinary team (including urologists, radiation oncologists, medical oncologists, pathologists, and radiologists), and after the balance of benefits and side effects of each therapy modality has been considered together with the patient.

Comparing various local therapies

The ProtecT trial is the only available RCT comparing three treatment modalities. A total of 1643 patients were randomised between active treatment (RP or EBRT + 6 mo of ADT) and active monitoring (AM) [175]. In this AM schedule, only patients with a PSA rise of >50% in 12 mo underwent a repeat biopsy. Of the patients, 56% had low-risk disease, with 90% having a PSA level of <10 ng/mL, 77% having ISUP grade 1 (20% ISUP grade 2–3), and 76% having T1c, whilst the other patients were mainly of

Alternative local treatment options

Besides RP, EBRT, and BT, other modalities have emerged as possible therapeutic options in patients with clinically localised PCa. However, patients with life expectancy of >10 yr should be informed fully that there are limited data on the long-term outcome for cancer control beyond 10 yr [180].

A systematic review compared cryotherapy versus RP and EBRT [181]. Data from 3995 patients across 19 studies were included. In the short term, there was conflicting evidence relating to cancer-specific

Conclusions

The present text represents a summary of the 2020 EAU-EANM-ESTRO-ESUR-SIOG PCa guidelines. A summary of recommendations is presented in Table 13. For more detailed information and a full list of references, refer to the full-text version available at the EAU web site (http://uroweb.org/guideline/prostate-cancer/).


Author contributions: Nicolas Mottet had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.


Study

References (189)

  • J. Hugosson et al.

    A 16-yr Follow-up of the European randomized study of screening for prostate cancer

    Eur Urol

    (2019)
  • S.P. Kelly et al.

    Past, current, and future incidence rates and burden of metastatic prostate cancer in the United States

    Eur Urol Focus

    (2018)
  • R. Arnsrud Godtman et al.

    Opportunistic testing versus organized prostate-specific antigen screening: outcome after 18 years in the Goteborg randomized population-based prostate cancer screening trial

    Eur Urol

    (2015)
  • H.J. Boyle et al.

    Updated recommendations of the International Society of Geriatric Oncology on prostate cancer management in older patients

    Eur J Cancer

    (2019)
  • P.J. Lamy et al.

    Prognostic biomarkers used for localised prostate cancer management: a systematic review

    Eur Urol Focus

    (2018)
  • K.S. Louie et al.

    Do prostate cancer risk models improve the predictive accuracy of PSA screening? A meta-analysis

    Ann Oncol

    (2015)
  • O. Rouviere et al.

    Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy-naive patients (MRI-FIRST): a prospective, multicentre, paired diagnostic study

    Lancet Oncol

    (2019)
  • M. van der Leest et al.

    Head-to-head comparison of transrectal ultrasound-guided prostate biopsy versus multiparametric prostate resonance imaging with subsequent magnetic resonance-guided biopsy in biopsy-naive men with elevated prostate-specific antigen: a large prospective multicenter clinical study

    Eur Urol

    (2019)
  • J.C. Weinreb et al.

    PI-RADS Prostate Imaging - Reporting and Data System: 2015, version 2

    Eur Urol

    (2016)
  • H. Shaish et al.

    Impact of a structured reporting template on adherence to prostate Imaging Reporting and Data System version 2 and on the diagnostic performance of prostate MRI for clinically significant prostate cancer

    J Am Coll Radiol

    (2018)
  • S. Hamid et al.

    The SmartTarget biopsy trial: a prospective, within-person randomised, blinded trial comparing the accuracy of visual-registration and magnetic resonance imaging/ultrasound image-fusion targeted biopsies for prostate cancer risk stratification

    Eur Urol

    (2019)
  • A.P. Kenigsberg et al.

    Optimizing the number of cores targeted during prostate magnetic resonance imaging fusion target biopsy

    Eur Urol Oncol

    (2018)
  • A.J. Lu et al.

    Role of core number and location in targeted magnetic resonance imaging-ultrasound fusion prostate biopsy

    Eur Urol

    (2019)
  • M.J. Roberts et al.

    Prostate biopsy-related infection: a systematic review of risk factors, prevention strategies, and management approaches

    Urology

    (2017)
  • C.F. Kweldam et al.

    Disease-specific survival of patients with invasive cribriform and intraductal prostate cancer at diagnostic biopsy

    Mod Pathol

    (2016)
  • A.M. Hovels et al.

    The diagnostic accuracy of CT and MRI in the staging of pelvic lymph nodes in patients with prostate cancer: a meta-analysis

    Clin Radiol

    (2008)
  • M. Perera et al.

    Gallium-68 prostate-specific membrane antigen positron emission tomography in advanced prostate cancer-updated diagnostic utility, sensitivity, specificity, and distribution of prostate-specific membrane antigen-avid lesions: a systematic review and meta-analysis

    Eur Urol

    (2020)
  • F.E. Lecouvet et al.

    Can whole-body magnetic resonance imaging with diffusion-weighted imaging replace Tc 99m bone scanning and computed tomography for single-step detection of metastases in patients with high-risk prostate cancer?

    Eur Urol

    (2012)
  • M.S. Hofman et al.

    Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study

    Lancet

    (2020)
  • M.E. Charlson et al.

    A new method of classifying prognostic comorbidity in longitudinal studies: development and validation

    J Chronic Dis

    (1987)
  • T.B.L. Lam et al.

    EAU-EANM-ESTRO-ESUR-SIOG Prostate Cancer guideline Panel consensus statements for deferred treatment with curative intent for localised prostate cancer from an international collaborative study (DETECTIVE study)

    Eur Urol

    (2019)
  • S. Loeb et al.

    Active surveillance for prostate cancer: a systematic review of clinicopathologic variables and biomarkers for risk stratification

    Eur Urol

    (2015)
  • F. Petrelli et al.

    Predictive factors for reclassification and relapse in prostate cancer eligible for active surveillance: a systematic review and meta-analysis

    Urology

    (2016)
  • H.B. Musunuru et al.

    Active surveillance for intermediate risk prostate cancer: survival outcomes in the Sunnybrook experience

    J Urol

    (2016)
  • P. Satasivam et al.

    Can confirmatory biopsy be omitted in patients with prostate cancer favorable diagnostic features on active surveillance?

    J Urol

    (2016)
  • L. Klotz et al.

    Randomized study of systematic biopsy versus magnetic resonance imaging and targeted and systematic biopsy in men on active surveillance (ASIST): 2-year postbiopsy follow-up

    Eur Urol

    (2020)
  • F.B. Thomsen et al.

    Association between PSA kinetics and cancer-specific mortality in patients with localised prostate cancer: analysis of the placebo arm of the SPCG-6 study

    Ann Oncol

    (2016)
  • N. Mottet et al.

    EAU - EANM - ESTRO - ESUR - SIOG guidelines on prostate cancer

    (2020)
  • G.H. Guyatt et al.

    Going from evidence to recommendations

    BMJ

    (2008)
  • M.F. Leitzmann et al.

    Risk factors for the onset of prostatic cancer: age, location, and behavioral correlates

    Clin Epidemiol

    (2012)
  • K. Esposito et al.

    Effect of metabolic syndrome and its components on prostate cancer risk: meta-analysis

    J Endocrinol Invest

    (2013)
  • F. Albright et al.

    Prostate cancer risk prediction based on complete prostate cancer family history

    Prostate

    (2015)
  • D.S. Tan et al.

    Cancer genomics: diversity and disparity across ethnicity and geography

    J Clin Oncol

    (2016)
  • P. Nicolosi et al.

    Prevalence of germline variants in prostate cancer and implications for current genetic testing guidelines

    JAMA Oncol

    (2019)
  • H.T. Lynch et al.

    Screening for familial and hereditary prostate cancer

    Int J Cancer

    (2016)
  • J.D. Brierley et al.

    TNM classification of malignant tumors. Ed. 8. UICC International Union Against Cancer. Wiley-Blackwell

    (2017)
  • Z.S. Zumsteg et al.

    Unification of favourable intermediate-, unfavourable intermediate-, and very high-risk stratification criteria for prostate cancer

    BJU Int

    (2017)
  • G. van Leenders et al.

    The 2019 International Society of Urological Pathology (ISUP) consensus conference on grading of prostatic carcinoma

    Am J Surg Pathol

    (2020)
  • J.I. Epstein et al.

    The 2014 International Society of Urological Pathology (ISUP) consensus conference on Gleason grading of prostatic carcinoma: definition of grading patterns and proposal for a new grading system

    Am J Surg Pathol

    (2016)
  • S.E. Eggener et al.

    Molecular biomarkers in localized prostate cancer: ASCO guideline

    J Clin Oncol

    (2020)
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