AUA, ASTRO Issue Updated Guidelines for Clinically Localized Prostate Cancer

James A. Eastham, MD

The American Urologic Association (AUA) in collaboration with the American Society for Radiation Oncology (ASTRO) has issued new practice guidelines for the management of clinically localized prostate cancer. Additionally, the Society of Urologic Oncology has endorsed the updated recommendations.^1-3

A panel of experts, including members of both the AUA and ASTRO, drafted a total of 44 statements discussing appropriate staging and risk assessment for newly diagnosed patients, risk-based treatment approaches, optimal use of radiation therapy, and recommendations for posttreatment follow-up in prostate cancer, among other topics.

The new guidelines have strengthened support for active surveillance as the preferred management option for patients with low-risk disease, giving the practice its highest recommendation. Furthermore, patients in active surveillance should be monitored with serial prostate-specific antigen (PSA) values and undergo MRI for risk assessment, but MRI should not replace periodic biopsy.

The panel also combined the “very low risk” and “low risk” disease categories because management is the same for both groups.

“The recommendations in this guideline provide a framework to facilitate care decisions and guide clinicians in the implementation of selected management options,” guideline development panel chair James A. Eastham, MD, chief of urology services at Memorial Sloan Kettering Cancer Center, said in a news release.⁴ “The guideline is clear in that patients must be fully informed regarding the potential risks and benefits of each management option and that care decisions must take into account patient preferences and priorities.”

The AUA says that prostate cancer remains the most common non-cutaneous cancer among men in the United States, with 268,490 new diagnoses and 34,500 deaths estimated for 2022. The American Society of Clinical Oncology estimates that 84% patients with newly diagnosed prostate cancer clinically localized disease.⁵ For that reason, AUA/ASTRO says that providing evidence-based guideline statements to support clinical decision-making represents an important component of facilitating the delivery of standardized, effective care.

Experts conducted a systemic review of studies collected in the Cochrane Central Register of Controlled Trials as of August 2021 and of the Cochrane Database of Systematic Reviews and the Ovid MEDLINE as of September 2021. They supplemented these searches by reviewing reference lists of relevant articles. Studies were included or excluded based on the Key Questions and the populations, interventions, comparators, outcomes, timing, types of studies and settings of interest.

For the first time, treatment guidelines for localized prostate cancer include recommendations regarding the use of genomic testing. The expert panel said that clinicians can make selective use of tissue-based genomic biomarkers when added risk stratification may affect clinical decision making but should not use such tests as a matter of routine. Although there are studies evaluating these tests for their ability to predict risks for biochemical recurrence, metastasis, and prostate cancer death, these data do not meet inclusion criteria because the studies relied on surgical rather than biological specimens.

Principles of Radiation

The AUA worked closely with ASTRO to develop guidelines related to the use of radiation therapy in patients with prostate cancer. The panel issued a strong recommendation for dose escalation when using external beam radiation therapy (EBRT) as primary treatment. Further, clinicians should make use of available target localization, normal tissue avoidance, simulation, advanced treatment planning/delivery, and image-guidance procedures to optimize EBRT.

Proton beam therapy is a viable option for patients with prostate cancer. However, the guidelines say clinicians should inform patients that, according to existing data, proton beam is not superior to other radiation modalities when it comes to outcomes or toxicity profile.

Moderate or ultra dose–escalated hypofractionated EBRT, permanent low-dose rate seed implant, or temporary high-dose rate prostate implant are equivalent forms of treatment for patients with low- or favorable intermediate-risk prostate cancer. The guidelines go on to say that clinicians should offer moderate hypofractionated EBRT and may offer ultra hypofractionated EBRT for patients with low- or intermediate-risk disease.

For patients with high-risk disease who are candidates for EBRT, clinicians should offer moderate hypofractionated EBRT. Clinicians should recommend 18 to 36 months of androgen deprivation therapy for patients receiving radiation therapy.

Following treatment for clinically localized prostate cancer, the guidelines call for clinicians to monitor all patients with PSA and symptom assessment. Clinicians also should provide continued symptom management and encourage patients to engage with professional or community-based resources for further support.

References

1. Eastham JA, Auffenberg GB, Barocas DA et al: Clinically localized prostate cancer: AUA/ASTRO guideline part I: introduction, risk assessment, staging and risk-based management. J Urol 2022; https://doi.org/ 10.1097/JU.0000000000002757.
2. Eastham JA, Auffenberg GB, Barocas DA et al: Clinically localized prostate cancer: AUA/ASTRO guideline part II: principles of active surveillance, principles of surgery and follow-up. J Urol. 2022; https://doi.org/10.1097/JU.0000000000002758.
3. Eastham JA, Auffenberg GB, Barocas DA et al: Clinically localized prostate cancer: AUA/ASTRO guideline part III: principles of radiation and future directions. J Urol. 2022; https://doi.org/10.1097/JU.0000000000002759.
4. AUA, ASTRO release new clinically localized prostate cancer guideline. News release. American Urological Association. May 10, 2022. Accessed May 17, 2022. https://prn.to/3Nh49vy
5. Cancer.net. Prostate cancer: statistics. February 2022. Accessed May 17, 2022. https://bit.ly/3wxQlWO