Elsevier

European Urology

Volume 59, Issue 1, January 2011, Pages 61-71
European Urology

Guidelines
EAU Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis, and Treatment of Clinically Localised Disease

https://doi.org/10.1016/j.eururo.2010.10.039Get rights and content

Abstract

Objective

Our aim was to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the screening, diagnosis, and treatment of clinically localised cancer of the prostate (PCa).

Methods

The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and level of evidence and grade of recommendation were 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 Web site (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. PSA doubling time in <3 yr or a biopsy progression indicates the need for active intervention. In men with locally advanced PCa in 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 mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy (RP) shown to be superior to WW in a prospective randomised trial. Nerve-sparing RP 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 74 Gy and 78 Gy in low-risk and intermediate/high-risk PCa, respectively. For locally advanced disease, adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice. Follow-up after local therapy is largely based on PSA, and a disease-specific history with imaging is indicated only when symptoms occur.

Conclusions

The knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarise 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 2008 [1]. The long version of these guidelines has been continuously updated because many important changes affecting the clinical management of PCa have occurred. This paper summarises the 2010 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. Thus about 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 in Malta to 182 in Belgium [4].

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, ethnicity, 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 5- to 11-fold [5]. About 9% of individuals with PCa have true hereditary PCa, defined as three or more relatives affected or at least two who have developed

Classifications

The Union Internationale Contre le Cancer 2009 TNM classification is used throughout the guidelines [6]. The Gleason score is recommended 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 (no 5% rule) [7]. In radical prostatectomy (RP) specimens, both the primary and the secondary

Prostate cancer screening

There is currently no evidence for introducing widespread population-based screening programmes for early PCa detection in all men [8] (LE: 2). To evaluate the efficacy of PCa screening, two large randomised trials have been published: the Prostate, Lung, Colorectal, and Ovary (PLCO) trial in the United States and the European Randomised Study of Screening for Prostate Cancer (ERSPC) in Europe [9], [10] (LE: 1b).

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

Diagnosis and staging of prostate cancer

The main diagnostic tools to diagnose PCa include DRE, serum concentration of PSA, and transrectal ultrasound (TRUS)–guided biopsies. In about 18% of all patients, PCa is detected by a suspect DRE alone, irrespective of the PSA level [14] (LE: 2a). A suspect DRE in patients with a PSA level of up to 2 ng/ml has a positive predictive value of 5–30% [15] (LE: 2a).

A threshold level of PSA that indicates the highest risk of PCa needs to be defined (Table 1). When analysing PSA serum levels, it has

Primary local treatment of prostate cancer

Therapeutic management of PCa, even in clinically localised disease, has become more and more complex because of the various stage-specific therapeutic options available. It is advisable (1) to 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 an urologist and a radiation oncologist, (2) to discuss neoadjuvant and adjuvant treatment

Follow-up of prostate cancer patients

Patients diagnosed with PCa who underwent local treatment with curative intent are usually followed for at least 10 yr or until advanced age makes follow-up superfluous (Table 5). Determination of serum PSA together with a disease-specific history can be supplemented by DRE if locally recurrent disease is suspected.

Alternative local treatment options of prostate cancer

In addition to RP, EBRT, and/or brachytherapy, cryosurgical ablation of the prostate (CSAP) and high-intensity focussed ultrasound (HIFU) have emerged as alternative therapeutic options in patients with clinically localised PCa who are not suitable for RP [84], [85]. However, at the time of writing, data from HIFU were not extensive enough to be considered in treatment recommendations. Applying the Grading of Recommendations Assessment, Development and Evaluation approach, the available

Summary

The present text represents a summary, and for more detailed information and a full list of references, we refer you to the full-text version. These EAU guidelines (ISBN 978-90-79754-70-0) are available at the EAU Web site (www.uroweb.org).

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