Review – Prostate CancerEAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer. Part II—2020 Update: Treatment of Relapsing and Metastatic Prostate Cancer☆
Introduction
A prior summary of the European Association of Urology (EAU) guidelines on prostate cancer (PCa) was published in 2017 [1]. This paper summarises the many changes that have occurred in the treatment of relapsing, metastatic, and castration-resistant PCa (CRPC) over the past 4 yr. The guidelines on screening, diagnosis, and treatment of clinically localised and locally advanced PCa were published in a separate paper [2]. To facilitate evaluation of the quality of the information provided, a grade form has been completed for each recommendation also providing the strength of recommendation based on a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) process [3].
Section snippets
Diagnosis and treatment of relapse after curative therapies
Between 27% and 53% of all patients undergoing radical prostatectomy (RP) or radiation therapy (RT) develop a rising prostate-specific antigen (PSA) level (PSA recurrence). Physicians face a difficult set of decisions in attempting to delay the onset of metastatic disease and death whilst avoiding overtreatment of patients whose disease may never affect their overall survival (OS) or quality of life (QoL).
Metastatic PCa
The definition of metastatic spread has relied upon the detection of lesions on CT scan and bone scan. This has also been the basis of the available prospective data. The influence on treatment and outcome of newer and more sensitive imaging has not been assessed yet.
Median survival of treated patients with newly diagnosed metastases is approximately 42 mo with ADT monotherapy [50]; however, the M1 population is heterogeneous. Several prognostic factors for survival have been suggested,
Definition
CRPC is defined as castrate serum testosterone <50 ng/dl or 1.7 nmol/l plus one of the following types of progression:
- 1
Biochemical progression: three consecutive rises in PSA 1 wk apart, resulting in two 50% increases over the nadir, and PSA > 2 ng/mL
- 2
Radiological progression: the appearance of new lesions—either two or more new bone lesions on bone scan or a soft tissue lesion using the Response Evaluation Criteria in Solid Tumours [34], [94]
Management of CRPC
Selection of treatment for CRPC is multifactorial and
QoL outcomes in PCa
Living longer with PCa does not necessarily equate to living well [169]. There is clear evidence of unmet needs and on-going support requirements for some men after diagnosis and treatment for PCa [170]. Cancer impacts the wider family, and cognitive behavioural therapy can help reduce depression, anxiety, and stress in caregivers [171]. Radical treatment for PCa can negatively impact long-term QoL (eg, sexual, urinary, and bowel dysfunction), as can ADT used in short- or long-term treatment,
Conclusions
The present text represents a summary of the EAU-EANM-ESTRO-ESUR-SIOG prostate cancer guidelines. For more detailed information and a full list of references, refer to the full-text version. These guidelines are available on the EAU website (http://uroweb.org/guideline/prostate-cancer/).
Author contributions: Philip Cornford had full access to all the data and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Cornford, Mottet.
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