EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part II: Treatment of Relapsing, Metastatic, and Castration-Resistant Prostate Cancer

Objective:  To present a summary of the 2016 version of the European Association of Urology (EAU) – European Society for Radiotherapy & Oncology (ESTRO) – International Society of Geriatric Oncology (SIOG) Guidelines on the treatment of relapsing, metastatic, and castration-resistant prostate cancer (CRPC).

Evidence acquisition:  The working panel performed a literature review of the new data (2013–2015). The guidelines were updated, and the levels of evidence and/or grades of recommendation were added based on a systematic review of the literature.

Evidence synthesis:  Relapse after local therapy is defined by a rising prostate-specific antigen (PSA) level >0.2 ng/ml following radical prostatectomy (RP) and >2 ng/ml above the nadir after radiation therapy (RT). 11C-choline positron emission tomography/computed tomography is of limited importance if PSA is <1.0 ng/ml; bone scans and computed tomography can be omitted unless PSA is >10 ng/ml. Multiparametric magnetic resonance imaging and biopsy are important to assess biochemical failure following RT. Therapy for PSA relapse after RP includes salvage RT at PSA levels <0.5 ng/ml and salvage RP, high-intensity focused ultrasound, cryosurgical ablation or salvage brachytherapy of the prostate in radiation failures. Androgen deprivation therapy (ADT) remains the basis for treatment of men with metastatic prostate cancer (PCa). However, docetaxel combined with ADT should be considered the standard of care for men with metastases at first presentation, provided they are fit enough to receive the drug. Follow-up of ADT should include analysis of PSA, testosterone levels, and screening for cardiovascular disease and metabolic syndrome. Level 1 evidence for the treatment of metastatic CRPC (mCRPC) includes, abiraterone acetate plus prednisone (AA/P), enzalutamide, radium 223 (Ra 223), docetaxel at 75 mg/m2 every 3 wk and sipuleucel-T. Cabazitaxel, AA/P, enzalutamide, and radium are approved for second-line treatment of CRPC following docetaxel. Zoledronic acid and denosumab can be used in men with mCRPC and osseous metastases to prevent skeletal-related complications.

Conclusions:  The knowledge in the field of advanced and metastatic PCa and CRPC is changing rapidly. The 2016 EAU-ESTRO-SIOG Guidelines on PCa summarise the most recent findings and advice for use in clinical practice. These PCa guidelines are the first endorsed by the European Society for Therapeutic Radiology and Oncology and the International Society of Geriatric Oncology and reflect the multidisciplinary nature of PCa management. A full version is available from the EAU office or online (http://uroweb.org/guideline/prostate-cancer/).

Patient summary: In men with a rise in their PSA levels after prior local treatment for prostate cancer only, it is important to balance overtreatment against further progression of the disease since survival and quality of life may never be affected in many of these patients. For patients diagnosed with metastatic castrate-resistant prostate cancer, several new drugs have become available which may provide a clear survival benefit but the optimal choice will have to be made on an individual basis.

Take Home Message:  This paper summarises the 2016 European Association of Urology (EAU)- European Society for Radiotherapy & Oncology (ESTRO) - International Society of Geriatric Oncology (SIOG) Prostate Cancer Guidelines Prostate Cancer Guidelines. Standard therapy for PSA relapse after radical prostatectomy is salvage radiotherapy at a PSA of <0.5 ng/ml. Recommendations for treatment of progression after primary radiotherapy include salvage radical prostatectomy, high-intensity focused ultrasound (HIFU) and cryosurgical ablation. Androgen deprivation therapy (ADT) remains the basis for the treatment of metastatic prostate cancer; however, docetaxel combined with ADT should be considered the standard of care for men with metastases at first presentation, provided patients are fit. In patients diagnosed with metastatic castrate-resistant PCa, chemotherapy, new bone-targeting agents and agents targeting the antiandrogen axis and immunotherapy are treatment options.  European Urology, September 2016  Published online: 01 September 2016  PII: S0302-2838(16)30469-9 DOI: 10.1016/j.eururo.2016.08.002 © 2016 European Association of Urology, Published by Elsevier B.V.

Authors: Philip Cornforda, Joaquim Bellmuntb c, Michel Bollad, Erik Brierse, Maria De Santisf, Tobias Grossg, Ann M. Henryh, Steven Joniaui, Thomas B. Lamj k, Malcolm D. Masonl, Henk G. van der Poelm, Theo H. van der Kwastn, Olivier Rouvièreo, Thomas Wiegelp and Nicolas Mottetq

Keywords: Prostate cancer, Staging, Relapse, Metastatic, Castration-resistant, EAU-ESTRO-SIOG Guidelines, Hormonal therapy, Chemotherapy, Follow-up, Palliative.


a Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK

b Bladder Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA

c Harvard Medical School, Boston, MA, USA

d Department of Radiation Therapy, CHU Grenoble, Grenoble, France

e Patient Advocate, Hasselt, Belgium

f University of Warwick, Cancer Research Centre, Coventry, UK

g Department of Urology, University of Bern, Inselspital, Bern, Switzerland

h Leeds Cancer Centre, St. James's University Hospital, Leeds, UK

i Department of Urology, University Hospitals Leuven, Leuven, Belgium

j Academic Urology Unit, University of Aberdeen, Aberdeen, UK

k Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK

l Velindre Hospital, Cardiff, UK

m Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands

n Department of Pathology, Erasmus Medical Centre, Rotterdam, The Netherlands

o Hospices Civils de Lyon, Radiology Department, Edouard Herriot Hospital, Lyon, France

p Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany

q Department of Urology, University Hospital, St. Etienne, France

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