Elsevier

European Urology

Volume 79, Issue 2, February 2021, Pages 263-282
European Urology

Review – Prostate Cancer
EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer. Part II—2020 Update: Treatment of Relapsing and Metastatic Prostate Cancer

https://doi.org/10.1016/j.eururo.2020.09.046Get 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 & Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-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 (2016–2019). 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

Prostate-specific membrane antigen positron emission tomography computed tomography scanning has developed an increasingly important role in men with biochemical recurrence after local therapy. Early salvage radiotherapy after radical prostatectomy appears as effective as adjuvant radiotherapy and, in a subset of patients, should be combined with androgen deprivation. New treatments have become available for men with metastatic hormone-sensitive prostate cancer (PCa), nonmetastatic CRPC, and metastatic CRPC, along with a role for local radiotherapy in men with low-volume metastatic hormone-sensitive PCa. Also included is information on quality of life outcomes in men with PCa.

Conclusions

The knowledge in the field of advanced and metastatic PCa and CRPC is changing rapidly. The 2020 EAU-EANM-ESTRO-ESUR-SIOG guidelines on PCa summarise the most recent findings and advice for use in clinical practice. These PCa guidelines are first endorsed by the EANM 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

This article summarises the guidelines for the treatment of relapsing, metastatic, and castration-resistant prostate cancer. These guidelines are evidence based and guide the clinician in the discussion with the patient on the treatment decisions to be taken. These guidelines are updated every year; this summary spans the 2017–2020 period of new evidence.

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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