Introduction

This guideline updates and replaces 'Prostate cancer' (NICE clinical guideline 58). The recommendations are labelled according to when they were originally published (see About this guideline for details).

Prostate cancer is the most common cancer in men and makes up 26% of all male cancer diagnoses in the UK. In 2008, 34,335 men were diagnosed with prostate cancer and there were 9376 deaths from prostate cancer in England, Wales and Northern Ireland. This figure increased to 9632 deaths in 2010.

Prostate cancer is predominantly a disease of older men (aged 65–79 years) but around 25% of cases occur in men younger than 65. There is also higher incidence of and mortality from prostate cancer in men of black African-Caribbean family origin compared with white Caucasian men.

Prostate cancer is usually diagnosed after a blood test in primary care has shown elevated prostate-specific antigen (PSA) levels. The introduction of PSA testing has significantly reduced the number of men presenting with metastatic cancer since the 1980s. Most prostate cancers are now either localised or locally advanced at diagnosis, with no evidence of spread beyond the pelvis.

A number of treatments are available for localised disease, including: active surveillance, radical prostatectomy, external beam radiotherapy and brachytherapy. Hormone therapy (androgen deprivation or anti-androgens) is the usual primary treatment for metastatic prostate cancer, but is also increasingly being used for men with locally advanced, non-metastatic disease.

This updated guidance includes several treatments that have been licensed for the management of hormone-relapsed metastatic prostate cancer since the publication of NICE clinical guideline 58 (2008). It also aims to reduce the uncertainty and variations in practice that remain in some areas of prostate cancer diagnosis and management. Updated recommendations are provided on:

  • pre-biopsy imaging

  • management after an initial negative biopsy

  • imaging for T and N staging

  • groups for whom active surveillance is suitable and a protocol for active surveillance

  • the most effective radical prostatectomy method

  • the combination of external beam radiotherapy and brachytherapy in non-metastatic prostate cancer

  • management of radiation-induced enteropathy

  • the combination of hormone therapy and external beam radiotherapy in non-metastatic prostate cancer

  • intermittent compared with continuous hormone therapy for men having long-term hormone therapy

  • management of side effects resulting from long-term androgen deprivation therapy.

This guideline covers the care of men referred to secondary care with suspected or diagnosed prostate cancer, including follow-up in primary care for men with diagnosed prostate cancer. The guideline does not cover men with an abnormal PSA (prostate-specific antigen) level detected in primary care who have no symptoms and are not referred for subsequent investigation.

An update of Referral for suspected cancer (NICE clinical guideline 27) is in development. For more information see clinical guidelines in development on the NICE website.

Drug recommendations

The guideline assumes that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or those with authority to give consent on their behalf) should provide informed consent, which should be documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information. Where recommendations have been made for the use of drugs outside their licensed indications ('off-label use'), these drugs are marked with a footnote in the recommendations.

  • National Institute for Health and Care Excellence (NICE)