Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

Information and decision support for men with prostate cancer, their partners and carers

Decision support

  • Discuss all relevant management options recommended in this guideline with men with prostate cancer and their partners or carers, irrespective of whether they are available through local services. [2008]

Assessment

Diagnosis

Magnetic resonance imaging for rebiopsy
  • Consider multiparametric MRI (using T2- and diffusion-weighted imaging) for men with a negative transrectal ultrasound 10–12 core biopsy to determine whether another biopsy is needed. [new 2014]

Staging

  • Consider multiparametric MRI, or CT if MRI is contraindicated, for men with histologically proven prostate cancer if knowledge of the T or N stage could affect management. [new 2014]

Localised and locally advanced prostate cancer

Low-risk localised prostate cancer

Active surveillance
  • Offer active surveillance (in line with the following recommendation) as an option to men with low-risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable. [new 2014]

  • Consider using the protocol in table 2 for men who have chosen active surveillance. [new 2014]

Table 2 Protocol for active surveillance

Timing

Tests 1

At enrolment in active surveillance

Multiparametric MRI if not previously performed

Year 1 of active surveillance

Every 3–4 months: measure PSA2

Throughout active surveillance: monitor PSA kinetics3

Every 6–12 months: DRE4

At 12 months: prostate rebiopsy

Years 2–4 of active surveillance

Every 3–6 months: measure PSA2

Throughout active surveillance: monitor PSA kinetics3

Every 6–12 months: DRE4

Year 5 and every year thereafter until active surveillance ends

Every 6 months: measure PSA2

Throughout active surveillance: monitor PSA kinetics3

Every 12 months: DRE4

1 If there is concern about clinical or PSA (prostate-specific antigen) changes at any time during active surveillance, reassess with multiparametric MRI and/or rebiopsy.

2 May be carried out in primary care if there are agreed shared-care protocols and recall systems.

3 May include PSA doubling time and velocity.

4 Should be performed by a healthcare professional with expertise and confidence in performing DRE (digital rectal examination).

Intermediate- and high-risk localised prostate cancer

Active surveillance
  • Consider active surveillance (in line with the recommendation above) for men with intermediate-risk localised prostate cancer who do not wish to have immediate radical prostatectomy or radical radiotherapy. [new 2014]

Radical treatment
  • Offer men with intermediate- and high-risk localised prostate cancer a combination of radical radiotherapy and androgen deprivation therapy, rather than radical radiotherapy or androgen deprivation therapy alone. [new 2014]

Managing adverse effects of radical treatment

Sexual dysfunction
  • Ensure that men have early and ongoing access to specialist erectile dysfunction services. [2008, amended 2014]

Radiation-induced enteropathy
  • Ensure that men with signs or symptoms of radiation-induced enteropathy are offered care from a team of professionals with expertise in radiation-induced enteropathy (who may include oncologists, gastroenterologists, bowel surgeons, dietitians and specialist nurses). [new 2014]

Men having hormone therapy

  • Consider intermittent therapy for men having long-term androgen deprivation therapy (not in the adjuvant setting), and include discussion with the man, and his partner, family or carers if he wishes, about:

    • the rationale for intermittent therapy and

    • the limited evidence for reduction in side effects from intermittent therapy and

    • the effect of intermittent therapy on progression of prostate cancer. [new 2014]

  • National Institute for Health and Care Excellence (NICE)