08 January 2014

New protocol for active surveillance of men with early prostate cancer

Men undergoing active surveillance for prostate cancer, which can avoid or delay unnecessary treatment, should have their prostate specific antigen (PSA) levels measured every 3-4 months initially, according to updated guidelines from NICE.

Men undergoing active surveillance for prostate cancer, which can avoid or delay unnecessary treatment, should have their prostate specific antigen (PSA) levels measured every 3-4 months initially, according to updated guidelines from NICE.

Prostate cancer is among the most common cancers in men, making up more than a quarter of diagnoses and accounting four seven per cent of cancer deaths.

Around 37,000 men are diagnosed each year, and while it mostly affects older men, men under 65 can be affected too. Men from a black African-Caribbean family origin are also three times more likely to develop the disease than white Caucasian men.

Among the updated recommendations, is a new protocol for active surveillance. This is a way of monitoring slow-growing prostate cancers that might never progress or cause any symptoms, and can help avoid or delay treatment such as radiotherapy or surgery which might otherwise be unnecessary.

NICE recommends that doctors should offer active surveillance for men with low-risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable.

The protocol recommends measuring PSA levels every 3-4 months in the first year of surveillance, and then at increasing intervals if there is no evidence of disease progression.

NICE also recommends considering this protocol for active surveillance as an option for men with intermediate risk localised prostate cancer who do not wish to have immediate radical prostatectomy or radical radiotherapy.

Active surveillance should not, however, be offered to men with high-risk localised prostate cancer.

Elsewhere, the guidance includes new recommendations that cover the diagnosis of prostate cancer through multiparametric magnetic resonance (MRI) imaging for rebiopsy.

NICE recommends that doctors should 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.

For men with locally advanced prostate cancer, radical treatment through surgery or radiotherapy is often considered as treatment options. However, these options can have side effects such as erectile dysfunction and urinary incontinence, which can greatly impact affect quality of life.

Consequently, NICE says that doctors should discuss all relevant management options recommended in the guideline with men with prostate cancer and their partners or carers, irrespective of whether they are available through local services.

Men with prostate cancer should have early and ongoing access to specialist erectile dysfunction services.

Furthermore, men with troublesome urinary symptoms after treatment should have access to specialist continence services for assessment, diagnosis and conservative treatment. This may include coping strategies, along with pelvic floor muscle re-education, bladder retraining and pharmacotherapy.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: "The updated guideline includes a number of new recommendations on the swift diagnosis and treatment of different stages of the disease and a new protocol for men who choose active surveillance, which involves regular check-ups to see if and how the cancer is developing, rather than immediate radical treatment.

"The aim of this NICE guideline is to ensure that excellent treatment is provided for men who will benefit from it."

Dr John Graham, Consultant Lead Clinical Oncologist at Taunton and Somerset NHS Trust, said: "All treatments for prostate cancer have serious side effects which can affect the quality of life, especially their effects on erectile function, fertility and continence.

"This is why it is so important that men are able to understand the treatment options available to them and, with the support of their healthcare professional, are able to make a choice to suit their individual needs, both clinically and related to their quality of life.

He added: "It is important that information and support is available and easily accessible to ensure patients can make the most appropriate decision for them in terms of treatment. This guideline acknowledges that, and makes recommendations about supportive care."

Read about how Bedford and Addenbrooke's Cambridge University Hospitals put this guideline into practice by providing exercise counselling to men with prostate cancer.

A table outlining the guideline's protocol for active surveillance has also been produced to help put this guideline into practice.