Prostate cancer: diagnosis and treatment

National Institute for Health and Clinical Excellence

Diagnosing prostate cancer

• Before referral to specialist care, men with suspected prostate cancer should have been offered a digital rectal examination (DRE) and prostate-specific antigen (PSA) test as set out in 'Referral guidelines for suspected cancer' (NICE clinical guideline 27)

Biopsy

• Provide information, support and allow sufficient time for the man to decide whether to have a biopsy
• Discuss:
  • the risks and benefits of biopsy
  • their individual risk factors (including increasing age and black African or black Caribbean ethnicity)
  • their estimated prostate size, DRE findings and PSA level
  • any comorbidities
  • any previous negative biopsy
• Use nomograms to help with decision making and to predict the biopsy results. Explain their reliability and limitations
• Do not biopsy:
  • on the basis of serum PSA level alone
  • if suspicion of prostate cancer is high because of PSA level and evidence of bone metastases, unless required as part of a clinical trial

Before starting treatment

• Discuss all relevant management options
• Inform men that treatment may result in:
  • altered physical appearance
  • altered sexual experience
  • possible loss of sexual function, ejaculation, and fertility
  • changes in urinary function
• Support men in making treatment decisions, taking into account survival and quality of life benefits
• Advise men about the potential long-term adverse effects of treatment and when and how to report them

Localised prostate cancer

Watchful waiting

• If men choose watchful waiting and show evidence of disease progression, they should be reviewed by a member of the urological cancer multidisciplinary team (MDT)

Active surveillance

• Active surveillance is the preferred option for low-risk men who are candidates for radical treatment. It is particularly suitable for men with clinical stage T1c, Gleason score 3+3 and PSA density <0.15 ng/ml/ml who have cancer in less than 50% of their biopsy cores, with <10 mm of any core involved
• Candidates for active surveillance should:
  • have had at least 10 biopsy cores taken
  • have at least one re-biopsy which may be performed according to the ProSTART protocol^*
• If men on active surveillance show evidence of disease progression, offer radical treatment. Treatment decisions should be made with the man, taking into account comorbidities and life expectancy

Radical treatments

• All candidates for radical treatment should have the opportunity to discuss their treatment options with a surgical oncologist and a clinical oncologist
• Offer adjuvant hormonal therapy for a minimum of 2 years to men receiving radiotherapy who have a Gleason score of ≥8

Locally advanced prostate cancer

• Offer:
  • neoadjuvant and concurrent luteinising hormone-releasing hormone agonist (LHRHa) therapy for 3—6 months to men receiving radiotherapy
  • adjuvant hormonal therapy for a minimum of 2 years to men receiving radiotherapy who have a Gleason score of ≥8
• Do not offer:
  • adjuvant hormonal therapy in addition to prostatectomy, even to men with margin-positive disease (unless as part of a clinical trial)
  • bisphosphonates to prevent bone metastases
  • immediate post-operative radiotherapy routinely after prostatectomy, even to men with margin-positive disease (unless as part of a clinical trial)
  • high-intensity focused ultrasound (HIFU) or cryotherapy (unless as part of a clinical trial)