Before offering a prostate-specific antigen (PSA) test, ensure that the man has carefully considered its possible

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1 Prstate cancer - Management Scenari: Diagnsis f prstate cancer Overview f the diagnsis f prstate cancer Befre ffering a prstate-specific antigen (PSA) test, ensure that the man has carefully cnsidered its pssible benefits and harms. Offer PSA testing t men wh request a PSA test and t men in whm prstate cancer is suspected, fr example because f such symptms as unexplained back pain, bne pain, erectile dysfunctin, unexplained haematuria, and unexplained weight lss. When interpreting a PSA result, use age-specific threshlds fr referring men as having suspected prstate cancer. If the PSA level is slightly abve the referral threshld, take int accunt any risk factrs fr high-grade prstate cancer when deciding whether t refer, btain specialist advice, r repeat the test. Offer a digital rectal examinatin (DRE) when a man is cncerned abut prstate cancer r has symptms f suggestive f prstate cancer r f benign prstatic enlargement. Refer urgently t a urlgical cancer specialist if prstate cancer is suspected either because the prstate is hard and irregular n DRE, r because the PSA levels are increased mre than brderline r are rising. Basis fr recmmendatin These recmmendatins reflect guidelines frm the NHS Prstate Cancer Risk Management Prgramme n prstate-specific antigen testing in asymptmatic men [Burfrd et al, 2009], and are in line with guidelines f the Natinal Institute fr Health and Clinical Excellence (NICE) n referring suspected cancer in adults and children [Natinal Cllabrating Centre fr Primary Care, 2005], guidelines frm NICE n the management f lwer urinary tract symptms in men [Natinal Clinical Guideline Centre, 2010], and guidelines frm NICE n the diagnsis and management f prstate cancer [Natinal Cllabrating Centre fr Cancer, 2008a]. When shuld I suspect prstate cancer? Suspect prstate cancer in men wh have: Any f the fllwing symptms that are unexplained: Lwer back pain. Bne pain. Erectile dysfunctin prstate cancer is unlikely t present with erectile dysfunctin as the nly clinical feature; it shuld be investigated with digital rectal examinatin (DRE) and a prstate-specific antigen (PSA) test. 1

2 Haematuria unexplained haematuria is als a sign f ther urinary tract cancers and indicates referral t be seen within 2 weeks. Weight lss, especially in the elderly. A prstate that is hard and irregular n DRE nrmal DRE des nt exclude prstate cancer. PSA levels that are increased r rising (and urinary tract infectin has been excluded). Lwer urinary tract symptms (LUTS) are nt listed abve as a clinical feature that wuld particularly raise suspicin f prstate cancer, because LUTS are cmmn in lder men and are rarely the presenting symptm f prstate cancer. Hwever, lcally advanced prstate cancer may cause bstructive LUTS. Therefre a PSA test and DRE shuld be ffered t men with bstructive LUTS see the sectin Investigatins in the CKS tpic n LUTS in men, age-related (prstatism). Basis fr recmmendatin These recmmendatins reflect guidelines f the Natinal Institute fr Health and Clinical Excellence (NICE) n referral fr suspected cancer in adults and children [Natinal Cllabrating Centre fr Primary Care, 2005]. NICE's recmmendatins are based n the expert pinin f the guideline develpment grup. PSA testing When shuld I ffer PSA testing fr prstate cancer? Befre ffering prstate-specific antigen (PSA) testing, ensure that the man has carefully cnsidered the benefits and limitatins f PSA tests. Offer PSA testing t: Men lder than 50 years f age wh ask fr a PSA test. Men with unexplained symptms that culd be caused by lcally advanced r metastatic prstate cancer. Men with bstructive lwer urinary tract symptms that culd be caused by benign prstatic enlargement (which is cmmn) r by lcally advanced prstate cancer (which is rare). Rutine screening fr prstate cancer is nt natinal plicy, because the benefits have nt been shwn t clearly utweigh the harms. Basis fr recmmendatin 2

3 These recmmendatins reflect guidelines frm the NHS Prstate Cancer Risk Management Prgramme n prstate-specific antigen testing in asymptmatic men [Burfrd et al, 2009], and are in line with guidelines f the Natinal Institute fr Health and Clinical Excellence (NICE) n referring suspected cancer in adults and children [Natinal Cllabrating Centre fr Primary Care, 2005], guidelines frm NICE n the management f lwer urinary tract symptms in men [Natinal Clinical Guideline Centre, 2010], and guidelines frm NICE n the diagnsis and management f prstate cancer [Natinal Cllabrating Centre fr Cancer, 2008a]. What practicalities are invlved in PSA testing? Offer prstate-specific antigen (PSA) testing t men wh have carefully cnsidered the benefits and limitatins f PSA tests. Advise men wh are cnsidering a PSA test abut decisin aids and nline surces f infrmatin. Because PSA levels are likely t be increased, the NHS Prstate Cancer Risk Management Prgramme advises that PSA testing shuld nt be dne within at least: 6 weeks f a prstate bipsy. 4 weeks f a prven urinary infectin PSA levels can remain increased fr many mnths. 1 week f digital rectal examinatin (DRE) hwever, experts suggest that gentle DRE is unlikely t increase PSA levels significantly. 48 hurs f vigrus exercise. 48 hurs f ejaculatin. The specimen shuld reach the labratry within 16 hurs. Basis fr recmmendatin These recmmendatins reflect guidelines frm the NHS Prstate Cancer Risk Management Prgramme n prstate-specific antigen (PSA) testing in asymptmatic men [Burfrd et al, 2009]. Effect f gentle digital rectal examinatin (DRE) n PSA levels Expert reviewers suggested t CKS that gentle DRE is unlikely t have a clinically imprtant effect n PSA levels, and that DRE is nt sufficient reasn t pstpne PSA testing. What shuld I advise men abut the benefits and harms f PSA testing t screen fr prstate cancer? Benefits f prstate-specific antigen (PSA) testing 3

4 Early detectin PSA testing may lead t prstate cancer being detected befre symptms develp. Early treatment detecting prstate cancer early befre symptms develp may extend life, r facilitate a cmplete cure. Harms f PSA testing False reassurance a false-negative PSA test can prvide false reassurance. Abut 15% f men with a negative PSA test have prstate cancer, althugh it is nt knwn what prprtin f these cancers becme clinically evident. Unnecessary anxiety a false-psitive PSA test can cause cnsiderable and prlnged anxiety. Abut 65% f men with a psitive PSA test have a negative prstate bipsy. Unnecessary investigatin a psitive PSA test may lead t invasive and expensive investigatins, such as prstate bipsy and imaging. If the PSA test is falsely psitive, r the prstate cancer is f n clinical cnsequence, investigatins prvide n useful infrmatin. Unnecessary treatment a psitive PSA test may lead t the treatment f indlent prstate cancers which wuld nt have becme clinically evident in the man s lifetime. Adverse effects f treatment are cmmn and serius and include urinary incntinence and sexual dysfunctin. Basis fr recmmendatin This infrmatin reflects guidelines frm the NHS Prstate Cancer Risk Management Prgramme n prstatespecific antigen testing in asymptmatic men [Burfrd et al, 2009]. These guidelines are supprted by recent evidence. A systematic review and meta-analysis f randmized cntrlled trials (RCTs) fund that screening fr prstate cancer increases the prbability f diagnsis, but there is n statistically significant effect n death rates. All trials had methdlgical limitatins. The included studies prvided little infrmatin abut ptential harms assciated with screening. A subsequently reprted RCT fund that ver 14 years f fllw up, the death rate frm prstate cancer was 0.50% in men wh were screened and 0.90% in men wh were nt screened, fr an abslute risk reductin f 0.40% (95% CI 0.17 t 0.64). T prevent ne death frm prstate cancer, abut 293 men needed t be invited fr screening and abut 12 t be diagnsed. Hw shuld I interpret PSA results? Prstate-specific antigen (PSA) levels shuld be interpreted accrding t age-specific reference limits. 4

5 The Prstate Cancer Risk Management Prgramme recmmends the fllwing threshlds fr referring men fr suspected prstate cancer: Fr men aged: years: refer if PSA level is 2.0 nangram/ml r higher years: refer if PSA level is 3.0 nangram/ml r higher years: refer if PSA level is 4.0 nangram/ml r higher. 70 years r lder: refer if PSA level is 5.0 nangram/ml r higher. There are n age-specific reference limits fr men lder than 80 years f age. Lcal labratries may have different referral threshlds. Basis fr recmmendatin These recmmendatins reflect guidelines frm the NHS Prstate Cancer Risk Management Prgramme n prstate-specific antigen testing in asymptmatic men [Burfrd et al, 2009]. Hw shuld I act n PSA results? If the prstate-specific antigen (PSA) level is high: Cnsider whether t advise the man that there is a substantial chance that the test result is false psitive; hwever bear in mind that the higher the PSA level, the greater the risk f prstate cancer. If there is an bvius cause fr the increased PSA level (such as recent urinary tract infectin, prstatitis, urinary retentin, instrumentatin, r benign prstatic enlargement), repeat the PSA test in 4 6 weeks. If there is n bvius cause fr the increased PSA level, refer urgently t a urlgical cancer specialist. If the PSA level is lw r nrmal, and: Digital rectal examinatin (DRE) is abnrmal, refer urgently t a urlgical cancer specialist. DRE is nrmal, remind the man that there is a small chance (arund 15%) that this is a false-negative result and infrm him that, if cancer has been missed, it is unlikely t be clinically imprtant. Repeat PSA testing is nt rutinely indicated. If the PSA level is brderline r slightly abve the referral threshld, and: DRE is abnrmal, refer urgently t a urlgical cancer specialist. DRE is nrmal: 5

6 Cnsider ther causes f increased PSA levels, such as recent urinary tract infectin, prstatitis, urinary retentin, instrumentatin, r benign prstatic enlargement. Repeat the PSA test after 4 6 weeks. If n the secnd test the PSA level has risen substantially, refer urgently. If in dubt, cnsider btaining specialist advice abut referral. Have a lwer threshld fr referral r btaining specialist advice if the man is f black African r black Caribbean ethnicity he is at increased risk fr a high-grade prstate cancer. Have a higher threshld fr referral r btaining specialist advice if the man has had a prstate bipsy that failed t reveal cancer he has a lwer risk f cancer. Basis fr recmmendatin These recmmendatins reflect guidelines frm the NHS Prstate Cancer Risk Management Prgramme n prstate-specific antigen testing in asymptmatic men [Burfrd et al, 2009], and guidelines f the Natinal Institute fr Health and Clinical Excellence (NICE) n referring men with suspected prstate cancer [Natinal Cllabrating Centre fr Primary Care, 2005]. What decisin aids are there fr men cnsidering a PSA test? Cmputerized decisin aids have been develped fr men cnsidering having a prstate-specific antigen (PSA) test. They prvide backgrund infrmatin abut the prstate and prstate cancer, infrmatin abut risk factrs fr prstate cancer, and infrmatin n uncertainties when interpreting PSA results and deciding n treatment. PROSDEX was develped in the UK and prvides UK-specific infrmatin. It is rganized arund a graphical display f the man's preference fr r against having a PSA test. The decisin aid is available at SWOP was develped in the Netherlands, but references UK-develped infrmatin. It is rganized arund graphical displays f the man's risk f prstate cancer. The decisin aid is available at The Natinal Prescribing Centre have a decisin aid that is 'intended t assist health prfessinals in cnsultatins with men wh d nt have symptms f prstate cancer, but wh are cnsidering whether r nt t have a prstate specific antigen (PSA) test'. It prvides a graphical aid t interpreting PSA test and bipsy results. The decisin aid is available at Basis fr recmmendatin 6

7 The Natinal Institute fr Health and Clinical Excellence (NICE) recmmends that men with prstate cancer shuld receive infrmatin abut the benefits and limitatins f tests and treatments, but des nt recmmend specific resurces [Natinal Cllabrating Centre fr Cancer, 2008a]. The resurces listed here have been identified by CKS r suggested by expert reviewers. The PROSDEX decisin aid is recmmended by the NHS Prstate Cancer Risk Management Prgramme guidance n prstate-specific antigen testing in asymptmatic men [Burfrd et al, 2009]. Where can men btain infrmatin abut PSA testing? NHS Prstate Cancer Risk Management Prgramme (PCRMP) The NHS PCRMP is ne f the English NHS Cancer Screening Prgrammes. It aims t ensure that peple make an infrmed chice when they decide whether r nt t have a screening test, such as prstate-specific antigen (PSA) fr prstate cancer. The fllwing leaflets can be dwnladed and printed: PSA testing in asymptmatic men (reference bklet) (pdf) Advising men abut the PSA test fr prstate cancer (summary sheet) (pdf) PSA testing fr prstate cancer (patient infrmatin leaflet) (pdf) PSA testing fr prstate cancer (patient infrmatin leaflet large print) (pdf) PSA testing in asymptmatic men (evidence) (pdf) Fr mre infrmatin, visit Cancer Research UK The Cancer Help sectin f Cancer Research UK prvides infrmatin fr peple with all frms f cancer. It includes symptms and causes f prstate cancer, tests and treatment, living with prstate cancer, and current research. A leaflet Abut prstate cancer - A quick guide (pdf) can be dwnladed fr printing. Fr mre infrmatin, visit Healthtalknline Healthtalknline prvides infrmatin abut PSA testing and prstate cancer, and peple's persnal stries. Fr mre infrmatin, visit The Prstate Cancer Charity The Prstate Cancer Charity prduce a wide range f publicatins fr health prfessinals t use when discussing diagnstic tests, treatments, and adverse effects with their patients. 7

8 Publicatins that can be dwnladed fr printing include: Knw yur prstate: a guide t cmmn prstate prblems (pdf) Understanding the PSA test: A guide fr men cncerned abut prstate cancer (pdf) What d yu knw abut prstate cancer? Infrmatin fr African Caribbean men (pdf) Fr mre infrmatin, visit Macmillan and Cancerbackup Macmillan Cancer Supprt and Cancerbackup merged in They aim t imprve the lives f peple affected by cancer by prviding practical, medical, and financial supprt. Infrmatin n prstate cancer, including hw it is diagnsed, treatments that might be given, pssible side effects, and hw t get further supprt, can be fund at Prstate UK Prstate UK has a range f publicatins and leaflets that ffer helpful infrmatin and advice n prstate diseases and their treatment. Fr mre infrmatin n what leaflets are available and hw they can be rdered, visit NHS Chices NHS Chices is a cmprehensive health infrmatin service, including prstate cancer. Fr mre infrmatin, visit Prstate Link UK Prstate Link UK prvides links t quality-assessed surces f infrmatin abut the questins men with prstate cancer cmmnly want t ask. Fr mre infrmatin, visit Basis fr recmmendatin The Natinal Institute fr Health and Clinical Excellence (NICE) recmmends that men with prstate cancer shuld receive infrmatin abut the benefits and limitatins f tests and treatments, but des nt recmmend specific resurces [Natinal Cllabrating Centre fr Cancer, 2008a]. The resurces listed here have been identified by CKS r suggested by expert reviewers. When shuld I ffer digital rectal examinatin t assess the risk f prstate cancer? Offer digital rectal examinatin (DRE) in men: 8

9 With lwer urinary tract symptms t assess fr benign prstatic enlargement (cmmn) and fr prstate cancer (uncmmn). With unexplained symptms that culd be due t advanced prstate cancer (fr example lwer back pain, bne pain, weight lss). With cncerns abut the pssibility f prstate cancer, fr example increased prstate-specific antigen levels. Explain that the findings n DRE are helpful but cannt definitely cnfirm r exclude prstate cancer DRE will nt detect early small prstate cancers, and bipsy is required t cnfirm and stage the diagnsis. Basis fr recmmendatin Offering digital rectal examinatin (DRE) in men with lwer urinary tract symptms This recmmendatin reflects the guideline frm the Natinal Institute fr Health and Clinical Excellence (NICE) n the management f lwer urinary tract symptms in men [Natinal Clinical Guideline Centre, 2010]. Offering DRE in men with unexplained symptms that culd be due t advanced prstate cancer r with cncerns abut the pssibility f prstate cancer These recmmendatins reflect NICE guidelines n referring adults and children with suspected cancer [Natinal Cllabrating Centre fr Primary Care, 2005]. NICE based these recmmendatins n expert pinin. Awareness f the effect f DRE n prstate-specific antigen levels This recmmendatin is based n infrmatin in guidelines frm the NHS Prstate Cancer Risk Management Prgramme n prstate-specific antigen testing in asymptmatic men [Burfrd et al, 2009]. When shuld I refer a man with suspected prstate cancer? Refer the man urgently t a urlgist in either f the fllwing circumstances: Digital rectal examinatin (DRE) reveals a hard, irregular prstate (typical f cancer). D a prstate-specific antigen (PSA) test, and arrange fr the man t take the results with him t the referral cnsultatin. Referral is nt necessary if the prstate is smth and enlarged, and the PSA levels are in the age-specific reference range. 9

10 The man's PSA levels are increased mre than brderline, r his PSA levels are increasing see Acting n PSA results. Referral (and PSA testing) may nt be apprpriate if the man has cmrbidities that cmprmise his clinical state r significantly shrten his life expectancy. In this situatin, discuss the ptins with the man and his carers, and cnsider btaining advice frm a specialist in urlgical cancer. Basis fr recmmendatin These recmmendatins reflect guidelines f the Natinal Institute fr Health and Clinical Excellence (NICE) n referring men with suspected prstate cancer [Natinal Cllabrating Centre fr Primary Care, 2005]. They are in line with guidelines frm NICE n the diagnsis and management f prstate cancer [Natinal Cllabrating Centre fr Cancer, 2008a], guidelines frm the NHS Prstate Cancer Risk Management Prgramme n prstate-specific antigen testing in asymptmatic men [Burfrd et al, 2009], and guidelines frm NICE n the management f lwer urinary tract symptms in men [Natinal Clinical Guideline Centre, 2010]. What investigatins may be perfrmed in secndary care t cnfirm and assess suspected prstate cancer? In secndary care, a man with suspected prstate cancer may be ffered a prstate bipsy t cnfirm r exclude the diagnsis, and imaging t assess the TNM stage f the prstate cancer. Prstate bipsy A bipsy invlves taking arund 10 specimens (cres) s that the whle prstate is representatively sampled. This is necessary because prstate cancer develps independently in multiple fci distributed randmly thrughut the prstate. The aim is t detect harmful cancers, nt t detect all cancerus fci. Because the number f cres is limited, arund 20% f small cancerus fci will nt be detected. Prstate bipsy may nt be required if the diagnsis is practically certain n clinical grunds, fr example the prstate-specific antigen level is very high and there is evidence f bne metastases. Imaging Magnetic resnance imaging, cmputed tmgraphy, radiistpe bne scans, and ultrasngraphy may be used t assess the prstate gland and determine the extent f lcally invasive cancer r presence f distant metastases. N imaging mdality is accurate enugh fr prstate cancer t be cnfidently excluded. Basis fr recmmendatin 10

11 This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) n the diagnsis and management f prstate cancer [Natinal Cllabrating Centre fr Cancer, 2008a]. Prstate cancer - Management Scenari: Treatment ptins fr prstate cancer What apprach t treating prstate cancer is recmmended? Treatment fr prstate cancer will be initiated and managed in secndary care. Primary care will be invlved in shared care with fllw up and mnitring, and early recgnitin and initial management f the cmplicatins f the cnditin and adverse effects f its treatment. Apprpriate treatment ptins depend n the stage f the prstate cancer (lcalized, lcally advanced, metastatic, r relapse), the man's prgnstic risk, the presence f lwer urinary tract symptms f bladder utlet bstructin, the risk f adverse effects frm treatment, his life expectancy, and persnal values. Treatments fr lcalized prstate cancer Treatment ptins include: N active treatment: watchful waiting, and active surveillance. Radical treatment: radical prstatectmy, external beam raditherapy, brachytherapy. Fcal treatments: high intensity fcused ultrasund and crytherapy are used in clinical trials. Adjuvant treatment: hrmnal treatment, including andrgen blckade and andrgen withdrawal a shrt curse may be given befre r during radical raditherapy. The sectin n Treatment ptins fr lcalized prstate cancer shws the recmmended ptins fr men at lw, intermediate, and high prgnstic risk. Treatments fr lcally advanced prstate cancer, metastatic prstate cancer, r relapse after radical treatment include: Neadjuvant and cncurrent luteinizing hrmne-releasing hrmne agnist r antagnist therapy see hrmnal treatment. Adjuvant hrmnal treatment. Raditherapy: external beam raditherapy and brachytherapy. Prstatectmy: radical prstatectmy, high intensity fcused ultrasund, and crytherapy. Chemtherapy sme centres may nt prvide sme treatments, such as thse being researched in clinical trials. 11

12 New treatments New treatments fr prstate cancer are underging clinical trials. Infrmatin abut these trials can be fund n Cancer Research UK's nline register. Summary f recmmended treatment ptins fr lcalized prstate cancer Table 1. Treatment ptins fr lcalized prstate cancer that are recmmended by the Natinal Institute fr Health and Clinical Excellence (NICE). Treatment Prgnstic risk grup * ptin Lw Intermediate High N active treatment Watchful waiting Optin Optin Optin Active surveillance Preferred Optin Nt apprpriate Radical treatment Radical prstatectmy Optin Preferred Preferred External-beam Optin Preferred Preferred raditherapy Brachytherapy Optin Optin Nt apprpriate High-intensity fcused ultrasngraphy Crytherapy Research ptin Research ptin Research Research ptin ptin Research Research ptin ptin Adjuvant treatment with radical raditherapy fr men with Gleasn scre f 8 r mre. Hrmnal treatment Recmmended if Gleasn scre 8 10 * Prgnstic risk gruping depends n prstate specific antigen level, TNM classificatin, and Gleasn scre. Only recmmended if there is a realistic prspect f lng-term disease cntrl. An ptin nly as part f a clinical trial cmparing it with established treatment. Includes andrgen withdrawal and andrgen blckade. Adapted frm: [Natinal Cllabrating Centre fr Cancer, 2008a]. Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. Infrmatin and supprt fr patients Where can men btain infrmatin abut prstate cancer and its treatment? Cancer Research UK The Cancer Help sectin f Cancer Research UK prvides infrmatin fr peple with all frms f cancer. It includes symptms and causes f prstate cancer, tests and treatment, living with prstate cancer, and current research. 12

13 A leaflet Abut prstate cancer - A quick guide (pdf) can be dwnladed fr printing. Fr mre infrmatin, visit The Prstate Cancer Charity The Prstate Cancer Charity prduce a wide range f publicatins fr health prfessinals t use when discussing diagnstic tests, treatments, and adverse effects with their patients. Publicatins that can be dwnladed fr printing include: Prstate cancer: a guide fr newly diagnsed men (pdf) Active surveillance (pdf) Radical prstatectmy (pdf) External beam raditherapy (pdf) Brachytherapy (pdf) Hrmne therapy (pdf) Crytherapy (pdf) High intensity fcused ultrasund (pdf) Fr mre infrmatin abut prstate cancer and ther treatments, visit Macmillan and Cancerbackup Macmillan Cancer Supprt and Cancerbackup merged in They aim t imprve the lives f peple affected by cancer by prviding practical, medical and financial supprt. Infrmatin n prstate cancer, including treatments, pssible side effects, and hw t get further supprt can be fund at Prstate UK Prstate UK has a range f publicatins and leaflets that ffer helpful infrmatin and advice n prstate diseases and their treatment. Fr mre infrmatin n what leaflets are available, and hw they can be rdered, visit NHS Chices NHS Chices is a cmprehensive health infrmatin service, including prstate cancer. Fr mre infrmatin, visit Prstate Link UK 13

14 Prstate Link UK prvides links t quality-assessed surces f infrmatin abut the questins men with prstate cancer cmmnly want t ask. Fr mre infrmatin, visit Basis fr recmmendatin The Natinal Institute fr Health and Clinical Excellence (NICE) recmmends that peple with prstate cancer shuld receive infrmatin abut the benefits and limitatins f tests and treatments, but des nt recmmend specific resurces [Natinal Cllabrating Centre fr Cancer, 2008a]. The resurces listed here have been identified by CKS r suggested by expert reviewers. What supprt resurces are there fr peple with prstate cancer? Healthtalknline Healthtalknline allws peple t share in ther peple's experiences f health and illness. Their infrmatin is based n research led by experts at the University f Oxfrd. Fr mre infrmatin, visit Macmillan and Cancerbackup Macmillan Cancer Supprt and Cancerbackup merged in They aim t imprve the lives f peple affected by cancer by prviding practical, medical and financial supprt. Fr mre infrmatin, visit r telephne their helpline n The Prstate Cancer Charity The Prstate Cancer Charity prvides links t vlunteers wh can prvide supprt ver the telephne t men with prstate cancer. Men needing t chse between treatments can be put in tuch with supprt vlunteers wh have tried the treatments. Visit r telephne their helpline n NHS Direct NHS Direct prvides advice and infrmatin n all health prblems, including prstate cancer. NHS direct als prvides advice fr carers f peple with cancer. Visit r telephne Prstate Link UK 14

15 Prstate Link UK prvides links t quality-assessed surces f infrmatin abut the questins men with prstate cancer cmmnly want t ask. Fr mre infrmatin, visit Basis fr recmmendatin The Natinal Institute fr Health and Clinical Excellence (NICE) recmmends that peple with prstate cancer shuld receive infrmatin abut the benefits and limitatins f tests and treatments, but des nt recmmend specific resurces [Natinal Cllabrating Centre fr Cancer, 2008a]. The resurces listed here have been identified by CKS r suggested by expert reviewers. Watchful waiting/active surveillance What is watchful waiting, and when is it an apprpriate treatment ptin fr prstate cancer? Prtcls fr watchful waiting include regular clinical assessments and repeat prstate-specific antigen (PSA) testing, but nt repeated digital rectal examinatin r prstate bipsies. Details fr fllw up vary with lcality. Watchful waiting is an ptin fr men with prstate cancer if radical treatment wuld nt be apprpriate, and hrmne therapy is nt necessary. Watchful waiting is ften suitable fr lder men, r men with significant cmrbidities wh have a lw risk f significant cancer prgressin during their expected lifespan. It is an ptin fr men in any prgnstic risk grup. If prgressive disease becmes apparent, fr example there is bne pain r PSA levels increase rapidly (as indicated in the shared care agreements), the man shuld be reviewed by the urlgical cancer service, which will initiate treatment (ften hrmnal treatment). Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. What is active surveillance, and when is it an apprpriate treatment ptin fr prstate cancer? Active surveillance invlves frequent serial prstate-specific antigen (PSA) tests, digital rectal examinatins, and prstate bipsies see Fllw up and mnitring. 15

16 The difference frm watchful waiting is that repeating the prstate bipsy at intervals depending n age and PSA levels allws the man's prgnstic risk categry t reassessed. The aim f active surveillance is t safely reduce the risk f ver treatment, as treatment is ffered nly when the risk increases. If there is evidence f disease prgressin, the man shuld be ffered radical treatment. His decisin shuld be infrmed by his preferences, cmrbidities, and life expectancy. Active surveillance is the preferred ptin fr men with lw prgnstic risk wh are fit fr radical treatment in the event f disease prgressin. It is an ptin fr men at intermediate risk, and it is nt recmmended fr men at high risk. Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. Radical treatments What is radical prstatectmy, and when is it apprpriate treatment fr prstate cancer? With radical prstatectmy, the whle prstate gland and the seminal vesicles are surgically remved. Surgical techniques include the pen retrpubic r perineal appraches and appraches using newer technlgies, such as laparscpic and rbtic-assisted surgery, that are less invasive but less well studied. Risks assciated with radical prstatectmy include urinary incntinence, erectile dysfunctin, and incmplete resectin f the tumur. Radical prstatectmy is an apprpriate ptin fr: Lcalized prstate cancer. Radical prstatectmy is ffered t fitter men withut cmrbidities. It is nt cmmn t ffer it t men lder than 70 years f age. It is an ptin fr men at lw prgnstic risk, and is a preferred ptin fr men at intermediate risk and thse at high risk wh have a realistic chance f gaining lng-term cntrl f the disease. Bichemical relapse after radical raditherapy. Radical prstatectmy is an ptin fr men wh have bichemical relapse increasing prstate-specific antigen levels after radical raditherapy. Hwever, the risk f incntinence, imptence, and rectal damage is higher than when it is used as primary treatment. Lcally advanced prstate cancer. Men with T3 cancers are smetimes treated with radical prstatectmy, althugh clinical r radilgical evidence f T3 prstate cancer is usually a cntraindicatin t radical surgery. 16

17 Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. What is external-beam raditherapy, and when is it an apprpriate treatment fr prstate cancer? External-beam raditherapy directs inizing radiatin at the tumur frm utside the bdy, using X-rays, fr example. Adverse effects Adverse effects f external-beam raditherapy include alteratin in urinary and bwel functin and erectile dysfunctin. External-beam raditherapy is an apprpriate ptin fr: Lcalized cancer f the prstate. External-beam raditherapy is the cmmnest treatment in the UK fr men diagnsed with lcalized prstate cancer. It is given as cnfrmal raditherapy in daily utpatient treatments ver 4 8 weeks. In cnfrmal raditherapy, the radiatin beam is directed t fit the prfile f the man's prstate. External-beam raditherapy is nt recmmended fr men at lw prgnstic risk, and is a preferred ptin fr men at intermediate risk and thse at high risk wh have a realistic chance f gaining lng-term cntrl f the disease. Men receiving radical raditherapy fr lcalized prstate cancer wh have a Gleasn scre f 8 r mre will als be treated fr at least 2 years with adjuvant hrmnal therapy. Relapse after radical treatment fr prstate cancer. Raditherapy t the prstate bed is recmmended fr men wh experience bichemical relapse with increasing prstate-specific antigen levels after radical prstatectmy, prvided that they d nt have metastases. Lcally advanced disease. External-beam raditherapy is smetimes cmbined with brachytherapy in lcally advanced disease. Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. 17

18 What is brachytherapy, and when is it apprpriate treatment fr men with prstate cancer? Brachytherapy is a type f raditherapy in which the radiactive surce is implanted in the prstate permanently with lw-dse rate radiactive seeds, r temprarily with high-dse rate radiactive wires. Cmplicatins Cmplicatins f brachytherapy include alteratin f urinary and bwel functin and erectile dysfunctin. Cntraindicatins Brachytherapy may nt be pssible in men with an enlarged prstate, and significant bstructive lwer urinary tract symptms are a relative cntraindicatin. Brachytherapy is an apprpriate ptin fr: Lcalized prstate cancer Brachytherapy is an ptin fr men at lw r intermediate prgnstic risk. It is nt recmmended fr thse at high risk. Lcally advanced prstate cancer Brachytherapy can be cmbined with external beam raditherapy t deliver a high-dse bst t the prstate in lcally advanced disease. Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2005e; NICE, 2006; Natinal Cllabrating Centre fr Cancer, 2008a]. What is high-intensity fcused ultrasund (HIFU), and when is it used t treat prstate cancer? High-intensity fcused ultrasngraphy (HIFU) is used t ablate (destry) prstate tissue by heating. Adverse effects f HIFU include sexual dysfunctin, stress incntinence, urethral strictures, and urinary tract infectin. HIFU is nt recmmended except as part f a clinical trial in which it is cmpared with established interventins. HIFU may be an apprpriate ptin fr: Lcalized cancer f the prstate. Lcally advanced prstate cancer. 18

19 Relapsed prstate cancer after raditherapy. Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2005b; Natinal Cllabrating Centre fr Cancer, 2008a]. What is crytherapy, and when is it used t treat prstate cancer? Crytherapy is used t ablate (destry) prstate tissue by freezing. Adverse effects f crytherapy mst cmmnly include sexual dysfunctin and stress incntinence. Crytherapy is nt recmmended except as part f a clinical trial in which it is cmpared with established interventins. Crytherapy may be an apprpriate ptin fr: Lcalized cancer f the prstate. Lcally advanced prstate cancer. Relapsed prstate cancer after radical raditherapy. Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2005c; NICE, 2005d; Natinal Cllabrating Centre fr Cancer, 2008a]. Adjunctive and palliative treatments What hrmnal treatment are used fr prstate cancer, and when are they indicated? Tw kinds f hrmnal treatment are used fr prstate cancer. Andrgen withdrawal with surgery (bilateral rchidectmy) r with gnadtrpin-releasing hrmne (GnRH) agnists (such as gserelin), r antagnists (such as degarelix). GnRH is als knwn as 'luteinizinghrmne-releasing hrmne' (LHRH). Andrgen blckade with drugs that bind t and blck the hrmne receptrs f cancer cells, thus preventing andrgens frm stimulating cancer grwth. Hrmnal treatment may be given at different times. Neadjuvant therapy is given fr several mnths befre radical treatment with surgery r raditherapy. 19

20 Cncurrent therapy is given at the same time as raditherapy. Adjuvant therapy is given after radical treatment with surgery r raditherapy. Hrmnal treatment may be given: Cntinuusly, r Intermittently. The adverse effects f hrmnal therapies reflect their mechanisms f actin. Andrgen withdrawal cmmnly causes ht flushes, lss f libid, weight gain, lethargy, cgnitive dysfunctin, diabetes, and excess cardivascular events. In the lng term, bne mineral density may decrease and pathlgical fractures becme mre likely. Andrgen blckade is less likely than andrgen withdrawal t cause sexual dysfunctin r lethargy. The mst prblematic adverse effects are breast enlargement (gynaecmastia) and breast pain (mastalgia). Hrmne therapy may be used t treat: Lcalised prstate cancer Adjuvant hrmnal therapy is recmmended fr men receiving radical raditherapy fr lcalized prstate cancer wh have a Gleasn scre f 8 r mre. Relapse after radical prstatectmy r raditherapy fr prstate cancer Hrmnal therapy is used fr men with symptmatic, prgressive, r metastatic disease after either initial surgery r raditherapy. It is recmmended fr men with bichemical relapse whse prstate-specific antigen levels have dubled in less than 3 mnths. Lcally advanced prstate cancer Neadjuvant and cncurrent LHRH agnist therapy is recmmended fr 3 6 mnths in men receiving radical raditherapy fr lcally advanced prstate cancer. Degarelix is an LHRH antagnist, which is licensed fr treatment f men with advanced hrmne-dependent prstate cancer. Adjuvant hrmnal therapy is recmmended fr a minimum f 2 years in men receiving radical raditherapy fr lcally advanced prstate cancer wh have a Gleasn scre f 8 r mre. Metastatic prstate cancer Bilateral rchidectmy and cntinuus LHRHa therapy are alternatives fr men with metastatic prstate cancer. The chice depends n the man's preferences. Fr example, bilateral rchidectmy is cnvenient but irreversible, whereas LHRHa therapy may be used intermittently but administratin and adherence t recmmended schedules may be prblematic. 20

21 Andrgen blckade mntherapy with bicalutamide may be the preferred ptin fr men wh hpe t retain sexual functin and are willing t accept the risk f reduced life expectancy and the pssibility f gynaecmastia (enlarged breasts). Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. Degarelix is licensed fr treatment f men with advanced hrmne-dependent prstate cancer, but was nt assessed by NICE because it was intrduced t the market after the guidance was published. What is strntium-89 therapy, and when is it used fr prstate cancer? The radiactive istpe f strntium, Sr-89, is an ptin fr men with hrmne-refractry prstate cancer and painful bne metastases. Strntium-89 is given intravenusly as a single dse r a shrt curse. It may be used as adjunctive treatment tgether with ther therapies. Because f its suppressive effects n bne marrw, treatment with strntium-89 is usually limited t ne curse. Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. What chemtherapy is used fr prstate cancer, and when is it ffered? Chemtherapy is usually given t men with symptmatic prgressin. It may be ffered t asymptmatic men with metastatic disease whse prstate-specific antigen level is rapidly increasing. It may als be ffered fr ther indicatins in clinical trials. Dcetaxel Dcetaxel in cmbinatin with prednislne is the nly chemtherapy regimen licensed fr hrmne-resistant metastatic prstate cancer. The adverse effects f this cmbinatin can be substantial, and it may nt be pssible t use dcetaxel if the disease has prgressed t a stage where it is causing significant symptms. 21

22 Mitxantrne Men wh are unlikely t tlerate dcetaxel are usually treated with the cmbinatin f mitxantrne and prednislne. Crticsterids A crticsterid, such as dexamethasne, is recmmended as third-line therapy after andrgen withdrawal and anti-andrgen therapy fr men with hrmne-refractry prstate cancer. Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. When are bisphsphnates used in men with prstate cancer? Bisphsphnates are recmmended as an ptin fr pain relief in men with hrmne-refractry prstate cancer when ther treatments (including analgesics and palliative raditherapy) have failed. Bisphsphnates are nt recmmended t prevent bne metastases r t reduce their cmplicatins. Bisphsphnates are nt recmmended t be used rutinely t prevent steprsis in men with prstate cancer receiving andrgen withdrawal therapy. Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. Prstate cancer - Management Scenari: Management f cmplicatins f prstate cancer and adverse effects f treatments Infrmatin and supprt fr patients Where can men btain infrmatin abut the cmplicatins f prstate cancer and adverse effects f treatment? The Prstate Cancer Charity The Prstate Cancer Charity prduce a wide range f publicatins fr health prfessinals t use with their patients when discussing the cmplicatins f prstate cancer and the adverse effects f treatments. 22

23 Publicatins that can be dwnladed fr printing include: Living with hrmne therapy: a guide fr men with prstate cancer (pdf) Recurrent prstate cancer: If yur cancer cmes back - risk and treatment (pdf) Diet and prstate cancer (pdf) Sex and prstate cancer (pdf) Urinary prblems and prstate cancer (pdf) Pain and advanced prstate cancer (pdf) Fr mre infrmatin, visit Cancer Research UK The Cancer Help sectin f Cancer Research UK prvides infrmatin fr peple with all frms f cancer. The sectin n living with prstate cancer includes infrmatin n: Cping with prstate cancer Sex life and prstate cancer Urinary prblems What t ask yur dctr abut living with prstate cancer Fr mre infrmatin, visit The Prstate Cancer Charity The Prstate Cancer Charity prduce a wide range f publicatins fr health prfessinals t use when discussing diagnstic tests, treatments, and adverse effects with their patients. Publicatins that can be dwnladed fr printing include: Living with hrmne therapy (pdf) Recurrent prstate cancer: If yur cancer cmes back risk and treatment (pdf) Diet and prstate cancer (pdf) Sex and prstate cancer (pdf) Pain and advanced prstate cancer (pdf) Urinary prblems (pdf) Fr mre infrmatin, visit Macmillan and Cancerbackup 23

24 Macmillan Cancer Supprt and Cancerbackup merged in They aim t imprve the lives f peple affected by cancer by prviding practical, medical, and financial supprt. The sectin n living with prstate cancer includes infrmatin n: Fllw up Side effects Living with and after cancer Mre infrmatin n prstate cancer, including treatments, pssible side effects, and hw t get further supprt can be fund at NHS Chices NHS Chices is a cmprehensive health infrmatin service, including prstate cancer. Fr mre infrmatin, visit Prstate Link UK Prstate Link UK prvides links t quality-assessed surces f infrmatin abut the questins men with prstate cancer cmmnly want t ask. Fr mre infrmatin, visit Basis fr recmmendatin The Natinal Institute fr Health and Clinical Excellence (NICE) recmmends that peple with prstate cancer shuld receive infrmatin abut the benefits and limitatins f tests and treatments, but des nt recmmend specific resurces [Natinal Cllabrating Centre fr Cancer, 2008a]. The resurces listed here have been identified by CKS r suggested by expert reviewers. What supprt resurces are there fr peple with prstate cancer? See the sectin Supprt fr patients in the Scenari: Treatment ptins. Basis fr recmmendatin The Natinal Institute fr Health and Clinical Excellence (NICE) recmmends that peple with prstate cancer shuld receive infrmatin abut the benefits and limitatins f tests and treatments, but des nt recmmend specific resurces [Natinal Cllabrating Centre fr Cancer, 2008a]. The resurces listed here have been identified by CKS r suggested by expert reviewers. 24

25 Hw are men with prstate cancer fllwed up and mnitred? When men with prstate cancer are fllwed up in primary care, this will be dne accrding t lcally agreed prtcls. Primary care fllw up may be apprpriate fr all men with lcalized prstate cancer, sme men with lcally advanced prstate cancer, and men wh have been stable with n significant treatment cmplicatins fr at least 2 years after radical treatment. The man (and when apprpriate his family and carers) shuld understand: The purpse f fllw up and its arrangements. What adverse effects f treatment t be aware f, and hw t reprt them. Fr all men being fllwed up fr prstate cancer, review and manage: Cmplicatins f the disease, including pain, lwer urinary tract symptms, and symptms f spinal crd cmpressin. Adverse effects frm treatment, including sexual dysfunctin and urinary incntinence. Adverse effects f andrgen withdrawal include change in bdy shape and weight gain, tiredness, ht flushes, lss f libid, erectile dysfunctin, gynaecmastia, and lss f bne density. Quality f life. Fllw up with watchful waiting Prstate-specific antigen (PSA) shuld be measured at least nce a year. Digital rectal examinatin (DRE) is nt recmmended n a rutine basis while the PSA level remains at baseline values. Fllw up with active surveillance Prtcls fr active surveillance include PSA testing, DRE, and repeat prstate bipsies. Sme centres fllw the prtcl in the PrSTART trial: Measure PSA every 3 mnths fr 2 years, then every 6 mnths. Perfrm DRE every 3 mnths fr 2 years, then every 6 mnths. Perfrm prstate bipsy after years 1, 4, 7, and 10, then every 5 years. Fllw up with radical treatment PSA levels shuld be measured nt earlier than 6 weeks after treatment, then at least every 6 mnths fr 2 years, and then at least nce a year. 25

26 Basis fr recmmendatin This infrmatin and the recmmendatins reflect guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. Hw shuld I manage adverse effects f hrmnal therapies, including rchidectmy, in men with prstate cancer? Ht flushes An ral r parenteral synthetic prgestgen is recmmended as first-line treatment fr ht flushes. Cnsider cyprterne acetate 50 mg t 150 mg daily. Oral treatment shuld be given fr 2 weeks, and restarted if symptms recur after effective suppressin. Fr prescribing infrmatin, see Cyprterne acetate. Fatigue Regular exercise imprves quality f life and reduces fatigue in men underging andrgen withdrawal therapy. Osteprsis Advise men that it is imprtant t keep physically active, t quit if they smke, t avid excessive alchl cnsumptin, and t eat a nutritius diet. Infrmatin n steprsis fr the general public is available frm NHS Chices, and includes infrmatin n preventin and calcium and vitamin D supplements. There are CKS tpics n Smking cessatin and Alchl - prblem drinking. Preventin and management f steprsis will be accrding t lcal prtcls; it may include vitamin D and calcium supplements, and a bisphsphnate r ther anti-steprsis drug. Gynaecmastia T prevent gynaecmastia in men starting lng-term bicalutamide mntherapy, raditherapy may be given t bth breast buds within the first mnth f treatment. Tamxifen taken weekly is an ptin if raditherapy did nt prevent gynaecmastia. Basis fr recmmendatin This infrmatin and the recmmendatins reflect guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. Hw shuld I manage palliative care and pain in a man with prstate cancer? 26

27 Healthcare prfessinals shuld ensure that palliative care is available when needed and is nt limited t the end f life. It shuld nt be restricted t being assciated with hspice care. The management f cancer pain is discussed in detail in the CKS tpic n Palliative cancer care - pain, which includes separate sectins n acute severe pain, assessment f pain, managing pain that is nt an emergency, and managing bne pain. This als includes sectins n suspecting and managing spinal crd cmpressin. If the usual stepwise apprach t prviding pain relief with analgesics is ineffective, btain specialist advice, as ther treatments are available in secndary care, fr example bisphsphnates and the radiactive strntium istpe Sr-89 may be used fr uncntrlled bne pain. Fr mre infrmatin n palliative care, including supprt fr carers, see the relevant CKS tpics, such as the CKS tpic n Palliative cancer care - general issues. Basis fr recmmendatin This infrmatin and the recmmendatins reflect guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. Hw shuld I manage radiatin-induced enterpathy in men with prstate cancer? Men wh present with symptms cnsistent with radiatin-induced enterpathy shuld be referred fr investigatin and management. Symptms may include diarrhea, passing bld r mucus with the stl, tenesmus (cnstantly feeling the need t defecate, even after emptying the bwels), and rectal pain. Specialist assessment is likely t invlve sigmidscpy t ascertain the nature f the radiatin injury and exclude such cnditins as inflammatry bwel disease and cancer f the large bwel. Basis fr recmmendatin This infrmatin and the recmmendatins reflect guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. Hw shuld I manage sexual dysfunctin in men with prstate cancer? Lss f libid and erectile dysfunctin are cmmn adverse effects f treatments fr prstate cancer. Cnsider prescribing a phsphdiesterase-5 inhibitr, such as sildenafil, tadalafil, r vardenafil prescribing infrmatin is detailed in the CKS tpic n Erectile dysfunctin. Als cnsider referral t a sexual dysfunctin specialist. 27

28 Basis fr recmmendatin This infrmatin and the recmmendatins reflect guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. Hw shuld I manage suspected spinal crd cmpressin in men with prstate cancer? Suspected spinal crd cmpressin is a medical emergency. It must be diagnsed and treated befre there is significant neurlgical cmprmise. Suspect spinal crd cmpressin if any f the fllwing features are present: Bne pain anywhere in the spine typically it is severe and unremitting, aggravated by cughing and sneezing, and disturbs sleep. Radicular pain. Weakness in any limb. Difficulty in walking. Sensry lss. Bladder dysfunctin, fr example urinary retentin, urinary hesitancy, r decreased urethral sensatin. Bwel dysfunctin, fr example incntinence r cnstipatin. If spinal crd cmpressin is suspected, btain immediate specialist advice, which is likely t include: Immediate admissin fr peple able t benefit frm diagnsis and treatment. Dexamethasne 16 mg rally immediately. Fr mre infrmatin and prescriptins, see the Scenari: Spinal crd cmpressin in the CKS tpic n Palliative cancer care - pain. Basis fr recmmendatin This infrmatin reflects guidelines frm the Natinal Institute fr Health and Clinical Excellence (NICE) [Natinal Cllabrating Centre fr Cancer, 2008a]. The recmmendatins abut management reflect the NICE guideline Metastatic spinal crd cmpressin [Natinal Cllabrating Centre fr Cancer, 2008b]. Hw shuld I manage urinary incntinence r retentin in men with prstate cancer? Urinary incntinence 28