An Update of the NCCN Guidelines for the Treatment of Prostate Cancer

The National Comprehensive Cancer Network (NCCN) serves as a generally accepted cookbook or road map for doctors as they put together treatment plans for their patients.  The NCCN relies on evidence-based findings as well as FDA approvals.  Their guidelines create the standard of care for the treatment of serious disease, including cancer.

As it just did, the NCCN periodically releases updates to their guidelines for prostate cancer treatment.

The recent update in their guidelines for prostate cancer included an extensive revision for initial prostate cancer diagnosis.  The revisions include a recommendation for germline genetic testing (germline genetics are the genes that you are born with, or that you inherit from your mother and father). 

The revised guidelines now say that for initial risk stratification and for the staging workup for clinically localized disease (cancer that is believed to still be in the gland), germline testing is now recommended.  This includes all groups from very low, to very high risk groups.

Additionally, for the algorithm for the very low risk group, EBRT plus ADT for 6 months was added for men after a radical prostatectomy performed as adjuvant therapy.   Additionally, the following was also added to the guidelines, “Consider Multi Parametric MRI (mpMRI) and/or prostate biopsy to confirm candidacy for active surveillance” was added to active surveillance recommendations.

In the algorithm for both the high or very high risk group, in men with an expected survival of more than 5 years now are recommended to have EBRT plus ADT (category 1) as an initial/adjuvant therapy option, respectively. EBRT plus brachytherapy and ADT also lists ADT as a category 1 recommendation.

For men in the regional risk group, EBRT plus ADT is now listed as “preferred.”

The section of the updates NCCN Guidelines for genetic molecular biomarker analysis for advanced prostate cancer changed the germline testing recommendation for regional and metastatic disease from “consider” to “recommended.”

There were also multiple changes made to the guideline in regard to systemic therapy for castration-naïve disease, “ADT and EBRT to the primary tumor for low volume M1” was added. Separate branches were added to the algorithm for M0 castration-resistant disease: PSADT > 10 months and PSADT less than or equal to 10 months. As for systemic therapy for M1 castration-resistant disease, bone antiresorptive therapy with denosumab is now listed as category 1 (preferred), followed by zoledronic acid as another option if bone metastases present. Furthermore, in the section for systemic therapy for M1 castration-resistant disease: adenocarcinoma with visceral metastases, treatment recommendations for subsequent treatment were added, all of which are listed as category 2B (excluding clinical trial and best supportive care).

As for principles of radiation therapy, “low-volume metastatic disease” and “high-volume metastatic disease” were added as new sections. Principles of ADT was revised extensively.

The section for principles of immunotherapy and chemotherapy featured a few modifications. Denosumab given subcutaneously every 4 weeks is now a preferred option, and zoledronic acid is now recommended intravenously every 3-4 weeks or every 12 weeks.