AUAGL Localized Prostate Cancer (2022)

Question 1

Risk Assessment 1/1

Answer 1

Clinicians should use clinical T stage, serum PSA, Grade Group (Gleason score), and tumor volume on biopsy to risk stratify patients with newly diagnosed prostate cancer. (Strong Recommendation; Evidence Level: Grade B)

Important things to remember:

PSA density (PSAD) not specifically included in the GL; however remember >0.15 is a/w risk of upgrading on subsequent biopsy for men on AS.

Question 2

Risk Assessment 2/2

Risk Assessment 3/3

Answer 2

2. Clinicians may selectively use tissue-based genomic biomarkers when added risk stratification may alter clinical decision-making. (Expert Opinion)
3. Clinicians should not routinely use tissue-based genomic biomarkers for risk stratification or clinical decision-making. (Moderate Recommendation; Evidence Level: Grade B)

Question 3

Risk Assessment 4/4

Answer 3

Clinicians should perform an assessment of patient and tumor risk factors to guide the decision to offer germline testing that includes mutations known to be associated with aggressive prostate cancer and/or known to have implications for treatment. (Expert Opinion)

Who should get germline testing?

Strong family hx of prostate cancer
Strong personal or family hx of related cancers (breast, ovarian, pancreatic)
Known family hx of familial cancer risk mutation
Ashkenazi Jewish ancestry
Adverse tumor characteristics (HR disease, IR disease w/ cribiform or intraductal disease)

Question 4

Staging 1/5

Answer 4

Clinicians should not routinely perform abdomino-pelvic computed tomography (CT) scan or bone scan in asymptomatic patients with low- or intermediate-risk prostate cancer. (Expert Opinion)

Question 5

Staging 2/6

Answer 5

Clinicians should obtain a bone scan and either pelvic multi-parametric magnetic resonance imaging (mpMRI) or CT scan for patients with high-risk prostate cancer. (Strong Recommendation; Evidence Level: Grade B)

GL states HR only, but can consider imaging in unfavorable IR.

Question 6

Staging 3/7

Answer 6

In patients with prostate cancer at high risk for metastatic disease with negative conventional imaging, clinicians may obtain molecular imaging to evaluate for metastases. (Expert Opinion)

i.e. PSMA scan

Question 7

Risk-Based Management 1/8

Answer 7

Clinicians should inform patients that all prostate cancer treatments carry risk. The risks of treatment, in particular to patients’ urinary, sexual, and bowel function, must be incorporated with the risk posed by the cancer, patient life expectancy, comorbidities, pre-existing medical conditions, and patient preferences to facilitate a shared decision-making approach to management. (Clinical Principle)

*Should evaluate baseline functional status in regards to urinary function and sexual/erectile funciton (SHIM, IPSS/AUASS, etc.) as these play a role in choosing treatment

Question 8

Risk-Based Management 2/9

Answer 8

Clinicians should provide an individualized risk estimate of post-treatment prostate cancer recurrence to patients with prostate cancer. (Clinical Principle)

Question 9

Risk-Based Management 3/10

Answer 9

For patients with low-risk prostate cancer, clinicians should recommend active surveillance as the preferred management option. (Strong Recommendation; Evidence Level: Grade A)

*LR PCa –> AS preferred in almost all cases

Question 10

Risk-Based Management 4/11

Answer 10

In asymptomatic patients with prostate cancer and limited life expectancy (determined on a patient-specific basis), clinicians should recommend watchful waiting. (Strong Recommendation; Evidence Level: Grade A)

*Patients with a life expectancy of ≤5 years do not benefit from prostate cancer screening, diagnosis, or treatment

Question 11

Risk-Based Management 5/12

Answer 11

For patients with favorable intermediate-risk prostate cancer, clinicians should discuss active surveillance, radiation therapy, and radical prostatectomy. (Strong Recommendation; Evidence Level: Grade A)

• Favorable IR PCa –> prostatectomy, XRT, AS all options
• Favorable IR PCa tx with XRT –> do NOT need ADT

Question 12

Risk-Based Management 6/13

Answer 12

Clinicians should inform patients with intermediate-risk prostate cancer considering whole gland or focal ablation that there are a lack of high-quality data comparing ablation outcomes to radiation therapy, surgery, and active surveillance. (Expert Opinion)

• LR –> should get AS
• IR –> carefully considered, focal therapy can be an option
• HR –> shouldn’t get focal ablative therapy

Question 13

Risk-Based Management 7/14

Answer 13

For patients with unfavorable intermediate- or high-risk prostate cancer and estimated life expectancy greater than 10 years, clinicians should offer a choice between radical prostatectomy or radiation therapy plus androgen deprivation therapy (ADT). (Strong Recommendation; Evidence Level: Grade A)

*For patients with sufficiently high-risk disease (clinically node positive, or with 2 of 3 of the following criteria: clinical stage T3 or T4, PSA ≥ 40 ng/mL, or ≥ Gleason 8), treatment with radiation and ADT can include two years of concurrent abiraterone acetate plus prednisone as well.

Question 14

Risk-Based Management 8/15

Answer 14

Clinicians should not recommend whole gland or focal ablation for patients with high-risk prostate cancer outside of a clinical trial. (Expert Opinion)

*This is bascially a repeat GL. Only RCT data on focal ablation looked at LR disease. ONLY OFFER FOCAL THERAPY TO IR DISEASE.

Question 15

Risk-Based Management 9/16

Answer 15

Clinicians may recommend palliative ADT alone for patients with high-risk prostate cancer, local symptoms, and limited life expectancy. (Expert Opinion).

*primary goals of care include symptom control/palliation and maintenance of QOL. As such, ADT may be used to manage urinary tract sequelae of local tumor growth through (albeit transient) cytoreduction.

Question 16

Principles of Active Surveillance 1/17

Answer 16

Patients managed with active surveillance should be monitored with serial PSA values and repeat prostate biopsy. (Expert Opinion)

• Lots of variation in practice
• PSA no more than q6mo
• DRE q1-2years

Question 17

Principles of Active Surveillance 2/18

Answer 17

In patients selecting active surveillance, clinicians should utilize mpMRI to augment risk stratification, but this should not replace periodic surveillance biopsy. (Expert Opinion)

• Confirmatory biopsy right away if mpMRI shows PIRADS 4-5
• Confirmatory within 12 months if mpMRI only shows PIRADS 1-3
• *This is assuming no mpMRI with initial diagnostic prostate biopsy

Question 18

Principles of Surgery 1/19

Answer 18

In patients electing radical prostatectomy, nerve-sparing, when oncologically appropriate, should be performed. (Moderate Recommendation; Evidence Level: Grade B)

Question 19

Principles of Surgery 2/20

Principles of Surgery 3/21

Principles of Surgery 4/22

Answer 19

Clinicians should inform patients that pelvic lymphadenectomy provides staging information, which may guide future management, but does not have consistently documented improvement in metastasis-free, cancer-specific, or overall survival. (Moderate Recommendation; Evidence Level: Grade B)

Clinicians should use nomograms to select patients for lymphadenectomy. The potential benefit of identifying lymph node positive disease should be balanced with the risk of complications. (Clinical Principle)

Clinicians performing pelvic lymphadenectomy should perform an extended dissection, which improves staging accuracy compared to a limited dissection. (Moderate Recommendation; Evidence Level: Grade: B)

*Limited = obturator fossa
Standard = limited plus external iliac lymph nodes
Extended = Standard plus internal iliac lymph nodes

Question 20

Principles of Surgery 5/23

Answer 20

Clinicians should complete a radical prostatectomy if suspicious regional nodes are encountered intraoperatively. (Moderate Recommendation; Evidence Level: Grade C)

*No prospective data to answer this question

Question 21

Principles of Surgery 6/24

Principles of Surgery 7/25

Answer 21

Clinicians should risk stratify patients with positive lymph nodes identified at radical prostatectomy based on pathologic variables and postoperative PSA. (Expert Opinion)

Clinicians may offer patients with positive lymph nodes identified at radical prostatectomy and an undetectable post-operative PSA adjuvant therapy or observation. (Conditional Recommendation; Evidence Level: Grade C)

*For positive LNs and undetectable PSA postop it isn’t clear what the is the correct answer: immediate