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Anglia Cancer Network
Guidelines for the Management of Prostate Cancer
GUIDELINES FOR THE MANAGEMENT
OF UROLOGICAL CANCER
Prostate Cancer
Date of Endorsement: January 2014
Authors: Mr. Vivekanandan Kumar and Mr. Robert Brierly
REF: AngCN-U-ProstateGuidelines 2014 v1
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Anglia Cancer Network
Guidelines for the Management of Prostate Cancer
Title: Guidelines for the Management of Prostate Cancer
Authors: Vivekanandan Kumar and Rob Briely
Document management
Document ratification and history
Date placed on electronic
library:
Approved by:
Urology NSSG Chair and Network CEO
Review period:
2 years (or earlier in the light of new evidence)
Amended items
Prostate Biopsy update (Feb 2014)
Management of erectile function post radical prostatectomy and radiotherapy (Feb 2014)
Authors:
Mr. Vivekanandan Kumar and
Rob Brierly
Version number as approved and published:
2014 v1
Aug 2014
Document Owner:
Anglia Cancer Network
Tel: 01638 608208
www.angliacancernetwork.nhs.uk
Unique identifier no.:
AngCN-U-ProstateGuidelines 2014 v1
For comments / amendments to these guidelines, please contact:
Name
Vivekanandan
Kumar
Robert Brierly
Hospital
Tel. No
Email
NNUH
01603 286286
[email protected]
Ipswich
[email protected]
For copies of guidelines, please refer to the Anglia Cancer Network website:
www.angliacancernetwork.nhs.uk
Monitoring the effectiveness of the Process
a) Process for Monitoring compliance and Effectiveness - Review of compliance as
determined by audit. Any non compliance to be presented by PQ Manager to the AngCN
Business Meeting on an annual basis – the minutes of this meeting are retained for a
minimum of five years.
b) Standards/Key Performance Indicators – This process forms part of a quality system
working to, but not accredited to, International Standard BS EN ISO 9001:2008. The
effectiveness of the process will be monitored in accordance with the methods given in the
quality manual, AngCN-QM
Equality and Diversity Statement
This document complies with the Suffolk PCT Equality and Diversity statement – an EqIA
assessment is available on request to Anglia Cancer Network PQ Manager, Gibson Centre,
Exning Road, Newmarket, CB8 7JG.
Disclaimer
It is your responsibility to check against the electronic library that this printed out
copy is the most recent issue of this document.
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CONTENTS
Page No
INTRODUCTION .................................................................................................................. 4
REFERRALS ........................................................................................................................ 4
PROSTATE BIOPSY ............................................................................................................ 4
LMDT REVIEW ..................................................................................................................... 5
STAGING ............................................................................................................................. 5
DEFINING TUMOUR STAGE AND GRADE ......................................................................... 5
MANAGEMENT OPTIONS FOR EARLY PROSTATE CANCER ......................................... 5
1. Active Surveillance alone ...................................................................................................... 6
2. Radical Prostatectomy .......................................................................................................... 6
3. External beam radiotherapy - EBRT ..................................................................................... 7
4. Radioactive seed implantation – Brachytherapy ................................................................... 9
5. Radiotherapy after radical prostatectomy ............................................................................. 9
6. Long term androgen deprivation therapy alone .................................................................... 9
MANAGEMENT OPTIONS BASED ON D’AMICO CLASSIFICATION............................... 10
MANAGEMENT OPTIONS FOR LOCALLY ADVANCED PROSTATE CANCER (WITHOUT
METASTASES) .................................................................................................................. 10
MANAGEMENT OPTIONS FOR METASTATIC DISEASE ................................................ 10
SMALL CELL CARCINOMA .............................................................................................. 11
PROSTATIC DUCTAL CARCINOMA. ................................................................................ 12
FOLLOW UP ...................................................................................................................... 12
APPENDICES..................................................................................................................... 13
Appendix 1 – Prostate histology, grading ................................................................................ 14
Appendix 2 - Staging ................................................................................................................ 15
Appendix 3 – Osteoporosis Guidelines .................................................................................... 16
Appendix 4 - Clinical Trials ...................................................................................................... 18
Appendix 5 – Prostate Cancer Pathway .................................................................................. 19
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Guidelines for the Management of Prostate Cancer
Introduction
The purpose of this manual is to collate the numerous guidelines that exist, into a
working manual for the management of prostate cancer within the Anglia Cancer
Network. It should act as a summary guide for the management of patients with
prostate cancer based on the available published evidence. Its scope is to aid all
health practitioners involved with the patient from primary care and referral through
treatment to follow up. However, as constant modifications are being made, these
guidelines should only be used to give an indication of current management. They
should not be used to treat patients without checking that changes have not been
made.
These guidelines have been developed by discussion between clinicians within the
Anglia Cancer Network Urology Site Specific Group but without the establishment of
a formal guideline development group. These guidelines have been endorsed by the
Anglia Cancer Network Urology Site Specific Group. They will be reviewed and
updated on an annual basis or more frequently as required.
The guidelines are intended as a working document for daily practice. For more
detailed sources, and for educational material, please refer to guidelines produced
by e.g. NICE, BAUS, EAU, AUA.
Referrals
For referrals from Primary and Secondary Care, see AngCN prostate cancer
pathway Appendix 5 – Prostate Cancer Pathway and DH suspected cancer
guidance.
Prostate biopsy
The following can be considered as indications for biopsy:

Any patient with PSA > age adjusted upper limit (ULN)

Other men with who wish to have a biopsy based on their PSA and general level
of risk

Any patient with palpably abnormal prostate.
A minimum of ten samples should be taken to reduce the risk of underestimating
tumour grade.
In patients with continued suspicion of prostate cancer, after first negative biopsy,
either in the form of rising PSA, change in DRE findings or MRI changes, a TRUS +
Trans perineal template, biopsies should be considered for subsequent biopsy to
reduce false negative results, especially from the anterior part of the prostate gland
and reduce underestimating the cancer grade of the cancer if found. An MRI before
repeat biopsies should be considered after discussions with the local MDT.
See AngCN Pathology guidelines for details of pathology assessment of biopsy
material.
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LMDT review
All positive prostate biopsies should be discussed in the LMDT.
The need for staging investigations can be based on the prostate cancer risk
categories devised by D’Amico.
Low Risk -T1c or T2a, Gleason <6 and PSA <10 ug/l
Intermediate Risk - T2b or Gleason 7 or PSA >10 and < 20 ug/l
High Risk - > T2c or Gleason > 8 or PSA > 20 ug/l
Staging

Bone scintigram in all patients in medium and high risk categories, or if bone
pain.

MR pelvis should be considered in all patients being considered for radical
therapy and in all patients considered for active surveillance. MRI should be
performed at least three weeks after biopsy to allow changes due to bleeding
from biopsy to subside.
Defining Tumour Stage and Grade
Pathology and tumour grade
The recommended histological grading system for adenocarcinoma is described by
Gleason (see Appendix 1).
Tumour stage
In the UK the TNM is used (see Appendix 2)
Management options for early prostate cancer
Patients will have been assigned a D’Amico Risk Category – low, intermediate or
high.
For most patients with early stage prostate cancer there are will be a number of
options available. These should be discussed with the patient. All patients with
prostate cancer being considered for surgery or brachytherapy should be discussed
with the Specialist Multi-disciplinary Team at Addenbrooke’s or the Norfolk and
Norwich University Hospital, and counselled initially by the local urological and
oncological core members of their LMDT.
The main management options include:
1.
2.
3.
4.
Active surveillance
Radical prostatectomy
3-D conformal external beam radiotherapy - EBRT
Radioactive seed implantation - brachytherapy
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5. Watchful wait
6. Hormone therapy alone
1. Active Surveillance alone
Type of patient who may be considered:






>10 years life expectancy
Gleason sum 6 or 7(3+4) (well/moderately well differentiated) tumours
T1/T2a and T2b
PSA<10
Asymptomatic
Patient preference
Baseline MRI should be considered for all patients contemplating active surveillance.
The risk of progression is related to grade and stage. These risks should be
explained to the patient. If the patient opts for active surveillance and he is suitable
for radical treatment should his disease progresses, he should be followed up initially
at three monthly intervals with a PSA and also rectal examination at least every 12
months. At a later stage once stability of the PSA reading has been established, the
appointment interval may be increased to 6 monthly. Monitoring should include a
measure of PSA doubling time (PDAdt). Active surveillance should involve repeat
prostate biopsies every 12 to 18 months.
The patients managed may be informed by the PSAdt, some suggestions are put
below but patient choice remains paramount.



PSAdt <10 months – intervention
PSAdt >4 years – no intervention / continued active monitoring
PDAdt between 10 months and 4 years – consider treatment according to
patient parameters (i.e. Radical or palliative treatment).
 Progression in repeat biopsies (eg. grade shift, increased tumor volume)
should trigger intervention
Patients with less than 10 years of life expectancy, older or serious medical
conditions should be offered watchful wait.
2. Radical Prostatectomy
Usually men undergoing radical prostatectomy would have the following criteria.





Patients with a predicted life expectancy in excess of 10-15 years; usually
these men will be aged under 73 years.
T1/T2N0M0 and PSA < 20 ug/l
Some men with operable cT3 disease may wish for surgery
Patient understands and accepts the risk of impotence and/or incontinence.
Patient preference.

Prostatectomy may be advantageous if there is a history of marked LUTS.

Patients should be offered open, laparoscopic and robotic radical
prostatectomy, depending on patient preference, after appropriate counseling,
supplemented by information sheets.
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Management of erectile function post radical prostatectomy and radiotherapy
Penile rehabilitation is defined as the use of any drug or device at or after radical
prostatectomy to maximize the recovery of erectile function. The purpose of penile
rehabilitation is the prevention of corpus cavernosum smooth muscle structural alterations,
to limit venous leak development during the period of recovery from neuropraxia, and
therefore to maximize the chances of a man returning to his preoperative level of erectile
function.
Recent studies(1-4) suggest a benefit from early pharmacological rehabilitation after radical
prostatectomy.
Proposed guideline :
a) Pre-op good Erectile function,( IIEF >16/25), Good unilateral / bilateral nerve spare:

Cialis (tadalfil) 5mg Once Daily (preferred treatment)

Review in 3 months if no early response, consider change to MUSE/ Intracavernosal
Injection alprostadil / Vacuum tumescence device.

Consider continuing any PDE5 after 3 months as return of normal erections can be
delayed up to 24 months
Consider use of Vacuum device in combination with PDE5
If at 3 months review there is early response to PDE5 – Cialis or Sildenafil then change over
to PRN dose
b) Pre-op ED or IIEF <16/25 or poor nerve spare:

Direct MUSE/ Intracavernosal Injection alprostadil / Vacuum tumescence device.
There is less evidence for management of ED post radiotherapy. However the above should
still be considered to offer potential benefit and has been recommended by NICE guidance
(2014).
Men should be provided with early and ongoing access to specialist erectile dysfunction
services including psychosexual counselling.
Androgen deprivation therapy and erectile dysfunction
NICE guidance (2014) recommends that men should be offered access to specialist erectile
dysfunction services including psychosexual counselling as well as treatment with PDE5
inhibitors for loss of erectile function on hormone treatments.
Department of Health Guidance
DoH guidance(5) (HSC1999/148) on treatment of erectile dysfunction states:
“the Department advises doctors that one treatment a week will be appropriate for most
patients treated for erectile dysfunction. If the GP in exercising his clinical judgement
considers that more than one treatment a week is appropriate he should prescribe
that amount on the NHS.”
3. External beam radiotherapy - EBRT
Patients should be staged as outlined above.
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





Guidelines for the Management of Prostate Cancer
T1-3 N0 M0
Any Gleason grade
Life expectancy > 10 years
No history of radio sensitivity or previous pelvic radiotherapy.
Contraindications to brachytherapy or radical prostatectomy.
Patient preference.
Radiotherapy and hormone therapy recommendations:
a) Radical radiotherapy without associated hormone therapy



pT1a/pT1c (10% sample volume) and Gleason <7 and PSA in normal range
Normal potency
Patient preference
b) Hormone cyto-reduction 3-6 months before and concurrent with radical
radiotherapy



pT1b/c-clinical T2a/b/c
Gleason < 8
PSA < = 20 ug/l
c) Continuing hormones after radical radiotherapy (3 years)
Patients at a higher risk of systemic disease may be considered for adjuvant
hormone therapy for 3 years.



Gleason 8 or above
Clinical T3/4a
Initial PSA > 20 ug/l (not in acute retention or with UTI)
In this setting three monthly LHRHa depot injections are preferred.
d) Indefinite Hormone Therapy Followed By Palliative Radiotherapy


N+ and/or M+ disease
T4b
In this setting three monthly LHRHa depot injections are preferred.
Patients intending to pursue long term ADT should be considered for bone
densitometry at the start of their treatment and then at two yearly intervals. If bone
density is < -2 or worse SD below the mean expected value, the patient should
receive oral bisphosphonates and calcium supplements as per the advice of the
bone densitometry report. See Appendix 3.
Salvage therapy for recurrent prostate cancer post-radiotherapy
In the event of biochemical recurrence after EBRT, salvage therapy needs to be
considered. Hormones or salvage radical prostatectomy or salvage cryotherapy
needs to be considered. There is no clear evidence to prefer one treatment over the
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other. In depth counseling of the patient is essential to inform the risks and benefits
of each. Refer to the Norfolk and Norwich University Hospital SMDT for
consideration of salvage therapy.
4. Radioactive seed implantation – Brachytherapy
Patients may be considered with the following factors:







Well or moderately differentiated tumours (Gleason < 7).
No greater than 2 positive cores and <20% of biopsy material in positive cores
No prior TURP
PSA <15 ug/l if Gleason 6 (3+3) and 10 ug/l if Gleason 7(3+4)
Prostate volume 20-50 mls-, no pubic arch interference
Minimal lower urinary tract symptoms (LUTS) - IPSS < 8/35
T1N0M0 or small volume T2N0M0
Patient preference
Patients should be referred to the Oncology Department at Addenbrooke’s Hospital
5. Radiotherapy after radical prostatectomy
Indications include a rising PSA post-operatively, or a PSA which fails to become
unrecordable, in men with pT3a disease, bladder neck or seminal vesicle
involvement, and with broadly positive margins. Positive margins alone are not an
indication for immediate post-operative radiotherapy unless the PSA begins to rise.
The use of androgen deprivation in this setting is decided on an individual patient
basis. Patients should be warned that there is a risk of worsening urinary
incontinence following radiotherapy in this setting.
6. Long term androgen deprivation therapy alone
Patients who may reasonably be considered include:



Life expectancy less than 10 years.
Significant urinary symptoms may increase the advantages of offering
androgen deprivation.
No other significant risk factor for osteoporosis
Patient preference.
The options for androgen deprivation are:



LHRH agonists – goserelin, leuprorelin, triptorelin (intermittent therapy may be
considered, particularly for low volume minimal metastatic disease with a low
PSA after 6 to 9 months of treatment).
LHRH antagonists - degaralix
Orchidectomy
Anti-androgen monotherapy therapy e.g. Bicalutamide, may be considered for
selected patients in whom active therapy is indicated but potency or the sideeffects of LHRH analogues are important issues.
See Appendix 3 for bone densitometry indications.
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Management options based on D’Amico classification
Low risk
The following options are possible, assuming a life expectancy of at least 10 years
and fitness for radical surgery, and all should be discussed with the patient:
 active surveillance
 radical surgery
 radical EBRT
 brachytherapy
If co-morbidity suggest that the patient’s life expectancy is less than 10 years, active
treatments may not be appropriate.
Intermediate risk
Active treatment will be preferred to active surveillance, although the latter option
can be considered. Active treatment will usually be either radical surgery or EBRT,
but some intermediate risk men may meet the indications for brachytherapy. Active
treatment in some men, who are not candidates for radical treatment on grounds of
age or frailty, may be with androgen deprivation therapy
High risk
Active treatment is required. Radical treatment may be considered for men who
otherwise have a life expectancy of at least 10 years: EBRT may be an option, and
for those fit enough, radical surgery may be considered. Brachytherapy is not an
option.
Palliative treatment with androgen deprivation therapy, and possibly also with
palliative radiotherapy, will be appropriate for men not treated radically.
Management options for locally advanced prostate cancer (without
metastases)
Patients with T3b or T4 could be considered for radical or palliative radiotherapy plus
hormone therapy (see radiotherapy section). Other options include hormone therapy
alone or active monitoring in patients with other serious medical conditions or patient
preference. Radical prostatectomy or brachytherapy are seldom appropriate for
patients with stage cT3b disease or more advanced disease.
See Appendix 3 for bone densitometry indications.
Management Options for Metastatic Disease
Local therapies for the prostate depend on the symptoms, extent of disease (locally
and metastatic) and the performance status of the patient. Assessing the
symptomatic response to hormone therapy is the usual course but palliative TURP or
radiotherapy may well be appropriate (Radical prostatectomy or brachytherapy are
not considered). Treatment of systemic disease depends on the existing therapies at
the time of metastatic development and the individual circumstances of the patient.
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An example of a possible pathway, purely for illustrative purposes, is:
First line
LHRH agonist or
orchidectomy
Next 
Second line
Third line
Fourth line
Add Antiandrogen
(e.g. Bicalutamide
50mg od)
Following antiandrogen
withdrawal
Diethystilboestrol 13 mg po od and
Aspirin 75mg od2,3
Also consider
clinical trials
Docetaxel
chemotherapy
75mg/m2 with
prednisolone
10mg daily.
Also consider
clinical trials
Other Considerations


Consider breast bud irradiation if long term bicalutamide or diethystilboestrol
is planned.
Cyproterone acetate 50–100 mg od is useful to treat the hot flushes
associated with LHRH analogue. As monotherapy there is a risk of liver
damage and it is less effective than LHRH analogue.
See Appendix 3 for bone densitometry indications.
Therapy for painful bone metastases
Local radiotherapy to the painful area is the treatment of choice. Usually an 8 Gy
single fraction is recommended, although five fractions may be need when retreated. Other therapies include: Strontium 89
 Surgical decompression
 Internal fixation
 Bisphosphonates
Small cell carcinoma
Exclude a small cell tumour of the bladder with prostatic infiltration. For patients with
apparently localized disease is initial chemotherapy, for up to six cycles, with CAV
(cyclophosphamide, doxorubicin, vincristine), ACE (doxorubicin, cyclophosphamide,
etoposide) or EP (etoposide, cisplatin), followed by radiotherapy to a dose of
55Gy/20 fractions over four weeks. For patients with metastatic disease at
presentation chemotherapy alone is more appropriate unless there is concern
regarding the risk of uncontrolled local progression when a palliative radiotherapy
treatment schedule to the prostate can be offered.
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Prostatic ductal carcinoma.
This is an aggressive tumour which should be managed along the lines of a
transitional cell carcinoma. Fit patients with apparently localized disease should be
offered radical radiotherapy (55Gy/20 fractions). For advanced disease consider
chemotherapy with cisplatin/gemcitabine or M-VAC.
In elderly and unfit patients a trial of androgen deprivation therapy is appropriate.
Follow up
Following treatment patients should be given an appointment for review in the
appropriate clinic. Thereafter follow up will be three to six monthly for first year, six
monthly year two – four and thereafter, if conditions stable, annual follow up.
If the condition is stable, consider referral back to Primary Care.
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Appendices
Appendix 1
Prostate Histology, grading
Appendix 2
Staging
Appendix 3
Osteoporosis Guidelines
Appendix 4
Clinical Trials supported by the network
Appendix 5
Prostate Cancer Pathway
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Appendix 1 – Prostate histology, grading
 Gleason Score
Grading systems have been shown to correlate with tumour stage, incidence of
seminal vesicle and lymph node involvement, occurrence of distant metastases and
survival. However, the reproducibility of such systems is not perfect and there is
considerable intra- and inter-pathologist variability (Gallee et al, 1990)
The histological grading system most commonly used is that described by Gleason
(Gleason et al, 1974) and is given on adenocarcinoma and its variants.
Unlike other grading systems, emphasis is placed on the assessment of the
architectural growth pattern and degree of glandular differentiation, rather than
cytological features, thus enabling grading to be performed at low or medium power
magnification. Five tumour grades 1-5 are recognised (with sub-divisions to form 9
originally described patterns), forming a continuous spectrum of appearances from
grade 1 being the well differentiated to grade 5, the most poorly differentiated. A
simplified description of the histological appearances is given here:
Gleason Grading of Prostate Cancer – summary of histological appearances:
 Grade 1 Uniform closely packed separate glands forming a circumscribed nodule
 Grade 2 Slightly less uniform, separate glands, more loosely packed, with a
partially circumscribed margin
 Grade 3 Single separate infiltrating often angulated glands (3A), very small
infiltrating glands (3B) or circumscribed cribriform or papillary masses (3C)
 Grade 4 Fused raggedly infiltrating glands (4A), which may also consist of large
pale cells ‘hypernephroid’ cells (4B)
 Grade 5 Solid rounded masses with necrosis (5A) or ragged infiltrating tumour
(5B)
The majority of tumours do not have a uniform appearance, therefore the primary
grade is assigned to the pattern which is predominant, and the secondary grade to
the next most frequent. The Gleason score is the sum of the primary and secondary
grades, unless only one tumour grade is represented, when the score is then simply
the grade doubled. This gives a Gleason score range of 2-10. If a third less frequent
grade is present, this is the tertiary grade and should be clearly reported if this is of
higher grade than the primary and secondary grades. Modifications to the scoring
system to incorporate higher grades into the Gleason score have been proposed for
needle biopsy reports (e.g. Pan et al, 2000) because of the worse prognosis
conferred by the presence of poorly differentiated elements. If a ‘modified’ method of
Gleason score is used (i.e. including the tertiary higher grade element in the score),
this should be clear from the text of the report. ‘Modified’ scores are not used in
reporting radical prostatectomy specimens.
A Gleason grade should be assigned, even for small tumour foci. However, Gleason
grading of tumours showing therapy related changes is not possible, unless sufficient
areas can be identified within the tumour which do not show these artefacts.
Gleason scores of less than 5 are not usually made in assessing needle core
biopsies, since entire tumour nodules are not represented in the fine cores. For
biopsies from different sites, the Gleason scores at those sites should be stated.
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Appendix 2 - Staging
TNM Classification of Prostate Cancer (TNM 2002 edition)
TO
TX
No evidence of primary tumour
Primary tumour cannot be assessed
T1
Clinically unapparent tumour, impalpable and not visible by imaging
T1a Tumour an incidental finding in <5% of resected tissue
T1b Tumour an incidental finding in > 5% of resected tissue
T1c Tumour identified by needle biopsy (e.g. because of raised PSA)
T2
Tumour confined within prostate
T2a Tumour involves < half one lobe
T2b Tumour involves > half a lobe but not both lobes
T2c Tumour involves both lobes
T3
Tumour extends through the prostate capsule
T3a Unilateral or bilateral extracapsular extension
T3b Tumour invades seminal vesicle(s)
T4
Tumour is fixed or invades adjacent structures – i.e. bladder neck,
external sphincter or rectum, levator muscles or fixed to pelvic side wall
Regional Lymph Nodes
NX
Nodes cannot be assessed
N0
No regional lymph node metastases
N1
Regional lymph node metastasis
Distant Metastases
MX
Distant metastasis cannot be assessed
M0
No distant metastasis
M1
Metastasis
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Appendix 3 – Osteoporosis Guidelines
GUIDELINES FOR THE PREVENTION AND MANAGEMENT OF OSTEOPOROSIS
IN PATIENTS WITH PROSTATE CANCER EXPECTED TO RECEIVE
PROLONGED ANDROGEN DEPRIVATION.
Dr Helen Patterson, Professor Juliet Compston.
This recommendation relates to patients on:
1. Indefinite LHRH analogue therapy or
2. Three years of adjuvant androgen deprivation following radical radiotherapy.
Bone densitometry (hip and lumbar spine) should be requested at the time the
decision to initiate LHRH analogue therapy is made and at 2 yearly intervals if
androgen deprivation therapy is continued if initial densitometry satisfactory.
If the T score is -2 or worse at initiation of LHRH analogues then patients should
commence treatment with oral bisphosphonates e.g. Alendronate 70mg po once
weekly or Risedronate 35mg po once weekly with calcium and vitamin D
supplementation eg Adcal-D3 one tablet b.d., Calcichew D3 forte one b.d. or Calcit
D3 one b.d. A repeat DEXA scan should be repeated at 5 years to reassess the
need for continued bisphosphonate and supplement treatment.
If the T score is -2 or worse perform lateral thoracic and lateral lumbar spine films to
exclude a pre-existing crush vertebral fracture as 2/3 do not come to medical
attention, and patients who experience a vertebral fracture have a 20% incidence of
a further fracture over the ensuing 12 months. If a fracture is identified, commence
treatment as above with oral bisphosphonates, calcium and vitamin D.
If the T score is between -1 and -2 patients should have repeat densitometry at 2
years and thereafter every 2 years and if higher than -1 repeat at 3 years to monitor
progress.
In addition, any patient considered to be at increased risk (see below) of
osteoporosis, prior to the commencement of LHRH analogue therapy, should also be
considered for bisphosphonate therapy.
Past history of fragility fracture.
Concurrent corticosteroid therapy.
Low body mass index <19kg/m2.
Heavy smoking.
High alcohol intake.
There are national guidelines which state that anyone over the age of 65 years
started on any dose of oral corticosteroid expected to be continued for more than 3
months should be offered oral prophylaxis against osteoporosis with a
bisphosphonate, either Alendronate 70mg once weekly or Risedronate 35mg once
weekly together with calcium and vitamin D supplementation as above.
II:\CPC1\MEDICAL DIRECTORATE\SCN Team\4. Cancer 13
\NCGs\Urology\AngCN Key documents\ AngCN-U-ProstateGuidelines 2014 v1
Updated, Approved and Published: Feb 2014
Anglia Cancer Network
Guidelines for the Management of Prostate Cancer
Patients expected to undergo short-term LHRH analogue therapy (neo-adjuvant and
concurrent with radical radiotherapy alone) do not need to undergo routine bone
densitometry.
For patients who are on treatment for known osteoporosis, LHRH analogue therapy
should still be considered the treatment of choice to accompany their radical
radiotherapy treatment unless other issues indicate the use of bicalutamide.
II:\CPC1\MEDICAL DIRECTORATE\SCN Team\4. Cancer 13
\NCGs\Urology\AngCN Key documents\ AngCN-U-ProstateGuidelines 2014 v1
Updated, Approved and Published: Feb 2014
Anglia Cancer Network
Guidelines for the Management of Prostate Cancer
Appendix 4 - Clinical Trials
The Manual for Cancer Services 2004 states that one of the responsibilities of the
MDT Lead Clinician is ‘To ensure mechanisms are in place to support entry of
eligible patients into clinical trials…’. The infrastructure to support clinical trials
activity is the responsibility of the West Anglia, Norfolk & Waveney and Ipswich
locality of the Mid-Anglia Cancer Research Networks (WACRN, NWCRN and
MACRN) which provide facilities enabling patient entry into clinical trials in all of its
units.
The Anglia Cancer Network Urology SSG committed to participation in high quality
research studies and clinical trials. Whenever possible, patients should be
considered for inclusion in local and national research studies and clinical trials.
There is an NSSG agreed single list of clinical trials and research studies supported
by the individual MDTs. This is updated at least annually. Further details and
protocols are available as follow:
Trust
Addenbrooke’s
Bedford
Hinchingbrooke
Ipswich
James Paget
King’s Lynn
Norfolk &
Norwich
Papworth
Peterborough
West Suffolk
Contact
West Anglia
Cancer Research
Network
West Anglia
Cancer Research
Network
West Anglia
Cancer Research
Network
Anglia East
Cancer Research
Network
Anglia East
Cancer Research
Network
West Anglia
Cancer Research
Network
Anglia East
Cancer Research
Network
West Anglia
Cancer Research
Network
West Anglia
Cancer Research
Network
West Anglia
Cancer Research
Network
II:\CPC1\MEDICAL DIRECTORATE\SCN Team\4. Cancer 13
\NCGs\Urology\AngCN Key documents\ AngCN-U-ProstateGuidelines 2014 v1
Telephone
01223
256193
Email
[email protected]
01223
256193
[email protected]
01223
256193
[email protected]
01603
289860
[email protected]
01603
289860
[email protected]
01223
256193
[email protected]
01603
289860
[email protected]
01223
256193
[email protected]
01223
256193
[email protected]
01223
256193
[email protected]
Updated, Approved and Published: Feb 2014
Anglia Cancer Network
Guidelines for the Management of Prostate Cancer
Appendix 5 – Prostate Cancer Pathway
PROSTATE CANCER PATHWAY (E&W) Final
Other Referrals
i.e. non urgent 18ww
referral
Tertiary Referrals
Active
Monitoring
SPECIALIST
MULTIDISCIPLINARY
(SMDT) MEETING
OPA
Decision to
treat (DTT)
Recurrence detected
Brachytherapy
Cryotherapy
Urgent GP
suspected
cancer referral
(2WW)
Prostate Clinic
with biopsy
LOCAL
MULTIDISCIPLINARY
TEAM (LMDT) MEETING
Histology discussed.
Staging investigations
requested, if appropriate.
RRP
Patient informed of
diagnosis
(OPA / telephone)
- Decision to treat (DTT)
- Patient referred to SMDT if
appropriate (i.e. if patient
chooses brachytherapy/
surgery)
L/SMDT /
OPA
to assess
fitness for
subsequent
treatment
Radiotherapy
+/- Androgen
Deprivation
Therapy (ADT)
Staging
MRI / Bone/CT
LMDT
MEETING
Earliest
clinically
appropriate
date, decision to
treat (DTT)
ADT
Adjuvant
Radiotherapy
Palliative Care
Androgen
Deprivation
Therapy (ADT)
Active
Monitoring
Consultant upgrade points
e.g. referral meets NICE criteria; at first seen,
during or after diagnostic tests; on or before
MDT date & decision to treat date +62 days
from these upgrade point dates
Palliative Care
Consider Clinical Trial and Follow Up
Referral to extended MDT services at any point in pathway e.g. Palliative care specialists, Specialist Nurses and AHPs, education about adverse effects of treatment; access to help and advice from all specialists; staff alert to psychosocial needs;
therapists/local healthcare teams, Community Matron, Pharmacists (medicines usage review), Social Services, Mental Health Services, Housing benefits (Social Care and other agencies), GPs, Expert Patient Programme, Smoking Cessation, Alcohol
Service (NORCAS), Voluntary organisations, information on prescription, Homeshield (over 60s)
Day 0
(Referral)
Key:
By Day 14
(1st seen)
Unit /
Centre
Centre
Access to specialist
services
By Day 28
(LMDT meeting)
GFOCW
PC1\MEDICAL DIRECTORATE\SCN Team\4. Cancer 13
NCGs\Urology\AngCN Key documents\ AngCN-U-ProstateGuidelines 2014 v1
By Day 42
(DTT)
Day 0
(DTT)
By Day 62
(treatment)
Elapsed time for follow up or presentation of recurrence,
mets or predetermined gap between treatments
Updated, Approved and Published: Feb 2014
By Day 31
(2nd treatment)