Clinically Localized Prostate Cancer Endorsement Guideline

An interview with Dr. Justin Bekelman from University of Pennsylvania Perelman School of Medicine on the ASCO endorsement of the AUA/ASTRO/SUO Guideline on the management of localized prostate cancer. Read the full guideline at www.asco.org/genitourinary-cancer-guidelines

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Hello and welcome to the ASCO Guidelines Podcast Series. My name is Shannon McKernin, and today I'm interviewing Dr. Justin Bekelman from University of Pennsylvania Perelman School of Medicine, lead author on "Clinically Localized Prostate Cancer: ASCO Clinical Practice Guideline Endorsement of an AUA/ASTRO/SUO Guideline." Thank you for being here today, Dr. Bekelman.

Thanks for having me.

First, can you give us a general overview of what this guideline covers?

Sure. So this guideline addresses the key question about what is the current best practice available for the management of localized prostate cancer. It's an endorsement guideline, which means it reinforces the recommendations offered by the American Urologic Association, ASTRO, SUO, which is the Society of Urologic Oncology.

In April of 2017, these three groups got together to release a joint evidence-based practice guideline on clinically localized prostate cancer. And then, now more recently, in 2018 ASCO assembled a panel to review those policies, update them, and endorse them as appropriate.

So this guideline has over 60 recommendations. So I'm not going to ask you to read through all of them. But can you talk about some of the key topics and discussion points that was added by the ASCO expert panel?

Yeah, absolutely. I'd like to highlight four areas. The first area-- panel endorsed guideline recommendations on active surveillance for men with low risk Gleason 6 prostate cancer, what's called grade 1 prostate cancer now. The panel also felt it reasonable to add that ASCO has also produced a guideline on active surveillance which provides more context and counsel for clinicians and patients.

It also includes a discussion of how surveillance might be considered for men with low volume Gleason 3+4, or what's called grade 2 cancers. And so I would reference that ASCO guideline on active surveillance for folks who are interested in that.

Second, panel updated the recommendation regarding the length of androgen deprivation therapy or hormone therapy for men with higher risk clinically localized prostate cancer. Prior recommendations considered 24 to 36 months to be appropriate. And that's what's captured in the 2017 guidelines from the AUA, ASTRO, and SUO.

But new evidence released after those guidelines were published from two trials-- one called RADAR and one called PCS IV trial-- shows that 18 months may be equivalent and permissible, and thus these trials should be followed really closely. But that's really interesting, provocative information for patients as they consider adjuvant hormone therapy for high risk cancers when they're receiving radiation.

Third, the panel describes two really high impact quality of life studies comparing surgery, external beam radiation, and brachytherapy that were published in JAMA in 2017, again, after the AUA guideline was published. These two studies are actually summarized in the discussion of the panel findings. And they are an excellent reference for both clinicians and patients as they consider the potential benefits and harms of the various treatments for prostate cancer.

The last one I'd want to highlight to the audience is the panel's recommendations regarding cryosurgery. And even though the original guidelines stated that selected patients are candidates for cryosurgery, the panel found that there was insufficient evidence to support the use of cryosurgery for clinically localized prostate cancer. So those are four highlights from the evidence based review.

And why is this guideline so important? And how will it change practice?

This guideline represents the most up to date consensus recommendations from the major professional societies that represent clinicians-- the surgeons, the radiation oncologists, the medical oncologists-- who counsel and treat men with prostate cancer. So it's a really important initial original guideline and then a really important endorsement. I think it will change practice by highlighting what the current best practice standards of care are for clinically localized prostate cancer.

And finally, how will these guideline recommendations affect patients?

I think this guideline will have an immediate impact on important questions that patients and their clinicians want answered. I think that's how the panel actually took its role, is thinking, how can we both endorse and provide further evidence that would be patient centered as we considered these guidelines.

So this endorsement and the guidelines, they ask questions like, how should we conduct shared decision making with our patients to offer the highest chance that treatment decisions will be concordant with our patient goals of care? That's number one and so crucial.

Who is appropriate for active surveillance? A top topic for men facing clinically localized prostate cancer. What are the differences and side effects among the major treatments for clinically localized prostate cancer, mostly focused on surgery and radiation?

The endorsement updates the latest data through 2017 and even in 2018 with really patient-centric information about what patients might expect with each of these treatments. Even what are the aspects of prostate cancer care that represent the highest quality? And how might patients assess that? What are the most important aspects of survivorship?

So the endorsement and recommendations from the original guidelines themselves hit on each of these. And I think that patients will find them very interesting and insightful.

Great. Thank you so much for your time today. And thank you for your work on this important guideline, Dr. Bekelman.

Oh, my pleasure.

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