Advanced Prostate Cancer Clinical Practice Guidelines (ASCO, 2020)

American Society of Clinical Oncology

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

January 31, 2020

The guidelines on imaging in advanced prostate cancer were released in January 2020 by the American Society of Clinical Oncology.[1]

Imaging is recommended for all patients with advanced prostate cancer, using one or more of the following modalities, according to the clinical scenario:

  • Conventional imaging – Computed tomography (CT), bone scan, prostate magnetic resonance imaging (MRI)

  • Next-generation imaging (NGI) – Positron emission tomography (PET), PET/CT, PET/MRI, whole-body MRI)

Disease states and clinical scenarios should be taken into consideration when choosing an imaging modality, as the modality may guide treatment or change clinical treatment decisions.

Newly Diagnosed Clinically High-Risk/Very High-Risk Localized Prostate Cancer

When conventional imaging is negative in patients with a high risk of metastatic disease, NGI may add clinical benefit, although prospective data are limited.

When conventional imaging is suspicious or equivocal, NGI may be offered to patients for clarification of equivocal findings or detection of additional sites of disease, which could potentially alter management, although prospective data are limited.

Rising Prostate-specific Antigen Level after Prostatectomy and Negative Conventional Imaging

When the prostate-specific antigen (PSA) level is initially undetectable but subsequently rises, or the PSA level never nadirs to undetectable, this indicates potentially undetected residual local, locoregional, or micrometastatic disease; imaging options are not distinct or different between those scenarios. The goal of therapy and the potential use of salvage local therapies in these scenarios should guide the choice of imaging. For men who are not candidates or are unwilling to receive salvage local or regional therapy, additional NGI should not be offered.

For men for whom salvage radiotherapy is contemplated, NGI should be offered. Imaging with new radiopharmaceuticals coupled to prostate cancer–specific targets, such as prostate-specific membrane antigen (PSMA), where available; 11C-choline or 18F-fluciclovine PET/CT; or PET/MRI, whole-body MRI, and/or 18F-NaF PET/CT have superior disease detection performance characteristics and may alter management.

Rising PSA after Radiotherapy and Negative Conventional Imaging

For men for whom salvage local or regional therapy is not planned or is inappropriate, there is little evidence that NGI will alter treatment or prognosis. The role of NGI in this scenario is unclear and it should not be offered, except in the context of an institutional review board–approved clinical trial.

For men for whom salvage local or regional therapy (eg, salvage prostatectomy, salvage ablative therapy, or salvage lymphadenectomy) is contemplated, evidence supports NGI for detection of local and/or distant sites of disease. Findings on NGI could guide management in this setting (eg, salvage local, systemic or targeted treatment of metastatic disease, combined local and metastatic therapy). PSMA imaging (where available), 11C-choline or 18F-fluciclovine PET/CT or PET/MRI, whole-body MRI, and/or 18F-NaF PET/CT can provide superior disease detection compared with conventional imaging and their results may alter patient management, although data are limited.

Metastatic Prostate Cancer at Initial Diagnosis or after Initial Treatment, Hormone Sensitive

In the initial evaluation of men presenting with hormone-sensitive metastatic disease that is demonstrable on conventional imaging, NGI has a potential role in clarifying the burden of disease and potentially shifting the treatment intent from multimodality management of oligometastatic disease to systemic anticancer therapy alone or in combination with targeted therapy for palliative purposes. However, prospective data are limited.

Nonmetastatic Castration-Resistant Prostate Cancer

For men with nonmetastatic castration-resistant prostate cancer (CRPC), NGI can be offered only if a change in the clinical care is contemplated. Assuming patients have received or are ineligible for local salvage treatment options, NGI may clarify the presence or absence of metastatic disease, but the data on detection capabilities of NGI in this setting and impact on management are limited.

Metastatic CRPC

Because PSA progression alone should not be the sole reason to change therapy in men with metastatic CRPC, conventional imaging can be used for initial evaluation of PSA progression and should be continued to facilitate changes/comparisons and serially to assess for development of radiographic progression.

The use of NGI in this cohort is unclear, with a paucity of prospective data. When a change in clinical care is contemplated, in an individualized manner, and there is a high clinical suspicion of subclinical metastasis despite negative conventional imaging, the use of NGI could be contemplated, especially in the setting of a clinical trial.

In men who are receiving systemic therapy for metastatic CRPC and have clear evidence of radiographic progression on conventional imaging, NGI should not be routinely offered. NGI may play a role, if it had been performed at baseline, to facilitate comparison of imaging findings/extent of progression of disease.

For more information, see Prostate Cancer, Imaging in Prostate Carcinoma, and Metastatic and Advanced Prostate Cancer. For more Clinical Practice Guidelines, please go to Guidelines.

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