Prostate Cancer Clinical Practice Guidelines (2020)

Prostate Cancer Clinical Guidelines International Panel

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.

November 04, 2020

Guidelines on the diagnosis and treatment of prostate cancer released in October 2020 by a Prostate Cancer Clinical Guidelines International Panel.[1]

Screening for All Patients

Offer early PSA testing to well-informed men at elevated risk (men older than 40 yr with BRCA2 mutations).

Do not use multiparametric MRI (mpMRI) as an initial screening tool.

To avoid unnecessary biopsies, offer further risk assessment (an additional serum or urine-based test) to asymptomatic patients with a normal DRE and PSA level of 2-10 ng/ML before performing prostate biopsy.

Management of Patients With Low-Risk Disease

Offer active surveillance to patients with life expectancy >10 yr and low-risk disease.

Take both targeted biopsy (of any PI-RADS >3) and systematic biopsy if confirmatory biopsy is performed.

Perform serum PSA assessment every 6 mo.

Perform DRE every 12 mo.

Repeat biopsy should be performed if there is evidence of PSA progression, clinical progression on DRE, or radiologic progression on mpMRI.

Only offer whole-gland treatment (eg, cryotherapy, high-intensity focused ultrasonography) or focal treatment in a clinical trial setting or well-designed prospective cohort study.

Radical Treatment of High-Risk Localized Disease

Offer radical prostatectomy to selected patients with high-risk localized disease as part of multimodal therapy.

Radical Treatment of Locally Advanced Disease

Offer long-term androgen deprivation therapy (ADT) for at least 2 yr.

Only offer ADT monotherapy to patients unwilling or unable to receive local treatment if they have a PSA-doubling time <12 mo and have either a PSA >50 ng/mL, a poorly differentiated tumor, or troublesome local disease-related symptoms.

Offer patients with clinical N1 (cN1) disease local treatment (radical prostatectomy or external beam radiation therapy [EBRT]) plus long-term ADT.

Adjuvant Treatment Options After Radical Prostatectomy

Offer adjuvant EBRT to the surgical field to highly selected patients.

Discuss 3 management options with patients with lymph node positive (pN+) disease after an extended lymph node dissection on the basis of nodal involvement characteristics. The 3 options are (1)  adjuvant ADT; (2) adjuvant ADT with additional radiotherapy; and (3) observation (expectant management) to a patient after elective lymph node dissection (eLND) and ≤2 nodes with  microscopic involvement, as well as a PSA <0.1 ng/mL and absence of extranodal extension.

First-Line Treatment of Metastatic Disease

Offer immediate systemic treatment with ADT to palliate symptoms and reduce risk of potential serious sequelae of advanced disease (spinal cord compression, pathologic fracture, ureteral obstruction) to M1 symptomatic patients.

Offer surgery and/or local radiotherapy to patients with M1 disease and evidence of impending complications such as spinal cord compression or pathologic fracture.

Do not offer androgen receptor (AR) antagonist monotherapy to patients with M1 disease.

Offer ADT combined with docetaxel to patients whose first presentation is M1 disease and who are able to receive docetaxel.

Offer ADT combined with abiraterone acetate plus prednisone or apalutamide or enzalutamide to patients whose first presentation is M1 disease and who are able to receive the regimen.

Offer ADT combined with prostate radiotherapy to patients whose first presentation is M1 disease and have low-volume disease.

Do not offer ADT combined with any local treatment of radiotherapy or surgery to patients with high-volume M1 disease outside of clinical trials, except for symptom control.

Nonmetastatic Castrate-Resistant Disease

Offer apalutamide, darolutamide, or enzalutamide to patients with nonmetastatic castrate-resistant prostate cancer and a high risk of developing metastasis (PSA doubling time <10 mo), to prolong time to metastases.

For more information, please go to Prostate Cancer.

For more Clinical Practice Guidelines, please go to Guidelines.

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