Prostate cancer continues to be the most prevalent non-cutaneous cancer among men in the United States (US), with an estimated 268,490 new cases and 34,500 deaths projected for 2022. Given that the majority of newly diagnosed prostate cancer patients present with localized disease, it is crucial to provide evidence-based guideline statements to guide clinical decision-making and ensure the delivery of consistent, high-quality care.
This article, “Guidelines Side-By-Side,” offers a thorough comparison of the current clinical practice guidelines issued by the American Urological Association (AUA)/American Society for Radiation Oncology (ASTRO) and the European Society for Medical Oncology (ESMO). By examining these recommendations, the aim is to provide healthcare providers with valuable insights and best practices for the evaluation and management of prostate cancer. This approach is intended to promote evidence-based decision-making in addressing this complex condition, ultimately leading to improved health outcomes for patients and their families.
Titles of Comparison:
| AUA/ASTRO Guideline | ESMO Clinical Practice Guidelines | |
|---|---|---|
| Title | Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, Part I: Introduction, Risk Assessment, Staging, and Risk-Based Management | Prostate cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up |
| Society | American Urological Association (AUA) &American Society for Radiation Oncology (ASTRO) | European Society for Medical Oncology (ESMO) |
| Publication Date | July 2022 | September 2020 |
| Objective | The summary presented herein represents Part I of the three-part series dedicated to Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, discussing risk assessment, staging, and risk-based management in patients diagnosed with clinically localized prostate cancer. Please refer to Parts II and III for discussion of principles of active surveillance, surgery and follow-up (Part II), and principles of radiation and future directions (Part III). | This ESMO Clinical Practice Guideline provides key recommendations on the management of prostate cancer. Authorship includes a multidisciplinary group of experts from different institutions and countries in Europe. Key treatment recommendations are provided. Recommendations have been updated in the light of new evidence. |
| Target Population | Guideline is aimed at aiding clinicians in the management of patients with clinically localized prostate cancer. | The guideline is to educate doctors, cancer patients and the general public on the best practices and latest advances in oncology. |
| Methodology | Primary methodology was provided by the Pacific Northwest Evidence-based Practice Center of Oregon Health & Science University (OHSU).1 The Panel also utilized the systematic review developed by the Agency for Healthcare Research and Quality (AHRQ) on Therapies for Clinically Localized Prostate Cancer.2 A research librarian conducted searches in Ovid MEDLINE (September 2021), Cochrane Central Register of Controlled Trials (August 2021), and Cochrane Database of Systematic Reviews (September 2021). Searches were supplemented by reviewing reference lists of relevant articles. | These Clinical Practice Guidelines were developed in accordance with the ESMO standard operating procedures for Clinical Practice Guidelines development. |
| Graded Strength of Recommendations | Yes | Yes |
| Graded Level of Evidence | The AUA employs a three-tiered strength of evidence system to underpin evidence-based guideline statements. | Levels of evidence and grades of recommendations have been applied using a sysytem available on their website. |
| Systematic Review Conducted | Yes | Yes |
| Literature Review Conducted | Yes | Yes |
| COIs & Funding Source(s) Disclosed | Yes | Yes |
| Full-text | Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, Part I: Introduction, Risk Assessment, Staging, and Risk-Based Management | Journal of Urology | Prostate cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up† |
| Summary | ASTRO/AUA Clinically Localized Prostate Cancer: Introduction, Risk Assessment, Staging and Risk-Based Management Guideline Summary | N/A |
Assessment and Management Overview
| AUA/ASTRO Guideline | ESMO Clinical Practice Guidelines | |
|---|---|---|
| Risk Assessment | Utilize clinical T stage, serum PSA, Grade Group (Gleason score), and tumor volume on biopsy to categorize patients based on risk. It is not recommended for clinicians to routinely rely on tissue-based genomic biomarkers for risk stratification or clinical decision-making. | ESMO recommends that multiparametric magnetic resonance imaging (mpMRI) be conducted prior to prostate biopsy in order to accurately assess the need for further testing. Utilizing a prostate cancer risk calculator and/or mpMRI can help confirm the necessity of biopsy in men with elevated PSA levels. Transperineal biopsies are preferred over transrectal ultrasound-guided biopsies for improved accuracy and reduced risk of complications. |
| Staging | Risk stratification is crucial when beginning patient counseling in order to tailor the management approach to the severity of the disease. Various risk stratification systems, such as risk groups, risk scores, and nomograms, have been developed and utilized. | Localized disease should be classified as low, intermediate, or high-risk to help determine prognosis and treatment options. Patients with intermediate-risk disease should undergo staging for metastases using MRI or CT scans of the abdomen and pelvis, as well as a bone scan. Patients with high-risk disease should undergo staging for metastases using CT scans of the chest, abdomen, and pelvis, along with a bone scan. |
| Screening and Early Detection | Not specifically covered in this part of the guideline. | Emphasizes early PSA testing for men over 50, those with a family history of prostate cancer, African-Americans over 45, and BRCA1/2 carriers over 40. |
| Risk-Based Management | Provides a framework to guide clinicians in the implementation of selected management options based on risk stratification. | Provides stage-matched therapeutic strategies, including surgery, radiotherapy, hormone therapy, and chemotherapy. |
| Active Surveillance | Recommended for low-risk patients (Gleason score 6, PSA <10 ng/ml, and clinical stage T1c or T2a). | Recommended for very low-risk and low-risk patients; considers patient preference and life expectancy. |
| Radical Prostatectomy | Offered as a treatment option for intermediate and high-risk patients; robot-assisted, laparoscopic, and open techniques mentioned. | Recommended for intermediate and high-risk patients; emphasizes surgeon experience and patient comorbidity. |
| Radiation Therapy | External beam radiation therapy (EBRT) and brachytherapy recommended for intermediate and high-risk patients. | EBRT, brachytherapy, and combination therapy options; considers patient preference and comorbidities. |
| Hormone Therapy | Androgen deprivation therapy (ADT) as an adjunct to radiation therapy for high-risk patients. | ADT is recommended in combination with radiation therapy for high-risk patients and in metastatic disease. |
| Chemotherapy | Not typically recommended for localized disease; considered for metastatic or high-risk cases. | Chemotherapy (docetaxel) recommended for metastatic castration-resistant prostate cancer. |
Key Similarities:
- Risk Stratification:
- Both guidelines emphasize the importance of risk stratification in prostate cancer management. They categorize patients based on their cancer risk (low, intermediate, and high) and use risk factors like PSA levels, Gleason score, and clinical staging to guide management decisions.
- Staging and Diagnosis:
- Both guidelines recommend appropriate staging and diagnostic techniques, such as imaging (e.g., MRI, bone scans) and biopsy, to determine the extent of the disease and assess the need for treatment.
- Treatment Modalities:
- Both sets of guidelines acknowledge the major treatment options for localized prostate cancer, including surgery (radical prostatectomy), radiation therapy, and active surveillance/watchful waiting for low-risk cases.
- They both discuss the role of external beam radiation therapy (EBRT) and brachytherapy for patients who are candidates for radiation.
- Multidisciplinary Approach:
- Both guidelines stress the importance of a multidisciplinary approach to treatment involving urologists, oncologists, radiologists, and other specialists, ensuring comprehensive care for patients.
Key Differences:
- Guideline Focus and Scope:
- The AUA/ASTRO guideline is specifically focused on clinically localized prostate cancer, particularly in terms of risk assessment, staging, and risk-based management. It provides a detailed framework for deciding between active surveillance, surgery, or radiation therapy.
- The ESMO guidelines, on the other hand, cover a broader scope that includes advanced prostate cancer as well as localized disease. ESMO addresses the treatment of metastatic disease, including options like androgen deprivation therapy (ADT), chemotherapy, and novel agents for castration-resistant prostate cancer.
- Management Strategies for Low-Risk Disease:
- The AUA/ASTRO guideline provides a more structured decision-making framework for low-risk patients, often advocating for active surveillance as the primary option for men with low-risk, clinically localized prostate cancer.
- ESMO also supports active surveillance for low-risk disease but emphasizes a more individualized approach based on patient age, comorbidities, and personal preferences.
- Radiation Therapy Recommendations:
- The AUA/ASTRO guideline focuses more on the specifics of radiation therapy, such as dose escalation, treatment technique (e.g., external beam vs. brachytherapy), and the potential use of adjuvant therapies like androgen deprivation therapy (ADT) for intermediate- and high-risk patients.
- ESMO does discuss radiation but often in the context of advanced disease or as part of a broader treatment regimen, with less detailed emphasis on the technical aspects of radiation delivery in localized disease.
In conclusion, both the AUA/ASTRO and ESMO guidelines offer thorough and evidence-based recommendations for the management of prostate cancer, yet they differ in their focus and breadth. The AUA/ASTRO guideline concentrates on localized prostate cancer management, emphasizing risk-based stratification. On the other hand, ESMO covers a wider array of topics, including advanced and metastatic disease, and incorporates a more holistic approach to personalized treatment, molecular testing, and patient quality of life considerations. Both guidelines advocate for a multidisciplinary approach to care, but ESMO tends to prioritize systemic therapies and the management of complex disease states.
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