Guidelines on Management of Prostate Cancer

Abstract

therapeutic option has different risk-benefi t profi les. Hence the rationale, indications, risks and benefi ts are presented to assist the clinician in his discussion with his patient. The committee favours this open discussion strategy over explicit and potentially dogmatic emphasis on certain therapeutic strategies. Other novel therapies currently used in Singapore are also included and specifi cally highlighted for selective risk groups only. A detailed statement as to the investigative nature of these therapies is also included.Published data on cost-benefi t issues for prostate cancer in Singapore are currently lacking and cost discussions differ in different institutions with varying extent of government subsidies and service grants. Hence cost considerations were not included in this set of guidelines. Defi nition of Terms Early Prostate CancerThis refers to clinically localised prostate cancer without evidence of regional lymph node and distant metastasis. Treatment is mainly with curative intent in patients with longer life expectancy and minimal comorbidity. Locally Advanced Prostate CancerThis refers to clinically locally advance prostate cancer (≥T3b) with or without lymph node invasion within the pelvis. Treatment requires aggressive local multimodality therapy with surgery and/or defi nitive radiation therapy, combined either with or without androgen deprivation therapy. Metastatic Prostate CancerThis refers to prostate cancer with lymph node invasion beyond the pelvis and/or bony or visceral spread. Treatment

PSMA‐PET‐guided dose‐escalated volumetric arc therapy for newly diagnosed lymph node‐positive prostate cancer: 5 Year outcomes following the FROGG and EviQ node‐positive guidelines

“…Beside these RTOG studies, we are unaware of any other evidence comparing 1.8 and 2.0 Gy per fraction and doubt such studies would ever be done. Secondly, several other national protocols include the use of 1.8 Gy per fraction 5,7 . Finally, we have had an excellent experience using this fractionation schedule for localised prostate cancer, with very low rates of significant toxicity.…”

“…Our study protocol utilised the FROGG guidelines 1 and the EviQ protocol, 2 which recommend the use of long‐term ADT (18–36 months) in conjunction with radiotherapy. Despite a lack of strong evidence from randomised trials, a number of guidelines also recommend the same approach, 5–8 primarily because there are several retrospective evaluations that have shown favourable outcomes in failure‐free survival and overall survival. Our institution's results for newly diagnosed LN‐positive disease, following the FROGG guidelines 1 and EviQ protocol, 2 appear to be promising.…”

“…Secondly, several other national protocols include the use of 1.8 Gy per fraction. 5,7 Finally, we have had an excellent experience using this fractionation schedule for localised prostate cancer, with very low rates of significant toxicity. This is reflected by Zelefsky's seminal paper which showed excellent results with 81 Gy, and at the time this represented the longest follow-up of any study using high dose-escalated IMRT.…”

“…The role of involved node dose escalation is uncertain, with varying recommendations across different guidelines, including 'as dose-volume histogram parameters allow' in one guideline, 5 up to 79.2 Gy in another, 7 and above 60 Gy in yet another. 8 Some of these guidelines recommend the use of PSMA-PET to guide treatment, 1,8 as does the Australian EviQ protocol.…”

Managing advanced prostate cancer in the Asia Pacific region: “Real‐world” application of Advanced Prostate Cancer Consensus Conference 2019 statements

“…Some newer systemic therapies are more available in generic form in some APAC countries. The increased likelihood of systemic treatment toxicities among some Asian populations 4 , 5 also influences management.…”