2022.V1 NCCN prostate cancer guidelines update: the biggest change in 10 years, active monitoring of low-risk patients deletes "preferred"!

This article summarizes the updated content of PROS-4~PROS-15 in the first edition of the National Comprehensive Cancer Network (NCCN) Prostate Cancer Guidelines in 2022
.

For your reference
.

Initial treatment and adjuvant treatment for low-risk patients (PROS-4) For patients with life expectancy ≥10 years, active monitoring is recommended for initial treatment (delete "preferred")
.

Footnote m: Active monitoring includes active monitoring of disease progression.
If cancer progresses, potential curative interventions are expected to be used
.

Initial treatment and adjuvant treatment for moderate-risk patients with good prognosis (PROS-5) For patients with life expectancy> 10 years, consider definitive prostate biopsy ± mpMRI ± molecular analysis to determine whether it is suitable for active monitoring
.

Initial treatment and adjuvant treatment (PROS-6) for patients with poor prognosis and intermediate risk (PROS-6) For patients with a life expectancy of 5 to 10 years, observation is recommended (delete "preferred")
.

The initial treatment and adjuvant treatment (PROS-7) for high-risk and extremely high-risk patients.
The initial treatment for patients with a life expectancy of more than 5 years or symptomatic patients: External radiation therapy (EBRT) + androgen deprivation therapy (ADT) is recommended (1.
5 ~3y; category 1 recommendation); EBRT+ADT (2y) + docetaxel treatment for 6 cycles (only extremely high-risk patients); EBRT + brachytherapy + ADT (1~3y; category 1 recommendation); EBRT+ADT (2y) + Abiraterone (only extremely high-risk patients)
.

Initial treatment and adjuvant treatment (PROS-8) for patients with limitations (any T, N1, M0) For patients with a life expectancy of more than 5 years or symptomatic patients, the initial treatment is optional: EBRT+ADT (preferred); EBRT+ADT+Arbitrate Long; ADT ± abiraterone; radical prostatectomy (PR) + pelvic lymph node dissection (PLND)
.

Add footnote gg: N1 patients who have previously undergone pelvic lymph node radiotherapy should consider giving ADT + abiraterone for 2 years
.

Add footnote dd: Small particles of abiraterone can replace standard dosage forms
.

Monitoring after initial treatment (PROS-9) After initial treatment, if there is a recurrence (imaging confirmed as metastatic disease and no prostate-specific antigen [PSA] persistence/recurrence), a biopsy of the metastatic site is required
.

Modify footnote ii
.

PSA persistent/recurring after radical prostatectomy (PROS-10) For patients with persistent/recurring PSA after radical prostatectomy, a recommendation is added: bone and soft tissue imaging
.

Delete: bone imaging, chest CT, abdomen / pelvic CT or abdominal / pelvic MRI and so on
.

Monitoring of patients with recurrence after radiotherapy (PROS-11) For patients with PSA recurrence (deleted: PSA persistent) or positive digital rectal examination (DRE), bone and soft tissue imaging are added
.

Delete: bone imaging, such as MRI prostate
.

Systemic treatment of non-castrated prostate cancer (PROS-12) For M0 patients, priority is given to monitoring
.

For M1 patients after initial treatment, consider regular imaging examinations to monitor treatment response
.

Add footnote nn: When deciding whether to start ADT treatment, the patient’s prostate-specific antigen doubling time (PSADT) and grade should be considered
.

Add footnote oo: Patients with life expectancy ≤ 5 years should be considered for observation
.

Systemic therapy (PROS-13) for M0 castration-resistant prostate cancer (CRPC) (PROS-13) For CRPC patients whose imaging examinations show no distant metastasis, continue ADT treatment.
When PSADT ≤ 10 months, use the treatment plan (Apa After tartamide, dalolutamide, enzalutamide and other second-line hormone treatment options), consider regular disease assessment (PSA and imaging examination).
For patients with elevated PSA or radiological evidence of metastases, further treatment is required Imaging examination; for patients with stable PSA and no evidence of metastasis, continue to maintain current treatment and consider regular disease evaluation
.

Systemic treatment of M1 CRPC (PROS-14) For patients with metastatic CRPC confirmed by imaging examination, one of the recommendations is changed to: if not tested before, MSI-H or dMMR testing or homologous recombination gene mutation (HRRm) is recommended Testing; new recommendation: consider tumor mutational burden (TMB) testing
.

First-line and follow-up chemotherapy for small cell prostate cancer/neuroendocrine prostate cancer: newly added cabazitaxel/carboplatin
.

Added footnote aaa: If it has not been done before, the germline HRRm test is recommended
.

Systemic treatment of M1 CRPC: Adenocarcinoma (PROS-15) for previous docetaxel/none of new endocrine therapy, previous new endocrine therapy/none of docetaxel, previous new endocrine therapy For patients with docetaxel, pembrolizumab is recommended under certain conditions (MSI-H, dMMR, TMB>10mut/Mb)
.

References: 1.
NCCN Guidelines Version 1.
2022 Prostate Cancer 2.
NCCN Guidelines Version 2.
2021 Prostate Cancer Contribution email: tougao@medlive.
cn