Integrated diagnosis and treatment of early prostate cancer patients according to CACA guidelines

During the 2021 CCO conference, the intensive reading conference of "China Integrated Tumor Diagnosis and Treatment Guidelines-Prostate Cancer" was held online
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At the meeting, combined with the leading cases of prostate cancer provided by Professor He Liru of Sun Yat-sen University Cancer Center, Professor Yu Wei of Peking University First Hospital explained the integrated diagnosis and treatment of prostate cancer patients in the Chinese Guidelines for Integrated Diagnosis and Treatment of Cancer (CACA Guidelines)
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Let's take a look
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The case lead patient, a 54-year-old male, was previously healthy, denied family history, and was admitted to the hospital due to an elevated PSA on physical examination
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PSA: 4.
3ng/ml
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DRE: The second-degree prostate is large, with no obvious nodules
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MRI: abnormal signal in the right lobe of the prostate, PIRADS 3 points
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Prostate targeted biopsy: diagnosed with prostate cancer, Gleason score 3+3, 1/12 positive
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Active Surveillance: Considering that local treatment may affect the quality of life, the patient chooses to be actively followed up, and a second puncture is performed one year later due to an abnormal increase in PSA
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Secondary biopsy: Prostate cancer, Gleason score 4+3
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Treatment options: radiotherapy/surgery
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Robot-assisted radical prostatectomy: prostate cancer, Gleason score 4+3, negative margins, T2cN0M0 functional rehabilitation: levator ani exercise, TCM integration reduces the impact on life This patient is a case of very low-risk early-stage prostate cancer
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In clinical treatment, how to achieve a balance between tumor control and functional preservation in patients with early localized prostate cancer? Let's listen to Professor Yu Wei's interpretation
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Expert interpretation of MDT to HIM Prostate cancer due to its organ specificity, both tumor control and the impact of organ function brought about by tumor treatment should be considered in clinical treatment
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Therefore, the CACA guidelines recommend that for patients with localized prostate cancer, the MDT to HIM diagnosis and treatment model should be adopted, which requires the joint collaboration of multiple departments
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Department content Nuclear medicine, imaging department to determine the location of the lesion, clear metastatic status, pathological diagnosis gold standard, malignant degree stratified surgical radical treatment as the principle, preservation of function for the pursuit of radiotherapy radical cure, assistance, and rescue.
In addition, it is necessary to use integrated Medical thinking, consider whether the patient's physical state is enough to receive radical treatment; provide adjuvant/neoadjuvant therapy according to the malignancy of the patient's tumor; at the same time, it is also necessary to select a function-preserving treatment plan according to the patient's functional wishes, and develop an individualized treatment plan for the patient.
Follow-up treatment plan
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The CACA guidelines recommend that patients with localized prostate cancer should be managed from the outpatient clinic
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It is recommended that patients with positive PSA, DRE, MRI or B-ultrasound results actively undergo prostate biopsy
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For patients with no clear lesions on MRI, consider MRI fusion-targeted puncture
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If the puncture report is clearly malignant, the patient's MRI, bone scan and even PET/CT examinations need to be further improved to clarify the patient's tumor stage and select a targeted treatment plan
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At the same time, the CACA guidelines recommend that local treatment be the main treatment for patients with prostate cancer without metastasis
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Treatment options include: surgery (radical resection), radiotherapy (radical radiotherapy, adjuvant radiotherapy, salvage radiotherapy), endocrine therapy (adjuvant/neoadjuvant therapy), and active surveillance may also be considered for some patients
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Risk Stratification Due to the relatively obvious tumor heterogeneity of prostate cancer, CACA guidelines recommend that the patient's treatment strategy be formulated according to risk stratification
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Among them, PSA, clinical stage, and pathology are all important components of risk stratification
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The more risk factors a patient has, the higher the risk of postoperative recurrence and metastasis.
For patients with different risk stratifications, different treatment strategies should be used clinically
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In addition to emphasizing traditional clinical risk factors, CACA guidelines also actively recommend exploring the role of ultrasonography, CT, and magnetic resonance in risk stratification
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Clinical/pathological features of recurrence risk stratification: Very low risk and have the following features: stage T1c, pathological grade group 1, PSA <10ng/ml, and meet the requirement that cancer is seen in less than 3 tissues per puncture/the proportion of tumor in each punctured tissue is ≤50 % and prostate PSA density <0.
15ng/ml/g
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Low-risk patients also have the following characteristics: T1-T2a, pathological grade group 1, PSA<10ng/ml
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Intermediate risk with at least one intermediate risk factor (IRF) and no high-risk or very high-risk group features T2b-T2c pathological grading grouping 2 or 3 PSA 10-20ng/ml high-risk without very high-risk features and with at least one high-risk feature: T3a; Pathological grade group 4 or 5; PSA> 20ng/ml
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Very high risk with at least one of the following features: T3b-T4; major pathological grade group 5; more than 4 punctures at major grade 4 or 5
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For patients with different risk stratification, different treatment strategies are needed in clinical practice
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Low-risk PC class I recommended class II recommended initial treatment only with PC radical surgery (for patients who can tolerate the side effects of surgery) PC radical surgery + lymph node dissection EBRT or seed implantation radiotherapy Other local treatments for the prostate Active monitoring and adjuvant therapy EBRT (radical treatment) Postoperative pathology with poor prognostic features and no lymph node metastases) Follow-up ADT (with lymph node metastases) EBRT follow-up (after radical mastectomy, no adverse prognostic features and no lymph node metastases) Follow-up (for patients with IMRT) Active surveillance of ADT due to prostate cancer heterogeneity Some tumors are relatively indolent, so CACA guidelines recommend active surveillance for some very low-risk and strictly screened intermediate-risk patients
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The purpose of active surveillance is to avoid overtreatment of localized prostate cancer and to avoid unnecessary complications, but to be prepared to give curative treatment if necessary
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CACA guidelines recommend monitoring PSA every 6 months and digital rectal examination (DRE) every 12 months in very low-risk patients
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The CACA guideline recommends the clinical use of integrative medicine thinking, according to the characteristics of patients, to make treatment choices that are in line with national conditions, regions, and patients' personal wishes
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In recent years, with the development of precision medicine and the deepening of tumor heterogeneity research, domestic research centers have conducted extensive research on gene mutations in prostate cancer
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The study found that patients with BRAC1/2 mutations had a higher risk of disease progression
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Therefore, for patients who choose active surveillance, it is still necessary to pay attention to the molecular pathological characteristics of their tumors, and the guidelines recommend BRAC1/2 testing
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Active surveillance is not recommended for patients with positive test results
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Surgical treatment of prostate cancer Surgical treatment mainly refers to radical prostatectomy
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Because prostate cancer is located deep in the pelvis, traditional open surgery has a limited field of view and a small operating space, resulting in poor tumor control
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Since then, with the introduction of laparoscopic technology, the deep pelvic field of vision has been improved, and the problem of narrow operating space has been solved, so that radical prostatectomy technology has matured rapidly
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After 2000, robotic surgery with a larger, clearer field of view and more flexible operation came to the clinic.
While the tumor control effect was better, the patient's organ function was also better protected, expanding the application of radical prostatectomy.
crowd range
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Radical prostatectomy not only emphasizes tumor radical cure, but also emphasizes the protection of urinary continence and sexual function
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With the deepening of the understanding of the anatomical function of urinary continence and the anatomical level related to sexual nerves, clinicians can strengthen the protection of normal structures while completely removing the tumor during the operation, so that the patient's tumor control effect is better.
Well, post-operative recovery is smoother
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A new randomized controlled study shows that compared with traditional laparoscopic surgery, robotic surgery shows better protection of urinary continence at all postoperative periods, and patients have more rapid postoperative functional recovery
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Through robotic surgery, surgeons can achieve more precise surgical resection, more complex tissue structure reconstruction, and significantly speed up the patient's functional recovery while tumor control
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Therefore, the CACA guidelines recommend that qualified institutions actively carry out robotic radical prostatectomy
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Radical lymph node dissection is usually accompanied by lymph node dissection, but the risk of lymph node metastasis in prostate cancer is relatively low.
Therefore, the CACA guidelines recommend that the risk of lymph node metastasis should be determined in order to decide whether to perform lymph node dissection
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For low- and intermediate-risk patients, the class I recommendation of the guidelines is to give priority to radical treatment and appropriate lymph node dissection
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The risk of lymph node metastasis has always been a clinical research hotspot
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The 2018 version of the Briganti nomogram is updated, adding the results of magnetic resonance to the evaluation system based on PSA, Gleason score, clinical stage and puncture results, which has a stronger ability to predict lymph node metastasis, which is convenient for clinicians to select the needs In patients undergoing lymph node dissection, unnecessary lymph node dissection can be avoided while tumor control is performed, improving patient prognosis and speeding up patient recovery
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Radiotherapy An important means of local treatment of prostate cancer is radiotherapy, which has a place in the treatment of any course of limited-stage prostate cancer
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Radiation therapy can be used as a stand-alone therapy for low-, intermediate-, and high-risk patients, and it can still achieve radical cure
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For patients after radical resection, radiotherapy can adopt the strategies of adjuvant radiotherapy and salvage radiotherapy; brachytherapy combined with external beam radiation therapy is more effective
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For patients with lymph node metastases, endocrine therapy combined with external radiation therapy can be used
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CACA guidelines recommend that low-risk patients should be treated with external radiation therapy + brachytherapy; intermediate-risk patients should be treated with ADT for 4-6 months on the basis of external radiation therapy
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At present, there are still several controversies regarding the treatment options for high-risk and very high-risk patients: 1.
The initial treatment options for high-risk/very-high-risk patients? The CACA guidelines point out that the initial treatment of high-risk and very high-risk patients is to choose multidisciplinary diagnosis and treatment based on radiotherapy or radical surgery, and it is necessary to consider whether the patients have high-risk adverse prognostic factors
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2.
Does the patient choose adjuvant radiation therapy or salvage radiation therapy after radical resection? The CACA guidelines recommend that early salvage radiotherapy appears to be a better option for patients after surgery, considering the patient's urinary continence until long-term follow-up data are available
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3.
Postoperative treatment options for patients with pN1 prostate cancer? The CACA guidelines suggest that adjuvant radiation therapy combined with endocrine therapy is the first choice for patients; early endocrine therapy is the second choice.

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Selected active wait-and-see regimens are available for some patients
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For patients with regional lymph node metastasis, CACA guideline class I recommends endocrine therapy (2-3 years) combined with radiotherapy, and abiraterone combined with prednisone can be considered; class II recommends radical prostatectomy + lymph node dissection, and then After the characteristics of the selection of the appropriate treatment strategy
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For such patients, the diagnosis and treatment mode of MDT to HIM should be adopted to analyze the patient's physical condition and pathological characteristics, and select radiotherapy, endocrine therapy and surgical treatment in a targeted manner, so that the patient can get better physical recovery while controlling the tumor.

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A major feature of the CACA guidelines for TCM diagnosis and treatment is to actively recommend the application of TCM rehabilitation in patients with localized prostate cancer
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First of all, these patients can be diagnosed with traditional Chinese medicine and syndrome diagnosis, and then the physical and psychological treatment of patients can be strengthened by means of traditional Chinese medicine, and the recovery of patients can be promoted
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For postoperative patients, traditional Chinese medicine rehabilitation can be used to improve the patient's urinary control function and sexual function recovery, and to accelerate the postoperative recovery of patients
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Conclusion Finally, Professor Ye Dingwei from Fudan University Affiliated Cancer Hospital made a summary of the above content
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Professor Ye pointed out that clinicians should follow the principle of radical cure of tumors, at the same time pay attention to the wishes of patients, and pay attention to multidisciplinary cooperation in treatment, such as the combination of surgery and radiotherapy
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In addition, the characteristics of traditional Chinese medicine are applied in the rehabilitation treatment of patients to achieve rehabilitation and integrated diagnosis and treatment of patients
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Expert introduction Prof.
Dr.
He Liru Chief Physician and Doctoral Supervisor Visiting Scholar at MD Anderson Cancer Center, USA Member of the Special Committee of the Urological Oncology Group of the Radiotherapy Branch of the National Health and Health Commission Member of the Guangdong Anti-Cancer Association Urogenital Oncology Youth Committee Vice Chairman Professor Yu Wei, Standing Committee Member of the Radiation Oncology Branch of the Guangdong Women's Physician Association, Chief Physician, Professor, Doctoral Supervisor Member of the Oncology Group of the Urology Professional Committee of the Chinese Association of Integrative Medicine Member of the Urogenital Oncology Group of the Familial Inherited Tumor Cooperative Group of the Anti-Cancer Association : Minimally Invasive and Comprehensive Treatment of Urinary System Tumors Professor Ye Dingwei Director of the Institute of Prostate Cancer, Fudan University Director of the Shanghai Institute of Urologic Oncology Director of the Urogenital Tumor Special Committee of the China Anti-Cancer Association Executive Director of the China Anti-Cancer Association Chinese Medicine Deputy Head, Oncology Group, Urology Branch, President-elect, Asia Pacific Prostate Society (APPS) Editor: LR Reviewer: Mia Executive: LR