EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent

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Guidelines
EAU–ESTRO–SIOG Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent
Nicolas Mottet a,*, Joaquim Bellmunt b,c, Michel Bolla d, Erik Briers e, Marcus G. Cumberbatch f, Maria De Santis g, Nicola Fossati h,i, Tobias Gross j, Ann M. Henry k, Steven Joniau l,
Thomas B. Lam m,n, Malcolm D. Mason o, Vsevolod B. Matveev p, Paul C. Moldovan q,
Roderick C.N. van den Bergh r, Thomas Van den Broeck l, Henk G. van der Poel s,
Theo H. van der Kwast t, Olivier Rouvie`re q, Ivo G. Schoots u, Thomas Wiegel v, Philip Cornford w
a Department of Urology, University Hospital, St. Etienne, France; b Bladder Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA; c Harvard Medical School, Boston, MA, USA; d Department of Radiation Therapy, CHU Grenoble, Grenoble, France; e Patient Advocate, Hasselt, Belgium; f Academic Urology Unit, University of Sheffield, Sheffield, UK; g University of Warwick, Cancer Research Centre, Coventry, UK; h Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; i Universita` Vita-Salute San Raffaele, Milan, Italy; j Department of Urology, University of Bern, Inselspital, Bern, Switzerland; k Leeds Cancer Centre, St. James’s University Hospital, Leeds, UK; University of Leeds, Leeds, UK; l Department of Urology, University Hospitals Leuven, Leuven, Belgium; m Academic Urology Unit, University of Aberdeen, Aberdeen, UK; n Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK; o Cardiff University, Velindre Hospital, Cardiff, UK; p N.N. Blokhin Cancer Research Center, Moscow, Russia; q Hospices Civils de Lyon, Radiology Department, Edouard Herriot Hospital, Lyon, France; r Department of Urology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands; s Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands; t Department of Pathology, Erasmus Medical Centre, Rotterdam, The Netherlands; u Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands; v Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany; w Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK

Article info
Article history:
Accepted August 2, 2016
Associate Editor:
James Catto
Keywords:
Prostate cancer
Localised
EAU-ESTRO-SIOG Guidelines Screening
Diagnosis
Staging
Treatment
Radical prostatectomy Radiation therapy Androgen deprivation
http://dx.doi.org/10.1016/j.eururo.2016.08.003

Abstract
Objective: To present a summary of the 2016 version of the European Association of Urology (EAU) - European Society for Radiotherapy & Oncology (ESTRO) - International Society of Geriatric Oncology (SIOG) Guidelines on screening, diagnosis, and local treatment with curative intent of clinically localised prostate cancer (PCa).
Evidence acquisition: The working panel performed a literature review of the new data (2013–2015). The guidelines were updated and the levels of evidence and/or grades of recommendation were added based on a systematic review of the evidence.
Evidence synthesis: BRCA2 mutations have been added as risk factors for early and aggressive disease. In addition to the Gleason score, the five-tier 2014 International Society of Urological Pathology grading system should now be provided. Systematic screening is still not recommended. Instead, an individual risk-adapted strategy follow- ing a detailed discussion and taking into account the patient’s wishes and life expectancy must be considered. An early prostate-specific antigen test, the use of a risk calculator, or one of the promising biomarker tools are being investigated and might be able to limit the overdetection of insignificant PCa. Breaking the link between diagnosis and treat- ment may lower the overtreatment risk. Multiparametric magnetic resonance imaging using standardised reporting cannot replace systematic biopsy, but robustly nested within the diagnostic work-up, it has a key role in local staging. Active surveillance always needs to be discussed with very low-risk patients. The place of surgery in high- risk disease and the role of lymph node dissection have been clarified, as well as the management of node-positive patients. Radiation therapy using dose-escalated inten-
* Corresponding author. Department of Urology, University Hospital, St. Etienne, France. Tel. +33 477828331; Fax: +33 477517179.

1.

Introduction

well-established risk factors. If one first-degree relative has PCa, the risk is at least doubled. It increases by 5–11 times when two or more first-line relatives are affected [8]. About 9% of men with PCa have truly hereditary disease, which is associated with an onset 6–7 yr earlier than spontaneous cases, but does not differ in other ways. The only exception to this are carriers of the rare BRCA2 germline abnormality, who seem to have an increased risk of early-onset PCa with aggressive behav- iour [9–11].
2. Classification
The 2009 TNM classification for staging of PCa and the EAU risk group classification are used (Table 1). The latter classification is based on grouping patients with a similar risk of biochemical recurrence after local treatment.
The International Society of Urological Pathology (ISUP) 2005 modified Gleason score (GS) is the recommended PCa grading system. The biopsy GS consists of the Gleason grade of the most extensive pattern plus the highest pattern, regardless its extent. In radical prostatectomy (RP) speci- mens, the GS is determined differently: A pattern compris- ing 5% of the cancer volume is not incorporated in the GS, but its proportion should be reported separately if it is grade 4or5.
High-risk

The most recent summary of the European Association of Urology (EAU) Guidelines on prostate cancer (PCa) was published in 2013 [1]. This update is based on structured yearly literature reviews and systematic review through an ongoing process. Evidence levels and grade of recommen- dation have been inserted according to the general principles of evidence-based medicine [2].
PCa remains the most common cancer in men in Europe (excluding skin cancer). Although the incidence of autopsy- detected cancers is roughly the same in different parts of the world, the incidence of clinically diagnosed PCa varies widely and is highest in Northern and Western Europe (>200 per 100 000 men/year) [3]. This is suggested to be a consequence of exogenous factors such as diet, chronic inflammation, sexual behaviour, and low exposure to ultraviolet radiation [4].
Metabolic syndrome has been linked with an increased risk of PCa [5], but there is insufficient evidence to recommend lifestyle changes or a modified diet to lower this risk. In hypogonadal men, testosterone therapy is not associated with an increased PCa risk [6]. No drugs or food supplements have been approved for PCa prevention.
Apart from age and African American origin, a family history of PCa (both paternal and maternal [7]) are