This consensus document is not a rigid constraint on clinical practice, but a concept of good practice against which the needs of the individual patient should be considered. It therefore remains the responsibility of the individual clinician to interpret the application of these guidelines, taking into account local service constraints and the needs and wishes of the patient. It is not intended that these consensus documents are applied as rigid clinical protocols.
Score |
Parameters |
|
1 |
GG1, PSA <10, T1-2 |
|
2 |
GG2 or PSA 10-20, T1-2 |
|
3 |
GG2 and PSA 10-20, T1-2 |
|
4 |
GG4 or PSA >20 or T3/4 |
|
5 |
GG4 and PSA >20/T3 |
Risk stratification is based on the Cambridge Prognostic Group (CPG) 
criteria.
For patients declining active surveillance, non-surgical options include:
Notes:
ADT (Androgen Deprivation Therapy) can be offered on a case-by-case basis if required for prostate shrinkage/symptom control.
Patients should have access to an ultrahypofractionated approach if no contraindications (prostate size, symptoms, hip replacements).
Patients should have access to LDR brachytherapy if no contraindications (IPSS <15, Qmax >10ml/s, no prior TURP, gland size <50cc (50-70cc may be treatable with ADT to allow prostatic shrinkage).
Options include:
Notes:
*The National Comprehensive Cancer Network (NCCN) favourable intermediate risk group is defined as a) predominantly grade 3, and b) less than 50% biopsy cores positive, and c) no more than one of the following: T2b/c, grade group 2, PSA 10 to 20 ng/ml.
ADT was omitted from the control arm of PACE B (60Gy in 20 fractions) without detriment.
Where ADT is used, the neoadjuvant component should be minimised unless needed for prostatic shrinkage.
Patients should have access to an ultrahypofractionated approach if no contraindications (prostate size, symptoms, hip replacements) potentially allowing omission of ADT.
Patients should have access to low dose rate (LDR) brachytherapy if no contraindications (IPSS <15, Qmax >10ml.s, no prior transurethral resection of the prostate (TURP), gland size <50cc (50-70cc may be treatable with ADT to allow prostatic shrinkage)).
Options include:
Notes:
* The National Comprehensive Cancer Network (NCCN) unfavourable intermediate risk group is defined as a) predominantly grade 4, or b) more than 50% biopsy cores positive, or c) more than one of the following: T2b/c, grade group 2, PSA 10 to 20 ng/ml
ADT can be omitted in context of significant cardiovascular comorbidity.
Where ADT is used, the neoadjuvant component should be minimised unless needed for prostatic shrinkage.
Patients should have access to an ultrahypofractionated approach if no contraindications (prostate size, symptoms, hip replacements) potentially allowing omission of ADT.
Patients should have access to LDR brachytherapy if no contraindications.
For suitable patients (with a dominant intraprostatic lesion (DIL)), a boost can be considered (brachytherapy or simultaneous integrated boost (SIB)).
Nodal radiotherapy should not routinely be used but is accepted in the context of an Ascende-RT approach.
Options include:
Notes:
Pelvic nodal radiotherapy (44-47Gy in 20 fractions) can be considered.
Prostatic boost can be considered (brachytherapy, stereotactic body radiotherapy (SBRT), SIB to DIL).
Abiraterone for 2 years should be offered to patients who are eligible (any 2 of the following features:
Options include:
Notes:
A simultaneous integrated boost to the involved nodes to 51-55Gy can be considered.
Notes:
*The SPPORT study showed greatest benefit to addition of pelvic nodal treatment at PSA >0.35.
Bicalutamide is not routinely recommended as hormonal therapy in this setting.
Salvage radiotherapy to the prostate can be delivered following HIFU (high intensity focused ultrasound) but should be with conventionally fractionated external beam radiotherapy (e.g. 74Gy in 37 fractions over 7.5 weeks).
Notes:
Suitable patients can be referred to the Edinburgh Cancer Centre.
A planning study is performed in Edinburgh under GA, with template biopsies taken at that procedure.
Focal salvage brachytherapy for brachytherapy failure can be considered for patients on a case-by-case basis where there is a focal area of biopsy proven recurrence. The evidence base for such an approach is developing, and this procedure should ideally be performed in the context of a national or international registry with prospectively collected data.
Note:
Suitable patients can be referred to the Edinburgh Cancer Centre.
A national cancer prehabilitation website is available, providing resources for patients and healthcare professionals at www.prehab.nhs.scot . Specifically relevant to radiotherapy, some patients will require interventions to improve urinary symptoms, flow and residual volumes through advice regarding fluid, alcohol and caffeine intake, information relating to pelvic floor exercises, alpha blockade or antimuscarinic medication, pre-radiotherapy TURP or teaching intermittent self catheterisation.
Note:
The process of such monitoring may differ between centres but patients should be re-referred to the treatment team if the threshold for biochemical relapse is reached.
Patients with biochemical relapse following radical radiotherapy (defined according to Phoenix criterion of nadir PSA + 2.0 ug/l) should be considered for reimaging including axial imaging and bone scan, with PSMA-PET considered if there are potential options of local salvage with brachytherapy, cryotherapy or prostatectomy or management of oligometastatic disease with SBRT.
Note:
For patients with significant competing comorbidities, a symptom-directed approach with reduced or no routine monitoring may be appropriate.
Public Health Scotland hosts a REDCap database to facilitate electronic collection of PROMS for all men undergoing treatment of prostate cancer in Scotland, allowing meaningful comparisons of functional outcomes across the country. The treating clinical team may wish to consider using this tool to collect PROMS for their patients undergoing radiotherapy.
In context of low burden metastatic disease (M1A or M1B disease with 4 or fewer bony metastases) patients should be offered radiotherapy to the prostate gland (in addition to lifelong ADT and ARPI - see SACT pathway for further information on these agents).
Options include:
For patients with a single bony metastasis or low M1A metastases that is encompassable in a radical radiotherapy volume, consideration can be given to treating the prostate +/- pelvic nodes and oligometastasis in continuity.
Palliative radiotherapy for symptom control should be considered for locoregional or metastatic disease according to local protocols.
Scottish Cancer Network: Clinical Management Pathways
