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Prostate cancer
Short Text
Introduction
This pathway covers the diagnosis and treatment of prostate cancer.
Prostate cancer is one of the most common cancers in men. Every year there are 34,986 new cases in England and Wales and 10,000 deathsCancer Research UK (2007). Prostate cancer is predominantly a disease of older men but around 20% of cases occur in men under the age of 65 years. Over the past 10 to 15 years there have been a number of significant advances in prostate cancer management but also a number of major controversies, especially about the clinical management of men with early, non-metastatic disease. These uncertainties clearly cause anxieties for men with prostate cancer and their families. There is evidence of practice variation around the country and of patchy availability of certain treatments and procedures. A clinical guideline will help to address these issues and offer guidance on best practice.
Source guidance
The NICE guidance that was used to create the pathway.
Prostate cancer: diagnosis and treatment. NICE clinical guideline 58 (2008)
Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours. NICE technology appraisal guidance 265 (2012)
Abiraterone for castration-resistant metastatic prostate cancer previously treated with a docetaxel-containing regimen. NICE technology appraisal guidance 259 (2012)
Cabazitaxel for hormone-refractory metastatic prostate cancer previously treated with a docetaxel-containing regimen. NICE technology appraisal guidance 255 (2012)
Denosumab for the treatment of therapy-induced bone loss in non-metastatic prostate cancer (terminated appraisal). NICE technology appraisal 194 (2010)
Docetaxel for the treatment of hormone-refractory metastatic prostate cancer. NICE technology appraisal guidance 101 (2006)
Focal therapy using high-intensity focused ultrasound for localised prostate cancer. NICE interventional procedure guidance 424 (2012)
Focal therapy using cryoablation for localised prostate cancer. NICE interventional procedure guidance 423 (2012)
Transperineal template biopsy and mapping of the prostate. NICE interventional procedure guidance 364 (2010)
Laparoscopic radical prostatectomy. NICE interventional procedure guidance 193 (2003)
High dose rate brachytherapy in combination with external-beam radiotherapy for localised prostate cancer. NICE interventional procedure guidance 174 (2006)
Cryotherapy as a primary treatment for prostate cancer. NICE interventional procedure guidance 145 (2005)
Low dose rate brachytherapy for localised prostate cancer. NICE interventional procedure guidance 132 (2005)
Cryotherapy for recurrent prostate cancer. NICE interventional procedure guidance 119 (2005)
High-intensity focused ultrasound for prostate cancer. NICE interventional procedure guidance 118 (2005)
Quality standards
Quality statements
Effective interventions library
Successful effective interventions library details
Implementation
Audit support
Audit support provides ready-to-use criteria, including exceptions, definitions, suggested data sources and a data collection tool.
Costing support
Costing support includes national cost impact reports that summarise the national costs and savings and discuss the assumptions used; costing templates to assess the impact on local budgets; and costing statements when the impact is not significant or impossible to quantify at a national level.
Service planning
Providing implementation advice, these tools help people to plan or deliver services. They can include an overview of the key steps and decision points in the care pathway and suggestions for putting the guidance into practice locally.
Slide sets
Slide sets provide a framework for discussion and assist in local dissemination of the guidance. The slides contain the key messages from NICE guidance and can be tailored for local presentations.
Pathway information
Updates to this pathway
25 April 2012 'Focal therapy using high-intensity focused ultrasound for localised prostate cancer' (NICE interventional procedures guidance 424) and 'Focal therapy using cryoablation for localised prostate cancer' (NICE interventional procedures guidance 423) added to localised prostate cancer.
11 May 2012 'Cabazitaxel for hormone-refractory metastatic prostate cancer previously treated with a docetaxel-containing regimen' (NICE technology appraisal guidance 255) added to hormone-refractory prostate cancer.
27 June 2012 'Abiraterone for castration-resistant metastatic prostate cancer previously treated with a docetaxel-containing regimen' (NICE technology appraisal guidance 259) added to hormone-refractory prostate cancer.
31 August 2012 Minor maintenance updates.
03 October 2012 Minor maintenance updates.
23 October 2012 'Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours' (NICE technology appraisal guidance 265) added to hormone-refractory prostate cancer.
30 October 2012 Minor maintenance updates.
Information for patients and the public
NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
Information about prostate cancer
Information about drug treatment
Information about surgery and other procedures
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.
Supporting information
Glossary
Castration-resistant is now used to refer to hormone-refractory prostate cancer because the cancer still depends on hormones to activate androgen receptors, but no longer responds to traditional androgen-reducing treatments.
Digital rectal examination
An internationally recognised grading system, based on examination of tissue obtained by prostate biopsy, where a pathologist allocates an overall cell abnormality score that can help predict prostate tumour behaviour. A low Gleason score (≤ 6) indicates a relatively favourable cancer, a high Gleason score (≥ 8) indicates a relatively aggressive cancer.
High-intensity focused ultrasound
Luteinising hormone-releasing hormone agonist
Multidisciplinary team
Magnetic resonance imaging
Magnetic resonance spectroscopy
Phosphodiesterase type 5
Prostate specific antigen
Man with suspected prostate cancer
Man with suspected prostate cancer
Support and information
Support and information
Support and information
Advise on sources of information and support, including cancer information services, support groups and websites (for example, UK Prostate Link). Check their content is clear, reliable and up-to-date and seek feedback on their quality.
NICE has written information for the public explaining this guidance.
NICE has produced information for the public explaining the guidance on referral guidelines for suspected cancer.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeDiagnosis
Diagnosis
Diagnosis
Before referral to specialist care, men with suspected prostate cancer should have been offered a DRE and PSA test as set out in the guidance on referral for suspected cancer.
Biopsy
Provide information and support and allow sufficient time for the man to decide whether to have a biopsy.
Discuss:
- the risks and benefits of biopsy
- their individual risk factors (including increasing age and black African or black Caribbean ethnicity)
- their estimated prostate size, DRE findings and PSA level
- any comorbidities
- any previous negative biopsy.
Use nomograms to help with decision making and to predict the biopsy results. Explain their reliability and limitations.
Do not biopsy:
- on the basis of serum PSA level alone
- if suspicion of prostate cancer is high because of PSA level and evidence of bone metastases, unless required as part of a clinical trial.
If the man chooses biopsy, perform according to undertaking a transrectal ultrasound guided biopsy of the prostate.
Biopsy results and re-biopsy
The urological cancer MDT should review the biopsy results.
After a negative biopsy result the urological cancer MDT should review the man's risk (life expectancy, DRE findings and estimated prostate size) and discuss with him the risks and benefits of a re-biopsy.
NICE interventional procedures guidance
NICE interventional procedures guidance makes recommendations on whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use, and whether special arrangements are needed for patient consent. The interventional procedures NICE considers are usually new, but NICE also issues guidance for established procedures when there is uncertainty about their safety or how well they work. The following NICE interventional procedure guidance is relevant to this part of the pathway.
Transperineal template biopsy and mapping of the prostate
Current evidence on the efficacy of transperineal template biopsy of the prostate shows an increase in diagnostic yield in patients with suspected prostate cancer who have had negative or equivocal results from other biopsy methods. There are no major safety concerns. Therefore this procedure may be used for this indication provided that normal arrangements are in place for clinical governance, consent and audit.
Evidence was not found to support the use of transperineal template biopsy of the prostate as a mapping technique to determine the exact location and extent of prostate cancer in order to guide focal therapy, nor as part of an active surveillance regime. Therefore the procedure should be used with these intentions only with special arrangements for clinical governance, consent and audit or research.
Clinicians wishing to undertake transperineal template biopsy of the prostate as part of an active surveillance regime or as a mapping technique to guide focal therapy of prostate cancer should take the following actions.
- Inform the clinical governance leads in their trusts.
- Ensure that patients and their carers understand the uncertainty about the use of the procedure for active surveillance and/or mapping, and provide them with clear written information. In addition, the use of NICE's information for the public is recommended.
- Audit and review clinical outcomes of all patients having transperineal template biopsy of the prostate. This guidance requires that clinicians undertaking the procedure as part of an active surveillance regime or as a mapping technique to guide focal prostate cancer therapy make special arrangements for audit. NICE has identified relevant audit criteria and has developed an audit tool (which is for use at local discretion).
NICE encourages further research on the use of transperineal template biopsy of the prostate for both mapping and active surveillance. Comparing the results with specimens obtained at prostatectomy will help to define the accuracy of the procedure in determining the location and extent of prostate cancer.
These recommendations are from transperineal template biopsy and mapping of the prostate (NICE interventional procedure guidance 364).
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleManaging prostate cancer
View the 'Managing prostate cancer' pathUrological cancer services
Urological cancer services
Urological cancer services
Follow the communication recommendations given in improving outcomes in urological cancers and supportive and palliative care for people with cancer.
Paths in this pathway
- Managing prostate cancer
- Managing prostate cancer: before treatment
- Prostate cancer: treatment and management options
Pathway created: October 2011 Last updated: October 2012
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