Upload
arif-tri-prasetyo-harun
View
225
Download
0
Embed Size (px)
Citation preview
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 1/41
NCCN Guidelines IndexTable of Contents
Discussion
Version 2.2012, 05/02/12 © National Comprehensive Cancer Network, Inc. 2011, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN .®®
NCCN Guidelines Version 2.2012Prostate Cancer Early Detection
Continue
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) ®
Prostate Cancer
Early DetectionVersion 2.2012
www.NCCN.org
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 2/41
NCCN Guidelines IndexTable of Contents
Discussion
Version 2.2012, 05/02/12 © National Comprehensive Cancer Network, Inc. 2011, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN .®®
NCCN Guidelines Version 2.2012Prostate Cancer Early Detection
Joseph C. Presti, MD/Chair
Stanford Cancer Institute
Gerald Andriole, MDSiteman Cancer Center at Barnes-JewishHospital and Washington University Schoolof Medicine
Robert R. Bahnson, MD
The Ohio State University ComprehensiveCancer Center - James Cancer Hospital andSolove Research Institute
Daniel A. Barocas, MD, MPH Vanderbilt-Ingram Cancer Center
Michael Barry, MDMassachusetts General Hospital Cancer
Center
J. Erik Busby, MDUniversity of Alabama at BirminghamComprehensive Cancer Center
H. Ballentine Carter, MD
The Sidney Kimmel Comprehensive Cancer
Center at Johns Hopkins
William J. Catalona, MDRobert H. Lurie Comprehensive Cancer Center of Northwestern University
Þ
Peter R. Carroll, MDUCSF Helen Diller Family Comprehensive
Cancer Center
John W. Davis, MD
The University of Texas MD AndersonCancer Center
Jonathan I. Epstein, MDThe Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins
Ruth B. Etzioni, PhDFred Hutchinson Cancer ResearchCenter/Seattle Cancer Care Alliance
Veda N. Giri, MDFox Chase Cancer Center
George P. Hemstreet, III, MD, PhDUNMC Eppley Cancer Center at TheNebraska Medical Center
Mark H. Kawachi, MDCity of Hope Comprehensive Cancer Center
Paul H. Lange, MDUniversity of Washington MedicalCenter/Seattle Cancer Care Alliance
Kevin R. Loughlin, MDDana-Farber/Brigham and Women’sCancer Center
&
†
James Mohler, MD
Roswell Park Cancer Institute
Judd Moul, MD
Duke Cancer Institute
Robert B. Nadler, MDRobert H. Lurie Comprehensive Cancer Center of Northwestern University
Antoinette M. Stroup, PhD &Huntsman Cancer Institute at the University of Utah
Andrew J. Vickers, PhDMemorial Sloan-kettering Cancer Center
Robert Wake, MDSt. Jude Children’s Research Hospital/Universityof Tennessee Cancer Institute
Jingsong Zhang, MD, PhDH. Lee Moffitt Cancer Center & ResearchInstitute
Maria Ho, PhDDorothy A. Shead, MS
††
NCCN Staff
† Medical oncology
§ Radiotherapy/Radiation oncology
* Writing committee member
Urology
Þ Internal Medicine
Pathology
& Epidemiology†† Biostatistician
¥ Patient advocacyContinue
NCCN Guidelines Panel Disclosures
Panel Members
Printed by Arif Tri Prasetyo on 12/7/2012 8:47:48 AM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved.
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 3/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 4/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 5/41
NCCN Guidelines IndexTable of Contents
Discussion
Version 2.2012, 05/02/12 © National Comprehensive Cancer Network, Inc. 2011, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN .®®
NCCN Guidelines Version 2.2012Prostate Cancer Early Detection
It is neither the intent nor the suggestion of the panel that all men diagnosed with prostate cancer require treatment. It is inherent that
as we maximize the detection of early prostate cancer we will increase the detection of both non-aggressive (slow-growing) and
aggressive (faster growing) prostate cancers. The challenge is to identify the biology of the cancer that is detected and thus identify
cancers that, if treated effectively, will result in a significant decrease in morbidity and mortality.
This variability in prostate tumor behavior is unlike any other cancer, and consequently, causes major concern with the problem of over-
treatment resulting in potentially significant adverse implications on quality-of-life issues (eg, urinary, bowel and erectile dysfunction).
The natural history of prostate cancer is that it will progress over time, but the unanswerable question is over what period of time.
The Prostate Cancer Early Detection guidelines do not address the treatment of prostate cancer. The guidelines are specifically for men
opting to participate in an early detection program (after receiving the appropriate counseling on the pros and cons). It is the majority
opinion of the Prostate Cancer Early Detection Panel Members that there is a growing population of men currently being diagnosed with
prostate cancer who can, and should, be monitored for their disease as presented in the Prostate Cancer Treatment Guidelines. The
guidelines for a baseline PSA and lowering the PSA thresholds for biopsy were recommended by most panel members, but a consensus
was not reached.
The guidelines are continuously in a state of evolution, and the panel will incorporate changes based on new evidence and expert
opinion and provide a rating of consensus with respect to each recommendation.
See Talking Points About the Pros and Cons of PSA Testing (PROSD-A).
INTRODUCTION
PROSD-1
See Baseline Evaluation(PROSD-2)
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Printed by Arif Tri Prasetyo on 12/7/2012 8:47:48 AM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved.
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 6/41
Printed by Arif Tri Prasetyo on 12/7/2012 8:47:48 AM For personal use only Not approved for distribution Copyright © 2012 National Comprehensive Cancer Network Inc All Rights Reserved
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 7/41
NCCN Guidelines IndexTable of Contents
Discussion
Version 2.2012, 05/02/12 © National Comprehensive Cancer Network, Inc. 2011, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN .®®
NCCN Guidelines Version 2.2012Prostate Cancer Early Detection
PROSD-3
EARLY DETECTION EVALUATION FOLLOW-UP
PSA 1.0 ng/mLe
or
African Americanor Family historyor Men taking 5- alpha-reductase
inhibitors (5ARI)
PSA <1.0 ng/mLe Repeat at age 45
PSA ng/mL1.0
PSA 1.0 ng/mL>Annual follow-up:
DRE
PSA
Annual follow-up : f
DRE
PSA
Offer early detection
testing at age 50g
See Early Detection
Results (PROSD-4)
See Early DetectionResults (PROSD-4)
See DiagnosticEvaluation
(PROSD-4)
e
g
The reported median PSA values for men age 40-49 y range from 0.5-0.7 ng/mL, and the 75th percentile values range from 0.7-0.9 ng/mL; therefore, the PSA value of 1.0 ng/mL selects for the upper range of PSA values. Men who have a PSA above the median for their age group are at a higher risk for prostate cancer and for theaggressive form of the disease, and the higher above the median, the greater the risk.
There is no evidence in the literature to support the follow-up recommendations listed; they represent the consensus-based opinions of the panel based upon their clinical experience.
Less frequent PSA/DRE follow-up in the older patient may be appropriate based on their individual risk stratification.
f
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
PSA 1.0 ng/mLRepeat at
age 45
PSA 1.0 ng/mL>Annual follow-up:
DRE
PSA
If PSA ,
offer early detection
testing at age 50
1.0 ng/mL
g
See DiagnosticEvaluation(PROSD-4)
Printed by Arif Tri Prasetyo on 12/7/2012 8:47:48 AM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved.
Printed by Arif Tri Prasetyo on 12/7/2012 8:47:48 AM For personal use only Not approved for distribution Copyright © 2012 National Comprehensive Cancer Network Inc All Rights Reserved
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 8/41
NCCN Guidelines IndexTable of Contents
Discussion
Version 2.2012, 05/02/12 © National Comprehensive Cancer Network, Inc. 2011, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN .®®
NCCN Guidelines Version 2.2012Prostate Cancer Early Detection
PROSD-4
DIAGNOSTIC EVALUATION
h
In patients using finasteride or dutasteride, failure to have a substantial decrease (approximately 50%) inPSA or an increase while on medication can be associated with an increased risk for prostate cancer.
DREOffer total PSAh
See Early Detection
Results and Follow-Up(PROSD-6)
See Follow-Up(PROSD-5)
DRE positive
regardless of
PSA results
Transrectal
ultrasound
(TRUS)-guided
biopsy
(See PROSD-5)
RESULTS FOLLOW-UP
DRE negative
PSA performed
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
PSA
Ejaculation:Results are more reliable if the patient
has abstained from ejaculation for 48 h.
If this condition is not met repeat after
48 h abstention, if the original sample
was marginally elevated.
Medicines that affect PSA:
Ketoconazole
5ARIsdutasteridefinasteride
h
h
Printed by Arif Tri Prasetyo on 12/7/2012 8:47:48 AM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved.
Printed by Arif Tri Prasetyo on 12/7/2012 8:47:48 AM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved.
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 9/41
NCCN Guidelines IndexTable of Contents
Discussion
Version 2.2012, 05/02/12 © National Comprehensive Cancer Network, Inc. 2011, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN .®®
NCCN Guidelines Version 2.2012Prostate Cancer Early Detection
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
PROSD-5
Managementof biopsyresults
hIn patients using finasteride or dutasteride, failure to have a substantial decrease (approximately 50%) in PSA or an increase while on medication can be associated
with an increased risk for prostate cancer.
Cancer See NCCN Prostate Cancer Treatment Guidelines
Atypia,
suspiciousfor cancer
Extended pattern rebiopsy (within 6 mo) with
increased sampling of the atypical small acinar
proliferation (ASAP) site and adjacent areas. If nocancer is found, close follow-up with PSA and DRE
is recommended
High-grade
prostatic
intraepithelial
neoplasia
(PIN)
Benign
Follow-up, based on DRE and PSA findings:
Positive DRE (See PROSD-4)
High Risk (See PROSD-5)
PSA 4-10 (See PROSD-7)
PSA > 10 (See PROSD-8)
TRUS-GUIDED BIOPSY
Initial and Repeat
Number of cores:Sextant (6) ,Lateral peripheral zone (6), andLesion-directed at palpable nodule or
suspicious imageAnteriorly directed biopsy is not supported in
routine biopsy. However, the addition of a
transition zone biopsy to an extended biopsyprotocol may be considered in a repeat
biopsy if PSA is persistently elevated.After 2 negative extended TRUS biopsies,
prostate cancer is not commonly found at
repeat biopsy. Additional MRI imaging (T2
plus diffusion weighting) may help identify
regions of cancer missed on prior biopsies
and should be considered in selected cases.
For high-risk men with multiple negativebiopsies, consideration can be given to a
saturation biopsy strategy.Local anesthesia can decrease
pain/discomfort associated with prostate
biopsy.
Extended-pattern biopsy (12 cores)
If initial sextant biopsy used,
rebiopsy using extended pattern
Repeat biopsy within the first
year, if high-grade PIN is
multi-focal ( 2 cores)
If no cancer is
found, close
follow-up with
PSA and DRE is
recommended
MANAGEMENT OF BIOPSY RESULTS
y y p y pp py g p , , g
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 10/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 11/41
Printed by Arif Tri Prasetyo on 12/7/2012 8:47:48 AM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved.
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 12/41
NCCN Guidelines IndexTable of Contents
Discussion
Version 2.2012, 05/02/12 © National Comprehensive Cancer Network, Inc. 2011, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN .®®
NCCN Guidelines Version 2.2012Prostate Cancer Early Detection
Note: All recommendations are category 2Aunless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
PROSD-8
Biopsy
Benign Negative
Re-evaluate with PSAand DRE
Consider rebiopsy
timing interval 3-
to12-mo based on
doctor-patient
discussion
Positive
See NCCN Prostate Cancer Treatment Guidelines
See NCCN Prostate
Cancer TreatmentGuidelines
PSA >10 ng/mL
EARLY DETECTION RESULTS FOLLOW-UP
Cancer
Atypia,
suspicious
for cancer or
high-grade
PIN
See TRUS-guided biopsy (PROSD-5)
6- to 12-mo follow-up withDRE, and total or percent-free PSA including PSAV;c
Consider a third biopsybased on individual patientparameters and choice
cPSA velocity: For men with a PSA <4 ng/mL, data suggest that a continuously increasing PSA velocity ( 0.35 ng/mL/y) is suspicious for the possible presence of life-threatening cancer (Carter HB, Ferrucci L, Kettermann A et al. Detection of Life-Threatening Prostate Cancer With Prostate-Specific Antigen Velocity During a Window
of Curability. 2006;98(21):1521-1527) and a biopsy should be considered; for men with a PSA 4-10 ng/mL, a PSA velocity of 0.75 ng/mL/y issuspicious for cancer. PSA velocity in men with a PSA >10 ng/mL is not useful. Measurement should be made on at least three consecutive specimens drawn over atleast an 18- to 24- mo interval. There is some variability between different laboratories and different assays. Longer time periods increase reliability, but, as calculationof PSA velocity over longer prior time intervals usually decreases the PSA velocity estimate, it might decrease predictive power. It is also important to remember thatbiologic variability and/or prostatitis may be confounding factors in determining PSA velocity; therefore, an abnormal PSA should be repeated and a course of antibiotic
may be considered to minimize these sources of confusion.
J Natl Cancer Inst.
Biopsy
not done
Repeat PSA and DRE
in 6-12 mo
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 13/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 14/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 15/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 16/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 17/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 18/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 19/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 20/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 21/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 22/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 23/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 24/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 25/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 26/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 27/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 28/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 29/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 30/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 31/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 32/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 33/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 34/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 35/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 36/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 37/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 38/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 39/41
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 40/41
NCCN Guidelines IndexProstate Early Detection TOC
NCCN Guidelines Version 2.2012P t t C E l D t ti
Printed by Arif Tri Prasetyo on 12/7/2012 8:47:48 AM. For personal use only. Not approved for distribution. Copyright © 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved.
8/13/2019 Prostate Detection
http://slidepdf.com/reader/full/prostate-detection 41/41
Version 2.2012, 05/02/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any for m without the express written permission of NCCN®. REF-8
Prostate Early Detection TOCDiscussionProstate Cancer Early Detection
intraepithelial neoplasia is associated with high likelihood of prostate
cancer, independent of change in prostate specific antigen levels. JUrol 2002;168:1415-1418. Available at:http://www.ncbi.nlm.nih.gov/pubmed/12352407 .
104. Chan TY, Epstein JI. Follow-up of atypical prostate needlebiopsies suspicious for cancer. Urology 1999;53:351-355. Available at:http://www.ncbi.nlm.nih.gov/pubmed/9933053 .
105. Mian BM, Naya Y, Okihara K, et al. Predictors of cancer in repeat
extended multisite prostate biopsy in men with previous negativeextended multisite biopsy. Urology 2002;60:836-840. Available at:http://www.ncbi.nlm.nih.gov/pubmed/12429311 .