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Prostate cancer

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Updated 2024 EAU guidelines for the diagnosis and management of prostate cancer.

Background

Overview

Definition
Prostate cancer is a neoplastic disease arising from malignant transformation of cells within the prostate gland, of which adenocarcinoma is the most common subtype.
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Pathophysiology
Risk factors include advanced age, race (African black men, Caucasians), family history, exposure to radiation, UTIs, smoking, obesity, physical inactivity, diet factors (red meat, dairy protein, dietary fat), and elevated endogenous hormones (insulin-like growth factors).
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Epidemiology
The incidence of prostate cancer in the US is estimated at 123-183 cases per 100,000 person-years.
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Disease course
The progression of prostate cancer is impingent on activation of the androgen receptor nuclear receptor, and as such, treatment options for invasive disease rely on targeting this pathway. Progression to castrate-resistant prostate cancer is mediated by aberrant reactivation of the androgen receptor, as well as alterations in cell cycle pathways that result in uncontrolled proliferation.
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Prognosis and risk of recurrence
In men with localized prostate cancer, the 10-year disease-specific mortality ranges from 3% to 18%, depending on the risk category. In men with metastatic prostate cancer, the 5-year survival rate is estimated at 29.3%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of prostate cancer are prepared by our editorial team based on guidelines from the American Urological Association (AUA/SUO/ASTRO 2024,2021), the European Association of Urology (EAU 2024), the International Society of Urological Pathology (ISUP/EANM/SIOG/ESUR/EAU/ESTRO 2024), the American Society of Clinical Oncology (ASCO 2023,2022,2020), the American Urological Association (AUA/SUO 2023), the Canadian Urological ...
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Screening and diagnosis

Indications for screening, general considerations: as per EANM/EAU/ESTRO/ESUR/ISUP/SIOG 2024 guidelines, do not subject males to PSA testing without counseling them on the potential risks and benefits.
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  • Indications for screening (general population, age < 54 years)

  • Indications for screening (general population, age 55-69 years)

  • Indications for screening (general population, age > 70 years)

  • Indications for screening (high-risk population)

  • Indications for screening (repeat screening)

Classification and risk stratification

Risk assessment, undiagnosed: as per EANM/EAU/ESTRO/ESUR/ISUP/SIOG 2024 guidelines, use one of the following tools to decide on biopsy indication in asymptomatic males with a PSA level of 3-20 ng/mL and a normal DRE:
risk-calculator, provided it is correctly calibrated to the population prevalence
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prostate MRI
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additional serum or urine biomarker test.
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  • Risk assessment (newly diagnosed, localized disease)

  • Risk assessment (newly diagnosed, advanced disease)

  • Staging

Diagnostic investigations

Prostate MRI
As per AUA/SUO 2023 guidelines:
Consider obtaining prostate MRI before the initial biopsy to increase the detection of grade group ≥ 2 prostate cancer.
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Use the PI-RADS system in the reporting of multiparametric MRI.
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  • Adjunctive biomarkers

  • Imaging for staging (clinically localized)

  • Imaging for staging (metastatic)

  • Germline testing (general indications)

  • Germline testing (positive family history)

  • Germline testing (metastatic disease)

Diagnostic procedures

Prostate biopsy, indications: as per EANM/EAU/ESTRO/ESUR/ISUP/SIOG 2024 guidelines, perform targeted biopsy with perilesional sampling in patients with positive MRI (PI-RADS ≥ 4).
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  • Prostate biopsy (pre-biopsy evaluation)

  • Prostate biopsy (approach)

  • Prostate biopsy (antibiotics prophylaxis)

  • Prostate biopsy (technical considerations)

  • Prostate biopsy (reporting)

  • Prostate biopsy (counseling)

  • Prostate biopsy (repeat biopsy)

  • Molecular testing

Medical management

Management of local/locoregional disease, initial treatment, low-risk localized disease: as per ASTRO/AUA 2022 guidelines, offer active surveillance as the preferred management option in patients with low-risk localized prostate cancer.
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  • Management of local/locoregional disease (initial treatment, intermediate-risk localized disease)

  • Management of local/locoregional disease (initial treatment, high-risk localized disease)

  • Management of local/locoregional disease (initial treatment, locally advanced disease)

  • Management of local/locoregional disease (initial treatment, non-curative/palliative intent)

  • Management of local/locoregional disease (technical considerations for radical prostatectomy)

  • Management of local/locoregional disease (technical considerations for radiotherapy)

  • Management of local/locoregional disease (adjuvant therapy after radical prostatectomy)

  • Management of local/locoregional disease (salvage therapy)

  • Management of advanced/metastatic disease (evaluation)

  • Management of advanced/metastatic disease (general principles of management)

  • Management of advanced/metastatic disease (systemic therapy)

  • Management of advanced/metastatic disease (radiotherapy)

  • Management of advanced/metastatic disease (management of metastases)

  • Management of castration-resistant prostate cancer (non-metastatic, pretreatment evaluation)

  • Management of castration-resistant prostate cancer (non-metastatic, surveillance)

  • Management of castration-resistant prostate cancer (non-metastatic, observation and androgen deprivation therapy)

  • Management of castration-resistant prostate cancer (non-metastatic, nonsteroidal antiandrogens)

  • Management of castration-resistant prostate cancer (non-metastatic, chemotherapy and immunotherapy)

  • Management of castration-resistant prostate cancer (metastatic, pretreatment evaluation)

  • Management of castration-resistant prostate cancer (metastatic, general principles of management)

  • Management of castration-resistant prostate cancer (metastatic, hormonal therapy)

  • Management of castration-resistant prostate cancer (metastatic, chemotherapy)

  • Management of castration-resistant prostate cancer (metastatic, PARP inhibitors)

  • Management of castration-resistant prostate cancer (metastatic, immunotherapy)

  • Management of castration-resistant prostate cancer (metastatic, radioligand therapy)

  • Management of castration-resistant prostate cancer (metastatic, prevention of skeletal-related events)

  • Management of castration-resistant prostate cancer (metastatic, surveillance)

  • Management of biochemical recurrence (evaluation)

  • Management of biochemical recurrence (androgen deprivation therapy)

  • Management of biochemical recurrence (salvage radiotherapy)

  • Management of biochemical recurrence (other modalities)

  • Management of biochemical recurrence (monitoring)

  • Management of local recurrence

  • Management of regional or distant recurrence

Specific circumstances

Elderly patients: as per EANM/EAU/ESTRO/ESUR/ISUP/SIOG 2024 guidelines, take into account individual life expectancy, health status, and comorbidities in the management of prostate cancer.
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  • Patients with premalignant lesions

Patient education

General counseling
As per ASTRO/AUA 2022 guidelines:
Counsel patients with prostate cancer that all treatment options carry risk. Incorporate the risks of treatment, in particular to the urinary, sexual, and bowel function, with the risk posed by cancer, patient life expectancy, comorbidities, preexisting medical conditions, and patient preferences in order to facilitate a shared decision-making approach to management.
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Provide an individualized risk estimate of post-treatment prostate cancer recurrence in patients with prostate cancer.
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Preventative measures

5-ARIs: as per ASCO/AUA 2009 guidelines, consider discussing the benefits of 5-ARIs for 7 years for the prevention of prostate cancer and the potential risks (including the possibility of high-grade prostate cancer) to be able to make a better-informed decision in asymptomatic males with a PSA level ≤ 3.0 undergoing regular screening with PSA or anticipating to undergo annual PSA screening for early detection of prostate cancer, as well as in patients taking 5-ARIs for benign conditions such as LUTS.
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Follow-up and surveillance

Monitoring for progression, on active surveillance: as per EANM/EAU/ESTRO/ESUR/ISUP/SIOG 2024 guidelines, repeat biopsies at least once every 3 years for 10 years.
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  • Monitoring for progression (after local treatment)

  • Monitoring for recurrence

  • Surveillance for osteoporosis

  • Multidisciplinary rehabilitation