NCCN Guidelines Version 1.2016 NCCN Guidelines Index Prostate Table of Contents Prostate Cancer Discussion NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Prostate Cancer Version 2.2017 — February 21, 2017 NCCN.org NCCN Guidelines for Patients® available at www.nccn.org/patients Continue Version 2.2017, 02/21/17© National Comprehensive Cancer Network, Inc. 2017, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Bryan Allen on 6/20/2017 4:42:31 PM. For personal use only. Not approved for distribution. Copyright © 2017 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 2.2017 NCCN Guidelines Index Table of Contents Prostate Cancer Panel Members Discussion * James L. Mohler, MD/Chair ω Eric Mark Horwitz, MD § Stan Rosenfeld ‡ Roswell Park Cancer Institute Fox Chase Cancer Center University of California San Francisco Patient Services Committee Chair * Emmanuel S. Antonarakis, MD † Michael Hurwitz, MD, PhD † The Sidney Kimmel Comprehensive Yale Cancer Center/Smilow Cancer Hospital Edward Schaeffer, MD, PhD ω Cancer Center at Johns Hopkins Robert H. Lurie Comprehensive Cancer Christopher J. Kane, MD ω Center of Northwestern University * Andrew J. Armstrong, MD † UC San Diego Moores Cancer Center Duke Cancer Institute Ted A. Skolarus, MD ω Michael Kuettel, MD, MBA, PhD § University of Michigan Robert R. Bahnson, MD ω Roswell Park Cancer Institute Comprehensive Cancer Center The Ohio State University Comprehensive Cancer Center - James Cancer Hospital Joshua M. Lang, MD † Eric J. Small, MD † and Solove Research Institute University of Wisconsin Carbone Cancer Center UCSF Helen Diller Family Comprehensive Cancer Center Cheryl Clark, MD Þ Richard J. Lee, MD, PhD † Dana-Farber/Brigham and Women’s Dana-Farber/Brigham and Women’s Guru Sonpavde, MD † Cancer Center | Massachusetts General Cancer Center | Massachusetts General Hospital University of Alabama at Birmingham Hospital Cancer Center Cancer Center Comprehensive Cancer Center Anthony Victor D’Amico, MD, PhD § * David F. Penson, MD, MPH ω Sandy Srinivas, MD † Dana-Farber/Brigham and Women’s Vanderbilt-Ingram Cancer Center Stanford Cancer Institute Cancer Center | Massachusetts General Hospital Cancer Center Elizabeth R. Plimack, MD, MS † Þ Seth A. Strope, MD, MPH ω Fox Chase Cancer Center Siteman Cancer Center at Barnes- Brian J. Davis, MD, PhD § Jewish Hospital and Washington Mayo Clinic Cancer Center Julio M. Pow-Sang, MD ω University School of Medicine Moffitt Cancer Center James A. Eastham, MD ω * Jonathan Tward, MD, PhD § Memorial Sloan Kettering Cancer Center David Raben, MD § Huntsman Cancer Institute University of Colorado Cancer Center at the University of Utah Rodney Ellis, MD § Case Comprehensive Cancer Center/ Sylvia Richey, MD † Przemyslaw Twardowski, MD † ‡ University Hospitals Seidman Cancer Center and St. Jude Children’s Research Hospital/ City of Hope Comprehensive Cancer Center Cleveland Clinic Taussig Cancer Institute University of Tennessee Health Science Center NCCN Charles A. Enke, MD § Mack Roach, III, MD § Deborah Freedman-Cass, PhD * Dorothy A. Shead, MS Fred & Pamela Buffett Cancer Center UCSF Helen Diller Family Comprehensive Cancer Center Thomas A. Farrington ‡ Prostate Health Education Network (PHEN) Þ Internal medicine † Medical oncology ‡ Patient advocate Celestia S. Higano, MD † ω § Radiotherapy/Radiation oncology Fred Hutchinson Cancer Research Center/ Seattle Continue ω Urology Cancer Care Alliance * Discussion Section Writing Committee NCCN Guidelines Panel Disclosures Version 2.2017, 02/21/17© National Comprehensive Cancer Network, Inc. 2017, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Bryan Allen on 6/20/2017 4:42:31 PM. For personal use only. Not approved for distribution. Copyright © 2017 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 2.2017 NCCN Guidelines Index Table of Contents Prostate Cancer Discussion NCCN Prostate Cancer Panel Members Clinical Trials: NCCN believes that Summary of Guidelines Updates the best management for any patient Initial Prostate Cancer Diagnosis (PROS-1) with cancer is in a clinical trial. Very Low-Risk: Initial Therapy, Adjuvant Therapy (PROS-2) Participation in clinical trials is Low-Risk: Initial Therapy, Adjuvant Therapy (PROS-3) especially encouraged. Intermediate-Risk: Initial Therapy, Adjuvant Therapy (PROS-4) To find clinical trials online at NCCN High-Risk: Initial Therapy, Adjuvant Therapy (PROS-5) Member Institutions, click here: nccn.org/clinical_trials/physician.html. Very High-Risk, Regional, and Metastatic Disease: Initial Therapy, Adjuvant Therapy (PROS-6) Monitoring, Recurrence (PROS-7) NCCN Categories of Evidence and Consensus: All recommendations Radical Prostatectomy Biochemical Failure (PROS-8) are category 2A unless otherwise Radiation Therapy Recurrence (PROS-9) specified. Systemic Therapy for Progressive Castration-Naive Disease (PROS-10) See NCCN Categories of Evidence Systemic Therapy for M0 CRPC (PROS-11) and Consensus. Systemic Therapy for M1 CRPC (PROS-12) Subsequent Systemic Therapy for M1 CRPC: No Visceral Metastases (PROS-13) Subsequent Systemic Therapy for M1 CRPC: Visceral Metastases (PROS-14) Principles of Life Expectancy Estimation (PROS-A) Principles of Imaging (PROS-B) Principles of Active Surveillance and Observation (PROS-C) Principles of Radiation Therapy (PROS-D) Principles of Surgery (PROS-E) Principles of Androgen Deprivation Therapy (PROS-F) Principles of Immunotherapy and Chemotherapy (PROS-G) Staging (ST-1) Gleason Grade Group Definitions (ST-3) The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2017. Version 2.2017, 02/21/17© National Comprehensive Cancer Network, Inc. 2017, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. Printed by Bryan Allen on 6/20/2017 4:42:31 PM. For personal use only. Not approved for distribution. Copyright © 2017 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN Guidelines Version 2.2017 NCCN Guidelines Index Table of Contents Prostate Cancer Updates Discussion Updates in Version 2.2017 of the NCCN Guidelines for Prostate Cancer from Version 1.2017 include: Discussion • The Discussion section was updated to reflect the changes in the algorithm. Updates in Version 1.2017 of the NCCN Guidelines for Prostate Cancer from Version 3.2016 include: PROS-1 PROS-6 • Initial prostate cancer diagnosis, added a bullet for “Family history" • Very high risk group, initial therapy, ADT replaced “in select patients” with “or with a new footnote: "The following should be considered: brother or observation for patients who are not candidates for definitive therapy.” father or multiple family members diagnosed with prostate cancer at • Added a new footnote "RP + PLND can be considered in younger, healthier less than 60 years of age, germline DNA repair gene abnormalities, patients without tumor fixation to the pelvic side-wall." especially BRCA2 mutation or Lynch syndrome (germline mutations in • Deleted footnote: “Primary therapy with ADT should be considered only for MLH1, MSH2, MSH6, or PMS2) and/or strong family history for breast or patients who are not candidates for definitive therapy.” ovarian cancer (suggests possibility of BRCA2 mutation) or colorectal, PROS-7 endometrial, gastric, ovarian, pancreatic, small bowel, urothelial, • Changed “Advanced disease” to “Progression to metastatic disease without kidney, or bile duct cancer (suggests possibility of Lynch syndrome)." biochemical failure.” • Modified the following footnote: Androg“ en deprivation therapy (ADT) • N1 or M1, added "on ADT." or radiation therapy (RT) may be considered in selected patients • Branches for recurrence after initial definitive therapy and N1 and M1 onADT with high- or very-high-risk disease, where complications, such as were separated hydronephrosis or metastasis, can be expected within 5 y. (See PROS-5 • Added “Progression” to bottom branch, with links to PROS-11 and PROS-12. or PROS-6). PROS-8 • Removed text box: “Preferred treatment for any therapy is approved • Clarified "abdominal/pelvic" CT or MRI. clinical trial.” • "Progression" was split into separate pathways depending on previous • Risk Group - added the ISUP/WHO Grade Groups. (See ST-3) treatment, with links to PROS-10, PROS-11, and PROS-12. PROS-2, -3, -4, -5, -6 • Added a new footnote defining "castration-naive." The term "castration-naive" • Modified “Adverse feature(s) and no lymph node metastases.” is used to define patients who