Prostate Cancer Survivorship Care Guideline

Creado por Shannon McKernin , modificado por última vez en feb 12, 2015

This is an original JCO publication from 2015. Please visit the JCO website to access the full article.
Prostate Cancer Survivorship Care Guideline: American Society of Clinical Oncology Clinical Practice Guideline Endorsement


The American Society of Clinical Oncology (ASCO) endorses the American Cancer Society (ACS) Prostate Cancer Survivorship Care Guidelines, with minor modifications and qualifying statements (in bold italics).

Target Population

Prostate cancer survivors.

Target Audience

Primary care providers, medical oncologists, radiation oncologists, urologists, and other providers.

Methods

The ASCO Endorsement Panel was convened to evaluate the ACS Prostate Cancer Survivorship Care Guidelines recommendations that were based on a systematic review of the medical literature. The ASCO Endorsement Panel considered the methodology used in the ACS guidelines by considering the results from the Appraisal of Guidelines for Research and Evaluation II review instrument. The ASCO Endorsement Panel carefully reviewed the ACS guidelines content to determine appropriateness for ASCO endorsement.

ASCO Key Recommendations for Prostate Cancer Survivorship Care

See Summary of Recommendations Table below

Additional Resources

More information, including a Data Supplement, Methodology Supplement, slide sets, and clinical tools and resources, is available at www.asco.org/endorsements/prostatesurvivorship. Patient information is available at www.cancer.net. A link to the ACS Prostate Cancer Survivorship Care Guidelines can be found at http://www.cancer.org/cancer/news/news/longterm-careguidelines-for-prostate-cancer-survivors. ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate.

SUMMARY OF RECOMMENDATIONS

Clinical Question


American Cancer Society (ACS) Recommendation with ASCO Qualifying Statement in Bold Italics

Health Promotion


Assess information needs related to prostate cancer and its treatment, side effects, other health concerns, and available support services and provide or refer survivors to appropriate resources to meet these needs.

Counsel survivors to achieve and maintain a healthy weight by limiting consumption of high-calorie foods and beverages and promoting increased physical activity.

Counsel survivors to engage in at least 150 minutes per week of physical activity, this may include weight-bearing exercises.

Counsel survivors to achieve a dietary pattern that is high in fruits and vegetables and whole grains.

Consume a diet emphasizing micronutrient-rich and phytochemical-rich vegetables and fruits, low amounts of saturated fat, intake of at least 600 IU of vitamin D per day, and consuming adequate, but not excessive, amounts of dietary sources of calcium (not to exceed 1,200 mg/d).
Refer survivors with nutrition-related challenges (eg, bowel problems that impact nutrient absorption) to a registered dietitian.

Counsel survivors to avoid or limit alcohol consumption to no more than two drinks per day.

Assess for tobacco use and offer and/or refer survivors to cessation counseling and resources. Counsel survivors to avoid tobacco products.

Surveillance for prostate cancer recurrence


Measure serum PSA [prostate-specific antigen] level every 6 to 12 months for the first 5 years, then recheck annually thereafter.

Prostate cancer specialists may recommend more frequent PSA monitoring during the early survivorship experience for some men, particularly men with higher risk of prostate cancer recurrence and/or men who may be candidates for salvage therapy. The exact schedule for PSA measurement should be determined by both the prostate cancer specialist and primary care physician in collaboration.

Ensure that survivors with elevated or rising PSA level are evaluated by their primary treating specialist for further follow-up and treatment.

Perform an annual DRE [digital rectal examination] in coordination with cancer specialist to avoid duplication.

Primary care physicians should discuss with the prostate cancer specialist the need for annual digital rectal examination (DRE), specifically as it relates to detection of disease recurrence in prostate cancer survivors.

Screening for second primary cancers


Adhere to American Cancer Society screening and early detection guidelines (cancer.org/professionals). Prostate cancer survivors having undergone radiation therapy may have slightly higher risk of bladder and colorectal cancersa and may need to follow screening guidelines for higher-risk individuals, if available.

Patients and physicians should be informed of the increased risk of bladder and colorectal cancer (CRC) after pelvic radiation therapy. Patients should undergo routine screening for CRC as suggested by existing evidence-based guidelines and should undergo appropriate evaluation for any signs or symptoms suggestive of either bladder cancer or CRC.

For survivors presenting with hematuria, perform a thorough evaluation to determine the cause of symptoms and to rule out bladder cancer, including urologist referral for cystoscopy and upper urinary tract evaluation.

Refer survivors presenting with persistent rectal bleeding, pain, or other symptoms of unknown origin to the appropriate specialist as well as the treating radiation oncologist to conduct a thorough evaluation for cause of symptoms and to evaluate for colorectal cancer.

Assessment and management of physical and psychosocial effects of prostate cancer and treatment

Anemia: specific risk for men receiving ADT [androgen-deprivation therapy]


Perform annual CBC to monitor hemoglobin levels, particularly in men presenting with symptoms suggestive of anemia.

[the ASCO Panel has changed “Perform” to “Consider”]

Bowel dysfunction


Discuss bowel function and symptoms (eg, rectal bleeding) with survivors.

For men with a negative colorectal cancer screening result, prescribe stool softeners, topical steroids, or anti-inflammatories for survivors experiencing rectal bleeding.

For survivors experiencing rectal bleeding after radiation therapy, CRC should be ruled out and appropriate management should be discussed with the treating Radiation Oncologist. Management may include corticosteroid suppositories to decrease inflammation, stool softeners, and dietary changes.

Refer survivors with persistent rectal symptoms (eg, bleeding, sphincter dysfunction, rectal urgency, and frequency) to the appropriate specialist

Cardiovascular and metabolic effects: specific risk for men receiving ADT


Follow USPSTF [US Preventive Services Task Force] guidelines for evaluation and screening for cardiovascular risk factors, blood pressure monitoring, lipid profiles, and serum glucose (http://www.uspreventiveservicestaskforce.org//uspstopics.htm)

Distress/depression/PSA anxiety


Assess for distress/depression/PSA anxiety at initial visit, at appropriate intervals, and as clinically indicated. (Note. The Panel removed wording that recommended assessment should occur “periodically, at least annually” and removed the suggestion that a “simple screening tool” be used “such as the Distress Thermometer.”)

Physicians should refer to ASCO’s Screening, Assessment, and Care of Anxiety and Depressive Symptoms in Adults With Cancer guideline (www.asco.org/adaptations/depression) for more information on management of this important problem.

Manage distress/depression using in-office counseling resources or pharmacotherapy as appropriate

If office-based counseling and treatment are insufficient, refer survivors experiencing distress/depression for further evaluation and or treatment by appropriate specialists.

Fracture risk/osteoporosis: specific risk for men receiving ADT


Assess risk of fracture for men treated with ADT or older radiation techniques through baseline DEXA [dual energy x-ray absorptiometry] scan and calculation of a FRAX [WHO fracture risk assessment] score.

For men determined to be high risk, prescribe weekly bisphosphonate therapy (oral alendronate at a dose of 70 mg) or annual intravenous zoledronic acid at a dose of 5 mg to increase bone density. Denosumab is also approved by the FDA [US Federal Drug Administration] to treat men at increased risk of osteoporosis.

A collaborative strategy should be developed between the primary care physician and prostate cancer specialist to optimize bone health in men at risk for osteoporosis. This strategy should include a thorough discussion of the benefits and harms of bone-targeted agents.

Sexual dysfunction/body image


Discuss sexual function with survivors.

Use validated tools to monitor erectile function over time. (Note: The ASCO Panel removed the reference to “the SHIM” tool)

Erectile dysfunction may be addressed through a variety of options, including penile rehabilitation or prescription of phosphodiesterase type 5 inhibitors (eg, sildenafil, vardenafil, tadalafil 25).

Refer men with persistent sexual dysfunction to a urologist, sexual health specialist, or psychotherapist to review treatment and counseling options.

Sexual intimacy


Encourage couples to discuss their sexual intimacy and refer to counseling or support services as appropriate.

Prescribe medication as described above to address erectile dysfunction.

Instruct couples on use of sexual aids to improve erectile dysfunction for men/male partners as well as postmenopausal symptoms for women. Refer to mental health professional with expertise in sex therapy.

Urinary dysfunction


Discuss urinary function (eg, urinary stream, difficulty emptying the bladder) and incontinence with all survivors.

Consider timed voiding, prescribing anticholinergic medications (eg, oxybutynin) to address issues such as nocturia, frequency, or urgency. Consider alpha-blockers (eg, tamsulosin) for slow stream.

Refer survivors with postprostatectomy incontinence to a physical therapist for pelvic floor rehabilitation; at a minimum, instruct survivors about Kegel exercises

Refer men with persistent, bothersome leakage or other urinary symptoms to a urologist for further evaluation (eg, urodynamic testing, cystoscopy) and discussion of treatment options including surgical placement of a male urethral sling or artificial urinary sphincter for incontinence.

Vasomotor symptoms (eg, hot flushes): specific risk for men receiving ADT


Although not approved by the FDA for this indication, prescription of selective serotonin or noradrenergic reuptake inhibitors or gabapentin may offer symptom relief.

The Endorsement Panel believes further clinical investigation is required to validate this recommendation. Until that time, physicians should be aware of the development of vasomotor symptoms with ADT and should discuss with their patients the risks, benefits, and costs of available therapies for possible symptom relief.

Care coordination and practice implications


The primary treating specialist is encouraged to provide a treatment summary and survivorship care plan to the primary care clinician (PCC) when survivorship care is transferred to the PCC. PCCs and treating oncology specialists should confer regarding the survivorship care plan components and determine roles and responsibilities that are appropriate for the survivor’s condition and the resources available in the primary care setting.

PCCs should maintain their role as general medical care coordinator throughout the spectrum of prostate cancer detection, treatment, and aftercare, focusing on preventive care and the management of preexisting comorbid conditions, regularly addressing the patient’s overall physical and psychosocial status, and those components of survivorship care that are mutually agreed upon with the treating clinicians.

Annually assess for the presence of long-term or late effects of prostate cancer and its treatment, including potential urinary, bowel, sexual, and hormonal symptoms.

The ASCO Panel removed the following: “Use of a validated tool such as EPIC-CP may be helpful in this assessment.”

Encourage the inclusion of caregivers, spouses, or partners in usual prostate cancer survivorship care.

Refer survivors to appropriate community-based and peer support resources.

aASCO Footnote: Based on Level 2A evidence

25.Pisansky TM, Pugh SL, Greenberg RE, et al.: Tadalafil for prevention of erectile dysfunction after radiotherapy for prostate cancer: the Radiation Therapy Oncology Group [0831] randomized clinical trial. JAMA 311:1300-7, 2014