Introduction

Prostate cancer remains the most common noncutaneous cancer among U.S. men, with an estimated 268,490 new cases and 34,500 deaths in 2022.¹ The majority of newly diagnosed patients have clinically localized disease.¹ Providing evidence-based guideline statements to support clinical decision making represents an important component of delivering high-quality care. Given the recent breadth of investigation into various aspects of the evaluation and management of clinically localized prostate cancer (CLPC), the AUA, in collaboration with ASTRO (American Society for Radiation Oncology), updated the organization’s prior guideline. The 2022 iteration summarizes current evidence and provides specific guidance for patients and physicians in the management of CLPC.

The selection of a management strategy for CLPC is preference sensitive and includes patients’ interpretation of treatment-specific risks and benefits. Clinicians must inform patients thoroughly regarding the risks and benefits of various management options. Clinicians also must elicit patient values, preferences and concerns about treatment outcomes. This collaborative shared decision making (SDM) process is designed to yield a well-informed, high-quality management decision.²

Risk Assessment

An important component of the updated guideline is the continued utilization of a risk stratification classification for patients with newly diagnosed CLPC. Patients should be counseled regarding the severity of disease and documented natural history to provide perspective for SDM regarding the tradeoff between treatment-related side effects and the likelihood of disease progression.^3–5 Furthermore, risk level dictates the intensity of the staging evaluation and subsequent management while also facilitating clinical trial enrollment.

While recognizing that risk groups are updated as new information is gained, the guideline maintains a risk group approach as a framework to discuss relevant management options. To this end, the guideline discusses the roles of clinical T stage, serum prostate specific antigen, Grade Group (Gleason score) and tumor volume on biopsy as means to inform risk.

Staging

Imaging studies are intended to define the local extent of disease as well as determine the presence of nodal and distant metastases, and thereby inform management. The guideline emphasizes the use of a risk-based approach to staging for patients with newly diagnosed CLPC, considering the probability of the patient harboring metastatic disease as well as the sensitivity and specificity of each imaging modality. The Panel acknowledges that the role of next generation imaging is an area of active investigation and that the impact on clinical decision making and patient outcomes remains to be determined.

Risk-Based Management

Recognizing that each management option is associated with its own unique benefit/risk profile for each patient, the patient should be well informed regarding potential cancer control outcomes as well as expected risks and side effects in order to compare the options and facilitate clear expectations. Specifying the likelihood of various outcome scenarios with each treatment can facilitate SDM, and there are tools available to estimate the likelihood of functional outcomes with each treatment.³ With this in mind, the Panel makes risk-based recommendations regarding multiple management options, including active surveillance, surgery, radiation, systemic therapy and ablation.

Followup after Treatment

Monitoring after treatment is necessary to identify recurrence as well as complications from treatment, and thereby facilitate early intervention as appropriate. The Panel includes specific recommendations regarding initial and ongoing monitoring, and highlights the importance of routine discussion of urinary, bowel and sexual function with the use of standardized/validated instruments.

Clinicians should support patients with CLPC through continued symptom management and encourage engagement with professional or community-based resources. The array of survivorship needs for an individual patient and caregiver may be broad and should be explored by the clinician and team to ensure that appropriate support, especially peer support, is offered.

Conclusion

CLPC remains among the most active areas of investigation in urology. As such, patient care will likely continue to be refined—and enhanced—in the near future. The full unabridged guideline will be available online at auanet.org/guidelines and featured in plenary and course presentations at AUA Annual Meeting 2022.