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Prostate cancer: diagnosis and management

This Guidelines summary provides the recommendations that are relevant to primary care. Please refer to the full guideline for the complete list of recommendations

Low-risk localised prostate cancer

Active surveillance

  • Offer active surveillance as an option to men with low-risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable
  • Consider using the protocol below for men who have chosen active surveillance:
    • Year 1 of active surveillance; every 3–4 months, measure prostate-specific antigen (PSA)
    • Years 2–4 of active surveillance; every 3–6 months, measure PSA
    • Year 5 and every year thereafter until active surveillance ends: every 6 months, measure PSA

Intermediate- and high-risk localised prostate cancer

Radical treatment

  • Commissioners of urology services should consider providing robotic surgery to treat localised prostate cancer
  • Commissioners should ensure that robotic systems for the surgical treatment of localised prostate cancer are cost effective by basing them in centres that are expected to perform at least 150 robot-assisted laparoscopic radical prostatectomies per year

Locally advanced prostate cancer

  • Do not offer bisphosphonates for the prevention of bone metastases in men with prostate cancer

Managing adverse effects of radical treatment

Sexual dysfunction

  • Ensure that men have early and ongoing access to specialist erectile dysfunction services
  • Offer men with prostate cancer who experience loss of erectile function phosphodiesterase type 5 (PDE5) inhibitors to improve their chance of spontaneous erections
  • If PDE5 inhibitors fail to restore erectile function or are contraindicated, offer men vacuum devices, intraurethral inserts or penile injections, or penile prostheses as an alternative

Urinary incontinence

  • Ensure that men with troublesome urinary symptoms after treatment have access to specialist continence services for assessment, diagnosis, and conservative treatment. This may include coping strategies, along with pelvic floor muscle re-education, bladder retraining, and pharmacotherapy
  • Refer men with intractable stress incontinence to a specialist surgeon for consideration of an artificial urinary sphincter

Radiation-induced enteropathy

  • Ensure that men with signs or symptoms of radiation-induced enteropathy are offered care from a team of professionals with expertise in radiation-induced enteropathy (who may include oncologists, gastroenterologists, bowel surgeons, dietitians, and specialist nurses)

Follow-up

  • Discuss the purpose, duration, frequency, and location of follow-up with each man with localised prostate cancer, and if he wishes, his partner or carers
  • Men with prostate cancer who have chosen a watchful waiting regimen with no curative intent should normally be followed up in primary care in accordance with protocols agreed by the local urological cancer multi-disciplinary team (MDT) and the relevant primary care organisation(s). Their PSA should be measured at least once a year
  • Do not routinely offer digital rectal exam (DRE) to men with localised prostate cancer while the PSA remains at baseline levels
  • After at least 2 years, offer follow-up outside hospital (for example, in primary care) by telephone or secure electronic communications to men with a stable PSA who have had no significant treatment complications, unless they are taking part in a clinical trial that requires formal clinic-based follow-up. Direct access to the urological cancer MDT should be offered and explained

Managing relapse after radical treatment

  • Do not routinely offer hormonal therapy to men with prostate cancer who have a biochemical relapse unless they have:
    • symptomatic local disease progression, or
    • any proven metastases, or
    • a PSA doubling time of less than 3 months

Men having hormone therapy

  • Consider intermittent therapy for men having long-term androgen deprivation therapy (not in the adjuvant setting), and include discussion with the man, and his partner, family, or carers if he wishes, about:
    • the rationale for intermittent therapy and
    • the limited evidence for reduction in side-effects from intermittent therapy and
    • the effect of intermittent therapy on progression of prostate cancer
  • For men who are having intermittent androgen deprivation therapy:
    • measure PSA every 3 months and
    • restart androgen deprivation therapy if PSA is 10 ng/ml or above, or if there is symptomatic progression

Managing adverse effects of hormone therapy

Hot flushes

  • Offer medroxyprogesterone (20 mg per day), initially for 10 weeks, to manage troublesome hot flushes caused by long-term androgen suppression and evaluate the effect at the end of the treatment period
  • Consider cyproterone acetate or megestrol acetate (20 mg twice a day for 4 weeks) to treat troublesome hot flushes if medroxyprogesterone is not effective or not tolerated
  • Tell men that there is no good-quality evidence for the use of complementary therapies to treat troublesome hot flushes

Sexual dysfunction

  • Ensure that men starting androgen deprivation therapy have access to specialist erectile dysfunction services
  • Consider referring men who are having long-term androgen deprivation therapy, and their partners, for psychosexual counselling
  • Offer PDE5 inhibitors to men having long-term androgen deprivation therapy who experience loss of erectile function

Osteoporosis

  • Consider assessing fracture risk in men with prostate cancer who are having androgen deprivation therapy, in line with NICE clinical guideline 146
  • Offer bisphosphonates to men who are having androgen deprivation therapy and have osteoporosis
  • Consider denosumab for men who are having androgen deprivation therapy and have osteoporosis if bisphosphonates are contraindicated or not tolerated

Fatigue

  • Tell men who are starting androgen deprivation therapy that fatigue is a recognised side-effect of this therapy and not necessarily a result of prostate cancer
  • Offer men who are starting or having androgen deprivation therapy supervised resistance and aerobic exercise at least twice a week for 12 weeks to reduce fatigue and improve quality of life

Metastatic prostate cancer

Information and support

  • Ensure that palliative care is available when needed and is not limited to the end of life. It should not be restricted to being associated with hospice care
  • Offer a regular assessment of needs to men with metastatic prostate cancer

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/CG175

National Institute for Health and Care Excellence. Prostate cancer: diagnosis and management. January 2014
First included: October 2011.