A Look at the Updates in the NCCN Clinical Practice Guidelines For Prostate Cancer

The NCCN clinical practice guidelines for patients with prostate cancer have been updated. With a survival rate of 97% in patients that receive a diagnosis, prostate cancer has a much higher survival rate compared to other forms of cancer. The general public being more aware of prostate cancer has helped patients to receive earlier diagnoses than in previous years. However, the NCCN guidelines note that there are inequities in the incidence rate and mortality across different ethnic groups. For example, among Black individuals the prostate cancer incidence rate is 70% higher than in their White peers, and the mortality rate for Black individuals is 2-4x higher than all ethnic groups. The changes NCCN has made to the clinical practice guidelines are in regard to preventive screening and patient management.

NCCN guidelines recommend androgen deprivation therapy (ADT) with treatment intensification for patients with metastatic castration-sensitive prostate cancer. Physicians should not use ADT monotherapy unless the patient exhibits clear contraindications to a combination therapy. Doublet and triplet therapies are all preferred treatment methods. Some of the treatment intensification options listed that align with NCCN guidelines are doublet therapy of ADT with abiraterone, apalutamide, or enzalutamide; triplet therapy of ADT with docetaxel and abiraterone or darolutamide; or ADT with external beam radiation therapy to the primary tumor.

Furthermore, patients that received ADT showed enhanced autocrine, or paracrine, synthesis in their tumor’s microenvironment. The presence of androgen signaling has changed the understanding of the responsiveness of castration-resistant prostate cancer (CRPC) to additional hormone therapies, leading to a reconsideration of the beliefs in previous NCCN guidelines. This development in CRPC treatment has changed how physicians use novel hormonal agents for prostate cancer.

Radiopharmaceuticals have also received an update. Radium-223 may be safe for use in treatment with a secondary hormone therapy, but more research needs to be done to determine its efficacy levels. Lu-177-PSMA-617 is a highly recommended therapy for patients with metastatic disease that is predominately PSMA-positive. The NCCN Prostate Cancer Panel also recommended F-18 piflufolastat PSMA and F-18 flotufolastat PSMA, as they have found several reports that describe the two imaging agents as equals.

The NCCN guidelines are created to provide physicians with a framework for treatment. Physicians need to keep in mind that each patient will still need therapy tailored to their unique experience with prostate cancer. Conditions such as life expectancy, disease characteristics, predicted outcomes, and patient preferences may change throughout treatment.

Source:

Schaeffer EM, Srinivas S, Adra N, et al. Prostate Cancer, Version 4.2023, NCCN Clinical Practice Guidelines in Oncology. Journal of the National Comprehensive Cancer Network. 2023;21(10):1067-1096. doi:10.6004/jnccn.2023.0050