EURURO Vol. 71 No. 4

631 692

1. Introduction
A prior summary of the European Association of Urology
(EAU) Guidelines on prostate cancer (PCa) was published in
2013 This paper summarises the many changes that
have occurred in the treatment of metastatic, relapsing, and
castration-resistant PCa (CRPC) over the past 3 yr. The
Guidelines on screening, diagnosis, and treatment of
clinically localised and locally advanced PCa were published
in a separate paper To facilitate evaluation of the quality
of the information provided, levels of evidence (LEs) and
grades of recommendation (GRs) have been inserted
according to the general principles of evidence-based
medicine
2. Diagnosis and treatment of relapse after curative
therapies
Physicians treating patients with prostate-specific antigen
(PSA)–only recurrence face a difficult set of decisions in
attempting to delay the onset of metastatic disease and
death while avoiding overtreatment of patients whose
disease may never affect their overall survival (OS) or
quality of life (QoL). It has to be emphasised that treatment
recommendations for these patients should be given after
discussion with a multidisciplinary team.
2.1. Definitions
Following radical prostatectomy (RP), biochemical recur-
rence (BCR) is defined by two consecutive rising PSA
values >0.2 ng/ml . After primary radiation therapy
(RT), the Radiation Therapy Oncology Group (RTOG) and
American Society for Radiation Oncology Phoenix Con-
sensus Conference definition of PSA failure is any PSA
increase 2 ng/ml higher than the PSA nadir value,
regardless of the serum concentration of the nadir
. Importantly, patients with PSA recurrence after RP
or primary RT have different risks of subsequent PCa-
specific mortality. For both groups, however, men with a
PSA doubling time (PSA DT) of <3 mo, stage T3b or higher,
Gleason score 8–10, and time to BCR of <3 yr represent a
subgroup with a high risk of developing metastases and
dying from PCa .
2.2. Staging
Because biochemical recurrence (BCR) after RP or RT
precedes clinical metastases by 7–8 yr on average, the
diagnostic yield of common imaging techniques is poor in
asymptomatic patients .
In men with PSA-only relapse after RP, the probability of
a positive bone scan is <5% if the PSA level is <7 ng/ml
. Consequently, bone scan and abdominopelvic com-
puted tomography (CT) should be considered only for
patients with BCR after RP who have a high baseline PSA
(>10 ng/ml) or high PSA kinetics (PSA DT <6 mo) or in
patients with symptoms of bone disease . Although its
sensitivity is low when the PSA level is <1 ng/ml, choline
positron emission tomography (PET)/CT may be helpful
in selecting patients for salvage therapy after [1_TD$DIFF]RP ,
especially if PSA DT is <6 mo Salvage RT (SRT) after RP
is usually decided on the basis of BCR, without imaging.
In patients with BCR after RT, the biopsy status is a major
predictor of outcome, provided the biopsies are obtained
18–24 mo after treatment. Given the morbidity of local
salvage options, it is necessary to obtain histologic proof of
the local recurrence before treating the patient Multi-
parametric magnetic resonance imaging (MRI) has yielded
excellent results in detecting local recurrences and
can be used for biopsy targeting and guidance of local
salvage treatment. Detection of local recurrence is also
feasible with choline and acetate PET/CT, but PET/CT has
poorer spatial resolution than MRI .
2.3. Management of prostate-specific antigen relapse following
radical prostatectomy
Early SRT provides a possibility of cure for patients with an
increasing PSA after RP. More than 60% of patients who are
treated before the PSA level rises to >0.5 ng/ml will achieve
an undetectable PSA level , providing patients with an
80% chance of being progression-free 5 yr later . The
addition of androgen deprivation therapy (ADT) to salvage
treatment of CRPC following docetaxel. Zoledronic acid and denosumab can be used in men
with mCRPC and osseous metastases to prevent skeletal-related complications.
Conclusions: The knowledge in the field of advanced and metastatic PCa and CRPC is
changing rapidly. The 2016 EAU-ESTRO-SIOG Guidelines on PCa summarise the most recent
findings and advice for use in clinical practice. These PCa guidelines are the first endorsed by
the European Society for Therapeutic Radiology and Oncology and the International Society
of Geriatric Oncology and reflect the multidisciplinary nature of PCa management. A full
version is available from the EAU office or online (
).
Patient summary: In men with a rise in their PSA levels after prior local treatment for
prostate cancer only, it is important to balance overtreatment against further progression of
the disease since survival and quality of life may never be affected inmany of these patients.
For patients diagnosed with metastatic castrate-resistant prostate cancer, several new
drugs have become available which may provide a clear survival benefit but the optimal
choice will have to be made on an individual basis.
# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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