The Society of Surgical Oncology surgical practice guidelines focus
on the signs and symptoms of primary cancer, timely evaluation of the symptomatic
patient, appropriate preoperative evaluation for extent of disease, and
role of the surgeon in diagnosis and treatment. Separate sections on adjuvant
therapy, follow-up programs, or management of recurrent cancer have been
intentionally omitted. Where appropriate, perioperative adjuvant combined-modality
therapy is discussed under surgical management. Each guideline is presented
in minimal outline form as a delineation of therapeutic options.
Since the development of treatment protocols was not the specific aim
of the Society, the extensive development cycle necessary to produce evidence-based
practice guidelines did not apply. We used the broad clinical experience
residing in the membership of the Society, under the direction of Alfred
M. Cohen, md, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer
Center, to produce guidelines that were not likely to result in significant
Following each guideline is a brief narrative highlighting and expanding
on selected sections of the guideline document, with a few relevant references.
The current staging system for the site and approximate 5-year survival
data are also included.
The Society does not suggest that these guidelines replace good medical
judgment. That always comes first. We do believe that the family physician,
as well as the health maintenance organization director, will appreciate
the provision of these guidelines as a reference for better patient care.
Symptoms and Signs
- Early-stage disease
- Related to prostatism
- Diminished force of stream
- Frequency and urgency related to benign prostate hyperplasia (BPH)
or prostate cancer
- Palpation for nodularity or firmness on digital rectal examination
- Routine prostate specific antigen (PSA) test more than 4 ng/mL
- Age-specific reference ranges have been suggested but have not proven
to be beneficial.
- Advanced-stage disease
- Symptoms secondary to disseminated disease
serum alkaline phosphatase, especially isoenzymes.
with elevation in serum creatinine or blood urea nitrogen, and secondary
metabolic effects associated with azotemia.
be related to widespread bone marrow replacement and secondary involvement
of the bone marrow, particularly platelets and red cell count.
Evaluation of the Symptomatic Patient
- Previous health history or the previous studies obtained by the referring
- PSA: normal range 0-4 ng/mL. Some authors have advocated age-related
PSA values. PSA velocity more than 0.8 ng/mL per year is cause for concern.
- CBC and evaluation of renal function
- Physical examination
- Include palpation of the abdomen and digital rectal examination.
- Transrectal ultrasound with biopsy is often utilized for patients with
elevation of PSA alone.
- The major role of transrectal ultrasound is identification of hypoechoic
areas and guidance of needle biopsies into different areas of the prostate.
- Cystoscopy may be indicated for hematuria.
- Appropriate timeliness of surgical referral
- Depends upon the degree and severity of signs and symptoms, as well
as laboratory tests compatible with either localized or disseminated disease
- Reasonable interval for evaluation should be within 4 weeks.
Preoperative Evaluation for Extent of Disease
- Staging studies for localized disease
- Digital rectal examination
- Transrectal ultrasound
- Gleason sum of the biopsy specimen
- Number and percentage of cores involved with prostate cancer and level
- For extracapsular disease involvement, include CT scan, which seems
to be useful predominantly for involvement of seminal vesicles, or endorectal
surface coil MRI.
- MRI seems to be the most accurate imaging study for local staging,
although data with clinical surgical correlation are still accumulating.
- Evaluation for metastatic disease
- Include a bone scan of the bony skeleton if PSA more than 8 ng/mL
- Regional lymph node involvement. CT scan is only modestly useful for the evaluation of the regional lymph
nodes that lie in the obturator and external iliac chain.
Role of the Surgeon in Initial Management
- Evaluation of the symptomatic patient
- The surgeon is often involved in establishing the diagnosis of prostate
cancer. Patients with a palpable nodule or elevated PSA generally undergo
transrectal ultrasound, done either by a urologist or radiologist, with
ultrasound-directed needle biopsies using a spring-loaded biopsy gun.
- For patients with palpable nodules, digitally directed biopsies may
- For patients with hypoechoic areas seen on ultrasound, biopsies can
be directed through the hypoechoic area.
- For patients with elevated PSA but no palpable or visual abnormalities,
six sector biopsies of the prostate are obtained. The surgeon generally
assumes the role of diagnostician to obtain selected staging studies as
indicated, based on the patient's symptoms.
- Diagnostic procedures
- Transrectal ultrasound-guided needle biopsies of the prostate
- Surgical considerations
- Unilateral or bilateral nerve-sparing radical retropubic prostatectomy
- Radical perineal prostatectomy
- Lymphadenectomy via open or laparoscopic approach
- Other therapeutic considerations
- External-beam radiation therapy
- Interstitial radiation therapy
- Hormonal manipulation
These guidelines are copyrighted by the Society of Surgical Oncology
(SSO). All rights reserved. These guidelines may not be reproduced in any
form without the express written permission of SSO. Requests for reprints
should be sent to: James R. Slawny, Executive Director, Society of Surgical
Oncology, 85 W Algonquin Road, Arlington Heights, IL 60005.
An estimated 317,100 new cases of prostate cancer were diagnosed in
the United States in 1996 with 41,400 concurrent deaths. The most important
risk factors for prostate cancer, as they are understood today, are a positive
family history and being of the African-American race. For this and
other reasons, the American Cancer Society, American Urologic Association,
American College of Radiology, and College of American Pathology all recommend
an annual digital rectal examination and a prostate-specific antigen (PSA)
blood test commencing at age 50. However, for those with either of the
two risk factors, annual testing is recommended beginning at age 40.
The American Cancer Society has followed a cohort of men, age 55 years
and older, since 1988, and based on these and other data, has determined
that the tumors detected by early detection efforts are clinically significant
and warrant treatment.[3-6]
In general, 0 to 4 ng/mL (Hybritech Tandem-R) is considered the normal
range for PSA. Other applications of PSA evaluation include PSA density,
PSA velocity, and age-related levels. All of these, with the exception
of the age-related levels, appear to offer some individual benefit with
regard to increased sensitivity but at the expense of decreased specificity.[5,6]
1. Cancer Facts & Figures--1996. Atlanta, American Cancer Society,
2. Mettlin C, Jones G, Averette H, et al: Defining and updating the
American Cancer Society guidelines for the cancer-related check-up: Prostate
and endometrial cancer. CA Cancer J Clin 43(1):42-46, 1993.
3. Murphy GP: Prostate cancer: Here and now. CA Cancer J Clin 45(3):133,
4. Slawin KM, Ohori M, Dillioglugil O, et al: Screening for prostate
cancer: An analysis of the early experience. CA Cancer J Clin 45(3):134-147,
5. Brawer MK: How to use prostate-specific antigen in the early detection
or screening for prostatic carcinoma. CA Cancer J Clin 45(3):148-164, 1995.
6. Denis LJ, Murphy GP, Schröder FH: Report of the Consensus Workshop
on Screening and Global Strategy for Prostate Cancer. Cancer 75(5):1187-1207,
7. Partin AW, Yoo J, Carter HB, et al: The use of prostate specific
antigen, clinical stage, and Gleason score to predict pathological stage
in men with localized prostate cancer. J Urol 150:110-4, 1993.
8. Labrie F, Dupont A, Cusan L: Downstaging of localized prostate cancer
by neoadjuvant therapy with flutamide and Lupron: The first controlled
and randomized trial. Clin Invest Med 16:499-509, 1993.
9. Wolf LS Jr, Shinohara K, Carroll PR, et al: Combined role of transrectal
ultrasonography, Gleason score, and prostate-specific antigen in predicting
organ-confined prostate cancer. Urology 41:207-216, 1993.
10. Mettlin C, Murphy GP, Menck H: Trends in treatment of localized
prostate cancer by radical prostatectomy: Observations from the Commission
on Cancer National Cancer Database, 1985-1990. Urology 43(4):488-492, 1993.
11. Murphy GP, Mettlin C, Menck H, et al: National patterns of prostate
cancer treatment by radical prostatectomy: Results of a survey by the American
College of Surgeons Commission on Cancer. J Urol 152(suppl):1817-1819,
12. Hanks GE, Krall JM, Hanlon AL, et al: Patterns of care and RTOG
studies in prostate cancer: Long-term survival, hazard rate observations,
and possibilities of cure. Int J Radiat Oncol Biol Phys 28:39-45, 1994.
13. Bagshaw MA, Kaplan ID, Cox R: Radiation therapy for localized disease.
Cancer 71:939-52, 1993.
14. Porter AT, Blasko JC, Grimm PD, et al: Brachytherapy for prostate
cancer. CA Cancer J Clin 45(3):165-178, 1995.
15. Johansson J, Adami A, Andersson S, et al: High 10 year survival
rate in patients with early, untreated prostate cancer. JAMA 267:2191-6,
16. Whitmore WF, Warner JA, Thompson IM: expectant management of localized
prostatic cancer. Cancer 67:1091-1096, 1991.
17. Wynant GE, Murphy GP, Horoszewicz JD, et al: Immunoscintigraphy
of prostatic cancer: Preliminary results with 111In-labeled monoclonal
antibody 7E11.C5.3 (CYT-356). Prostate 18(3):229-241, 1991.
18. Murphy GP: Radioscintiscanning of prostate cancer. Cancer 75(7;
19. Murphy GP: Follow-up evaluation of National Prostatic Cancer Project
protocols and other studies. Urology 44(6A):61-66, 1994.
20. Murphy GP, Holmes EH, Boynton AL, et al: Comparison of prostate
specific antigen, prostate specific membrane antigen, and LNCaP-based enzyme-linked
immunosorbent assays in prostatic cancer patients and patients with benign
prostatic enlargement. Prostate 26(3):164-168, 1995.