Prostate Cancer Surgical Practice Guidelines

Scope and Format of Guidelines

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 controversy.

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.

Society of Surgical Oncology Practice Guidelines: Prostate Cancer

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
1. Pain
2. Anemia
3. Azotemia
• Above symptoms may cause shortness of breath, easy fatigability, or generalized debility.
• Signs are related to elevations in PSA and secondary alterations in serum alkaline phosphatase, especially isoenzymes.
• Other symptoms may be secondary to progressive obstructive disease with elevation in serum creatinine or blood urea(Drug information on urea) nitrogen, and secondary metabolic effects associated with azotemia.
• Further symptoms may be related to widespread bone marrow replacement and secondary involvement of the bone marrow, particularly platelets and red cell count.
• Hematuria may be noted but is rare.

Evaluation of the Symptomatic Patient

Work-up

• Previous health history or the previous studies obtained by the referring physician
• 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 of PSA
• 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 be utilized.
• 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
• Observation

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.[1] 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.[2] 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.[2] However, for those with either of the two risk factors, annual testing is recommended beginning at age 40.[2]

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.[5] Other applications of PSA evaluation include PSA density, PSA velocity, and age-related levels.[5] 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]