[Moderate recommendation] Clinicians should obtain tissue diagnosis from the primary tumor or site of metastases when clinically feasible in patients with suspicion of advanced prostate cancer and no prior histologic confirmation. [Very low evidence] Based on Clinical Principle (consensus without direct evidence).
[Moderate recommendation] Clinicians should discuss treatment options based on life expectancy, comorbidities, preferences, and tumor characteristics, and incorporate a multidisciplinary approach when available in advanced prostate cancer patients. [Very low evidence] Based on Clinical Principle.
[Moderate recommendation] Clinicians should optimize pain control or other symptom support and encourage engagement with professional or community-based resources, including patient advocacy groups, in advanced prostate cancer patients. [Very low evidence] Based on Clinical Principle.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation based on expert opinion] Clinicians should discuss the risk of osteoporosis associated with ADT and assess the risk of fragility fracture in patients with advanced prostate cancer.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation based on expert opinion] Clinicians should recommend preventative treatment for fractures and skeletal-related events, including supplemental calcium, vitamin D, smoking cessation, and weight-bearing exercise, to advanced prostate cancer patients on ADT.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation based on expert opinion] In advanced prostate cancer patients at high fracture risk due to bone loss, clinicians should recommend preventative treatments with bisphosphonates or denosumab and consider referral to specialists.
[Strong recommendation] Yes, clinicians should use PSA as the first screening test for prostate cancer. [High evidence] This is based on multiple RCTs demonstrating benefit in reducing metastasis and mortality.
[Strong recommendation] Moderate hypofractionation should be offered to low-risk prostate cancer patients who reject active surveillance and are receiving EBRT to the prostate with or without seminal vesicles irradiation. [High evidence] Based on multiple RCTs demonstrating similar cancer control and toxicity compared to conventional fractionation.
[Strong recommendation] Moderate hypofractionation should be offered to intermediate-risk prostate cancer patients receiving EBRT to the prostate with or without seminal vesicles irradiation. [High evidence] Based on multiple RCTs showing non-inferior cancer control and comparable toxicity.
[Strong recommendation] Moderate hypofractionation should be offered to high-risk prostate cancer patients receiving EBRT to the prostate without pelvic lymph node irradiation. [High evidence] Based on RCTs demonstrating similar cancer control and toxicity across risk groups.
[Conditional recommendation] Ultra-hypofractionation can be offered as an alternative to conventional fractionation for low-risk prostate cancer patients who reject active surveillance and choose active treatment with EBRT. [Moderate evidence] Based on prospective non-randomized studies showing acceptable outcomes, but limited long-term data.
[Conditional recommendation] Ultra-hypofractionation can be offered as an alternative to conventional fractionation for intermediate-risk prostate cancer patients receiving EBRT, but the task force strongly recommends that these patients be treated as part of a clinical trial or multi-institutional registry. [Low evidence] Based on limited comparative data, with insufficient evidence from randomized trials.
[Conditional recommendation] Ultra-hypofractionation is not suggested for high-risk prostate cancer patients receiving EBRT outside of a clinical trial or multi-institutional registry due to insufficient comparative evidence. [Low evidence] Based on limited data, with no published RCTs comparing ultra-hypofractionation to conventional fractionation in this population.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should inform patients undergoing localized prostate cancer treatment of all known factors that could affect continence. [Moderate evidence] This is based on Grade B evidence, indicating moderate certainty.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should counsel patients regarding the risk of sexual arousal incontinence and climacturia following localized prostate cancer treatment. [Moderate evidence] This is based on Grade B evidence, indicating moderate certainty.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should not routinely perform abdomino-pelvic CT scan or bone scan in asymptomatic patients with low- or intermediate-risk prostate cancer. [Expert opinion] This is based on expert consensus.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should obtain a bone scan and either pelvic mpMRI or CT scan for patients with high-risk prostate cancer. [Moderate evidence] This recommendation is based on moderate-quality evidence.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may obtain molecular imaging to evaluate for metastases in patients with prostate cancer at high risk for metastatic disease with negative conventional imaging. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should provide an individualized risk estimate of post-treatment prostate cancer recurrence to patients. [Expert opinion] This is based on clinical principle and expert consensus.
[STRONG recommendation, HIGH evidence] [Strong recommendation] For patients with favorable intermediate-risk prostate cancer, clinicians should discuss active surveillance, radiation therapy, and radical prostatectomy. [High evidence] This is based on high-quality evidence from well-conducted studies.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should inform patients with intermediate-risk prostate cancer considering ablation about the lack of high-quality data compared to other treatments. [Expert opinion] This is based on expert consensus.
[STRONG recommendation, HIGH evidence] [Strong recommendation] For patients with unfavorable intermediate- or high-risk prostate cancer and estimated life expectancy greater than 10 years, clinicians should offer a choice between radical prostatectomy or radiation therapy plus ADT. [High evidence] This is based on high-quality evidence from well-conducted studies.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should not recommend whole gland or focal ablation for patients with high-risk prostate cancer outside of a clinical trial. [Expert opinion] This is based on expert consensus.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may recommend palliative ADT alone for patients with high-risk prostate cancer, local symptoms, and limited life expectancy. [Expert opinion] This is based on expert consensus.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Clinicians should utilize dose escalation when EBRT is the primary treatment for patients with prostate cancer. [High evidence] This is based on high-quality evidence from well-conducted studies.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Clinicians should offer moderate hypofractionated EBRT for patients with low- or intermediate-risk prostate cancer who elect EBRT. [High evidence] This is based on high-quality evidence from well-conducted studies.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may offer ultra hypofractionated EBRT for patients with low- or intermediate-risk prostate cancer who elect EBRT. [Moderate evidence] This is based on moderate-quality evidence, and the decision should be individualized.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should not electively radiate pelvic lymph nodes in patients with low- or intermediate-risk prostate cancer electing radiation therapy. [Moderate evidence] This is based on moderate-quality evidence.
[MODERATE recommendation, MODERATE evidence] [Moderate recommendation] Clinicians should not routinely use ADT in patients with low- or favorable intermediate-risk prostate cancer electing radiation therapy. [Moderate evidence] This is based on moderate-quality evidence.
[STRONG recommendation, HIGH evidence] [Strong recommendation] In patients with unfavorable intermediate-risk prostate cancer electing radiation therapy, clinicians should offer the addition of short-course ADT. [High evidence] This is based on high-quality evidence from well-conducted studies.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Clinicians should offer moderate hypofractionated EBRT for patients with high-risk prostate cancer who are candidates for EBRT. [Low evidence] This is based on low-quality evidence from studies with limitations.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may offer radiation to the pelvic lymph nodes in patients with high-risk prostate cancer electing radiation therapy. [Moderate evidence] This is based on moderate-quality evidence, and the decision should be individualized.
[STRONG recommendation, HIGH evidence] [Strong recommendation] In patients with high-risk prostate cancer electing radiation therapy, clinicians should recommend the addition of long-course ADT. [High evidence] This is based on high-quality evidence from well-conducted studies.
[Strong recommendation] Inform patients that there is no evidence linking testosterone therapy to prostate cancer development. [Moderate evidence] Based on moderate certainty evidence.
[Strong recommendation] Clinicians should inform patients of the absence of evidence linking testosterone therapy to the development of prostate cancer. [Moderate evidence] Based on Grade B evidence.
[Conditional recommendation] Patients with testosterone deficiency and a history of prostate cancer should be informed that there is inadequate evidence to quantify the risk-benefit ratio of testosterone therapy. [Expert opinion] Based on expert consensus.
[CONDITIONAL recommendation, MODERATE evidence] [Conditional recommendation] Clinicians may inform patients that no causal link has been established between vasectomy and prostate cancer. [Moderate evidence] Based on Grade B evidence with moderate certainty.
[Strong recommendation] Use the TNM classification for staging prostate cancer. [Expert opinion] Based on guideline consensus.
[Strong recommendation] Use the ISUP 2019 system for grading prostate cancer. [Expert opinion] Based on guideline consensus.
[Strong recommendation] Offer active surveillance as the standard of care for low-risk prostate cancer. [Expert opinion] Based on guideline consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should inform patients about treatment risks and incorporate these with cancer risk, life expectancy, and preferences to facilitate shared decision-making. [Expert opinion] This is based on clinical principle and expert consensus.
[Conditional recommendation] Offer active surveillance as first-line; consider radical prostatectomy or radiotherapy if active surveillance is not suitable. [High evidence] Based on the UK ProtecT trial showing benefits and risks.
[Conditional recommendation] Consider a suspected cancer pathway referral for individuals with symptoms as per 1.6.2 if their PSA exceeds age-specific thresholds, taking into account patient preferences and comorbidities.
[MODERATE recommendation, LOW evidence] [Moderate recommendation] Men post-RP or RT should be informed that early PDE5i use may not improve spontaneous, unassisted erectile function. [Low evidence] This is based on low-quality evidence from observational studies.
[Weak recommendation] Yes, clinicians should engage in shared decision-making with appropriate patients, proceeding based on patient values and preferences. [Expert opinion evidence] This is based on clinical consensus rather than direct evidence.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Efforts should be made by clinicians, payors, and healthcare systems to bridge the gap in access and affordability of diagnostic or imaging modalities. [Moderate evidence] This is based on observational studies showing dramatic disparities.
[Moderate recommendation] Moderate hypofractionated radiotherapy is recommended as it provides similar efficacy to conventional fractionation based on high evidence from multiple randomized controlled trials.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Clinicians should use clinical T stage, serum PSA, Grade Group, and tumor volume on biopsy for risk stratification. [High evidence] This recommendation is based on high-quality evidence from well-conducted studies.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may selectively use tissue-based genomic biomarkers when added risk stratification may alter clinical decision-making. [Expert opinion] This is based on expert consensus without direct evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] In patients selecting active surveillance, clinicians should utilize mpMRI to augment risk stratification, but not replace periodic biopsy. [Expert opinion] This is based on expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should utilize available techniques like target localization and image-guidance to optimize the therapeutic ratio of EBRT. [Expert opinion] This is based on clinical principle and expert consensus.
[CONDITIONAL recommendation, LOW evidence] [Conditional recommendation] Clinicians may counsel patients that proton therapy is an option, but it has not been shown superior to other modalities. [Low evidence] This is based on low-quality evidence, and the decision should be individualized.
[STRONG recommendation, MODERATE evidence] [Strong recommendation] Clinicians should offer dose-escalated hypofractionated EBRT, LDR seed implant, or HDR implant as equivalent treatments. [Moderate evidence] This is based on moderate-quality evidence from studies.
[STRONG recommendation, HIGH evidence] [Strong recommendation] Clinicians should offer dose-escalated hypofractionated EBRT or combined EBRT + brachytherapy with ADT. [High evidence] This is based on high-quality evidence from well-conducted studies.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may use combined androgen suppression, LHRH agonist alone, or LHRH antagonist alone when combining ADT with radiation therapy. [Expert opinion] This is based on expert consensus without direct evidence.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should monitor patients post therapy with PSA and symptom assessment. [Expert opinion] This is based on clinical principle and expert consensus.
[MODERATE recommendation, EXPERT OPINION evidence] [Moderate recommendation] Clinicians should support patients through symptom management and encouraging engagement with resources. [Expert opinion] This is based on clinical principle and expert consensus.
[WEAK recommendation, EXPERT OPINION evidence] [Weak recommendation] Clinicians may use combined androgen suppression, an LHRH agonist alone, or an LHRH antagonist alone, based on expert opinion.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should monitor patients with PSA and symptom assessment, based on clinical principles and expert opinion.
[STRONG recommendation, EXPERT OPINION evidence] [Strong recommendation] Clinicians should support patients through continued symptom management and encouraging engagement with professional or community-based resources, based on clinical principles and expert opinion.
[Strong recommendation] Offer multiparametric MRI and report results using a 5-point Likert scale. [High evidence] Based on good evidence from clinical trials, including a large UK study.
[Strong recommendation] Do not routinely offer isotope bone scans. [Moderate evidence] Based on committee assessment and alignment with current practice.
[Weak recommendation] Discuss docetaxel chemotherapy as an option, explaining benefits and harms for shared decision-making. [High evidence] Based on a large UK randomised trial showing delay in disease progression but unclear survival benefit.
[Strong recommendation] Offer docetaxel chemotherapy, starting within 12 weeks of androgen deprivation therapy, using six cycles at 75 mg/m2. [High evidence] Based on good evidence from RCTs demonstrating improved survival.
[Conditional recommendation] Clinicians may perform SABR MDT, but must weigh toxicity risks against potential benefits. [Low evidence] Based on phase 2 trials and observational data (Grade C).
[Strong recommendation] Inform them that there is inadequate evidence to quantify the risk-benefit ratio of therapy. [Expert opinion] Based on expert consensus.
[Strong recommendation] Clinical stage should be based on digital rectal examination only, with imaging findings reported separately. [Expert opinion] Based on guideline consensus.
[Strong recommendation] Offer early PSA testing to well-informed men at elevated risk, including those aged 50+, those with family history from 45+, African descent from 45+, and BRCA2 mutations from 40+. [Expert opinion] Based on guideline consensus.
[Strong recommendation] Offer ADT combined with abiraterone plus prednisone, apalutamide, or enzalutamide to fit patients with M1 disease. [Expert opinion] Based on guideline consensus.
[Strong recommendation] Offer 177Lu-PSMA-617 to pre-treated mCRPC patients with PSMA-expressing metastases on PET/CT scan. [Expert opinion] Based on guideline consensus.
[Moderate recommendation] Consider PSA testing and digital rectal examination for individuals with lower urinary tract symptoms, erectile dysfunction, or visible haematuria.
[Strong recommendation] Moderate hypofractionation should be offered to prostate cancer patients candidates for EBRT regardless of age, comorbidities, anatomy, or urinary function. [High evidence] Based on RCTs indicating no significant impact of these factors on treatment efficacy.
[Strong recommendation] Yes, measure PSA in men over 40 years old before therapy to exclude prostate cancer. [Expert opinion] Based on clinical principle and consensus.