title: EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part II: Treatment of Relapsing, Metastatic, and Castration-Resistant Prostate Cancer.
abstract: To present a summary of the 2016 version of the European Association of Urology (EAU) - European Society for Radiotherapy & Oncology (ESTRO) - International Society of Geriatric Oncology (SIOG) Guidelines on the treatment of relapsing, metastatic, and castration-resistant prostate cancer (CRPC).
  
  
  
  The working panel performed a literature review of the new data (2013-2015). The guidelines were updated, and the levels of evidence and/or grades of recommendation were added based on a systematic review of the literature.
  
  
  
  Relapse after local therapy is defined by a rising prostate-specific antigen (PSA) level >0.2ng/ml following radical prostatectomy (RP) and >2ng/ml above the nadir after radiation therapy (RT).11C-choline positron emission tomography/computed tomography is of limited importance if PSA is <1.0ng/ml; bone scans and computed tomography can be omitted unless PSA is >10ng/ml. Multiparametric magnetic resonance imaging and biopsy are important to assess biochemical failure following RT. Therapy for PSA relapse after RP includes salvage RT at PSA levels <0.5ng/ml and salvage RP, high-intensity focused ultrasound, cryosurgical ablation or salvage brachytherapy of the prostate in radiation failures. Androgen deprivation therapy (ADT) remains the basis for treatment of men with metastatic prostate cancer (PCa). However, docetaxel combined with ADT should be considered the standard of care for men with metastases at first presentation, provided they are fit enough to receive the drug. Follow-up of ADT should include analysis of PSA, testosterone levels, and screening for cardiovascular disease and metabolic syndrome. Level 1 evidence for the treatment of metastatic CRPC (mCRPC) includes, abiraterone acetate plus prednisone (AA/P), enzalutamide, radium 223 (Ra 223), docetaxel at 75 mg/m2every 3 wk and sipuleucel-T. Cabazitaxel, AA/P, enzalutamide, and radium are approved for second-line treatment of CRPC following docetaxel. Zoledronic acid and denosumab can be used in men with mCRPC and osseous metastases to prevent skeletal-related complications.
  
  
  
  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 (http://uroweb.org/guideline/prostate-cancer/).
  
  
  
  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 in many 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.
authors: Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK. Electronic address: Philip.Cornford@rlbuht.nhs.uk.
authors: Philip
authors: P
authors: Cornford
authors: Bladder Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
authors: Joaquim
authors: J
authors: Bellmunt
authors: Department of Radiation Therapy, CHU Grenoble, Grenoble, France.
authors: Michel
authors: M
authors: Bolla
authors: Patient Advocate, Hasselt, Belgium.
authors: Erik
authors: E
authors: Briers
authors: University of Warwick, Cancer Research Centre, Coventry, UK.
authors: Maria
authors: M
authors: De Santis
authors: Department of Urology, University of Bern, Inselspital, Bern, Switzerland.
authors: Tobias
authors: T
authors: Gross
authors: Leeds Cancer Centre, St. James's University Hospital, Leeds, UK.
authors: Ann M
authors: AM
authors: Henry
authors: Department of Urology, University Hospitals Leuven, Leuven, Belgium.
authors: Steven
authors: S
authors: Joniau
authors: Academic Urology Unit, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK.
authors: Thomas B
authors: TB
authors: Lam
authors: Velindre Hospital, Cardiff, UK.
authors: Malcolm D
authors: MD
authors: Mason
authors: Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
authors: Henk G
authors: HG
authors: van der Poel
authors: Department of Pathology, Erasmus Medical Centre, Rotterdam, The Netherlands.
authors: Theo H
authors: TH
authors: van der Kwast
authors: Hospices Civils de Lyon, Radiology Department, Edouard Herriot Hospital, Lyon, France.
authors: Olivier
authors: O
authors: Rouvière
authors: Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany.
authors: Thomas
authors: T
authors: Wiegel
authors: Department of Urology, University Hospital, St. Etienne, France.
authors: Nicolas
authors: N
authors: Mottet
mesh_terms: D000069501:Abiraterone Acetate / Q000008:administration & dosage; D000726:Androgen Antagonists / Q000627:therapeutic use*; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D001549:Benzamides; D001918:Brachytherapy; D002277:Carcinoma / Q000556:secondary / Q000628:therapy*; D003452:Cryosurgery; D000077143:Docetaxel; D057086:High-Intensity Focused Ultrasound Ablation; D006801:Humans; D008297:Male; D009362:Neoplasm Metastasis; D009364:Neoplasm Recurrence, Local / Q000628:therapy*; D009570:Nitriles; D010669:Phenylthiohydantoin / Q000008:administration & dosage / Q000031:analogs & derivatives; D017410:Practice Guidelines as Topic; D011471:Prostatic Neoplasms / Q000473:pathology / Q000628:therapy*; D064129:Prostatic Neoplasms, Castration-Resistant / Q000628:therapy; D016879:Salvage Therapy; D043823:Taxoids / Q000008:administration & dosage; D014020:Tissue Extracts / Q000008:administration & dosage
chemical_list: D000726:Androgen Antagonists; D001549:Benzamides; D009570:Nitriles; D043823:Taxoids; D014020:Tissue Extracts; D000077143:Docetaxel; D010669:Phenylthiohydantoin; C552428:cabazitaxel; C511774:sipuleucel-T; C540278:enzalutamide; D000069501:Abiraterone Acetate
keywords: Castration-resistant; Chemotherapy; EAU-ESTRO-SIOG Guidelines; Follow-up; Hormonal therapy; Metastatic; Palliative; Prostate cancer; Relapse; Staging