Patients and physicians should be informed of the increased risk of bladder and colorectal cancers after pelvic radiation therapy. Patients should undergo routine screening for colorectal cancer as suggested by existing evidence-based guidelines and should undergo appropriate evaluation for any signs or symptoms suggestive of either bladder cancer or colorectal cancer.
—Matthew J. Resnick, MD (top), David F. Penson, MD (bottom), and colleagues
As reported in the Journal of Clinical Oncology by Matthew J. Resnick, MD, of Vanderbilt University Medical Center, and colleagues, ASCO has endorsed the 2014 American Cancer Society Prostate Cancer Survivorship Care Guidelines.1,2 The ASCO endorsement panel was co-chaired by Dr. Resnick and David F. Penson, MD, also of Vanderbilt University Medical Center. The endorsement panel noted that there is limited availability of high-quality evidence to support many of the guideline recommendations.
The recommendations, with ASCO qualifying statements in bold italics, are provided below.
Assess information needs related to prostate cancer and its treatment, adverse effects, other health concerns, and available support services and provide or refer survivors to appropriate resources to meet these needs.
Counsel survivors to achieve and maintain a healthy weight by limiting consumption of high-calorie foods and beverages and promoting increased physical activity.
Counsel survivors to engage in at least 150 minutes per week of physical activity, which may include weight-bearing exercises.
Counsel survivors to achieve a dietary pattern that is high in fruits and vegetables and whole grains. Diet should emphasize micronutrient-rich and phytochemical-rich vegetables and fruits, low amounts of saturated fat, intake of at least 600 IU of vitamin D per day, and adequate (but not excessive) amounts of dietary sources of calcium (not to exceed 1,200 mg/d). Those with nutrition-related challenges (eg, bowel problems that impact nutrient absorption) should be referred to a registered dietitian.
Alcohol consumption should be avoided or limited to no more than two drinks per day.
Assess for tobacco use and offer and/or refer survivors to cessation counseling and resources. Counsel survivors to avoid tobacco products.
Surveillance for Prostate Cancer Recurrence
Measure serum prostate-specific antigen (PSA) level every 6 to 12 months for the first 5 years and annually thereafter. Prostate cancer specialists may recommend more frequent PSA monitoring during the early survivorship experience for some men, particularly men with a higher risk of prostate cancer recurrence and/or men who may be candidates for salvage therapy. The exact schedule for PSA measurement should be determined by both the prostate cancer specialist and primary care physician in collaboration.
Ensure that survivors with an elevated or rising PSA level are evaluated by their primary treating specialist for further follow-up and treatment.
Perform annual digital rectal examination in coordination with cancer specialist to avoid duplication. Primary care physicians should discuss with the prostate cancer specialist the need for annual digital rectal examination, specifically as it relates to detection of disease recurrence in prostate cancer survivors.
Screening for Second Primary Cancers
Adhere to American Cancer Society screening and early detection guidelines (cancer.org/professionals).
Survivors who underwent radiation therapy may have a slightly higher risk of bladder and colorectal cancers and may need to follow screening guidelines for higher-risk individuals, if available. Patients and physicians should be informed of the increased risk of bladder and colorectal cancers after pelvic radiation therapy. Patients should undergo routine screening for colorectal cancer as suggested by existing evidence-based guidelines and should undergo appropriate evaluation for any signs or symptoms suggestive of either bladder cancer or colorectal cancer.
For survivors with hematuria, perform a thorough evaluation to determine the cause of symptoms and to rule out bladder cancer, including urologist referral for cystoscopy and upper urinary tract evaluation.
Refer survivors with persistent rectal bleeding, pain, or other symptoms of unknown origin to the appropriate specialist as well as the treating radiation oncologist to conduct a thorough evaluation for cause of symptoms and to evaluate for colorectal cancer.
Anemia: Specific Risk for Men on Androgen-Deprivation Therapy
Consider [ASCO Endorsement Panel changed from “perform”] an annual complete blood cell count to monitor hemoglobin levels, particularly in men presenting with symptoms suggestive of anemia.
Discuss bowel function and symptoms (eg, rectal bleeding) with survivors.
For men with a negative colorectal cancer screening result, prescribe stool softeners, topical steroids, or anti-inflammatories for survivors experiencing rectal bleeding. For survivors experiencing rectal bleeding after radiation therapy, colorectal cancer should be ruled out, and appropriate management should be discussed with the treating radiation oncologist. Management may include corticosteroid suppositories to decrease inflammation, stool softeners, and dietary changes.
Refer survivors with persistent rectal symptoms (eg, bleeding, sphincter dysfunction, rectal urgency, and frequency) to the appropriate specialist.
Cardiovascular and Metabolic Effects: Specific Risk for Men Receiving Androgen-Deprivation Therapy
Follow U.S. Preventive Services Task Force (USPSTF) guidelines for evaluation and screening for cardiovascular risk factors, blood pressure monitoring, lipid profiles, and serum glucose (uspreventiveservicestaskforce.org/uspstopics.htm).
Assess for distress/depression/PSA anxiety at initial visit, at appropriate intervals, and as clinically indicated [ASCO Endorsement Panel removed wording that recommended assessment should occur “periodically, at least annually” and removed suggestion that “simple screening tool” be used “such as the Distress Thermometer”.] Physicians should refer to the ASCO Screening, Assessment, and Care of Anxiety and Depressive Symptoms in Adults With Cancer guideline (www.asco.org/adaptations/depression) for more information on management of this important problem.
Manage distress/depression using in-office counseling resources or pharmacotherapy as appropriate.
If office-based counseling and treatment are insufficient, refer survivors experiencing distress/depression for further evaluation or treatment by appropriate specialists.
Fracture Risk/Osteoporosis: Specific Risk for Men Receiving Androgen-Deprivation Therapy
Assess risk of fracture for men treated with androgen-deprivation therapy or older radiation techniques through baseline dual-energy x-ray absorptiometry scan and calculation of a World Health Organization fracture risk assessment (FRAX) score. For men determined to be high risk, prescribe weekly bisphosphonate therapy (oral alendronate at a dose of 70 mg) or annual intravenous zoledronic acid at a dose of 5 mg to increase bone density. Denosumab (Xgeva) is also approved by the U.S. Food and Drug Administration (FDA) to treat men at increased risk of osteoporosis. A collaborative strategy should be developed between the primary care physician and prostate cancer specialist to optimize bone health in men at risk for osteoporosis. This strategy should include a thorough discussion of the benefits and harms of bone-targeted agents.
Sexual Dysfunction/Body Image, Sexual Intimacy
Discuss sexual function with survivors. Use validated tools to monitor erectile function over time. [ASCO Endorsement Panel removed reference to Sexual Health Inventory for Men tool.]
Erectile dysfunction may be addressed through a variety of options, including penile rehabilitation or prescription of phosphodiesterase type 5 inhibitors (eg, sildenafil, vardenafil, tadalafil).
Refer men with persistent sexual dysfunction to a urologist, sexual health specialist, or psychotherapist to review treatment and counseling options.
Encourage couples to discuss their sexual intimacy and refer to counseling or support services as appropriate. Prescribe medication as described previously to address erectile dysfunction. Instruct couples on the use of sexual aids to improve erectile dysfunction for men/male partners as well as postmenopausal symptoms for women. Refer to mental health professional with expertise in sex therapy.
Discuss urinary function (eg, urinary stream, difficulty emptying the bladder) and incontinence with all survivors. Consider timed voiding, prescribing anticholinergic medications (eg, oxybutynin) to address issues such as nocturia, frequency, or urgency. Consider alpha-blockers (eg, tamsulosin) for slow stream.
Refer survivors with postprostatectomy incontinence to a physical therapist for pelvic floor rehabilitation; at a minimum, instruct survivors about Kegel exercises.
Refer men with persistent, bothersome leakage or other urinary symptoms to a urologist for further evaluation (eg, urodynamic testing, cystoscopy) and discussion of treatment options including surgical placement of a male urethral sling or artificial urinary sphincter for incontinence.
Vasomotor Symptoms: Specific Risk for Men Receiving Androgen-Deprivation Therapy
Although not approved by the FDA for this indication, prescription of selective serotonin or noradrenergic reuptake inhibitors or gabapentin may offer symptom relief. The ASCO Endorsement Panel believes further clinical investigation is required to validate this recommendation. Until that time, physicians should be aware of the development of vasomotor symptoms with androgen-deprivation therapy and should discuss with their patients the risks, benefits, and costs of available therapies for possible symptom relief.
Care Coordination and Practice Implications
The primary treating specialist is encouraged to provide a treatment summary and survivorship care plan to the primary care clinician when survivorship care is transferred to the primary care clinician. Primary care clinicians and treating oncology specialists should confer regarding the survivorship care plan components and determine roles and responsibilities that are appropriate for the survivor’s condition and the resources available in the primary care setting.
Primary care clinicians should maintain their role as general medical care coordinator throughout the spectrum of prostate cancer detection, treatment, and aftercare, focusing on preventive care and the management of preexisting comorbid conditions as well as regularly addressing the patient’s overall physical and psychosocial status and those components of survivorship care that are mutually agreed on with the treating clinicians.
Annually assess for the presence of long-term or late effects of prostate cancer and its treatment, including potential urinary, bowel, sexual, and hormonal symptoms. [The ASCO Endorsement Panel removed the following: “Use of a validated tool such as EPIC-CP (Expanded Prostate Cancer Index Composite for Clinical Practice) may be helpful in this assessment.”]
Encourage the inclusion of caregivers, spouses, or partners in usual prostate cancer survivorship care.
Refer survivors to appropriate community-based and peer-support resources. ■
Disclosure: Drs. Resnick and Penson reported no potential conflicts of interest.
1. Resnick MJ, Lacchetti C, Bergman J, et al: Prostate cancer survivorship care guideline: American Society of Clinical Oncology clinical practice guideline endorsement. J Clin Oncol 33:1078-1085, 2015.
2. Skolarus TA, Wolf AM, Erb NL, et al: American Cancer Society prostate cancer survivorship care guidelines. CA Cancer J Clin 64:225-249, 2014.
Matthew J. Resnick, MD, MPH, of Vanderbilt University Medical Center, offers further commentary on the American Cancer Society Prostate Cancer Survivorship Care Guidelines.
Prostate cancer survivors currently approach 3 million in number and comprise 43% of all male cancer survivors in the United States.1 These men face myriad unique oncologic, functional, emotional, and psychological issues that require evaluation and management throughout the survivorship phase of...