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James L. Mohler

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James L. Mohler

The NCCN Prostate Cancer Clinical Practice Guidelines in Oncology are revised at least annually using teleconferences, and every 3 years, they are examined in greater detail in face-to-face panel meetings. The 2006 face-to-face meeting addressed 5 major issues. To give guidelines users an appreciation for the process used to make the fairly substantial changes in the 2007 Guidelines, this issue of the Journal of the National Cancer Network (JNCCN) includes point/counterpoint manuscripts for 3 of those 5 debates.Can Life Expectancy Be Estimated Accurately?Life expectancy is estimated using the Minnesota Metropolitan Life Insurance Tables or the Social Security Administration Life Expectancy tables. It can then be adjusted for individual patients by adding or subtracting 50% based on whether one believes the patient is in the healthiest quartile or the unhealthiest quartile, respectively.1 Thus, treatment recommendations can change if a man was judged to be in poor or excellent health.The perceived need to incorporate life expectancy estimation resulted in the panel's first point/counterpoint debate, the flavor of which was captured in the articles in this issue by Clayton and Urban and McCloskey and Kuettel. The debate resulted in the panel reaching several conclusions, and the 2007 guidelines, for the first time, included a “Principles of Life Expectancy Estimation” table (see page 659). • Prediction of life expectancy in individuals (not groups) is not possible. • The Panel was concerned that patients would receive information about their life expectancy and not have the ability to consider it appropriately. • The Panel agreed that...
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James L. Mohler

This issue includes the latest version of the NCCN Clinical Practice Guidelines in Oncology on Prostate Cancer, as well as several articles that clarify and expand on themes in those guidelines. For example, the excellent manuscript from Lee and Amling provides the basis for updating the best available nomograms in the 2010 version of the NCCN Guidelines to help provide more individualized recommendations. This need for individualization includes both choice of treatment (active surveillance vs. radical prostatectomy vs. external beam radiation vs. brachytherapy) and type of treatment (need for neurovascular bundle resection and/or pelvic lymph node dissection during radical prostatectomy) for clinically localized prostate cancer or adjuvant or salvage radiation therapy for biochemical recurrence after radical prostatectomy. The review by Nielson, Trock, and Walsh describes the evolution of the Johns Hopkins' position on salvage or adjuvant radiation therapy. Reanalysis of this experience led to a change from a relatively rare recommendation of additional treatment to the recognition that use of the “Johns Hopkins criteria” for local versus systemic recurrence was denying radiation to many men who might benefit. Finally, Saylor and Smith provide a detailed description of the morbidity associated with androgen deprivation therapy and recommend evidence-based steps that urologists, radiation urologists, and medical oncologists should take in collaboration with primary care physicians to minimize the impact of androgen deprivation therapy on quality of life. These articles expand on 3 of the many changes in the 2010 NCCN Guidelines on Prostate Cancer. Perhaps the most significant change is the recommendation...
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James L. Mohler

Since its introduction more than 70 years ago, the use of androgen deprivation therapy (ADT) for prostate cancer has evolved to become part of a multimodal management approach. In this presentation from the NCCN 21st Annual Conference, James L. Mohler, MD, reviewed data that inform these strategies and gave his bottom-line recommendations on issues such as ADT plus radiotherapy, continuous versus intermittent ADT, ADT for positive nodes, and ADT plus docetaxel. He suggested that ADT plus radiation therapy should be used in patients at high risk, intermittent ADT is more appropriate for most patients than continuous ADT, and docetaxel should be given with ADT for high-volume metastatic disease.

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James L. Mohler and the NCCN Prostate Cancer Panel

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Peter H. Carroll and James L. Mohler

Peter H. Carroll, MD, MPH, and James L. Mohler, MD, updated attendees on what is new in the 2018 NCCN Guidelines for Prostate Cancer Early Detection and for Prostate Cancer, respectively. Their presentations touched on new screening recommendations, shared decision-making, risk stratification, the role of genomic and molecular testing, active surveillance, and newer systemic treatments.

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Philip W. Kantoff and James L. Mohler

Rapid progress was recently made in the treatment of prostate cancer, especially metastatic castration-resistant prostate cancer. At the NCCN 18th Annual Conference, Dr. Philip W. Kantoff reviewed the data supporting the use of abiraterone acetate, enzalutamide, cabazitaxel, sipuleucel-T, and radium-223 (pending approval), and offered recommendations for their sequential use in different settings. Dr. James L. Mohler described factors that dictate who should receive treatment, when they should receive it, and how to treat in the setting of prostate-specific antigen elevation. He explained how better treatment decisions will result from individualized estimation of threat-to-life posed by prostate cancer, chance of cure by treatment, and treatment risks.

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James L. Mohler and Emmanuel S. Antonarakis

Updates to the NCCN Guidelines for Prostate Cancer include further refinements in taking a family history, new recommendations for germline and somatic testing, use of androgen receptor blockers for nonmetastatic castration-resistant prostate cancer, advice regarding intermittent versus continuous androgen deprivation therapy, and consideration of whether to treat the primary tumor in men diagnosed with de novo metastatic prostate cancer.

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Hyung L. Kim, Marvin R. Puymon, Maochun Qin, Khurshid Guru and James L. Mohler

Prostate cancer can have a long and indolent course, and management without curative therapy should be considered in select patients. When counseling patients, a useful way to convey the risk for death from competing causes is to estimate their lifetime risk for dying from prostate cancer. Double-decrement life tables were constructed to calculate age-specific death rates using the death probabilities from the Social Security Administration life tables and Gleason score–specific mortality rates reported from pre-PSA cohort study. The lifetime risk for prostate cancer death was calculated. Life tables provided life expectancy and risk for prostate cancer death based on age at diagnosis. For example, 60-year-old patient with a Gleason score 6, 7, or 8 tumor had an overall life expectancy of 14.4, 10.2, or 6.6 years, respectively. The risk for prostate cancer death during the expected years of life was 33%, 49%, or 57%, respectively. If a 10-year lead-time bias was assumed for PSA detection, the risks for death from prostate cancer decreased to 16%, 26%, or 37%, respectively. If the patient was in the bottom quartile for overall health and disease was detected by prostate examination, the risk for death from prostate cancer was 21%, 32%, or 40%, respectively. A Web-based tool for performing these calculations is available at http://www.roswellpark.org/Patient_Care/Specialized_Services/Prostate_Cancer_Estimator.html. Life tables can be created to estimate overall life expectancy and risk for prostate cancer death, and to assist with decision-making when considering management without curative therapy.