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The NCCN guidelines represent a consensus statement that is compiled using data from a variety of clinical trials, notes Michael E. Williams, MD. The highest level of evidence, labeled category 1, is provided by multi-national, multi-institutional, randomized controlled trials. The next tier, category 2A and 2B, is generally based on smaller studies. In this category, there is less of a consensus as to whether or not a therapy is the best treatment, notes Williams. At category 3, there are far more opinions on a therapy. In this category, the right answer may not be known, Williams states.
For patients with advanced prostate cancer, all of the NCCN guidelines are based on category 2A evidence or better, representing a uniform consensus, William notes. The NCCN prostate cancer guideline provides an easy to use timeline that can broadly apply to multiple patients, whereas the AUA guideline requires that patients fit into a specific index, notes Kenneth M. Kernen, MD.
The AUA guideline stresses the importance of knowing exactly where the patient fits, which requires adequate history taking, patient evaluation, and focus on symptoms, believes Philippa J. Cheetham, MD. In terms of guidelines, there is not a "one size fits all" solution, with optimal treatment requiring collaboration between urologists and medical oncologists, Cheetham believes.
A challenge that currently faces many of the guidelines in metastatic prostate cancer is an abundance of category 1 evidence, notes A. Oliver Sartor, MD. Results from large randomized trials support the use of multiple therapies after progression on docetaxel, for instance. In general, guidelines are useful for listing options that are available, but they should not be the only decision factor, Sartor advises.