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Prostate Cancer Part 2: Follow-up in Primary Care

Last updated on December 10, 2022
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Effective Date: April 15, 2020

Recommendations and Topics

Scope

This guideline provides recommendations for the follow-up of patients who have returned to their primary care provider following curative-intent treatment for prostate cancer. Recommendations include the management of potential long-lasting side-effects from treatment, surveillance for possible recurrence, and if needed best supportive care and the early involvement of palliative services.

Prostate Cancer Part 1: Diagnosis and Referral in Primary Care provides recommendations for primary care providers for the investigation and management of adult male patients (≥19 years of age) who present with signs or symptoms that could lead to a diagnosis of prostate cancer.

This guideline was developed in collaboration with the BC Cancer Provincial Primary Care Program (Family Practice Oncology Network), and was developed using a guideline adaptation approach including a recent systematic review of the evidence (Refer to Appendix A: Guideline Development Methodology).

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Key Recommendations

  • PSA lab reports typically flag a PSA value of greater than the age-based reference range as abnormal, but a biochemical recurrence of the prostate cancer is detected at a much lower PSA value (for example > 0.2µg/L for a patient after radical prostatectomy).
  • Primary care providers should review the actual values and ensure patients are referred back to the oncologist if any measurable increase in PSA is detected (Refer to Table 2 – PSA Profile Indicative of Recurrent Disease (Biochemical Relapse)).
  • Consider referral to the Prostate Cancer Supportive Care Program, which is a comprehensive survivorship program for prostate cancer patients, their partners and family from the time of initial diagnosis onwards (see Resources).

Follow-up Prostate Cancer Care

Primary care practitioners provide an essential role for the continuity of patient care in all settings, both directly and through the coordination of care with other health care professionals. This reduces the fragmentation of care, improves patient safety, and enhances the overall quality of patient care.

  • PSA Testing for Surveillance of Recurrent Disease

In the absence of specific evidence to guide prostate-specific antigen (PSA) testing intervals in patients who have completed treatment, the following recommendations were adapted with modifications from Cancer Care Ontario (CCO), and are based on working group clinical consensus.1,2 These recommendations are intended for patients who have returned to their primary care practitioner for follow up.1,2 Surveillance intensity should reflect the risk of recurrence, and practitioners should use clinical judgement to evaluate the benefits of surveillance in patients who are unlikely to benefit from additional salvage therapy. These recommendations are not exhaustive and should be used in accordance with other available resources.2  If a patient develops biochemical relapse following treatment  Table 2 – PSA Profile Indicative of Recurrent Disease(Biochemical Relapse) for definitions), then refer the patient back to their treating physician (i.e., urology or radiation oncology).

 

Table 1 – Prostate Cancer Follow-up Care Surveillance for Patients who have Undergone Curative-Intent Treatment2

Prostate Cancer Follow-up Care Surveillance¥

Recommendations

Year 1

Year 2

Year 3

Medical follow-up care appointments:¥

  1. Medical history and physical examination where indicated
  2. Any new and persistent or worsening signs/symptoms to watch for, especially:
    • Severe and progressive axioskeletal bone pain
    • Hematuria
    • New urinary symptoms
      • Significant incontinence requiring changing of undergarments, pads, or diapers
      • Urgency
    • Obstructive symptoms
      • Voiding discomfort
      • Nocturia
    • New bowel symptoms
      • Rectal bleeding
      • Rectal pain
      • Urgency
      • Change in bowel movement
    • Vague constitutional symptoms such as:
      • Fatique
      • Unexplained weight loss

Note: For patients that present with symptoms that could suggest recurrence, a prostate-specific antigen (PSA) text should be performed and a referral back to the appropriate specialist should be considered.

c.  Health promotion and disease prevention counselling including (but not limited to):

  • Diet, exercise, smoking status, alcohol, sun safety, mental health, sexual health, and other informational needs

After first 3 months; then every 6 months

Every 6 months

Every 12 months

Prostate-specific antigen (PSA) test:¥

 a) For patients following curative-intent treatment with   surgery*

Every 3 months

Every 6 months

Every 6 months (until end of year 3; then annually thereafter)

 b) For patients following curative-intent treatment with   non-surgery primary therapy (e.g., radiation therapy,   cryotherapy, or high- intensity focused ultrasound)*

Every 6 months

Every 6 months

Every 12 months

*Caution: PSA lab test results: PSA lab reports typically flag a PSA value of greater than the age-based reference range as abnormal, but a biochemical recurrence of the prostate cancer is detected at a much lower PSA value (for example >0.2µg/L for a patient after radical prostatectomy). Therefore, primary care providers should review the actual values and ensure patients are referred back to the oncologist if any measurable increase in PSA is detected (Refer to Table 2 – PSA Profile Indicative of Recurrent Disease (Biochemical Relapse).

For patients on androgen deprivation therapy (ADT):

Consider a complete blood count (CBC) annually to monitor hemoglobin levels, particularly in men presenting with symptoms suggestive of anemia. Asses risk of fracture for men treated with ADT through baseline DEXA (dual energy x-ray absorptiometry) scan and calculation of a FRAX® (fracture risk assessment score). Recommend calcium and vitamin D supplementation.

¥ Adapted with permission from CCO with modifications: Ontario Prostate Cancer Follow-up Care Clinical Guidance Summary2

Special Considerations¥

Digital rectal exam (DRE): Routine DRE is not required after treatment of localized prostate cancer unless there is evidence of a PSA recurrence, or for the evaluation of symptoms (e.g., obstructive voiding symptoms, change in bowel habits or pelvic pain).

¥ Adapted with permission from CCO with modifications: Ontario Prostate Cancer Follow-up Care Clinical Guidance Summary2

 

Table 2 – PSA Profile Indicative of Recurrent Disease (Biochemical Relapse)3

Treatment

PSA Profile Indicating Possible Recurrent Disease

Note: If a patient develops a PSA profile indicative of recurrent disease, they should be referred back to their treating physician (i.e., urology or radiation oncology).

Radical prostatectomy
  • 2 successive increases to a level of >0.2µg/L.

External beam radiation therapy
  • After external beam radiation therapy, relapse may occur following achievement of nadir (the lowest post-therapy PSA value).
  • Biochemical relapse is defined as nadir plus 2.

 Brachytherapy
  • Biochemical relapse is defined as nadir plus 2.
  • The PSA level may ‘bounce’ typically as long as 1-3 years post-therapy.
  • PSA levels may temporarily rise to ≥4µg/L.

 

Management of Patients with Long-lasting Symptoms

Men can experience specific and often long-lasting effects usually occurring more than three months after surgery or radiation, or during/after androgen deprivation therapy.1,2  Refer to Table 3 – Common Long-term and Late Effects of Prostate Cancer Treatment, to identify common long-term and late effects of treatment including sexual, urinary, or bowel dysfunction, and other physical and/or psychological effects.1,2 For additional information on the management of common prostate cancer side effects in primary care refer to Appendix B: Long-term Side Effects and Recommendations for Management and Appendix C: Medications for the Management of Prostate Cancer Side Effects in Primary Care. To address individual variability in response to treatments, and to ensure optimal quality of life, individual patient-reported outcomes should be measured.1,4

Table 3 – Common Long-term and Late Effects of Prostate Cancer Treatment

Common Long-term and Late Effects¥

  Physical:

  • Sexual dysfunction (for all treatments)
    • Erectile dysfunction
    • Loss of libido
    • Anorgasmia
    • Dry ejaculate
    • Climacturia
    • Penile shortening or curvature
    • Infertility
  • Urinary dysfunction (for those treated with surgery or RT)
    • Obstructive symptoms
    • Urgency symptoms
    • Hematuria
    • Incontinence
  • Bowel dysfunction (for those treated with RT)
    • Rectal bleeding
    • Urgency and frequency sysmptoms
  • Other (mostly for those treated with ADT)
    • Anemia
    • Body composition alterations
    • Fatique (for all treatments)
    • Gynecomastia/mastodynia
    • Hot flashes
    • Bone health

  Psychosocial:

  • Psychological distress (e.g., depression, anxiety, worry, fear of recurrence)
  • Cognitive side-effects
  • Changes in sexual function/fertility
  • Challenges with body and/or self-image, relationships, and other social role difficulties
  • Return to work concerns and financial challenges

¥ Adapted with permission from CCO with modifications: Ontario Prostate Cancer Follow-up Care Clinical Guidance Summary2

Survivorship  

Survivorship care is a fundamental component of post-treatment care. It is the link between treatment and recovery, and a key point of continuity of care bridging the connections between the patient, BC Cancer, and the patient’s primary care team.

Patient quality of life and satisfaction have been shown to be higher in prostate cancer survivors who have access to survivorship care, and this suggests that disease-specific survivorship clinics that incorporate quality-of-life reporting may have better outcomes.1 Consider referral to the Prostate Cancer Supportive Care Program, which is a comprehensive survivorship program for prostate cancer patients, their partners and family from the time of initial diagnosis onwards (see Resources).

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Palliative Care and Advance Care Planning

While the majority of prostate cancers advance slowly and/or are potentially curable, some will be discovered in late stages, or will be aggressive and treatment resistant. Patients with a potentially life-limiting disease or illness may benefit from the development of an advance care plan (ACP) that incorporates the patient’s values and personal goals, indicates potential outcomes, and identifies linkages with other health care professionals that would be involved in the care, as well as their expected roles. The ACP is an opportunity to also identify the patient’s alternate substitute decision-maker or legal health representative. For information and tools on advance care planning refer to the Resources section below. For information on palliative care, including tools for identifying patients who would benefit from palliative care at earlier stages of the illness, refer to the Resources – Survivorship section below.

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Resources

References

  1. A. Matthew, L.H. Souter, R.H. Breau, C. Canil, M. Haider, L. Jamnicky, R. Morash, D. Smith, M. Surchin, A. Loblaw , Prostate Cancer Follow-up Expert Panel. Follow-up Care and Psychosocial Needs of Survivors of Prostate Cancer [Internet]. Cancer Care Ontario. [cited 2020 Jul 2]. Available from: https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/266
  2. Cancer Care Ontario – Prostate Cancer Follow-up Care Pathway Map Version 2018.03 [Internet]. Available from: https://www.cancercareontario.ca/sites/ ccocancercare/files/assets/CCOProstateFollowUpPathway.pdf
  3. BC Cancer. Prostate – Chapter 5 Management – Follow-up: Definitions of Biochemical Relapse. [Internet]. [cited 2020 Jul 2]. Available from: http://www. bccancer.bc.ca/health-professionals/clinical-resources/cancer-management-guidelines/genitourinary/prostate#Management-prostate
  4. Gilbert SM, Dunn RL, Wittmann D, Montgomery JS, Hollingsworth JM, Miller DC, et al. Quality of life and satisfaction among prostate cancer patients followed in a dedicated survivorship clinic. Cancer. 2015 May 1;121(9):1484–91.

Appendices

Associated Documents

Practitioner Resources

The guideline was developed by the BC Cancer Primary Care Program (Family Practice Oncology Network), and the Guidelines and Protocols Advisory Committee. This guideline is based on scientific evidence current as of November 2017. For more information about how this guideline was developed, refer to Appendix A: Guideline Development Methodology. For more information about how BC Guidelines are developed in general, refer to the GPAC Handbook available at BCGuidelines.ca: GPAC Handbook.

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THE GUIDELINES AND PROTOCOLS ADVISORY COMMITTEE

The principles of the Guidelines and Protocols Advisory Committee are to:

  • encourage appropriate responses to common medical situations
  • recommend actions that are sufficient and efficient, neither excessive nor deficient
  • permit exceptions when justified by clinical circumstances

Contact Information:

Guidelines and Protocols Advisory Committee

PO Box 9642 STN PROV GOVT

Victoria BC V8W 9P1

Email: hlth.guidelines@gov.bc.ca

Website: www.BCguidelines.ca

Disclaimer

The Clinical Practice Guidelines (the guidelines) have been developed by the BC Cancer Primary Care Program, Family Practice Oncology Network and the Guidelines and Protocols Advisory Committee, on behalf of the Medical Services Commission. The guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problem. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.

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