After Doc Uproar, NCCN Reverses Prostate Cancer Guidance

Nick Mulcahy

November 30, 2021

After making a controversial change in September to a long-standing recommendation about the use of active surveillance in men with prostate cancer, the National Comprehensive Cancer Network (NCCN) has today reversed course and reinstated its original advice, with a slight tweak.

The influential cancer organization, which is best known for its guidelines, now recommends that "most" men with low-risk prostate cancer be offered active surveillance as the lone "preferred" initial treatment option. This advice aligns closely with the group's initial recommendation, published over a decade ago.

But controversy erupted in late September when the NCCN suddenly changed its tune on active surveillance, recommending that men with low-risk disease be managed with either active surveillance, radiation therapy, or surgery, with equal weight given to all three.

The new advice angered physicians who support the concept of active surveillance, which aims to avoid or delay treatment — and potentially life-changing side effects — until signs of disease progression.

The NCCN listened to the complaints.

Today, the group largely reverted back to the original recommendation. In updated guidelines published today, active surveillance returned to its place as the sole "preferred" management option, but for "most" men with low-risk disease, not all.

In an email sent to Medscape Medical News, Edward Schaeffer, MD, PhD, chair of the prostate cancer treatment panel, said that "the NCCN Prostate Cancer Panel recently convened" and "extensively revised the Principles of Active Surveillance and Observation."

Schaeffer, who is from the Lurie Comprehensive Cancer Center of Northwestern University in Chicago, cited the heterogeneity across the low-risk disease group. Factors associated with an increased probability of near-term grade reclassification from low risk to higher risk include high PSA density, a high number of positive cores (≥ 3), high genomic risk (from tissue-based molecular tumor analysis), and/or a known BRCA2 germline mutation, he added.

Urologists cheered the NCCN's reversal today on Twitter.

"Big news! NCCN guidelines updated again — active surveillance is 'preferred for most patients' with low risk prostate cancer and life expectancy >=10 years," tweeted Stacy Loeb of NYU Langone in New York City.

"Very exciting if true," tweeted Matthew Cooperberg, MD, of University of California San Francisco, who was one of the most vocal critics of the NCCN's change in September, calling that move a "step backward" that would likely lead to overtreatment.

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