Impact on Practice

“I think the reason I and many others are a little bit worked up about [the guideline change] is what it represents about what we’re saying, as a community of experts, about active surveillance,” Dr Cooperberg said.

“That it says ‘preferred’ or not may affect some clinician’s behaviors, and it may have absolutely no effect on others. But you could easily see those who are a decade or more behind the times and still routinely treating low-risk disease with surgery or radiation pointing to these updated guidelines and saying the NCCN endorses this,” he added.

Continue Reading

Although conversations on Twitter2,3 suggest Dr Cooperberg is not alone in his concern about the guideline change, other physicians think the change may not have much impact on clinical practice.

“Those of us that believe in surveillance are not going to look at the guidelines and say that now the word ‘preferred’ is gone from one area, maybe I should rethink how I understand the data and treat men,” said Ashley Ross, MD, PhD, a urologic surgeon and associate professor of urology at Northwestern University’s Feinberg School of Medicine in Chicago.

“To me, that part of the guidelines is just saying, ‘Let’s take a balanced approach.’ I think that all NCCN was intending to advise was to do careful shared decision-making for this category of patients, which is more heterogeneous than very low-risk patients,” Dr Ross added.

“Surveillance can be nuanced,” he explained. “We have to continue to develop tools and monitor these methods in registries and prospective studies, and we must continue to investigate outcomes, including patient-reported outcomes.”

Other Updates: Inclusivity and Imaging

Another change to NCCN’s guidelines involves the removal of gendered pronouns and the use of more neutral descriptions to include people who have prostates but don’t identify as men.

In addition, prostate-specific membrane antigen (PSMA) PET/CT imaging was added to the guidelines due to the US approvals of Gallium 68 PSMA-11 and piflufolastat F 18 in December 2020 and May 2021, respectively.6,7

“Although PSMA has been internationally available in Europe and Australia for some time now, getting FDA approval for these agents and imaging in staging, initial staging, and recurrent disease is new to the US. So that’s a game-changer for our patients here,” said Edward Schaeffer, MD, PhD, chair of the guidelines panel and program director of the Genitourinary Oncology Program at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.

NCCN also attempted to improve the workflow of the guidelines to make them more user-friendly for patients and physicians.

Disclosures: All interviewees declared no relevant conflicts of interest.


  1. NCCN Clinical Practice Guidelines in Oncology, Prostate Cancer, Version 1.2022. Published September 10, 2021. Accessed October 26, 2021.
  2. Cooperberg M (@dr_coops). Twitter thread. Published September 28, 2021. Accessed October 26, 2021.
  3. Davies BJ (@daviesbj). Twitter thread. Published September 29, 2021. Accessed October 26, 2021.
  4. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. American Urological Association. Published 2017. Accessed October 26, 2021.
  5. Observation or Active Surveillance for Prostate Cancer. American Cancer Society. Accessed October 26, 2021.
  6. FDA approves first PSMA-targeted PET imaging drug for men with prostate cancer. US Food and Drug Administration. Published December 01, 2020. Accessed October 26, 2021.
  7. FDA approves second PSMA-targeted PET imaging drug for men with prostate cancer. US Food and Drug Administration. Published May 27, 2021. Accessed October 26, 2021.