STEP 3: Diagnosis, staging and treatment planning

Step 3 outlines the process for confirming the diagnosis and stage of cancer and for planning subsequent treatment. The guiding principle is that interaction between appropriate multidisciplinary team members should determine the treatment plan.

To help patients decide whether to have a prostate biopsy, discuss with them their PSA level, DRE findings (including an estimate of prostate size) and comorbidities, together with their risk factors (including family history, increasing age and family origin) and any history of previously negative prostate biopsies. Do not automatically offer a prostate biopsy on the basis of serum PSA level alone (NICE 2019).

Several risk calculators are available (e.g. the European Randomized Study of Screening for Prostate Cancer risk calculator), which may be useful for patient counselling and decision making.

The following tests may be performed to confirm a diagnosis:

  • DRE (prior to biopsy)
  • multiparametric MRI – this should be interpreted by a radiologist with adequate training and experience (FRANZCR or equivalent) and with MRI-specific accreditation
  • systematic and/or targeted prostate biopsy – in patients with a suspicious lesion on MRI, this should be specifically targeted.

An MRI before biopsy aids in diagnosis and biopsy planning and should be considered in all patients if available.

All biopsies should be completed by an adequately trained urologist or radiologist under transrectal ultrasound or MRI guidance, with biopsy needles placed either transrectally or transperineally.

Implications of both a positive and negative biopsy should be discussed with the patient before biopsy.

The specimen should be reviewed by an experienced uropathologist if there are uncertainties about diagnosis.

There should be standardised protocols for:

  • the minimum number of cores in the biopsy sample
  • interpreting the specimens
  • follow-up/re-biopsy of equivocal findings.

The lead clinician should review the risk factors of all men who have had a negative first prostate biopsy, and discuss with the man:

  • if there is still a risk that prostate cancer is present
  • if the risk is slightly higher if any of the following risk factors are present:
  • the biopsy showed atypical small acinar proliferation (ASAP)
  • abnormal DRE (NICE 2019)
  • a suspicious lesion on pre- or post-biopsy MRI.

If patients have a specific MRI lesion that hasn’t been targeted, there is increased risk of undiagnosed cancer. Discrepancies between imaging and biopsy findings need to be reviewed to avoid misdiagnosis.

Investigations should be completed within four weeks of the initial specialist appointment.

Five to 10 per cent of all cancers are due to a genetic predisposition. The features that suggest a genetic predisposition may include:

  • early age at onset
  • multiple primary cancers
  • family history of similar or related cancers.

In some cases certain pathological subtypes of cancer or tumour tests (immunohistochemistry or tumour genetic tests) may suggest an underlying inherited cancer predisposition.

Anyone diagnosed with cancer should have a detailed personal and family cancer history taken. Consult relevant guidelines to determine if referral to a familial cancer service is appropriate.

A familial cancer service assessment can determine if genetic testing is appropriate. Genetic testing is likely to be offered when there is at least a 10 per cent chance of finding a causative ‘gene error’ (pathogenic gene variant; previously called a mutation). Usually testing begins with a variant search in a person who has had cancer (a diagnostic genetic test). If a pathogenic gene variant is identified, variant-specific testing is available to relatives to see if they have or have not inherited the familial gene variant (predictive genetic testing).

Medicare funds some genetic tests via a Medicare Benefits Schedule (MBS) item number but most are not. Depending on the personal and family history, the relevant state health system may fund public sector genetic testing.

Pre-test counselling and informed consent is required before any genetic testing. In some states the treating team can offer ‘mainstream’ diagnostic genetic testing, after which referral is made to a familial cancer service if a pathogenic gene variant is identified. The familial cancer service can provide risk management advice, facilitate family risk notification and arrange predictive genetic testing for the family.

Refer to section section 1.3.1 ‘Genetic family history screening’ for more information.

Visit the Centre for Genetics Education website for basic information about cancer in a family.

For detailed information and referral guidelines for prostate cancer risk assessment and consideration of genetic testing, refer to Royal Australian College of General Practitioners 2019 ‘Genomics in general practice’.

Pharmacogenetics describes how individual genetic differences can lead to differences in the way certain medicines interact with the body. These interactions can affect the effectiveness of medications and any side effects. Applying pharmacogenetics to treatment planning may help patients to be prescribed the most appropriate treatment at the optimal dose from the beginning of treatment (NHMRC 2013).

Staging is a critical element in treatment planning and should be clearly documented in the patient’s medical record.

Staging for prostate cancer involves these tests:

  • DRE assessment to evaluate T-stage
  • a CT abdomen-pelvis and bone scan (this is the conventional staging) – PSMA-PET/CT has been shown to have greater accuracy than conventional imaging for high-risk prostate cancers for assessing nodal or distant metastatic disease and can be performed as an alternative if available (Hofman et al. 2020).

Staging should not be undertaken for men with a PSA < 10 ng/mL and a Gleason score < 7, unless otherwise clinically indicated (Parker et al. 2015).

Determine the provisional treatment intent (curative or non-curative) before decisions on imaging are made (NICE 2019). Do not routinely recommend imaging for asymptomatic patients who are not candidates for curative treatment (NICE 2019).

Appropriate bone imaging is recommended when hormonal therapy is being deferred through watchful waiting of asymptomatic men (with incurable disease) who are at high risk of developing bone complications (NICE 2019). Interval reimaging may have a role in determining the appropriate timing of androgen deprivation therapy (ADT).

Pathological staging occurs after surgery, and synoptic reporting is encouraged.

More information

Visit the Cancer Institute New South Wales website for information about understanding the stages of cancer.

Patient performance status is a central factor in cancer care and should be clearly documented in the patient’s medical record.

Performance status should be measured and recorded using an established scale such as the Karnofsky scale or the Eastern Cooperative Oncology Group (ECOG) scale.

Consideration should be given to frailty and the patient’s functional state. Consider referral to other disciplines such as geriatrics or endocrinology if appropriate.

A number of factors should be considered at this stage:

  • the patient’s overall condition, life expectancy, personal preferences and decision-making capacity
  • discussing the multidisciplinary team approach to care with the patient
  • appropriate and timely referral to an MDM
  • the patient’s carer, family or partner
  • pregnancy and fertility
  • support with travel and accommodation
  • teleconferencing or videoconferencing as required

The multidisciplinary team should meet to discuss newly diagnosed patients before definitive treatment and as soon as possible after the initial specialist consultation so that a treatment plan can be recommended and there can be early preparation for the post-treatment phase. Patients with localised/locally advanced prostate cancer who are considering curative treatment should consult with a urologist to discuss surgical treatment options and be referred to a radiation oncologist to discuss radiation therapy treatment options. Those with metastatic prostate cancer should also be referred to a medical oncologist. The level of discussion may vary, depending on the patient’s clinical and supportive care factors. In particular, all patients with Gleason 3+3 (ISUP GG 1) disease should be discussed at an MDM prior to surgery or radiation therapy.

Some patients with non-complex cancers may not be discussed by a multidisciplinary team; instead the team may have treatment plan protocols that will be applied if the patient’s case (cancer) meets the criteria. If patients are not discussed at an MDM, they should at least be named on the agenda for noting. The proposed treatment must be recorded in the patient’s medical record and should be recorded in an MDM database where one exists.

Teams may agree on standard treatment protocols for non-complex care, facilitating patient review (by exception) and associated data capture.

Results of all relevant tests and access to images should be available for the MDM. Information about the patient’s concerns, preferences and social and cultural circumstances should also be available.

The multidisciplinary team requires administrative support in developing the agenda for the meeting, for collating patient information and to ensure appropriate expertise around the table to create an effective treatment plan for the patient. The MDM has a chair and multiple lead clinicians. Each patient case will be presented by a lead clinician (usually someone who has seen the patient before the MDM). In public hospital settings, the registrar or clinical fellow may take this role. A member of the team records the outcomes of the discussion and treatment plan in the patient history and ensures these details are communicated to the patient’s general practitioner. The team should consider the patient’s values, beliefs and cultural needs as appropriate to ensure the treatment plan is in line with these.

The multidisciplinary team should be composed of the core disciplines that are integral to providing good care. Team membership should reflect both clinical and supportive care aspects of care. Pathology and radiology expertise are essential.

See ‘About this OCP’ for a list of team members who may be included in the multidisciplinary team for prostate cancer.

Core members of the multidisciplinary team are expected to attend most MDMs either in person or remotely via virtual mechanisms. Additional expertise or specialist services may be required for some patients. An Aboriginal and Torres Strait Islander cultural expert should be considered for all patients who identify as Aboriginal or Torres Strait Islander.

The general practitioner who made the referral is responsible for the patient until care is passed to another practitioner who is directly involved in planning the patient’s care.

The general practitioner may play a number of roles in all stages of the cancer pathway including diagnosis, referral, treatment, shared follow-up care, post-treatment surveillance, coordination and continuity of care, as well as managing existing health issues and providing information and support to the patient, their family and carer.

A nominated contact person from the multidisciplinary team may be assigned responsibility for coordinating care in this phase. Care coordinators are responsible for ensuring there is continuity throughout the care process and coordination of all necessary care for a particular phase (COSA 2015). The care coordinator may change over the course of the pathway.

The lead clinician is responsible for overseeing the activity of the team and for implementing treatment within the multidisciplinary setting.

Patients should be encouraged to participate in research or clinical trials where available and appropriate.

For more information visit the Cancer Australia website.

Cancer prehabilitation uses a multidisciplinary approach combining exercise, nutrition and psychological strategies to prepare patients for the challenges of cancer treatment such as surgery, systemic therapy and radiation therapy. Team members may include anaesthetists, oncologists, surgeons, haematologists, clinical psychologists, exercise physiologists, physiotherapists and dietitians, among others.

Patient performance status is a central factor in cancer care and should be frequently assessed. All patients should be screened for malnutrition using a validated tool, such as the Malnutrition Screening Tool (MST). The lead clinician may refer obese or malnourished patients to a dietitian preoperatively or before other treatments begin.

Patients who currently smoke should be encouraged to stop smoking before receiving treatment. This should include an offer of referral to Quitline in addition to smoking cessation pharmacotherapy if clinically appropriate.

Evidence indicates that patients who respond well to prehabilitation may have fewer complications after treatment. For example, those who were exercising before diagnosis and patients who use prehabilitation before starting treatment may improve their physical or psychological outcomes, or both, and this helps patients to function at a higher level throughout their cancer treatment (Cormie et al. 2017; Silver 2015).

For patients with prostate cancer, the multidisciplinary team should consider these specific prehabilitation assessments and interventions for treatment-related complications or major side effects:

  • conducting a physical and psychological assessment to establish a baseline function level
  • identifying impairments and providing targeted interventions to improve the patient’s function level (Silver & Baima 2013)
  • reviewing the patient’s medication to ensure optimisation and to improve adherence to medicine used for comorbid conditions
  • pre-surgery pelvic floor exercise advice
  • exercise programs for men having ADT.

Following completion of primary cancer treatment, rehabilitation programs have considerable potential to enhance physical function.

Cancer and cancer treatment may cause fertility problems. This will depend on the age of the patient, the type of cancer and the treatment received. Infertility can range from difficulty having a child to the inability to have a child. Infertility after treatment may be temporary, lasting months to years, or permanent (AYA Cancer Fertility Preservation Guidance Working Group 2014).

Patients need to be advised about and potentially referred for discussion about fertility preservation before starting treatment and need advice about contraception before, during and after treatment. Patients and their family should be aware of the ongoing costs involved in optimising fertility. Fertility management may apply in both men and women. Fertility preservation options are different for men and women and the need for ongoing contraception applies to both men and women.

The potential for impaired fertility should be discussed and reinforced at different time points as appropriate throughout the diagnosis, treatment, surveillance and survivorship phases of care. These ongoing discussions will enable the patient and, if applicable, the family to make informed decisions. All discussions should be documented in the patient’s medical record.

More information

See the Cancer Council website for more information.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

  • assistance for dealing with psychological and emotional distress while adjusting to the diagnosis; treatment phobias; existential concerns; stress; difficulties making treatment decisions; anxiety or depression or both; psychosexual issues such as potential loss of fertility and; history of sexual abuse; and interpersonal problems
  • counselling for decision regret and fear of cancer recurrence
  • management of physical symptoms such as pain and fatigue (Australian Adult Cancer Pain Management Guideline Working Party 2019), incontinence, urinary retention or voiding difficulties
  • sexual function/dysfunction and decreased fertility – evidence is limited, but fertility declines when erectile function and libido are affected; referral to counselling specialists for sperm banking may be required (Lotti & Maggi 2018)
  • malnutrition or undernutrition, identified using a validated nutrition screening tool such as the MST (note that many patients with a high BMI [obese patients] may also be malnourished [WHO 2018])
  • support for families or carers who are distressed with the patient’s cancer diagnosis
  • support for families/relatives who may be distressed after learning of a genetically linked cancer diagnosis
  • specific spiritual needs that may benefit from the involvement of pastoral/spiritual care.

Additionally, palliative care may be required at this stage.

For more information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

In discussion with the patient, the lead clinician should undertake the following:

  • provide the patient and carer with information, support and adequate time to decide whether or not they wish to undergo prostate biopsy including an explanation of the risks (not forgetting the increased chance of having to live with the diagnosis of clinically insignificant prostate cancer) and benefits of prostate biopsy
  • establish if the patient has a regular or preferred general practitioner and if the patient does not have one, then encourage them to find one
  • provide written information appropriate to the health literacy of the patient about the diagnosis and treatment to the patient and carer and refer the patient to the Guide to best cancer care (consumer optimal care pathway) for prostate cancer, as well as to relevant websites and support groups as appropriate
  • provide a treatment care plan including contact details for the treating team and information on when to call the hospital
  • discuss a timeframe for diagnosis and treatment with the patient and carer
  • discuss the benefits of multidisciplinary care and gain the patient’s consent before presenting their case at an MDM
  • provide brief advice and refer to Quitline (13 7848) for behavioural intervention if the patient currently smokes (or has recently quit), and prescribe smoking cessation pharmacotherapy, if clinically appropriate
  • recommend an ‘integrated approach’ throughout treatment regarding nutrition, exercise and minimal or no alcohol consumption among other considerations
  • communicate the benefits of continued engagement with primary care during treatment for managing comorbid disease, health promotion, care coordination and holistic care
  • where appropriate, review fertility needs with the patient and refer for specialist fertility management (including fertility preservation, contraception, management during pregnancy and of future pregnancies)
  • be open to and encourage discussion about the diagnosis, prognosis (if the patient wishes to know) and survivorship and palliative care while clarifying the patient’s preferences and needs, personal and cultural beliefs and expectations, and their ability to comprehend the communication
  • encourage the patient to participate in advance care planning including considering appointing one or more substitute decision-makers and completing an advance care directive to clearly document their treatment preferences. Each state and territory has different terminology and legislation surrounding advance care directives and substitute decision-makers.

The lead clinician has these communication responsibilities:

  • involving the general practitioner from the point of diagnosis
  • ensuring regular and timely communication (within a week of diagnosis or significant change in care plan) with the general practitioner about the diagnosis, treatment plan and recommendations from MDMs and inviting them to participate in MDMs (consider using virtual mechanisms)
  • supporting the role of general practice both during and after treatment
  • discussing shared or team care arrangements with general practitioners or regional cancer specialists, or both, together with the patient.
More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.