Controversy Prompts Another Update to NCCN Guidelines for Prostate Cancer


The National Comprehensive Cancer Network (NCCN) has updated its guidelines for prostate cancer in response to physician concerns about an active surveillance recommendation.1

The NCCN previously released updated guidelines in September, and that update changed the recommendation about active surveillance for low-risk prostate cancer.2 Active surveillance was no longer listed as the “preferred” management option for patients with low-risk prostate cancer and a life expectancy of 10 years or more.

Some physicians voiced concerns about this change, saying it could lead to overtreatment of low-risk patients by implying that active surveillance, surgery, and radiation are all equivalent management options for this patient group.

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“It’s a step in the wrong direction, and there’s no clear rationale for it in the guidelines text,” Matthew Cooperberg, MD, a professor of urology at the University of California, San Francisco, told Cancer Therapy Advisor in a previous interview.

Dr Cooperberg was one of the physicians speaking out about the September change to the guidelines on social media.4,5

In response to physicians’ concerns, the NCCN Prostate Cancer Panel convened to review the issue and “address the complexities underpinning management options for patients with localized prostate cancer,” said panel chair Edward Schaeffer, MD, PhD, program director of the Genitourinary Oncology Program at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago.

“More specifically, the panel extensively revised the ‘Principles of Active Surveillance and Observation’ to provide detailed guidance on important aspects of this disease state and, additionally, tabulated large active surveillance datasets as a reference,” Dr Schaeffer said in an emailed statement.

Details on the Latest Update

The new version of the guidelines now states that active surveillance is preferred for most patients with low-risk prostate cancer and a life expectancy of 10 years or more. 

“The panel confirmed that the utilization of active surveillance as a management strategy should be strongly considered for most patients with very low- and low-risk prostate cancer,” Dr Schaeffer said. “However, the panel also acknowledged that there is heterogeneity across the low-risk disease group and that some factors may be associated with an increased probability of near-term grade reclassification.”

These factors include high prostate-specific antigen (PSA) density, 3 or more positive cores, high genomic risk, and/or a known BRCA2 germline mutation, according to the guidelines. 

“In some of these cases, upfront treatment with radical prostatectomy or prostate radiation therapy may be preferred based on shared decision-making with the patient,” the guidelines state. 

In response to the new guideline change, Dr Cooperberg tweeted, “Very glad to see this update! Great news and clarity for patients.” 

“Maybe the first social media win in Urology?” tweeted Benjamin J. Davies, MD, a professor of urology at the University of Pittsburgh in Pennsylvania.


  1. NCCN Clinical Practice Guidelines in Oncology, Prostate Cancer, Version 2.2022. Published November 30, 2021. Accessed November 30, 2021.
  2. NCCN Clinical Practice Guidelines in Oncology, Prostate Cancer, Version 1.2022. Published September 10, 2021. Accessed November 30, 2021.
  3. Forster V. Docs disagree with update to NCCN guidelines for prostate cancer. Cancer Therapy Advisor. Published October 29, 2021. Accessed November 30, 2021.
  4. Cooperberg M (@dr_coops). Twitter thread. Published September 28, 2021. Accessed November 30, 2021.
  5. Davies BJ (@daviesbj). Twitter thread. Published September 29, 2021. Accessed November 30, 2021.

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