Manuel de Prise en Charge du Cancer de la Prostate

Objectives

Algeria’s prostate-cancer guide forms part of the national Cancer Plan and the Ministry of Health, Population and Hospital Reform programme to develop guidance for common cancers. Its overarching purpose is to harmonise and improve practice, make care more effective and efficient, and define an appropriate care pathway for people with prostate cancer.[1]The guide combines population-facing early-detection objectives with detailed standards for diagnosis, staging, treatment, follow-up and supportive care.[2][3]

• Promote individual screening for men aged 50 to 75 years to identify aggressive cancer at a localised and potentially curable stage, while limiting overdiagnosis. Screening combines digital rectal examination and prostate-specific antigen testing, with urology referral for an abnormal examination or prostate-specific antigen above 4 nanograms per millilitre.[4]
• Reduce diagnostic and treatment delays and improve the availability and quality of diagnostic and therapeutic tools.[2]
• Establish histological confirmation, disease stage and prognostic assessment through standardised biopsy, pathological processing, Gleason grading and tumour-node-metastasis classification.[5][6][7]
• Distinguish localised cancers eligible for curative treatment from disease with regional or distant extension through pre-treatment clinical, pathological and imaging assessment.[8][9]
• Provide risk-adapted treatment according to clinical stage, prostate-specific antigen level, Gleason score, metastatic risk, life expectancy, comorbidities and patient preferences.[10][11]
• Improve survival, delay symptomatic progression and preserve quality of life in advanced, recurrent and metastatic disease, while providing symptom control and palliative support where needed.[12][13]
• Involve patients in treatment decisions by explaining the advantages and disadvantages of available options and obtaining informed consent.[14]

Implementation

The guide is designed as a pragmatic reference for practitioners involved in prostate-cancer care, rather than a substitute for individual clinical judgement.[1]It uses a multidisciplinary, staged care model spanning referral, diagnostic confirmation, staging, treatment selection, surveillance, management of recurrence and supportive care.[2][15][3]National coordination is assigned principally to the Directorate-General for Health Structures within the Ministry of Health, Population and Hospital Reform.[15]

• Strengthen workforce capacity through initial and continuing training for medical and paramedical personnel, and disseminate updated guidance and technical materials.[2]
• Refer suspected cases from local public health establishments through the treating doctor to referral services; complete staging after diagnosis and present patients to multidisciplinary consultation meetings at university hospital centres or regional hospital establishments for treatment decisions.[2][15]
• Operate adaptable weekly multidisciplinary meetings involving urology, pathology, radiology, radiotherapy, oncology and psychology.[15]
• Coordinate dissemination and revision of the national guide, assess facility, equipment and medicine needs, manage the national database and mobilise multidisciplinary experts through the Directorate-General for Health Structures.[15]
• Conduct epidemiological surveys and applied field research through the National Institute of Public Health, working with clinicians, clinical researchers and the Directorate of Prevention.[15]
• Maintain medicine and laboratory-consumable supplies through the Central Hospital Pharmacy, using establishment orders and programme forecasts, with central and regional reserve stocks.[15]
• Standardise diagnostic practice through ultrasound-guided biopsy, structured pathology request forms, labelled specimen handling, systematic sampling and reporting of tumour burden, Gleason score, extension, margin status and pathological stage.[16][17][6][18]
• Use imaging and multidisciplinary review to support staging and treatment planning, including magnetic resonance imaging, computed tomography and bone scintigraphy according to clinical risk factors.[9][19]
• Deliver localised-disease care through active surveillance, prostatectomy, external-beam radiotherapy and, where available or suitable, brachytherapy, with hormone therapy added for specified intermediate- and high-risk disease.[10][11]
• Apply radiotherapy through defined target volumes, fractionation schedules, dose constraints, treatment-plan validation by the radiation oncologist and medical physicist, and imaging-based verification of positioning.[20][21]
• Manage locally advanced, metastatic and castration-resistant disease through selected combinations of radiotherapy, surgery, androgen-deprivation treatment, chemotherapy and other systemic therapies, based on symptoms, fitness, prior treatment and disease characteristics.[22][23][24]
• Provide follow-up using prostate-specific antigen testing, clinical review and targeted imaging when recurrence or treatment escape is suspected; provide analgesia, bone-directed treatment, psychological support, management of obstruction and end-of-life home hospitalisation when indicated.[3][25][13]
• Establish regional cancer registers and a computerised national prostate-cancer register to measure prevalence, disease progression and programme effectiveness; analyse notifications in collaboration with the National Institute of Public Health.[2][15]

Monitoring & Evaluation

Monitoring combines national programme surveillance, clinical follow-up, diagnostic documentation, pathological quality assurance and radiotherapy verification. The guidance provides defined patient-level measures and intervals for several treatment pathways, but does not set out a comprehensive national indicator set, reporting timetable, audit cycle or formal accountability framework.[2][15][3][25][13]

• Establish regional cancer registers and a computerised national prostate-cancer register to measure prevalence, disease progression and national programme effectiveness.[2]
• Assign management of the national database and analysis of case notifications, in collaboration with the National Institute of Public Health, to the Directorate-General for Health Structures.[15]
• Undertake epidemiological surveys and applied field research with clinicians, clinical researchers and the Directorate of Prevention to support surveillance and programme learning.[15]
• Update clinical guides when needed in response to national and international recommendations and important diagnostic or therapeutic developments.[1]
• Document screening and diagnostic findings, including digital rectal examination, prostate-specific antigen results, biopsy location, prior biopsies, clinical history and relevant imaging, through pathology request forms and biopsy-reporting templates.[17][5][26][27]
• Assess biopsy quality by requiring a mean core length of at least 10 millimetres, and report malignancy, stage and prognostic information through standardised pathological assessment.[5][28]
• Report pathological measures including tumour location and burden, Gleason score, grade 4 or 5 proportion where applicable, extraprostatic extension, perineural invasion, surgical-margin status, seminal-vesicle involvement and pathological tumour-node-metastasis stage.[6][29][18]
• Use repeat biopsy where prostate-specific antigen remains raised or rises, digital rectal examination remains suspicious, atypical small acinar proliferation is found, or diagnostic uncertainty persists.[17]
• Apply treatment-delivery checks in radiotherapy, including joint validation by the radiation oncologist and medical physicist, independent monitor-unit calculation, patient-identity verification, imaging-based first-session positioning checks, and dose-volume constraints for organs at risk.[20][21]
• Monitor active surveillance with prostate-specific antigen testing every three to six months, digital rectal examination every six to 12 months, and repeat biopsy three to 18 months after the initial biopsy; calculate prostate-specific antigen doubling time and reconsider curative treatment when surveillance criteria deteriorate.[12]
• Monitor postoperative patients with prostate-specific antigen testing every six months for three years and annually for a further four years, alongside six-monthly clinical examination and follow-up for at least seven years; review patients receiving adjuvant treatment or with positive margins every three months.[3][25]
• Define biochemical recurrence after surgery as prostate-specific antigen above 0.2 nanograms per millilitre, confirmed three months later, where the marker was previously undetectable or had reached a nadir below 0.1 nanograms per millilitre.[25]
• Maintain lifelong follow-up after radiotherapy, with first control at 18 to 24 months and subsequent six-monthly clinical, digital rectal examination and prostate-specific antigen assessment; use multiparametric magnetic resonance imaging after focal therapy to detect recurrence.[25]
• Review metastatic disease clinically every three months, measure prostate-specific antigen every six months during the first year and subsequently as required, perform annual abdominopelvic ultrasound, and monitor testosterone, transaminases, blood count and creatinine during hormone therapy according to treatment and disease status.[25][13]
• Assess castration-resistant disease through serial prostate-specific antigen increases, progression after secondary hormonal manipulation, new or progressive lesions and castration-level testosterone; define biological response to chemotherapy as a prostate-specific antigen fall of at least 50%, confirmed after at least four weeks without clinical or radiological progression.[23][30][13]
• Monitor abiraterone clinically and biologically for hypertension, oedema, hypokalaemia, liver-function abnormalities and corticosteroid-related effects.[23][31]

Costing & Financing

Financial detail is limited. No monetary budget, expenditure estimate, financing source, funding gap, resource-mobilisation plan or economic assumption is specified for the prostate-cancer programme or its diagnostic and treatment guidance.[2][15][16][3][13]

• Assess requirements for facilities, equipment and medicines using information provided by participating health structures.[15]
• Plan medicines and laboratory-consumable supplies using orders from public hospitals and local public health establishments and forecasts under the national prostate-cancer programme.[15]
• Maintain central and regional safety and reserve stocks of medicines and laboratory consumables through the Central Hospital Pharmacy and its regional branches.[15]
• Recognise service-availability constraints, as permanent iodine-125 brachytherapy, high-intensity focused ultrasound, cryotherapy and focal therapy were unavailable or under evaluation in Algeria in the cited section.[10]
• Note that complete androgen blockade entails greater treatment-related adverse effects and higher cost than androgen-blockade monotherapy, although no monetary estimate is provided.[32]
• Require clinical infrastructure and specialist inputs for specified care, including multidisciplinary consultation meetings, pathology processing, magnetic resonance imaging, radiotherapy planning and verification, surgery, laboratory testing and long-term follow-up, but without costing these inputs.[15][28][8][21][3]