Management of clinically localized prostate cancer

Abstract

Critics of screening have stated that early detection of prostate cancer does not necessarily reflect a diminishing death rate from the disease. However, several recent reports have demonstrated that the death rate from prostate cancer is decreasing, representing the most compelling validation for aggressive screening. Prostate cancer can be halted only if there is no evidence of systemic or regional metastases and the disease is confined to the surgical field or the radiation template. Surgeons and radiation oncologists must make a concerted effort to exclude men with regional and systemic metastases who are unlikely to benefit from treatment. With the widespread acceptance of prostate-specific antigen screening, a greater proportion of men are being diagnosed with clinically localized prostate cancer. Both radical prostatectomy and radiation therapy are able to halt disease spread in this significant subset of men, but survival outcomes indicate that radical prostatectomy is a more reliable treatment than radiation therapy for clinically localized prostate cancer. Overall, the immediate treatment-related morbidity of radical prostatectomy and radiation therapy in the modern era is quite low. Radical prostatectomy and radiation therapy appear to have a similar impact on continence and erectile function. There is a need for neoadjuvant and adjuvant therapies that can be utilized in those cases where radical prostatectomy and radiation are less likely to completely eradicate or destroy the cancer.

Figure 1

Survival for men with localized prostate cancer managed with “watchful waiting.” Inset shows ultimate risk of prostate cancer-related death. Reproduced with permission from Aus et al.

Figure 2

Kaplan-Meier actuarial likelihood of prostate-specific antigen (PSA) recurrence by Gleason score following radical prostatectomy. From Han et al, reproduced with permission.

Figure 3

Kaplan-Meier survival following external beam radiotherapy. Reproduced with permission from Bagshaw.

Figure 4

Disease-free survival following brachytherapy. The number of men who were available for evaluation is shown in parenthesis. From Korb and Brawer.

Figure 5

Seventeen days after radical prostatectomy, this 57-year-old man (no. 794, center) competed in the U.S. National Track and Field finals.

Figure 6

Acute bowel (A) and bladder (B) toxicities following three-dimensional conformal radiotherapy. From Michalski et al, reproduced with permission.