[Diagnostics and therapy of localized prostate cancer: a problem-oriented account]

Abstract

The diagnostics and treatment of prostate cancer (PCa) are currently encumbered with several problems: Only a small proportion of men attend medical check-ups. The PSA count, although invaluable in the early detection of PCa, is not being paid for by health insurance schemes, because its indiscriminate use would result in overdiagnosis of PCa which, in turn would burden patients with avoidable morbidity and the mutually supportive community with unnecessary costs. Accordingly, some clinically insignificant tumors are being detected and treated although treatment appears unnecessary. However, more importantly too many significant tumors which need early detection to be cured are being discovered too late due to diagnostic possibilities being neglected. At least one third of all tumors discovered are still found at a locally advanced stage. Following diagnosis by biopsy the therapeutic recommendations are guided by the clinical stage. In spite of recent advances in MR-based imaging the exact local extent of tumors remains uncertain. Prognostic and predictive biomarkers for aid in therapeutic decisions are also lacking. The more defensive therapeutic strategies, such as active surveillance should be recommended with special precautions in patients younger than 65 years, in the light of new Scandinavian data. Among the curative treatments radical prostatectomy claims the primary position. Minimally-invasive surgery for PCa has not come up to expectations regarding superior local tumor control, less perioperative complication, or better functional results, at the expense of appreciably higher costs.