Prostate cancer is the second cause of cancer death in men in the 'Western world; its medical and social impact is comparable to that of breast cancer in women. Although it is well recognized that early treatment is the only possibility for reducing the high rate of death from prostate cancer, screening and even early treatment are controversial issues due mainly to arguments based upon old Literature and lack of awareness of the significant advances recently made in this field. As it is well known that surgical removal of organ-confined prostate cancer cures the disease, and it has been demonstrated that annual screening with prostate-specific antigen coupled with digital rectal examination followed, when indicated, by transrectal ultrasonography of the prostate more than doubles the proportion of organ-confined disease, screening alone offers the possibility of at least doubling the number of patients curable from prostate cancer or the potential for a cure to an estimated 45% of prostate cancer patients compared to a maximum of 20% in the absence of screening. It is important to mention that screening does not detect small and insignificant cancers, especially when random biopsies are not performed routinely. The critical volume of prostate cancer is estimated at 0.3 cm or a tumor 7.5 mm in diameter, if spherical. Such a tumor should increase serum prostate-specific antigen by 0.5 ng/mL. Contrary to the belief that screening detects cancers that are too small, the fact is that screening detects prostate cancer too late or nonorgan-or nonspecimen-confined cancer in 35-50% of cases. There is, thus, a narrow window when prostate cancer can be detected ata curable stage, and even the best available screening techniques cannot succeed in all cases. It should be mentioned that the recent improvements of the technique of radical prostatectomy have markedly improved the acceptability of surgery. Concerning the recent publicity related to watchful waiting, it is essential to indicate that all such reports support the notion that prostate cancer grows slowly, but steadily and irremediably, with increasing malignancy and risk of distant metastases and death if sufficient time is allowed. Another serious limitation of watchful waiting is that the available prognostic factors have a large margin of error and cannot predict with certainty the rate of progression of the tumor. Consequently, watchful waiting or treatment deferred at the time of signs of progression is associated with an important (at least 15-20%) risk of dying from prostate cancer within 10 yr and a very high risk of distant metastases (at least 40%) within 10 yr, with death within the next 5 yr for all of those patients. For a patient with a life expectancy of more than 10 yr, the risk of dying from prostate cancer approaches 50% at 15 yr. Although screening is able to detect more than 90% of prostate cancers at the localized stage, a remaining problem is that even with screening, approximately 50% of cancers thought to be localized at diagnosis have, in fact, already migrated outside the prostate and cannot be completely removed by surgery. It is, thus, important to find a means of improving the stage of the disease so as to increase the success rate of curative therapy. A potential solution comes from recent data showing that treatment of patients for only 3 months with endocrine combination therapy before radical prostatectomy increased the proportion of organ-confined cancers from 49% to 79% whereas the proportion of patients with negative surgical margins increased from 66% to 92%. In fact, although screening alone using today's available information and techniques could potentially reduce the present 38,000 annual deaths due to prostate cancer in the United States by 12,000 (31%), 3-month preoperative combination therapy combined with screening could potentially decrease the number of annual deaths by 22,500 (59%) and 29,000 (76%) using organ-confined and specimen-confined disease as parameters of potential cure. Although the impact of screening itself is already well supported by long term survival data obtained by many studies in patients with organ-confined prostate cancer treated by radical prostatectomy, the impact of preoperative endocrine therapy on survival remains to be assessed by long term Follow-up of the patients in the current clinical trials. However, the major histopathological benefits already observed suggest that apoptosis or cancer cell death induced by preoperative endocrine therapy could well lead to a major decrease in deaths from prostate cancer with all of its associated social and economic benefits. To take advantage of the available technology, efficient screening must be performed in men older than 50 yr as recommended by the American Cancer Society. The diagnosis of prostate cancer can thus be made at a localized stage in more than 90% of patients, and one can then choose between temporary endocrine therapy before radical prostatectomy or radiotherapy, combination endocrine therapy alone, or deferred treatment with close follow-up, depending upon the age, general health, and personal choice of a well informed patient. Although watchful waiting can be a choice for some patients, it must be realized that screening is essential to diagnose early stage prostate cancer in a larger proportion of men and then be able to make any choice of therapy. Otherwise, advanced and incurable prostate cancer will remain the diagnosis for the majority of patients. It is also important to mention that even for men with a life expectancy shorter than 10 yr, no immediate treatment carries a high risk of poor quality of life by distant metastases and even death. When prostate cancer reaches a certain size, it migrates outside the prostate, becomes more dedifferentiated, and a cure is no longer possible. Furthermore, because of the uncertainty of staging and prognosis, it is reasonable to expect that most men diagnosed as having ''localized'' prostate cancer would choose the safest approach or the curative therapy with the best chance of eradicating the tumor before it becomes incurable.
