SHOULD WE TREAT LOCALIZED PROSTATE-CANCER - AN OPINION

Localized prostate cancer is a progressive disease if left untreated. However, cancer-specific mortality is low in patients with moderately and well-differentiated prostate cancer treated with observation and delayed hormonal therapy, being 13% at 10 years and 20% to 30% at 15 years. By and large, radiation therapy does not appear to improve survival in these patients. With modern surgical techniques, mortality from prostate cancer is lowered by 23% to 65% in patients with moderately or well-differentiated tumors. However, the impact on relative cancer-specific survival is modest, since the mortality rate in untreated patients is low. The survival of conservatively managed patients with poorly differentiated prostate cancer is dismal: here radiation therapy or surgery significantly improves outcome. The QOL of patients with localized prostate cancer is significantly affected by the occurrence of distant metastasis. Metastatic rates are high in patients who are followed with observation and delayed endocrine treatment (19% to 85%). We were unable to deduce the effects of radiation therapy on grade-specific metastatic rates at 10 and 15 years. The only surgical series that addresses the issue shows a 50% to 80% reduction in metastatic rates. This results in an improvement in metastasis-free survival of 19% to 300%. The reduction in metastatic rates with surgery holds true for patients with poorly, moderately, or well-differentiated tumors. However, a significant proportion of the surgical patients were treated with adjuvant endocrine therapy, and it is impossible to identify the benefit from surgery and the benefit from adjuvant therapy. Radical prostatectomy improves survival in men who are 65 years or younger with moderately or well-differentiated adenocarcinoma of the prostate, and in men 75 years or younger who have poorly differentiated adenocarcinoma of the prostate. Its efficacy in reducing cancer-specific mortality in patients who have a survival expectancy of less than 15 years (older than 65 years) and moderately or well-differentiated adenocarcinoma of the prostate is less clear. Radical prostatectomy, with or without adjuvant hormonal therapy, decreases metastatic rates in men with a life expectancy of 10 years or more (age 75 years or younger) irrespective of tumor grade and, thus, should improve the QOL expectancy in these men. Nevertheless, between 20% and 60% of patients undergoing radical prostatectomy have biochemical recurrence, as defined by a detectable PSA, at 10 years of follow-up. This is worrisome and may portend clinical failure with longer follow-up. Further improvements in survival in patients with localized prostate cancer must necessarily come from a multidisciplinary approach to the treatment of localized prostate cancer. Perhaps, cure is possible in some (many) men for whom it is necessary and is necessary in some (many) for whom it is possible. © 1995.