A diagnosis of early prostate cancer can send any man into a tunnel dark with uncertainty.
Once in this tunnel, he will stumble across a range of management options, each of which can have upsetting complications and none of which is definitively the best. There are no clear guidelines for management at this early stage; with the help of his doctor he will have to make a subjective choice and live with his doubts and the consequences of his decision.
Fortunately, this situation is changing, and some light is beginning to emerge along the tunnel. A huge international research effort is beginning to produce material that can be fashioned into reliable guidelines for the treatment of prostate cancer.
Publicity about prostate cancer in recent years has generated much anxiety among older men. Those over 50 who purposefully go looking for it stand a good chance of finding it. Cellular evidence of prostate cancer will be found in 30 to 40 per cent of them.
Left untreated, a few will succumb to the disease within 5 years of diagnosis, and only a minority will succumb within 10. Eventually, one in every four of these cancerous prostates will produce symptoms, and one in every 14 that produce symptoms will prove lethal.
The difficulty is in knowing which cancers will become life-threatening and which will continue to exist without causing problems. Early prostate cancer is, by definition, still localised and has not spread beyond the gland. The first thing to determine is whether the cancer is dormant or active. If it is dormant, how long will it be before it wakes (if it ever does)? If it is active, is it sluggish or aggressive?
Researchers have been working assiduously to develop mark ers that can reliably assess the ability of an individual prostate tumour to progress, and over the next few years better information should become available.
For many men, selecting treatment is an extremely challenging proposition. The options are controversial and each can have complications.
The main options are removing the prostate surgically; bombarding the prostate with external radiation beams; and, finally, only treating symptoms as they arise. Less popular options include hormone treatment, radiation from special seeds implanted in the prostate, freezing and any combination of the above.
On current evidence, it is difficult to compare these options according to the benefits they may confer and the harm they may cause, but controlled investigations are now under way and results could be available in 10 years.
In making a decision, men must weigh up their quality of life against their quantity of life and decide how much risk they are willing to accept. It is a hard call.
At present it is not possible to say with certainty that there is a survival advantage for any of the various management approaches when used in similarly selected patients. However, the consensus in the literature seems to be that surgical removal is best performed on men with early prostate cancer who expect to live longer than 10 years, who are fit for surgery and who have not had previous radiotherapy.
Sexual and urinary function can be affected by surgery, although nerve-sparing techniques have seen a reduction in these complications in recent years. There is general agreement that external beam radiotherapy is best suited to those who expect to live for more than 10 years. Side effects associated with bowel function and also with sexual performance are its main complications.
Ideally, the option of waiting is best suited to men whose cancer is not destined to progress, cause problems or lead to death. The great difficulty lies in predicting who these men are.
If a waiting strategy is adopted, treatment will be reserved for symptoms or complications and will not be expected to ‘cure’ the cancer. This strategy is appropriate for men who have a life expectancy of less than 10 years.
It is still not known what, apart from family history, causes prostate cancer or what prevents it, but there is growing interest in the role played by dietary components such as selenium and phyto-oestrogens. Although there is currently insufficient evidence for a firm judgement to be made as to their effectiveness, they may offer the prospect of primary prevention in the future.
The most positive news about prostate cancer today comes from the United States. After an inexorable increase over many years in the death rate for this cancer, data show that in the last decade there was actually a fall in the rate. It is not clear whether this is due to early detection or better treatment, but it provides a basis for research and something to build on.
Prostate cancer research is probably 15 years behind breast cancer research and 5 years behind colon cancer in terms of studies that could answer questions about treatment.
In Australia the incidence of prostate cancer, which rose steadily during the early nineties, also appears to have peaked in the last few years, although to date the death rate has remained stable.
The American trend is the first positive sign.
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