Does localized prostate cancer exist?

Does localized prostate cancer exist, and how do we diagnose it? Early diagnosis and screening programs for prostate cancer (PC) have led to a greater proportion of patients with a low-stage disease at diagnosis. More men are treated with curative intent by radical prostatectomy (RP), external beam radiotherapy, or brachytherapy. However, a substantial percentage of patients still experience a prostate-specific antigen (PSA) relapse within 5 years. Biochemical recurrence is observed in approximately 40% of patients who undergo RP, with 95% of those relapses in the first 5 years. To avoid the risk of recurrence, the recent tendency has been to detect PC at a lower PSA level than the level widely accepted (> or = 4.0 ng/ml). But the risk of overdiagnosis and overtreatment is a real problem in the PSA era. Discussion around the wide discrepancy between the high prevalence of histological changes recognizable as cancer and the much lower prevalence of clinical disease is prominent. The recent experience from studies on watchful waiting and the results of randomized trials between surgery and active surveillance have clearly demonstrated that many localized PC are overtreated. New screening and management strategies are required to target aggressive disease at an early stage while avoiding overdiagnosis and overtreatment.