The case for no initial treatment of localized prostate cancer

This contribution summarizes the evidence from the natural history and pathology of this disease that, given the high incidence of latent cancer, a policy of radical treatment at diagnosis will represent over-treatment in the majority of cases. As yet, neither radical prostatectomy nor radical radiotherapy has been shown to be effective in managing the poorly differentiated tumor in the patient with "localized" disease. For the patient with well-differentiated disease, there is little evidence that early treatment is mandatory, because the majority of these patients will not die of prostatic cancer. The adoption of a policy of diagnosis followed by active surveillance would spare many patients the hazard and discomfort of a major operation or of a course of radiotherapy, would minimize expenditure, and would ensure that treatment was given only to those patients in whom progression had been demonstrated. Such an approach is almost certain to be as effective as treatment at diagnosis. Confirmation of this view is likely to be obtained from the existing studies of immediate versus delayed orchiectomy or LHRH therapy currently being undertaken by the Urological Working Party of the Medical Research Council in the United Kingdom and the Urological Group of the EORTC within Europe.