Management of localized prostate cancer: an epidemiological perspective

Prostate cancer is an important and increasing source of male morbidity and mortality. In the absence of any primary preventative strategy, medical approaches to control it will concentrate on attempts at cure in localized disease and effective palliation otherwise. Observational epidemiological studies suggest that, in practice, differences in the effectiveness of aggressive and conservative approaches will be small, but may yet be worthwhile in selected groups of men. However, the confounding and biases inherent in all observational epidemiology mean that the data available from this source is insufficiently certain or precise either to make treatment recommendations for individuals, or to quantify relative benefits to inform health policy. Randomized trial data has not suggested any overwhelming benefit for any one treatment modality, but the five published trials have been small and lacked the statistical power to demonstrate potentially important differences. Aggressive management aimed at cure should be evaluated in adequately designed randomized trials in comparison with expectant medical management ('watchful waiting'). The trials currently planned or under way should be supported enthusiastically by all centres with an interest in management of prostate cancer.