The biologic dilemma of early carcinoma of the prostate

The clinician has long been challenged by the diversity in clinical expression of carcinoma of the prostate. On one end of the spectrum is a disease that is phenotypically malignant but biologically not virulent. It is the prostate carcinoma that males die with rather than of. On the other end of the spectrum, there is a carcinoma of the prostate that is relentless and virulent, and has been resistant to our intervention efforts. Although all males are known to be at risk for the occurrence of carcinoma of the prostate, there is no means at present to predict the type and behavior of the disease they will experience. This is the conundrum faced upon recognition of premalignant and early microscopic disease.

This paper presents a conceptual framework of the evaluation of disease behavior along one of three distinctive pathways. In this trilogy of expression of carcinoma of the prostate, there are the indolent (Type I), the slowly progressive (Type II), and the virulent and systemic (Type III). These general patterns of behavior may be an expression of the tumor cell ("seed") and the factors that were its genesis, or the effect of the environment ("soil") in which the tumor cell finds itself. The more likely fact is that it is the product of both ("seed and soil").

Our goal is to identify tumors for which no therapy is warranted at their outset by molecular and biologic methods; age group in whom curative local therapy is feasible; and the carcinomas that require effective systemic therapy.

The three general patterns of clinical expression provide a framework in which to identify the genetic, molecular, and cellular determinant of the biologic behavior of carcinoma of the prostate. Being able to correlate such parameters with likely behavior patterns would help us choose appropriate therapy.