Prostate cancer

Prostate cancer accounted for over 41,000 deaths in the United States in 1996. Prostate-specific antigen (PSA) screening is capable of detecting prostate cancer and appears to detect cancers that are both clinically significant as well as organ-confined, and therefore potentially curable. The positive predictive value of PSA value has been increased by the use of the free-to-total PSA ratio. The early detection of a large number of nonpalpable tumors has mandated the development of new risk assessment schemas, which include nomograms and equations in which Gleason score, PSA, and clinical stage play a prominent role. Definitive answers to the question of watchful waiting versus intervention await conclusion of the prostate cancer intervention-versus-observation trial. For both radical prostatectomy and radiation therapy, one means of potentially reducing the risk of relapse is the use of androgen deprivation. Neoadjuvant androgen deprivation prior to surgery results in a lower incidence of positive surgical margins, but impact on survival is unknown. By contrast, the use of concurrent androgen deprivation appears to be associated with enhanced survival in patients treated with definitive radiotherapy. For good risk tumors, modem brachytherapy results in freedom from biochemical relapse rates similar to those observed with surgery and external beam radiation therapy. The best therapy for patients with positive margins or serologic progression, including radiation therapy, remains to be identified. The widespread availability of PSA testing has led to an empirically driven redefinition of advanced disease and includes patients with earlier stage disease in which primary treatment has failed. In these patients, debate remains as to whether combined androgen deprivation is superior to monotherapy. A comparison of flutamide with bicalutamide awaits maturation of survival data. The utility of antiandrogen withdrawal in patients with progressive disease despite androgen deprivation has been confirmed. Thereafter, second-line hormonal maneuvers may be appropriate. In patients with truly hormone refractory prostate cancer, a variety of nonhormonal agents, including estramustine-based therapy, suramin, mitoxantrone, and doxorubicin-based regimens have demonstrated activity and remain as options.