Prostate cancer is the most common nondermatologic malignancy in the world and the second leading cause of deaths from cancer in men in the United States. Risk factors include age, family history of prostate cancer, black race and, possibly, high intake of dietary fat. The chance that men with well to moderately differentiated, palpable, clinically localized prostate cancer will remain free of symptomatic progression is 70 percent at five years and 40 percent at 10 years. Complications of local or regional progression include hematuria, bladder obstruction and lower-extremity edema. Despite the high rates of prostate-specific antigen (PSA) testing and treatment in the United States, mortality rates have not decreased substantially. Wilt and Brawer reviewed management options for men with nonmetastatic prostate cancer.
Randomized controlled trials and systematic reviews through December 1998 that outlined management options were identified and analyzed. The outcomes evaluated were survival, time to progression, response in terms of signs and symptoms, quality of life and adverse effects of treatment. Management options for clinically localized prostate cancers include the following: (1) watchful waiting, (2) radical prostatectomy, (3) external beam radiation therapy, (4) brachytherapy, (5) cryosurgery and (6) androgen deprivation.
The data collected did not provide clear evidence for the superiority of any of the options listed. Watchful waiting has not been shown directly to improve the length or quality of life. The results of comparisons of radical prostatectomy with watchful waiting and external beam radiation are inconclusive. Prostatectomy does not appear to be any more effective than watchful waiting, but it may reduce the risk of metastases associated with external beam radiation therapy. Potential adverse effects of prostatectomy include surgical complications, sexual dysfunction, urinary incontinence, urethral stricture and fecal incontinence.
Along with an increased risk of metastases, external beam radiation therapy has a number of serious adverse effects, including incontinence, impotence and bowel dysfunction. Brachytherapy and cryotherapy have not been shown to improve length or quality of life, and brachytherapy can result in urinary retention, incontinence and impotence. Androgen deprivation did not prove beneficial and has adverse effects such as osteoporosis, weight gain, hot flushes, gynecomastia, impotence and loss of libido. In addition, initiating androgen deprivation when the PSA increases and discontinuing it when the PSA decreases has no proven positive effect. In patients with locally advanced prostate cancer (stage C, American Urologic Staging System), androgen deprivation initiated at diagnosis reduces complications and may improve survival.
The authors conclude that no specific treatment for clinically localized disease is superior compared to the others or to watchful waiting, nor have all of the options been reviewed, although prostatectomy appears to reduce recurrence compared with radiation treatment. There is no evidence that androgen deprivation should be offered to asymptomatic men with an increasing concentration of PSA, and only limited evidence that androgen deprivation initiated at diagnosis improves survival and reduces complication risks compared with deferring treatment in men with locally advanced disease. A combination of androgen deprivation and radiation improves survival compared with radiation treatment alone, but little evidence exists to show that radiation alone is beneficial for survival.