Cancer of the prostate

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Abstract

Prostate carcinoma, with about 190,000 new cases occurring each year (15% of all cancers in men), is the most frequent cancer among men in northern and western Europe. Causes of the disease are essentially unknown, although hormonal factors are involved, and diet may exert an indirect influence; some genes, potentially involved in hereditary prostate cancer (HPC) have been identified. A suspect of prostate cancer may derive from elevated serum prostate-specific antigen (PSA) values and/or a suspicious digital rectal examination (DRE) finding. For a definitive diagnosis, however, a positive prostate biopsy is requested. Treatment strategy is defined according to initial PSA stage, and grade of the disease and age and general conditions of the patient. In localized disease, watchful waiting is indicated as primary option in patients with well or moderately differentiated tumours and a life expectancy <10 years, while radical prostatectomy and radiotherapy (with or without hormone-therapy) could be appropriate choices in the remaining cases. Hormone-therapy is the treatment of choice, combined with radiotherapy, for locally advanced or bulky disease and is effective, but not curative, in 80–85% of the cases of advanced disease. Patients who develop a hormone-refractory prostate cancer disease (HRPC) have to be evaluated for chemotherapy because of the recent demonstration of improved overall survival (2–2.5 months) and quality of life with docetaxel in more than 1600 cases.

Section snippets

Incidence and mortality

Carcinoma of the prostate is the most frequent cancer among men in northern and western Europe. About 190,000 new cases occur each year (15% of all cancers in men) [1]. In Europe, the annual incidence rates (ASW) in 2000 ranged between 19 (eastern Europe) and 55 (western Europe) per 100,000. In most European countries, the incidence has increased more than any other cancer over the past two decades [2]; it has been increasing by about 10% every 5 years in Europe (more in Sweden and France), as

Presentation

About 70–75% of prostate cancers arise in the peripheral zone of the gland, mainly in a posterior location, of the remaining cases, 15% derive from the central zone and 10–15% from the transitional zone. A high-grade prostatic intraepithelial neoplasia (HGPIN) may be associated with or precede cancer in a high percentage of cases [19].

Tumour growth

Prostate adenocarcinoma may spread locally, by direct invasion of seminal vesicles, urinary bladder or surrounding tissues or distantly. Distant metastases can

Symptoms

Low urinary tract symptoms (LUTS) can be present in organ-confined tumors but are usually due to concomitant benign prostatic hyperplasia (BPH). Locally advanced disease, however, is more likely to have an increase in LUTS due both to BPH and carcinoma. In the case of metastatic prostate cancer patients may present with lumbar or pelvic pain as the predominant symptom.

Physical signs

A diagnosis of prostate cancer may be suspected from symptoms, a suspicious digital rectal examination (DRE) finding and/or an

Stage classification

Two systems are usually employed in the staging of prostate cancer: the “Jewett System” (stages A–D) introduced in 1975 [64] and a revised TNM System proposed by the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC) which includes some subcategories in the same T categories of the Jewett System. The TNM System is more precise in stratifying newly diagnosed patients [65].

General consideration

Prostate cancer is characterized by an extremely high histological prevalence and a relatively low mortality. The 5-year observed survival of men with prostate cancer has increased steadily from 45% for men newly diagnosed in 1973 to 70% for men newly diagnosed in 1990, whereas the 10-year observed survival has increased by about 0.9 per year from 22% for men newly diagnosed in 1973 to 32% for men newly diagnosed in 1985. These data, however, derive from a substantial stage migration caused

General considerations

Treatment strategy is defined according to initial PSA, stage and grade of the disease and to the age and general conditions of the patient. Watchful waiting (WW), surgery and radiotherapy (with or without hormone-therapy) could be appropriate choices for patients with localized disease, while hormone-therapy plus radiotherapy should be considered treatment of choice for locally advanced or bulky disease. In cases of advanced disease, ablative hormone-therapy remains the mainstay of treatment

Late sequelae related to surgery

When making treatment choices in early prostate cancer, patients must weigh the benefits against adverse events such as incontinence and impotence that may affect quality of life (QoL) [170], [171].

Follow-up after curative treatments

Patients who underwent potentially curative treatments such as radical prostatectomy or radical radiotherapy are at risk of relapse. Incidence, site and timing of relapse depend of Gleason score, baseline PSA and clinical or pathological stage. Patients have to be followed at 3–4 monthly intervals with PSA, haemato-biochemistry and digital rectal exploration during the first year, every 6 months for the following 2 years and then yearly. Trans-rectal ultrasound, bone scintigraphy and other

Sergio Bracarda is specialist in medical oncology and urology and senior assistant of the Medical Oncology Division, Ospedale Silvestrini, Azienda Ospedaliera di Perugia.

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  • Cited by (0)

    Sergio Bracarda is specialist in medical oncology and urology and senior assistant of the Medical Oncology Division, Ospedale Silvestrini, Azienda Ospedaliera di Perugia.

    Ottavio de Cobelli is director of Urology Department at the European Institute of Oncology, Milan, Italy.

    Carlo Greco is associate professor of Radiation Oncology at the University of Magna Graecia, Catanzaro, Italy.

    Tommaso Prayer-Galetti is staff urologist at the Department of Urology, Padua University (Italy) and professor at the Residency Training Program in Urology. For 20 years he has been involved in a number of experimental and clinical projects on prostate oncology.

    Riccardo Valdagni is head of the prostate programme at Istituto Nazionale Tumori, Milan, Italy. He is involved in projects on experimental, clinical and psycho oncology.

    Gemma Gatta is assistant researcher in the Unit of Epidemiology of Istituto Nazionale Tumori, Milan, Italy. She is involved in projects with population based cancer registries on incidence, survival and prevalence.

    Filippo de Braud is clinical editor of START. He is director of clinical pharmacology and new drugs development unit at the European Institute of Oncology, Milan, Italy.

    Georg Bartsch is professor and chairman of the Department of Urology, Medical University of Innsbruck, Austria.

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