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In the United States, an estimated 238,590 men will be diagnosed with prostate cancer in 2013 with 29,720 deaths attributable to prostate cancer (1). These statistics highlight a paradox of prostate cancer. Although it is the second leading cause of cancer death for men in the United States, only a relatively small percentage of men diagnosed with prostate cancer will die of their disease. This chapter will present guidelines for the management of localized prostate cancer. It will describe the controversies associated with prostate-specific antigen (PSA) screening, describe the work up and staging of prostate cancer, and finally discuss treatment options for localized disease.
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PROSTATE-SPECIFIC ANTIGEN (PSA)
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PSA is an abundant exocrine protein of the prostate, which has function in seminal clot lysis. Serum PSA measurement is a useful, although highly controversial, biomarker commonly used as a screening tool for prostate cancer. In addition to prostate cancer, PSA elevations may be the result of a variety of nonmalignant conditions including benign prostatic hypertrophy, inflammation, or urinary tract infection. Traditionally, 4.0 ng/ml has been considered the upper limit of normal for serum PSA; however, recent data demonstrate that many men with a serum PSA in the normal range have prostate cancer if biopsied (2). Conversely, many men with elevated PSA levels do not. As PSA normally rises with age, an age-specific algorithm may be a more effective screening approach. Age-specific PSA normal ranges have been shown to aid in finding important early cancer in younger men and avoiding unnecessary procedures and over-diagnosis in older men (Table 40-1).
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CURRENT RECOMMENDATIONS FOR SCREENING
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Prostate cancer screening is a controversial topic with several large recent studies informing the debate over the benefits of screening (3,4,5). Although PSA screening has led to the detection of earlier stage prostate cancer, it is not clear if this has led to better outcomes for screened men. Many screen-detected cancers may be incidental cancers that would have never resulted in clinical sequelae within the man's lifetime. Given this lack of clear evidence, the United States Preventative Service Task Force has recently recommended against routine PSA screening, concluding that "many men are harmed as a result of prostate cancer screening and few, if any, benefit" (6). This recommendation has met significant resistance from the urologic and oncologic communities (7, 8). These groups point out the difficulty of interpreting PSA screening studies, given high levels of contamination, and that this broad recommendation may not apply to young healthy men. As such, The American Cancer Society and the National Comprehensive Cancer Network (NCCN) currently recommend ...