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Case History

Image not available. A 68-year-old man with newly diagnosed prostate cancer has a prostate-specific antigen (PSA) of 11 ng/ml, Gleason score of 7 (4 + 3), and asymmetrically enlarged nodular prostate on digital rectal examination. The clinical stage of the tumour is cT2b (TNM classification). He has no medical problems and leads an active life.

What are the treatment options?

What is watchful waiting?

What are the options for radical treatment?

What is the prognosis?

Background

What are the treatment options?

Image not available. Which is most effective therapy for clinically localized prostate cancer is not clear. The three standard treatment options for men with early stage (organ-confined) prostate cancer are: radical prostatectomy; radiotherapy (external beam radiotherapy (EBRT) or brachytherapy or both); and watchful waiting.

What is watchful waiting?

The term watchful waiting is used when men choose to forego or defer active treatment for observation. Therapy is typically started if one of the following occurs: a marked increase in serum PSA1 or a decrease in PSA doubling time to 3 years or less, a change on digital rectal examination, or detection of disease progression on surveillance biopsies.

The rationale for watchful waiting is that not all prostate cancers are clinically important, and that radical therapy constitutes over-treatment. This approach is based on data from Sweden.2 However, longer follow-up in that study (21 years) showed that only 36% remained progression-free at 15 years, and 50% had developed metastases.3 Randomized controlled trials are lacking in men with early stage prostate cancer, and only one trial has directly compared watchful waiting and radical prostatectomy in men with clinically localized disease, demonstrating a marked improvement in disease-specific survival as well as overall survival in men undergoing surgery.4 In 1994, Epstein et al.5 developed a set of criteria that could be used at the time of biopsy to predict the presence of clinically unimportant disease, which then could be used to decide if watchful waiting was an option. Men aged 70–75 years and older, and those with substantial comorbidity that may severely limit their life expectancy (e.g. to less than 10 years) may be considered for watchful waiting. Although younger men with favourable tumour characteristics may also do well with watchful waiting, published data show a considerably higher death rate with watchful waiting than with radical prostatectomy, particularly in those aged 65 and younger.4 Men who are considering watchful waiting should be aware that the risk of cancer progression and death is increased if treatment is deferred.

Discussion

What are the options for radical treatment?

Image not available. Radical treatment is given with curative intent and consists of radical prostatectomy or radiotherapy. No published trials have directly compared radical prostatectomy with either EBRT or brachytherapy. Observational series provide the only available data comparing outcomes following ...

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