ABSTRACT
The prevalence of pathologic prostate cancer (PCA) is extremely high and increases with age. One in six men will be diagnosed with PCA during their lifetime. Prostate cancer is a leading cause of male cancer-related death, second only to lung cancer1,2 and the American Cancer Society estimates that 230,110 American men will be diagnosed with PCA and 29,900 will die in 2004 representing 10% of all cancer deaths in men in the United States. Multiple factors contribute to the high incidence and prevalence of PCA. Risk factors include age, family history, and race. Environmental exposures also play a role. A single molecular test, the prostatespecific antigen (PSA) screening test, has impacted the detection of PCA and is directly responsible for a dramatic stage shift in many industrial countries. At time of initial diagnosis, 82% of PCA cases are clinically localized. A major limitation of the serum PSA test is a lack of PCA sensitivity and specificity, especially in the intermediate range of PSA detection (4-10 ng/ml). Elevated serum PSA levels can be detected in patients with nonmalignant conditions such as benign prostatic hyperplasia (BPH) or prostatitis. Therefore, PSA levels are not associated with tumor burden, and there is increasing evidence that PSA screening has led to the identification of insignificant prostate cancers.3-5
Thus, the clinical dilemma in the field of PCA today is that we are over-treating most men diagnosed with localized disease in the post-PSA screening era, yet inadequately treating those men diagnosed with metastatic PCA. The best example of this phenomenon
comes from the Swedish studies on the natural history of PCA.6-8 As demonstrated most recently by the randomized Scandinavian trial evaluating the benefit of prostatectomy over watchful waiting, surgery significantly decreased the incidence of metastatic PCA.6
