ABSTRACT
Excluding skin cancer, carcinoma of the prostate is the most common malig nancy in males (about 20%), accounting for about 10% of all new cancer per year. When the disease is localized, either surgery or radiotherapy offers a good chance for cure. The optimal treatment of prostate cancer depends on pretreatment PSA, Gleason score, clinical stage, patient s performance status, quality of life issues, and the patient s wish. Results for treatment outcomes should have long follow-up since late recur rence and distant metastases are frequent. The two primary treatment options for organ-confined disease are prostatectomy and radiotherapy. Hormonal manipula tion is useful for the advanced stage. Combination of hormonal manipulation and local treatment (surgery or radiotherapy) is under clinical investigation for patients with bulky localized disease and/or high risk. Candidates for definitive radiation therapy must have a confirmed pathological diagnosis of cancer that is clinically confined to the prostate and/or surrounding tissues (stages I, II, and III). High-risk patients should have a bone scan and computed tomographic scan negative for me tastases, but staging laparotomy and lymph node dissection are not required. Pro phylactic irradiation of clinically or pathologically uninvolved pelvic lymph nodes does not appear to improve overall survival. In addition, patients considered poor medical candidates for radical prostatectomy can be treated with acceptably low complications if care is given to delivery technique. Patients with extra-prostatic disease are usually not candidates for prostatectomy, and are best suited for radio therapy. One popular method used to predict extra-prostatic disease is Partin s Table, which relies on PSA, Gleason score and clinical stage. Roach et al developed an equation to assess the risk of extra-prostatic disease:
% Risk of extraprostatic disease = 2/3 PSA + 10 x (Gleason Score - 6)
Difficulties in comparing surgery and radiotherapy are due to: • Lack of well-designed randomized clinical trials comparing the two modalities. • Retrospective analyses are bias since patients in radiation series are generally
older and have more advanced disease. • Patients in surgical series are pathologically staged, while patients in
radiation series are clinically staged. C linical staging with DRE and im aging studies tends to underestimate the extra-prostatic disease and lymph node status.
