There are few topics that generate as much controversy as the screening, detection, and treatment of prostate cancer, especially in elderly men. The article by Drs. Ko and Bubley does a good job of reviewing the major relevant topics but leaves the reader without much definitive advice. For this reason, it is instructive to review what we know to be true.
Prostate cancer kills more than 31,000 men in the United States each year, and there are identified high-risk groups (ie, African-Americans and patients with a first-degree relative diagnosed at an early age). Screening combined with early curative treatment has resulted in decreased mortality despite the aging of the population. Since survival advantages only become apparent 10 years after treatment, screening has generally been reserved for those men with a life expectancy of at least 10 years. This is a prudent guideline to follow.
In order to garner an increase in life span, physicians must detect prostate cancer early and give definitive local therapy. Prostate-specific antigen (PSA)-detected prostate cancer is usually significant prostate cancer; it can only be ignored if outcome can be ignored. Failure to recommend screening, detection, and treatment to individuals over 50 (with 10 years of life to protect) is not advisable. Thus, the following discussions are relevant only in relation to those therapies capable of rendering cure for local disease: radiation and surgery.
There appears to be a real advantage in giving hormonal treatment before radiation therapy. There also appears to be a real advantage to treating minimal lymphatic metastasis with radical prostatectomy, regional lymphadenectomy, and postoperative hormonal therapy. Even acknowledging these minor exceptions, more than 55 years of experience with hormonal therapy shows there is no other evidence (despite the concerted efforts of the pharmaceutical industry) that hormonal therapy prolongs life, and, therefore, it should be regarded as palliative.
In a palliative context, hormonal therapy, spot radiotherapy, and transurethral resection of a malignant prostate can all be effective; palliative chemotherapy also works in rare instances. Because hormonal therapy is palliative and has adverse effects, it should not be recommended in asymptomatic patients. There are some exceptions, however, as previously discussed. Similarly, there is no compelling evidence that combined hormonal therapy is more effective than orchiectomy.