Advancing prostate cancer: treatment options for the urologist

Today's urologists often face the dilemma of how to treat patients who have advancing prostate cancer. The diversity of this patient population makes treatment decisions challenging. For over 60 years the mainstay of treatment for patients who have advancing prostate cancer has been androgen deprivation therapy. Now there are new chemotherapeutic options, novel hormone manipulations, and other adjunctive therapies available. Based on a case presentation, the authors have attempted to outline for the practicing urologist, a logical progression of treatment options for advancing prostate cancer.     

Prostate cancer in the elderly patient

Although malignant tumours occur at all ages, cancer disproportionately strikes individuals in the age group 65 years and older. The increasing statistical life expectancy of men together with the introduction of prostate specific antigen (PSA) as a screening tool have both contributed to a rising number of elderly men with a diagnosis of prostate cancer. Age is generally considered to be a key prognostic factor in terms of therapeutic decision making, perhaps as important as PSA level and Gleason score. Even in men over 70 years, treatment without curative intent may deprive frail patients of years of life. When considering local treatment, strong consideration should be given to radical surgery. Modern radical prostatectomy is associated with low perioperative morbidity, excellent clinical outcomes as well as long term disease control. Besides, overdiagnosis has led to the concept of expectant management for screening-detected small-volume, low grade disease, with intention of providing therapy for those men experiencing disease progression.     

Prostate cancer screening,detection and treatment practices,among Sub-Saharan African urologists

Introduction  

Prostate cancer is reported to be the leading cancer in men in Sub-Saharan Africa (SSA) and the number of prostate cancer deaths is expected to double in the next 20 years. Despite the importance of this public health issue in SSA, there remains relatively limited information about practices related to prostate cancer treatment in this population.     

Prostate cancer screening and informed decision-making: provider and patient perspectives

The objective was to determine the extent of informed decision making for prostate cancer screening in a defined population. A state-wide population based survey of men aged 50 and above (Behavioral Risk Factor Surveillance System, 2004, Washington state) and a simple random sample of primary care physicians, were conducted in the same geographic area. We examined prostate cancer screening rates among the men (defined as either PSA or digital rectal examination within the past year) and prostate cancer screening practices among the physicians. Screening rates were 56% at ages 50-64, 68% at ages 65-79 and 64% among men age 80 and older. Adjusted analyses indicated that age, income, marital status, possessing health insurance and a personal health care provider, and talking with a provider about prostate cancer screening tests were all positively associated with screening status. In the physician survey, most physicians recommend screening to their average-risk male patients. Three-fourths (74%) of physicians discussed benefits and risks of PSA testing with their patients; but few used educational tools. Only 35% discussed the side effects of prostate cancer treatment with their patients. The rates of screening reported by men were relatively high, given that current recommendations promote informed decision making rather than universal screening. The majority of physicians recommend prostate cancer screening to their patients, with few decision-making tools used. All relevant information may not be provided in the discussion. These results point to the need for increasing informed decision making about prostate cancer screening.     

AIDS and the urologist

The management of HIV infection has dramatically altered the natural history of the disease. Prevention of opportunistic infections and the development of HAART regimens altered the manifestations and conditions that urologists are being asked to evaluate and manage in this patient population.     

Susruta, the pioneer urologist of antiquity

PURPOSE: Susruta, a pioneer surgeon of antiquity, practiced around 1000 BC in India. We review his many contributions with special reference to the management of urological ailments. MATERIALS AND METHODS: Information gleaned from the available English translation of 3 volumes of Susruta's treatise in surgery is analyzed with commentaries and historical perspectives chronicled by Oriental and Occidental historians. RESULTS: Susruta belonged to the period between 600 and 1000 BC. His conceptions of anatomy, physiopathology and therapeutic strategies were of unparalleled brilliance, considering the early age in the history of mankind with no supportive knowledge base preceding his era. His discussions of many aspects of urological diseases are often reaffirmed in the principles of urology today. CONCLUSIONS: Through his rational understanding, elaborate teachings and practice of the art of surgery, and many urological ailments in particular Susruta has earned the glory of being the pioneer urologist of antiquity.     

Prostate cancer: Prevalence and treatment in African men

Epidemiological data from the United States of America (USA) indicate that the incidence and mortality of prostate cancer is higher among Black African-American men (AAM) than among White (Caucasian) American men (CAM). Earlier studies suggesting that prostate cancer is relatively rare among indigenous Black men in Africa are probably flawed by underreporting because recent studies indicate that the incidence rates among Black men are similar to those of White men living in Africa. The higher incidence of prostate cancer among AAM has been ascribed to racial differences in genetic susceptibility, dietary factors, or androgen metabolism. However, it may also be due to registration artefacts because in Africa the reported incidence rates of prostate cancer in different countries correlate directly with the per capita gross national product, suggesting improved access to medical facilities is responsible for higher reported incidence rates.

The greater prostate cancer mortality among AAM may result from higher tumour grade and stage and higher serum PSA at presentation, but it has also been suggested that prostate cancer is biologically more aggressive in AAM than in CAM. However, recent studies indicate that tumour grade and stage and serum PSA at presentation are similar in the races, with no difference in survival after multivariate analysis controlling for pretreatment cancer severity. This suggests that the higher prostate cancer mortality among AAM results from socio-economic factors and limited access to healthcare. Black men living inside as well as outside of Africa still tend to present with locally advanced or metastatic prostate cancer due to lack of early detection programmes.     

Prostate cancer with multiple lung metastases in a hemodialysis patient

In hemodialysis patients, few cases of prostate cancer have been reported until recently. We present a case of prostate cancer with multiple lung metastases in a chronic hemodialysis patient. A 65-year-old Japanese man who had maintained hemodialysis for 5 years was referred to our hospital with multiple metastatic lung tumors. Serum prostate tumor markers were highly elevated although his plasma testosterone level was within the normal range. A transrectal needle prostate biopsy confirmed a histologic diagnosis of moderately differentiated adenocarcinoma. Androgen blockade therapy was very effective as evidenced by a quick decrease of serum tumor markers. The follow-up computed tomography scan of the chest performed 3 months later showed a complete disappearance of the coin lesions. The early detection of prostate cancer in hemodialysis patients is difficult because of a lack of urologic symptoms, which indicate the importance of periodic screening by serum tumor markers. Combined androgen blockade is effective even in hemodialysis patients. However, close follow up is necessary because long-term results and prognoses are still unknown.     

Prostate cancer mortality rates compared to urologist population densities and prostate-specific antigen screening levels on a state-by-state basis in the United States of America

We hypothesized that prostate cancer screening and availability of urologists among states may be associated with reduced prostate cancer mortality in the United States. To test this hypothesis, state-specific prostate cancer mortality rates for white males were compared to urologist population densities and prostate-specific antigen (PSA) screening rates on a state-by-state basis. The urologist population density was calculated by dividing the number of urologists per state by the population. We found that prostate cancer mortality rates correlated inversely with urologist population densities (P<0.01) and PSA screening (P<0.01) suggesting that screening and treatment reduce prostate cancer mortality.