Book Review

Cancer of the Prostate

N Engl J Med 1993; 329:1901December 16, 1993

Article

Cancer of the Prostate
Edited by Sakti Das and E. David Crawford. 462 pp., illustrated. New York, Marcel Dekker, 1993. $135. ISBN: 0-8247-8863-X

This book is one of several comprehensive reviews of the diagnosis and management of prostate cancer that have appeared recently. Still, it was a pleasure to read this compilation of timely, adequate, and precisely formatted review chapters. The book is readable, considering its size, and it provides valuable updates in several areas of a rapidly developing field. In the main, unfortunately, the book does not contain great news. There is still uncertainty about the most appropriate management of prostate cancer, and especially about how to decrease mortality from the disease, despite some very optimistic notes struck in the final three chapters.

This book contains sections on the epidemiologic and pathologic aspects of prostate cancer, diagnosis and screening, treatment of locally confined disease, endocrine treatment, and chemotherapy, and a final general section that addresses the management of prostate cancer stage by stage, and discusses the effect of recent developments in management on outcome, chemoprevention, and future perspectives. As for the confusing issue of the management of locally confined disease, the reader is left with chaos. A chapter that puts these treatment options into perspective from the patient's viewpoint would have been welcome, even if it reflected opinions more than facts.

The section on epidemiology is quite limited. In the confusion that exists, concise epidemiologic information is useful for understanding clinical facts. In this respect, it is remarkable that internationally comparable figures on incidence and mortality are not available. An excellent section on pathology and grading leaves little doubt that the Gleason grading system is now predominant in the United States but also stresses that it may not be the final answer. Unfortunately, the section on staging ignores the tumor-node-metastasis system of 1992 and even the agreed-on version of the American Joint Committee of 1987. To satisfy an international readership, a synopsis of the staging systems would be necessary.

The sections on diagnosis deal with all relevant aspects. The otherwise very careful design of the chapters could not prevent some duplication, especially as far as the description of transrectal ultrasonography is concerned. Screening and early detection are dealt with twice, in chapters 5 and 7. It is pleasant and refreshing to find two quite different views on the same issue in this book. The data on early detection and screening give an excellent overview of this controversial issue.

Chapter 9 presents and discusses laparoscopic lymphadenectomy as a new, minimally invasive tool for staging locally confined disease. But the opportunity to be critical is missed. How often is laparoscopic lymph-node dissection really indicated? If it is limited to patients with stage B2 or B3 disease (the locally more advanced disease), how often are these patients eligible for curative measures? In how many cases is the need for major surgery averted, and how many patients undergo two surgical procedures when one would have been sufficient?

The section on the treatment of local disease is comprehensive and easy to read. It includes a concise description of the surgical and radiologic techniques and their indications, results, and complications. The data presented are based on some of the largest and best-documented series available. This section does not answer some of the most relevant questions: Which patients should be selected for treatment? What is the best form of treatment? Is early treatment better than a wait-and-see policy? What are the advantages and disadvantages of the different methods? There is agreement that the answers to many of these questions can come only from randomized prospective trials, which unfortunately are unavailable.

The section on deferred treatment suffers from the incompleteness of its literature review. It avoids such difficult questions as these: How many cases found at autopsy can be detected clinically? What are the characteristics of cases detected by the application of modern diagnostic tests? How do these patients compare with those commonly treated? What can be done to lower mortality from prostate cancer if early detection and treatment fail? If there is no appreciable difference between early and delayed endocrine treatment, then which considerations are important for patients and those who have to give advice?

Endocrine management and total androgen blockade are dealt with in an extremely balanced fashion, even though the conclusion -- that castration is the “gold standard” -- may not reflect clinical practice around the world at this time.

This book is very readable, its format is quite attractive, and it includes or refers directly to many original data (although in some tables the references are missing). The book can be recommended for urologists, medical oncologists, and all other clinicians who have a special interest in prostate cancer.

Prof. Dr. F.H. Schroder
Erasmus University, Rotterdam, the Netherlands