Book Review

Prostate Cancer

N Engl J Med 1994; 331:1533-1534December 1, 1994

Article

Prostate Cancer
(Current Clinical Oncology.) Edited by Nancy A. Dawson and Nicholas J. Vogelzang. 288 pp., illustrated. New York, Wiley-Liss, 1994. $74.95. ISBN: 0-471-58834-2

Prostate cancer is now the most common type of cancer among American men. Over the past few years, new forms of technology such as prostate-specific-antigen (PSA) testing and transrectal ultrasonography have permitted the early detection of prostate cancer in asymptomatic men. The American Cancer Society recommends that men over 50 years of age have a yearly rectal examination and PSA measurement. Mass screening of this population has profoundly changed the incidence of diagnosed prostate cancer -- from 105,000 in 1990 to 165,000 in 1993. An estimated 200,000 cases of prostate cancer will be diagnosed in the year 2000.

These statistics are not surprising to pathologists, who have known for many years that prostate cancer is extremely common. Autopsy data show the presence of histologic foci of cancer in 30 percent of men over 50 years of age, increasing to 50 to 70 percent of all men 75 years old or older. The vast majority of men with histologic evidence of the disease or latent prostate cancer will never have clinically important disease in their lifetimes.

Are costly medical resources being allocated to the identification of the large number of men with indolent prostate cancer? Although the rate of detection of the disease has increased by 30 percent in the past 5 years, the mortality rate remains unchanged at 20 percent -- where it has been for the past 50 years. Does aggressive treatment of newly detected prostate cancer affect longevity? Should physicians recommend routine PSA screening for their asymptomatic male patients? How should physicians counsel these patients once disease is detected?

Prostate Cancer, a multiauthored textbook in the Current Clinical Oncology series, clarifies many of these controversial issues. A well-written chapter on the epidemiology of the disease underscores the fact that the effect of early detection on mortality from prostate cancer is unknown and that no intervention to date has been demonstrated to alter the natural course of the disease. The chapter on routine screening for prostate cancer questions whether the potential morbidity caused by detecting and treating clinically unimportant disease outweighs the potential advantage of early detection in the small group of men with biologically aggressive tumors. Practitioners who opt for active intervention will gain knowledge from the chapters on recent advances in conformal radiation therapy and surgical techniques.

One of the most interesting chapters discusses the option of observation only for men with clinically localized disease -- a practice common among European physicians. Chapters of special interest to urologists and medical oncologists discuss the types of antiandrogen treatments available for men with metastatic disease as well as the question of when to initiate endocrine treatment in asymptomatic patients. Discussions of recent therapeutic trials of suramin, a potent antiparasitic drug, and the use of intravenous radiopharmaceutical agents, such as strontium-89, are also included.

Prostate Cancer should be available to all health care providers who recommend cancer screening to their patients. Physicians who believe that aggressive intervention in cases of newly diagnosed cancer will prevent future disease progression should peruse this book before advising their patients. At a time when the number of cases of prostate cancer diagnosed is on a sharp upswing, the nontraditional views showcased in this book will cause many practitioners to adjust their attitudes toward screening for and treatment of this common cancer.

Barbara Bassil, M.D.
Massachusetts General Hospital, Boston, MA 02114