Book Review

New Perspectives in Prostate Cancer

N Engl J Med 1999; 340:158January 14, 1999

Article

New Perspectives in Prostate Cancer
Edited by Arie Belldegrun, Roger S. Kirby, and R.T.D. Oliver. 429 pp., illustrated. Oxford, England, Isis Medical Media, 1998. (Distributed by Mosby, St. Louis.) $150. ISBN: 1-899066-89-6

As the population ages and deaths from preventable causes decline, prostate cancer will more commonly appear on medical-chart “problem lists” and — in the absence of effective therapy — on death certificates. Three facts emphasize the importance of understanding the biology, diagnosis, and treatment of prostate cancer. In the United States, a man has a one-in-five chance that invasive prostate cancer will develop during his lifetime. His chances that prostate cancer will be diagnosed are nearly twice that of lung cancer and three times that of colorectal cancer. The number of deaths due to prostate cancer, although they represent only a fraction of all the cases of the disease, have steadily increased since 1930, and prostate cancer now represents the second leading cause of death from cancer in men.

Not long ago, the limited understanding of prostate cancer made it relatively easy to grasp almost all the known aspects of the disease. During the past 10 years, however, simultaneous advances in many areas of research and therapy have challenged basic scientists and practicing clinicians to maintain a comprehensive perspective. New Perspectives in Prostate Cancer helps with that task. As a multiauthored summary of the Second International Forum on Prostate Cancer (held in December 1996), the book is reasonably up to date. The chapters are short overviews written by experts on the topics. The first quarter of the book is devoted to the basic science of genetics, the biology of metastasis and growth factors, and androgen-independent progression of the disease. The presentations are neither comprehensive nor complicated and will be useful to practicing clinicians. However, because of the rapid expansion of basic research in prostate cancer, this section of the book is at greatest risk of being out of date soon.

Before the isolation of prostate-specific antigen, prostate cancers were usually discovered late, either by physical findings or by the presence of diffuse disease. Now, with the use of this nonspecific tool, tumors can be diagnosed early, raising issues about detection of and screening for clinically insignificant disease. Attempts to improve the usefulness of prostate-specific–antigen measurements in the diagnosis of prostate cancer through the use of age- and race-specific reference ranges, analysis of changes over time, relation to prostate size, and the ratio of free to total antigen are covered in detail in this book. The redundancy among these chapters is offset by the thoroughness of the reviews. Treatment directed at the primary tumor (radical surgery or radiotherapy) receives more limited attention.

One of the early triumphs in the treatment of prostate cancer — the identification and exploitation of hormonal dependence — remains the pillar of treatment for advanced disease. Despite the often dramatic objective and subjective responses to androgen ablation, it is still palliative therapy. Lethal prostate cancer is androgen-independent. Perhaps because of the absence of other effective treatments for metastatic disease, the book gives inordinate attention to this topic. Discussions about the nature of androgen deprivation (combined blockade vs. monotherapy) and its timing (early vs. intermittent vs. late) are zealous and somewhat puzzling, considering that this book is devoted to new perspectives on prostate cancer. The few chapters on novel treatments for advanced disease are exciting but underrepresent the recent activity in this area.

Once firmly in the domain of urologists, prostate cancer now is often diagnosed and treated by primary care physicians and oncologists. Debates about screening for prostate cancer and about the timing and nature of treatment are being joined by an increasingly informed and sophisticated patient population. The need for fluency with the issues and advances in prostate cancer is certain to grow, as the numbers of men at risk increase. This book is suited to those who wish to be well informed about this common malignant disease.

Joel Nelson, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21224