Clinically localised prostate cancer

doi:10.1136/bmj.39022.423588.DE

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Timothy J Wilt, professor of medicine1,
Ian M Thompson, professor and chair, department of urology2

¹Minneapolis VA Center for Chronic Disease Outcomes Research, 1 Veterans Drive (111-0), Minneapolis, MN 55417, USA
²University of Texas Health Science Center, San Antonio, USA

Correspondence to: T J Wilt Tim.wilt{at}med.va.gov

Prostate cancer is the most commonly diagnosed cancer in United Kingdom men.^w1 In 2002 it was diagnosed in 32 000 men, and more than 10 000 deaths were attributed to it. Its incidence increased with the introduction of the prostate specific antigen (PSA) blood test, and disease specific mortality has declined. This review provides evidence about risk factors, prevention, detection, natural course, and treatment, with a focus on clinically localised disease, to guide primary care doctors.

Summary points

Prostate cancer is a common and potentially serious disease
Risk factors include increasing age, family history of prostate cancer, and black race. There are few established prevention strategies
Early detection and treatment may prevent future cancer-related illness, extend life, and provide peace of mind
However, prostate cancer testing, by digital rectal examination and prostate specific antigen testing, can have false positive and false negative results and detects many cancers that would never cause symptoms.
Lower urinary symptoms such as frequency, hesitancy, night time urination, and slow stream do not increase prostate cancer risk but are associated with higher PSA values
The probability that further evaluation with a prostate biopsy will be required as a result of testing is relatively high. Biopsy can cause adverse effects including pain, bleeding, and urinary infection
Treatment options include observation, surgery, radiation, and early hormonal deprivation. Aggressive treatment is needed to realise any benefit from discovery of a tumour, but such treatment may not be necessary or effective
Treatment is associated with a small risk of death and a higher risk of side effects, particularly regarding sexual, urinary, and bowel function
Men with a life expectancy of <10-15 years (due to advanced age or a serious coexisting condition) are unlikely to benefit from routine testing