Directions in Diagnosis, Health Related Quality of Life and Therapy of Prostate Cancer – Controversies in Uro-oncology

Currently, it is recommended that prostate cancer be detected by digital rectal palpation and prostate specifi c antigen (PSA) elevation. TRUS coupled with ultrasound-guided biopsies might become the most appealing staging technique for early diagnosed prostate cancer. To promote earlier diagnosis, better PSA thresholds need to be defi ned, with a clear freePSA threshold. This could be complemented by the use of nomograms and, in suspected cases, repeated biopsies, TRUS, bone scans and new imaging techniques. Deferred therapy by means of active observation and alertness to start therapy when signs of rapid progression occur may therefore be an alternative to active therapy in patients with low-risk localized prostate cancer with life expectancy of 10 years or less. Radical prostatectomy was more effective than watchful waiting in terms of cancer-specifi c survival benefi t, when compared in a prospective randomized trial. Neoadjuvant hormonal therapy has a nonsignifi cant impact on overall and progression free survival. In Europe, the focus is on biochemical recurrence after curative treatment (nerve sparing radical prostatectomy and/or radiotherapy in low-, intermediateand high-risk patients with 72-78 Gy. In metastatic disease, adjuvant androgen deprivation is the treatment of choice. These are patients that cannot be cured. Identifi cation of intracellular androgen synthesis by prostate cancer cells has led to identifi cation of new targets, several novel strategies, third-generation drugs, inhibitors of androgen synthesis, more potent androgen receptor antagonists. Castration-resistant prostate cancer remains dependent on androgens and signaling through androgen receptor. Substantial pain reduction, improvement in PSA response and quality of life often make chemotherapy with docetaxel for hormone refractory prostate cancer better choice than simple pain and complication treatment. The main features of each condition and its management are summarized.