Introduction

Cancer of the prostate gland is one of the most controversial malignancies. Its pathogenesis is clearly androgen-dependent, and men who are castrated or are hypopituitary before 40 years rarely develop this tumour. Age is the most important risk factor and it is estimated that 70% of men over 80 years have histological evidence of cancer in the prostate; 5% of cases are due to inheritance of a susceptibility gene such as BRCA1. Other clinical observations such as the increased incidence in African-Americans are unexplained.

During the last 20 years the incidence and the number of deaths from prostate cancer in the US and Europe has inexorably risen. Since the development of assays to measure serum prostate-specific antigen (PSA) to diagnose prostatic disease, the condition has been increasingly diagnosed at an earlier stage. In 1974, in the UK, more than 50% of patients presented with metastatic disease. Twenty years later, more than 50% of patients are diagnosed as a result of PSA testing without any symptoms of prostatic disease.

The use of PSA has proved to be an ambiguous advance. In the US, in 1995, with widespread use of PSA testing in asymptomatic men, nearly 400 000 patients were diagnosed suffering from prostate cancer; in the same year approximately 38 000 patients died of prostate cancer. In Europe, 85 000 patients were diagnosed and around 20 000 died of prostate cancer. These figures suggest that too many cases were diagnosed in the US and treated without clear evidence that they would have died of the disease, or that European patients were diagnosed too late for curative treatment with a consequent higher death rate. In either case the net result is that more patients are presenting with early stage disease and suitable treatment strategies are required to cure those that can be cured and palliate optimally those that cannot.

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