Prostate cancer management- helping your patient choose what is best for him

The biggest problems in prostate cancer management are how to identify patients with potentially life-threatening cancer, and how to choose the best form of management from among the large array of treatment options. Although prostate cancer is the second or third most common cause of cancer death in males, most men with this diagnosis will die of other causes. The most important prognostic factors are the patient’s life expectancy, the grade and stage of the tumour and the serum prostate specific antigen (PSA) at diagnosis. The most important management options are (1) active surveillance (watchful waiting), (2) androgen deprivation therapy (ADT), (3) radical prostatectomy and (4) radiotherapy. Patients with a limited life expectancy or non-aggressive cancer can be managed with active surveillance and be treated only if and when it becomes necessary. ADT (hormone therapy) provides excellent palliation in men with locally advanced or metastatic cancer, but the side-effects decrease quality of life. Radical prostatectomy and radiotherapy are potentially curative if the cancer is localised to the prostate. The use of laparoscopic radical prostatectomy is increasing in affluent countries, although (apart from reduced blood loss) there are no significant advantages compared to retropubic or perineal radical prostatectomy. The main complications are erectile dysfunction and urinary incontinence. The use of brachytherapy is increasing, although there is no convincing evidence that it is more effective or has fewer complications than external beam radiotherapy