Diagnosis and Treatment of Localized Prostate Cancer

Since widespread prostate cancer screening was introduced in the United States in the late 1980s and early 1990s, the incidence of prostate cancer has increased dramatically. Prostate cancer is now the most commonly diagnosed cancer in US men after skin cancer. 1 Due to screening efforts, the vast majority of newly diagnosed prostate cancers are found early, while still confined to the prostate gland. Although early diagnosis leads to the possibility of curative therapy for most patients, optimal treatment, indeed the need for treatment altogether, remains subject to debate. Using the case of a primary care clinic patient who has prostate cancer diagnosed via screening as a guide, this article reviews the controversies in screening for localized prostate cancer as well as in its diagnosis and treatment. Given the ubiquity of prostate cancer in the US population and the tens of thousands of patients diagnosed with localized disease each year, all physicians should familiarize themselves with these issues and the trends in the field. PSA Screening Case Presentation A 65-year-old white man, LG, presents to his primary care physician for his yearly physical examination. Physically active and a nonsmoker, he has no medical problems and no significant family history of cancer. He reports experiencing nocturia twice per night, but has no increased urinary frequency, hesitancy, or dysuria. A routine screening test reveals a serum prostate-specific antigen (PSA) level of 2.8 ng/mL. In the prior year, his PSA level was 0.7 ng/mL. Because of this significant change, a repeat PSA test is performed 4 weeks later, which is reported as 2.7 ng/mL. Physical examination, including a digital rectal examination (DRE), is unremarkable. Most prostate cancer diagnoses in the United States are made via PSA screening. Following the introduction of PSA screening, the incidence of prostate cancer has risen significantly. For example, prostate cancer incidence in the United States in 1985, before widespread screening, was 86,000 cases per year, 2 while in 2007