Effect of complete androgen blockade on pathologic stage and resection margin status of prostate cancer: progress pathology report of the Italian PROSIT study

Effects of Delayed Radical Prostatectomy and Active Surveillance on Localised Prostate Cancer-A Systematic Review and Meta-Analysis

Simple Summary

We reviewed the evidence available for postponing or delaying cancer surgery for localised prostate cancer. Watchful waiting is an acceptable option in low-risk patients. Evidence is uncertain in postponing surgery, but conservative estimates suggest delays of over 5 months, 4 months, and 30 days for low-, intermediate-, and high-risk patients, respectively, can lead to worse survival outcomes. Neoadjuvant therapy can shrink the tumours prior to surgery and can be a useful adjunct in delaying surgery for, at the most, 3 months.

Abstract

External factors, such as the coronavirus disease 2019 (COVID-19), can lead to cancellations and backlogs of cancer surgeries. The effects of these delays are unclear. This study summarised the evidence surrounding expectant management, delay radical prostatectomy (RP), and neoadjuvant hormone therapy (NHT) compared to immediate RP. MEDLINE and EMBASE was searched for randomised controlled trials (RCTs) and non-randomised controlled studies pertaining to the review question. Risks of biases (RoB) were evaluated using the RoB 2.0 tool and the Newcastle–Ottawa Scale. A total of 57 studies were included. Meta-analysis of four RCTs found overall survival and cancer-specific survival were significantly worsened amongst intermediate-risk patients undergoing active monitoring, observation, or watchful waiting but not in low- and high-risk patients. Evidence from 33 observational studies comparing delayed RP and immediate RP is contradictory. However, conservative estimates of delays over 5 months, 4 months, and 30 days for low-risk, intermediate-risk, and high-risk patients, respectively, have been associated with significantly worse pathological and oncological outcomes in individual studies. In 11 RCTs, a 3-month course of NHT has been shown to improve pathological outcomes in most patients, but its effect on oncological outcomes is apparently limited.

Cholesterol Metabolic Reprogramming in Cancer and Its Pharmacological Modulation as Therapeutic Strategy

Cholesterol is a ubiquitous sterol with many biological functions, which are crucial for proper cellular signaling and physiology. Indeed, cholesterol is essential in maintaining membrane physical properties, while its metabolism is involved in bile acid production and steroid hormone biosynthesis. Additionally, isoprenoids metabolites of the mevalonate pathway support protein-prenylation and dolichol, ubiquinone and the heme a biosynthesis. Cancer cells rely on cholesterol to satisfy their increased nutrient demands and to support their uncontrolled growth, thus promoting tumor development and progression. Indeed, transformed cells reprogram cholesterol metabolism either by increasing its uptake and de novo biosynthesis, or deregulating the efflux. Alternatively, tumor can efficiently accumulate cholesterol into lipid droplets and deeply modify the activity of key cholesterol homeostasis regulators. In light of these considerations, altered pathways of cholesterol metabolism might represent intriguing pharmacological targets for the development of exploitable strategies in the context of cancer therapy. Thus, this work aims to discuss the emerging evidence of in vitro and in vivo studies, as well as clinical trials, on the role of cholesterol pathways in the treatment of cancer, starting from already available cholesterol-lowering drugs (statins or fibrates), and moving towards novel potential pharmacological inhibitors or selective target modulators.

[Neoadjuvant before surgery treatments: state of the art in prostate cancer]

GOAL

To study the impact of systemic treatment in neoadjuvant strategy before surgery in prostate cancer.

MATERIALS

Literature reviews with data analysis from PubMed search using the keywords "neoadjuvant", "chemotherapy", "hormonal therapy", "prostate surgery", "radical prostatectomy", but also reports from ASCO and ESMO conferences. The articles on neoadjuvant treatment before radiotherapy were excluded.

RESULTS

First studies with former therapy are more than 15-years-old and with questionable methodology: lack of power to have a clear idea of the impact on survival criteria such as overall survival or relapse-free survival. However, the impact of neoadjuvant hormone therapy on the classic risk factors for relapse (positive margins, intraprostatic disease, positive lymph nodes) was demonstrated by these studies and a Cochrane meta-analysis. The association with hormone therapy seems mandatory in comparison to treatment based solely on chemotherapy and/or targeted therapy. Promising data on the use of new drugs and their combinations arise: abiraterone acetate combined with LHRH analogue showed a fast PSA decrease and higher rates of pathologic complete response. Other results are promising with hormonal blockages at various key points.

CONCLUSION

Studies with 2nd generation anti-androgene agents or enzyme inhibitors seem to show very promising results. To provide answers about the effectiveness of current neoadjuvant strategy in terms of survival, other studies are needed: randomized phase III or phase II exploring predictive biomarkers. The design of such trials requires a multidisciplinary approach with urologists, oncologists, radiologists and methodologists.

Immunohistochemical expression of PDGFR, VEGF-C, and proteins of the mToR pathway before and after androgen deprivation therapy in prostate carcinoma: significant decrease after treatment

Targeted therapy in hormone refractory prostate cancer (HRPC) is currently under evaluation in many trials. The effect of androgen deprivation therapy (ADT) on many targets in prostate cancer is incompletely known. For the first time, immunohistochemical expression of the platelet-derived growth factor receptor (PDGFR), epidermal growth factor receptor (EGFR), vascular endothelial growth factor C (VEGF-C), mammalian target of rapamycin (mToR), p70 ribosomal protein S6 kinase 1 (PS6K), human epidermal growth factor receptor 2 (c-erbB-2), and carbonic anhydrase IX (CA9) was evaluated in 44 patients with prostate carcinoma treated with or without ADT, at biopsy time and after radical prostatectomy. PDGFR, VEGF-C, mToR, and PS6K expression was significantly reduced (p = 0.002, p = 0.035, p = 0.025, and p = 0.033, respectively) after ADT, whereas expression of EGFR, c-erbB-2, and CA9 was not influenced by ADT. In conclusion, targeting PDGFR, VEGF-C, mToR, or PS6K after ADT should be considered with precaution, as those targets can severely be altered or functionally deregulated by ADT.

A systematic review of the role of adjuvant and neoadjuvant pharmacotherapy in patients undergoing radical prostatectomy

INTRODUCTION

Between 25 and 30% of patients with newly diagnosed prostate cancer are classified as high risk for an adverse prognosis. A significant number of these will progress to biochemical or clinical relapse. As there is no consensus regarding the optimal treatment of these cases, a multimodal therapeutic approach, including radical prostatectomy, remains an option.

AREAS COVERED

The Pubmed/Medline database was searched to identify trials that have evaluated adjuvant and neoadjuvant pharmaceutical protocols combined with radical prostatectomy and provided information regarding efficacy and safety.

EXPERT OPINION

Improvements in adverse pathological findings, following operations in patients who received neoadjuvant treatment, have been reported in the majority of the reviewed studies. Furthermore, the addition of pharmacotherapy to radical prostatectomy has produced beneficial results in survival surrogates. However, no benefits in overall survival were observed with adjuvant or neoadjuvant protocols and toxicity was a concern, especially in combination regimens. New studies on the effects of current pharmacotherapy and of new agents on overall survival and quality of life, after defining well-established criteria for patient stratification and inclusion, are required urgently.

Comparison of proliferating cell nuclear antigen immunostaining in lymph node metastases and primary prostate adenocarcinoma after neoadjuvant androgen deprivation therapy

OBJECTIVE

To evaluate the effect of neoadjuvant androgen deprivation therapy (NADT) on the cellular proliferative activity in primary prostate cancer and lymph node metastases using proliferating cell nuclear antigen (PCNA) immunostaining.

MATERIAL AND METHODS

Metastatic pelvic lymph nodes and tumoral prostatic tissue were obtained from 21 patients after radical prostatectomy and pelvic lymphadenectomy. Sixteen patients received NADT for 3 months prior to surgery; five patients did not and were evaluated as a control group. Histopathologic analysis was performed using PCNA immunostaining. and histopathologic findings of primary tumors and lymph node metastases after NADT were reported. Clinical follow-up was performed for a mean of 43.7 months.

RESULTS

Evaluation of PCNA immunostaining of lymph node metastases in the 16 treated patients revealed a mean positivity for metastatic tumor of 4.5% (SD 3.1%); the corresponding value for the five patients who were not treated with NADT was 19.6% (SD 0.94%) (p < 0.05). In four of the treated cases the proliferative activity in the lymph node metastases was greater than that in the other 12 (9.3% and 3.0%, respectively) and no histopathologic regressive changes were observed in these four cases. The residual tumoral proliferative activity in lymph nodes was greater than that in primary tumors (4.5% and 1.3%, respectively).

CONCLUSIONS

This study shows that the nodal metastases were responsive to hormonal therapy, as assessed by PCNA staining, although a greater residual proliferative activity was observed after NADT in lymph node metastases in comparison with the primary prostatic tumor. This can be attributed to a metastatic phenotype less responsive to hormonal therapy compared to the primary tumor.

Morphological changes induced by androgen blockade in normal prostate and prostatic carcinoma

Maximal androgen blockade (MAB), combining a luteinizing hormone releasing hormone (LHRH) agonist and a pure or non-steroidal anti-androgen, induces significant morphologic changes in the prostate. The tumor volume, density, capsular penetration, and surgical margin involvement are strongly reduced following such treatment. On histology, normal prostate tissue and tumor undergo marked atrophy and shrinkage. Although residual cancer cells are readily identifiable in most cases, they may often be sparse and easily overlooked. The increased Gleason score apparent after MAB is most likely related to fragmentation of acinar structures, and grading is not recommended following MAB. Residual cancer cells show features of lower activity and increased apoptosis. Such therapy-induced changes may be reversible, although occasional clones of cancer cells are apparently not affected and have probably developed resistance. Finally, MAB leads to marked but reversible morphologic changes and reduction in prevalence and extent of prostatic intra-epithelial neoplasia (PIN). Monotherapy using a variety of agents causes comparable but often less extensive changes.

Neoadjuvant therapy and prostate cancer: what a urologist should know

PURPOSE OF REVIEW

Prostate cancer is curable only when treated at an early stage, when the tumor is still localized to the prostate gland. However, even in apparent cases of clinically localized disease, unsuspected extracapsular disease may significantly increase the risk of primary treatment failure. This risk is especially high if the patient has one or more of the following risk factors: a serum prostate-specific antigen level >20 ng/ml, a Gleason score >7, locally advanced disease (clinical stage T3/T4), and extensive disease on prostate biopsy.

RECENT FINDINGS

Various regimens of neoadjuvant hormonal therapy and/or chemotherapy have produced mixed results and generally have not influenced the rate of disease relapse (defined by prostate-specific antigen level) in high-risk patients with localized prostate cancer. In addition, antiangiogenic agents, gene therapy, molecular targeting agents, and other promising new therapies have been investigated in a neoadjuvant setting with limited results.

SUMMARY

Despite considerable advances, high-risk localized prostate cancer remains an extremely refractory disease. In patients with high-risk prostate cancer, single-modality treatment in the form of surgery offers a 5-year biochemical disease-free survival rate of no better than 50%. To further elucidate optimal treatment regimens for these patients we must actively enrol patients in clinical trials.

Choices for Surgery

Surgical treatment of prostate cancer has seen many improvements in the past two decades, including laparoscopy, robotic surgery, and better assessment of quality of life and functional results. The limits of surgery for locally advanced disease and after failure of radiotherapy have been better defined, together with the roles of neoadjuvant and adjuvant treatment. Patients with clinically organ-confined prostate cancer, reasonable life expectancy, and little or no co-morbidity are the best candidates for radical prostatectomy. This chapter reviews the different technical options for the treatment of prostate cancer, with their respective indications and functional and oncological results.

Neoadjuvant therapy before radical prostatectomy: Where have we been? Where are we going?

Prostate cancer is curable only when treated at an early stage, when the tumor is still localized to the prostate gland. However, even in apparent cases of clinically localized disease, unsuspected extracapsular disease may significantly increase the risk of primary treatment failure. This risk is especially high if the patient has > or =1 of the following risk factors: a serum prostate-specific antigen level of >20 ng/ml, a Gleason score of >7, locally advanced disease (clinical stage T3/T4), and extensive disease on prostate biopsy. Various regimens of neoadjuvant hormonal therapy, chemotherapy, or both have produced mixed results and, in general, have not significantly influenced the rate of disease relapse (as defined by prostate-specific antigen level) in high-risk patients with localized prostate cancer. In addition, anti-angiogenic agents, gene therapy, molecular targeting agents, and other promising new therapies have been investigated in a neoadjuvant setting with limited results. Therefore, this patient population continues to pose a therapeutic dilemma for physicians.

Pitfalls with MRI Evaluation of Prostate Cancer Detection

INTRODUCTION

To assess differences between MRI findings and histopathologically defined prostate cancer localization, we compared clinical results with mapping of radical prostatectomy specimens, and conducted a retrospective MRI cancer localization re-assessment by a urologist-technician after surgery.

METHODS

We performed MRI for a total of 37 suspected prostate cancer patients. Subsequently, all underwent retropubic radical prostatectomy after prostate biopsy for confirmation of the diagnosis. All the specimens were studied histopathologically with serial sectioning using a whole organ approach.

RESULTS

Of the 37 patients, 26 had positive MRI findings. All the surgical specimens contained cancerous lesions, and 23 had multiple foci. Twenty-four of the MRI-positive cases (92.3%) demonstrated coincidence of both MRI and histopathologically defined lesions. In the single focus cases, 78.6% (11/14) demonstrated exact coincidence, but in the multifocal cases there were no cases with exact coincidence of MRI and histopathological findings (0/23).

CONCLUSION

MRI evaluation cannot be considered an effective diagnostic tool in itself for detection of prostate cancers because sensitivity is far from satisfactory, especially in multi-focal cases.

Neo-adjuvant and adjuvant hormone therapy for localised and locally advanced prostate cancer

BACKGROUND

Hormone therapy for early prostate cancer has demonstrated an improvement in clinical and pathological variables, but not always an improvement in overall survival. We performed a systematic review of both adjuvant and neo-adjuvant hormone therapy combined with surgery or radiotherapy in localised or locally advanced prostate cancer.

OBJECTIVES

The objective of this review was to undertake a systematic review and, if possible, a meta-analysis of neo-adjuvant and adjuvant hormone therapy in localised or locally advanced prostate cancer.

SEARCH STRATEGY

We searched MEDLINE (1966-2006), EMBASE, The Cochrane Library, Science Citation Index, LILACS, and SIGLE for relevant randomised trials. Handsearching of appropriate publications was also undertaken.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of patients with localised or locally advanced prostate cancer, that is, stages T1-T4, any N, M0, comparing neo-adjuvant or adjuvant hormonal deprivation in combination with primary therapy (radical radiotherapy or radical prostatectomy) versus primary therapy alone were included in this review.

DATA COLLECTION AND ANALYSIS

Data were extracted from eligible studies and assessed for quality, and included information on study design, participants, interventions, and outcomes. Comparable data were pooled together for meta-analysis with intention-to treat principle.

MAIN RESULTS

Men with prostate cancer have different clinical outcomes based on their risk (T1-T2, T3-T4, PSA levels and Gleason score). However, the majority of studies included in this review did not report results by risk groups; therefore, it was not possible to perform sub-group analysis. Neo-adjuvant hormonal therapy prior to prostatectomy did not improve overall survival (OR 1.11, 95% CI 0.67 to 1.85, P = 0.69). However, there was a significant reduction in the positive surgical margin rate (OR 0.34, 95% CI 0.27 to 0.42, P < 0.00001) and a significant improvement in other pathological variables such as lymph node involvement, pathological staging and organ confined rates. There was a borderline significant reduction of disease recurrence rates (OR 0.74, 95% CI 0.55 to 1.0, P = 0.05), in favour of treatment. The use of longer duration of neo-adjuvant hormones, that is either 6 or 8 months prior to prostatectomy, was associated with a significant reduction in positive surgical margins (OR 0.56, 95% CI 0.39 to 0.80, P = 0.002). In one study, neo-adjuvant hormones prior to radiotherapy significantly improved overall survival for Gleason 2 to 6 patients; although, in two studies, there was no improvement in disease-specific survival (OR 0.99, 95% CI 0.75 to 1.32, P = 0.97). However, there was a significant improvement in both clinical disease-free survival (OR 1.86, 95% CI 1.93 to 2.40, P < 0.00001) and biochemical disease-free survival (OR 1.93, 95% CI 1.45 to 2.56, P < 0.00001). Adjuvant androgen deprivation following prostatectomy did not significantly improve overall survival at 5 years (OR 1.50, 95% CI 0.79 to 2.85, P = 0.2); although one study reported a significant disease-specific survival advantage with adjuvant therapy (P = 0.001). In addition, there was a significant improvement in disease-free survival at both 5 years (OR 3.73, 95%CI 2.30 to 6.03, P < 0.00001) and 10 years (OR 2.06, 95% CI 1.34 to 3.15, P = 0.0009). Adjuvant therapy following radiotherapy resulted in a significant overall survival gain apparent at 5 (OR 1.46, 95% CI 1.17 to 1.83, P = 0.0009) and 10 years (OR 1.44, 95% CI 1.13 to 1.84, P = 0.003); although there was significant heterogeneity (P = 0.09 and P = 0.07, respectively). There was also a significant improvement in disease-specific survival (OR 2.10, 95% CI 1.53 to 2.88, P = 0.00001) and disease-free survival (OR 2.53, 95% CI 2.05 to 3.12, P < 0.00001) at 5 years.

AUTHORS' CONCLUSIONS

Hormone therapy combined with either prostatectomy or radiotherapy is associated with significant clinical benefits in patients with local or locally advanced prostate cancer. Significant local control may be achieved when given prior to prostatectomy or radiotherapy, which may improve patient's quality of life. When given adjuvant to these primary therapies, hormone therapy, not only provides a method for local control, but there is also evidence for a significant survival advantage. However, hormone therapy is associated with significant side effects, such as hot flushes and gynaecomastia, as well as cost implications. The decision to use hormone therapy should, therefore, be taken at a local level, between the patient, clinician and policy maker, taking into account the clinical benefits, toxicity and cost. More research is needed to guide the choice, the duration, and the schedule of hormonal deprivation therapy, and the impact of long-term hormone therapy with regard to toxicity and the patient's quality of life.

Trends and predictors of aggressive therapy for clinical locally advanced prostate carcinoma

OBJECTIVE

To determine the patterns and predictors of aggressive local therapies for patients with clinically advanced (cT3) prostate carcinoma, as the USA National Cancer Institute considers external beam radiotherapy (EBRT) to be the most appropriate treatment for these patients, and currently there is less evidence supporting the use of radical prostatectomy (RP).

PATIENTS AND METHODS

We used the Surveillance, Epidemiology and End Results (SEER) cancer registries to identify patients diagnosed with cT3 disease between 1995 and 2001. Sociodemographic and clinical data included patient age, race/ethnicity, marital status, SEER registry, year of diagnosis, tumour stage and grade, and treatment. Multivariate logistic regression was used to identify significant predictors of receiving (i) RP vs EBRT, (ii) any aggressive local treatment (RP or EBRT) or no treatment.

RESULTS

Between 1995 and 2001, the proportion of men receiving aggressive local therapy for cT3 disease increased by 11% (58.4% to 69.4%), with a 20% increase in EBRT (40.3% to 60.2%) but a decline by half in RP (18.1% to 9.3%). Younger age was the strongest predictor of receiving RP rather than EBRT, and younger age with being married being a predictor of receiving aggressive local therapy (adjusted relative risk for marriage 1.33, 95% confidence interval 1.18-1.87). Black men were significantly less likely than non-Hispanic white men to receive aggressive therapy, with a relative risk of 0.56 (0.45-0.69).

CONCLUSION

By 2001, 70% of patients with cT3 disease were receiving aggressive local therapy, with EBRT 6.5 times more common than RP. Clinical trials are needed to rigorously assess the effects of different local treatment strategies on clinical outcomes in men with cT3 prostate carcinoma.

Injection systems for two luteinising hormone-releasing hormone agonists: a comparative assessment of administration times and nurses' perceptions

The aim of this study was to compare the speed of administration (preparation and delivery) and nurses' perceived ease of use and relative safety of two injection systems used to administer luteinising hormone-releasing hormone agonists: a depot system used to administer goserelin acetate ('Zoladex', AstraZeneca) and a vial system used to administer leuprorelin acetate ('Prostap', Wyeth). This was a randomised, crossover study with 82 volunteer nurses (50 pre-registration and 32 post-registration). All nurses were timed in the administration of both systems and all were required to assess the two systems by completing a questionnaire. Results indicate that both pre- and post-registration nurses administered the depot system in less time than the vial system. Overall mean times for administration of the depot system and the vial system were 1.70 and 3.34min, respectively. In questionnaire responses, significantly more nurses thought that the depot system had 'good safety precautions' compared with the vial system (85% versus 40%; P<0.001) and significantly more nurses also expressed a preference for the depot system (58% versus 42%; P=0.036). In conclusion, this study demonstrates that nurses prefer the one-step depot system used to administer goserelin acetate over the vial system used to administer leuprorelin acetate.

Does needle size matter? Patient experience of luteinising hormone-releasing hormone analogue injection

To determine whether needle size influences a patient's perception of pain, 50 patients requiring hormonal manipulation for prostate cancer were blindfolded and randomised to receive two goserelin ('Zoladex') or two leuprorelin ('Prostap') injections, using 16- or 23-gauge needles, respectively. Median visual analogue scale pain scores for the first injections of goserelin and leuprorelin were below the level of clinical significance and were not statistically different. Mean administration time for goserelin was significantly shorter than for leuprorelin. In conclusion, there was no statistically significant difference in pain experienced on injection of goserelin and leuprorelin when patients were unaware of needle size.

Early versus late hormonal therapy for prostate cancer

Hormonal therapy remains the critical therapeutic option for men with advanced prostate cancer. However, considerable uncertainty remains regarding the appropriate choice/timing and actual benefits of hormonal therapy in various situations. This article reviews the relevant studies of immediate versus deferred hormonal therapy in patients with prostate cancer. The evidence from the data supports that early treatment is beneficial to many patients. Significant survival benefit of early hormonal therapy has been observed among patients with asymptomatic metastatic disease, node-positive but clinically localized disease after radical prostatectomy and lymphadenectomy, and advanced local/regional disease during and after radiotherapy.

Elevated E-cadherin and alpha/beta-catenin expression after androgen deprivation therapy in prostate adenocarcinoma

The histological patterns of anti-androgen-treated prostate adenocarcinoma mimic high grade tumors classified according to the widely used Gleason scoring system. However, the biological characteristics of anti-androgen treated carcinoma are largely unknown. E-cadherin, alpha-catenin, and beta-catenin adhesion molecules are down-regulated in pharmacologically untreated high grade prostate carcinoma. In this study, we used immunohistochemical techniques to investigate their expression in twenty acinar adenocarcinomas after anti-androgen therapy in prostatectomy specimens. After adrogen ablation therapy, expression of all these adhesion molecules was higher than that of pretreatment biopsies of the same patient group and high grade matched untreated controls. These results emphasize the inaccuracy of the Gleason score for anti-androgen-treated prostate adenocarcinoma and the more differentiated phenotype of prostate adenocarcinoma after anti-hormonal therapy.

Follow-up of nondetectable prostate carcinoma (pT0) after prolonged PSA-monitored neoadjuvant hormonal therapy followed by radical prostatectomy

OBJECTIVES

To test the hypothesis that in patients with Stage pT0 after prolonged prostate-specific antigen (PSA)-monitored neoadjuvant endocrine therapy, biochemical relapse is extremely rare and derives from systemic tumor recurrence.

METHODS

A total of 227 patients with Stage cT1-3 carcinoma underwent PSA-monitored prolonged neoadjuvant endocrine treatment followed by radical prostatectomy. In all pT0 patients, PSA follow-up data were obtained. Patients with a PSA relapse (0.2 ng/mL or greater) underwent biopsy from the vesicourethral anastomosis, and some underwent radiotherapy.

RESULTS

Stage pT0 was diagnosed in 38 (16.7%) of 227 patients. The pT0 rate in those with cT1, cT2, and cT3 cancer was 28.2% (11 of 39), 26.3% (20 of 76), and 6.25% (7 of 112), respectively. In Gleason score 2 to 4, 5 to 6, and 7 to 10 carcinoma, the pT0 rate was 50% (3 of 6), 28.4% (25 of 88), and 7.1% (9 of 126), respectively. The median follow-up was 47.0 months (range 20 to 180). PSA relapse was seen in 7 (18.4%) of 38 patients. PSA relapse derived from local tumor relapse in 2 cases, local and systemic tumor relapse in 1 case, and local benign prostate glands in 2 cases. In 2 cases, the nature of the PSA relapse remained unknown.

CONCLUSIONS

Mainly clinically organ-confined, low and intermediate-grade tumors were converted to Stage pT0. Local PSA relapse was surprisingly frequent. In part, its malignant nature was confirmed histologically. However, the finding of residual benign prostate glands shows that PSA relapse does not always correspond with tumor relapse. Whether the prognosis in pT0 patients is significantly improved compared with nonpretreated patients cannot be answered on the basis of our data. Nevertheless, the presented results were disappointing.

Early prostate cancer: is there a need for new treatment options?

Improvements in diagnostic techniques have led to prostate cancer being diagnosed in younger patients and at an earlier stage of disease. The question therefore arises as to what is the best treatment for early prostate cancer. The main issues to be considered are whether the cancer is likely to progress quicker if these patients do not receive early treatment and what the quality of life implications are for patients receiving early treatment. As yet, due to the lack of valid comparisons of treatments, there is no clear "best treatment" for early prostate cancer. A number of clinical trials, comparing current treatments or investigating potential new treatment options for early prostate cancer, are in progress. The results of these should clarify the relative benefits of currently available treatments. This article reviews the latest information on the incidence, prognosis and current treatments for early prostate cancer and discusses the need for new treatments. Potential clinical benefits and cost implications of new treatments for early prostate cancer, such as improved surgical and radiotherapy techniques and adjuvant medical therapy, are also evaluated.