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Prostate Cancer: Screening, Diagnosis, and Management

Marc B. Garnick, MD
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From Dana-Farber Cancer Institute, Boston, Massachusetts, and Genetics Institute, Inc., Cambridge, Massachusetts. Requests for Reprints: Marc B. Garnick, MD, Genetics Institute, 87 Cambridge Park Dr., Cambridge, MA 02140.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;118(10):804-818. doi:10.7326/0003-4819-118-10-199305150-00008
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Objective: To provide physicians with a review of diagnosis, screening, staging evaluation, treatment options, prognosis, psychosocial issues, economic considerations, and future research directions in the management of patients with all stages of prostate cancer.

Data Sources: A MEDLINE search of articles relating to the diagnosis, staging, screening, surgery, radiation therapy, medical management, and research in prostate cancer. Emphasis on information reported from government- and nongovernment-sponsored large cooperative trials, consensus development conferences, and proceedings of prostate cancer organ site workshops.

Study Selection: Results of randomized treatment trials and consensus summary statements are reported where long-term results (> 5 years follow-up) are available for localized prostate cancer treatment and where survival outcomes are available for metastatic disease treatment.

Data Synthesis: Both qualitative and quantitative data are reported. Information on staging, management, and prognosis of localized prostate cancer is based on studies that are predominantly nonrandomized, include heterogeneous patient groups, and often use differing outcome measures. Information on management of metastatic prostate cancer is more quantitative and includes side effects of treatment and survival results obtained from randomized, prospective, multi-institutional studies.

Conclusions: Despite the increase in prostate cancer incidence and detection, substantial controversy still exists about the advisability and effectiveness of screening programs, the most appropriate staging evaluation, and the optimal management of patients with all stages of prostate cancer. Although randomized, prospective studies attempt to address some of these issues, physicians must appreciate inherent ambiguities involved in recommending staging and treatment choices.


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Figure 1.
Long-term survival.

Comparison of long-term survival of patients with stage T2a (B1) disease treated by radiation therapy in the Stanford University Hospital series (134 patients, triangles) and those treated by radical prostatectomy in the series at The Johns Hopkins Hospital (57 patients, open circles) and Virginia Mason Medical Center (195 patients, closed circles) according to a personal communication (Shipley WU). (Reprinted with permission from Bagshaw MA, et al. NCI Monogr. 1988; 7:47-60.).

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Figure 2.
Scheme of achieving castrate androgen levels.

Estrogens such as diethylstilbestrol inhibit the release of luteinizing hormone-releasing hormone (LHRH) from the hypothalamus, thus also diminishing the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary gland. Analogs of LHRH initially stimulate but ultimately inhibit the release of FSH and LH from the anterior pituitary gland. Ketoconazole and aminogluthethimide inhibit steroid synthetic pathways. In the prostate cells, testosterone is converted into dihydrotestosterone (DHT) by the enzyme 5--reductase. Anti-androgens block the binding of DHT to its cytoplasmic receptor. (Garnick MB. Urologic Cancer. In: Rubenstein E, Federman DD; eds. Scientific American Medicine. New York, Scientific American. Section 12, IX:1-17, with permission.).

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