Management of Prostate Cancer

Abstract

Interactive at www.nejm.org C a se Vigne t teA 63-year-old man who has been under your care for the past 3 years undergoes an annual check-up. He believes he is in excellent health, and he has no medical problems to report. In 2006, his physical examination and routine laboratory tests were normal, and the prostate-specific antigen (PSA) level was 1.5 ng per milliliter. There had been no new findings in 2007, except that the PSA level had risen to 3.1 ng per milliliter. This year's annual check-up reveals a PSA level of 3.8 ng per milliliter, and a digital rectal examination is normal. Concerned about the rising PSA level, you refer the patient to a urologist, who performs ultrasonography and biopsy of the prostate. The prostate volume is 22 cm 3 , and of 12 biopsy cores, 2 (10% of one and 20% of another) show involvement with adenocarcinoma, with a Gleason score of 6.The patient, a widower with normal sexual function, plans to continue to run his advertising business. He does not smoke, drinks only occasionally, and jogs 2 miles three times a week. He Tre atment Op tion 1 This interactive feature addresses the diagnosis or management of a clinical case. A case vignette is followed by specific clinical options, none of which can be considered either correct or incorrect. In short essays, experts in the field then argue for each of the options. In the online version of this feature, available at www.nejm.org, readers can participate in forming community opinion by choosing one of the options and, if they like, providing their reasons. The New England Journal of Medicine Downloaded from nejm.org at NYU WASHINGTON SQUARE CAMPUS on June 1, 2015. For personal use only. No other uses without permission.

Prostate Cancer: People Transforming A Diagnosis, A Diagnosis Transforming People

“…To understand how this dynamic process works, I analysed a online poll of readers' responses to a clinical vignette of a 63-year-old man with a rising PSA level (Schröder et al, 2008). Subsequent biopsies showed good prognosis prostate cancer (Gleason score 6) in two of twelve samples.…”

New immunotherapeutic paradigms for castration-resistant prostate cancer

“…However, the actual incidence of this malignancy cannot be precisely assessed, as several cases never become clinically manifest owing to the death of patients for cancer-unrelated causes. Indeed, malignant lesions of the prostate generally progress at a slow pace and early stage neoplasms are associated with few, if any, symptoms 3 , 4 . Many factors have been tentatively implicated in the etiology of prostate cancer, including genetic alterations as well as viral, alimentary and sexual determinants.…”

“…A reduced fraction of patients, however, present with aggressive lesions at a young age (50–60), calling for the delineation of a therapeutic strategy. The most appropriate therapeutic option for the management of prostate carcinoma obviously depends on several tumor-related parameters such as stage, Gleason score and prostate-specific antigen (PSA) circulating levels, as well as on the age and general health status of the patient 3 , 4 . Of note, a large fraction of patients is eligible for active surveillance, entailing the careful observation of the neoplasm over time until signs of progression (which may never manifest).…”

“…Of note, a large fraction of patients is eligible for active surveillance, entailing the careful observation of the neoplasm over time until signs of progression (which may never manifest). Conversely, subjects bearing aggressive prostate cancers are generally treated with radical prostatectomy (if eligible) combined with cryotherapy or radiation therapy (in the case of localized lesions), or with chemotherapy and/or hormonal therapy (in the case of metastatic disease) 3 , 4 . Unfortunately, most hormone-dependent cancers eventually become refractory to androgen deprivation and often metastasize to the bones 9 .…”