Localized carcinoma of the prostate : Aspects on screening, staging, and surgical treatment

Sammanfattning: The management of localized carcinoma of the prostate is controversial.Opinions vary about whether screening is appropriate for this particular cancer, about the accuracy of pretreatment staging of the primary tumour, and about the value of potentially curable treatment such as radical prostatectomy.In the present study screening was assessed from an organizational,medical, economical, and psychological view. 1 494 men were selected from a population of 9 026 men aged 50-69 years and allocated at random to a screening programme for prostate cancer by digital rectal examination. There were two screening rounds, that in 1987 being conducted by an urologist and a general practitioner, and that in 1990 by a general practitioner only. The remaining 7 532 men served as a control group. 78% accepted the invitation to the first screening round, and 70% to the second. In the study group 17.4 prostate cancers were diagnosed per 1 000 men, and in the control group 8.6 per 1 000 men. The screening cost of the programme was 18 000 SEK per detected cancer, and 25 700 SEK per detected cancer treated by a potentially curative method. The long term consequences were analysed using a decision analysis model, and compared with 2 other alternatives for early detection. Inter observer variation in the digital assessment by urologist and general practitioner was analysed. Contrary to the general belief that digital rectal examination is highly subjective, we found good conformity between the observations of the two categories of examiner.In 29 patients the predictive value of fine-needle aspiration biopsy was compared with the histological findings in whole organ sections of radical prostatectomy specimens. The preoperative cytological examination predicted correctly the grade of malignancy in the whole organ sections in 59% of the cases. No overestimation of the grade occurred.Transrectal ultrasonography was used to predict the category of the primary tumour in 59 patients, and ultrasonically guided biopsies were added in 35. Histopathological examination of the whole organ sections was compared with the ultrasonic findings in 49 cases. The accuracy of staging improved with increasing experience.To investigate the role of radical prostatectomy a series of 182 patients was reviewed. The pathological staging was based on whole organ sections. In 109 (60%) cases the tumour was confined to the prostate or the specimen. The Gleason score was significantly higher in patients with involvement of the surgical margin or the seminal vesicles. Urinary continence was regained in 79%, but only 19% were potent after operation. In 131 patients who underwent radical prostatectomy the quality of life was studied by questionnaires. In the long term only distress due to loss of erection persisted, but the overall wellbeing after 18 months was better than before operation.CONCLUSION.Screening for carcinoma of the prostate by digital rectal examination can be organized with a high population acceptance and at reasonable cost per detected cancer. The introduction of general screening would call for a moderate expansion of available resources. The impact of screening on mortality remains uncertain. Fine-needle aspiration biopsy predict the grade of malignancy in most cases. Transrectal ultrasonography in combination with ultrasonically guided biopsy can facilitate the choice of treatment. The complication rate after radical prostatectomy is low, and assessment of quality of life complements knowledge concerning the clinical outcome of radical prostatectomy.