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Radiotherapy of Prostate Cancer aims to guide the reader through the recent data from clinical trials, to highlight the various approaches and to clarify the role of traditional radiation therapy in the management of the disease. It details established management protocols as well as more controversial isssues and experimental approaches ranging from external beam radiotherapy, 3-dimensional conformal radiotherapy, heavy particle therapy and brachytherapy. The reader will not only gain a vast amount of knowledge regarding the many modes of currently available radiotherapy strategies for this disease, but will also gain a clearer perspective of the indications of a particular modality's use and how best to integrate therapy for the individual patient.
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Prostate cancer is the most commonly diagnosed noncutaneous cancer and the second leading cause of death due to cancer among men living in the United States. During the year 2000, approximately 180,000 new cases were diagnosed in the United States, and the trend continued toward fewer new cases of advanced disease and more early-stage disease. This trend is attributable to the increased use of the serum level of prostate-specific antigen (PSA) as part of screening. Despite early detection, however, the effect on survival of screening with PSA is unknown and is the subject of randomized trials worldwide.
Along with the increase in the incidence of prostate cancer attributed to PSA-based screening, the number of radiotherapeutic options for early-stage disease has soared. Prostate brachytherapy ("seed" therapy) with use of permanent or temporary radioactive sources, sometimes coupled with external-beam radiation therapy, hormonal (androgen-suppression) therapy, or both, has become popular because of improved imaging guidance. Having been in use for only 10 years or so, these relatively new radiotherapeutic approaches await the long-term follow-up needed for an assessment of their influence, if any, on survival. In addition, given the lack of a definitive demonstration that any treatment for early-stage prostate cancer affects survival, the effects of treatment on the quality of life are increasingly important.
It has become clear that radiation-therapy techniques that tightly confine the dose of radiation to the prostate and keep it away from normal surrounding structures have decreased the incidence and severity of rectal injury. These technical improvements have allowed the delivery of higher doses of radiation without an increase in its toxic effects. Higher doses have recently been shown to prolong disease-free survival in men with early-stage prostate cancer. Moreover, it is becoming clear that the combination of androgen-suppression therapy and external-beam radiation therapy is associated with higher survival rates among patients with advanced prostate cancer than is radiation therapy alone.
Given our rapidly expanding knowledge of prostate cancer and the numerous technical advances in treatment, Radiotherapy of Prostate Cancer is timely. The book, edited by two authorities on genitourinary radiation oncology, is a state-of-the-art compendium written by a group of experts. The book focuses on the radiotherapeutic management of newly diagnosed early-stage or advanced prostate cancer and recurrent prostate cancer. Because many of the newer forms of radiation therapy (conformal radiation therapy and brachytherapy, for example) have been developed during the PSA era (which spans just over a decade), most cancer-control outcomes reported for men with early-stage disease are based on PSA measurements rather than survival rates. Longer follow-up will be necessary to determine whether the PSA level after treatment is an appropriate surrogate for survival. It will also be necessary, as pointed out in the book, to consider both life expectancy and tumor characteristics to determine the probable effects in an individual patient of improvements in therapy for early-stage disease.
Given the uncertainty about the efficacy of local therapy for early-stage prostate cancer, noted in the comprehensive section on "watchful waiting," the effect of treatment on the quality of remaining life is paramount. The editors have included a section on the ways in which newer forms of radiation therapy have affected the quality of life during and after therapy. The inclusion of evaluations by both physicians and patients highlights how different these two assessments can be.
The book concludes with a section on the management of advanced prostate cancer that brings home the point that systemic disease is still the chief cause of morbidity and mortality. This fact provides food for thought regarding future innovations in systemic management that, together with the advances in local therapy outlined in the book, may hasten the eradication of this disease.
Anthony V. D'Amico, M.D., Ph.D.
Copyright © 2001 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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