Prostate cancer remains the most common malignant tumor in elderly men. The National Cancer Institute estimated 210,000 new cases of prostate cancer in 1997. There is, however, no means of documenting the true incidence of prostate cancer because of the difficulty in detecting all cases. Even using yearly rectal exams, PSA determinations, and ultrasound-guided prostate biopsies, many cases are missed. Suffice it to say that prostate cancer is a widely occurring disease in men and early detection and treatment are extremely important. When I trained in Urology under Dr. Reed Nesbit at the University of Michigan from 1956 to 1959, the diagnosis of prostate cancer was made by a rectal examination and an acid phosphatase determination. If there was a small nodule in the prostate, then an anterior-posterior X-ray of the pelvis was obtained to look for possible bony metastases. If the acid phosphatase was normal and there was no evidence ofa bony metastasis, the prostate was exposed through the perineal approach and a biopsy of the nodule was obtained and sent for frozen section to Pathology to determine if it was indeed a cancer of the prostate. If the biopsy came back positive, the surgeon then proceeded to do a radical perineal prostatectomy. In those days, we usually did eight to ten radical perineal prostatectomies yearly. Many times the nodule that was biopsied was benign, and the incision was simply closed.
Prostate cancer is the most common cancer in men. The increase in basic and clinical research on this type of cancer has been logarithmic. Although this is clearly a good thing from the standpoint of scientific advancement, it would take an entire day just to read the title of every recent article on prostate cancer. For this reason, a book on the subject is easily justified at least biennially to update physicians, including those who specialize in prostate cancer. Klein's Management of Prostate Cancer provides a balanced and comprehensive review.
This book covers the gamut of topics, from epidemiology and molecular genetics to treatment options for localized disease and disease that is refractory to hormone therapy. Overall, the 20 chapters are well written and provide a balanced view of the issues in diagnosis and treatment. The book's best feature is that it presents both sides of the picture. Several chapters stand out in this regard. Thompson and Foley present in a point-counterpoint style arguments that support or refute the effectiveness of screening, the clinical significance of detected disease, and the effectiveness of local treatment, as well as opposing views on cost and the quality of data from prospective trials. Their presentation clearly shows how the same information can be interpreted in opposite ways and why major organizations differ in their recommendations for screening.
Two equally excellent chapters are "Counseling the Patient on Choice of Therapy and Outcomes: Surgeon's Perspective," by Vashi and Montie, and "Counseling the Patient on Choice of Therapy and Outcomes: Radiation Oncologist's Perspective," by Hanks. As one would expect, the surgeons consider surgery the treatment of choice, and the radiation oncologist favors radiation therapy; the two views are defended with equal eloquence. These chapters will be especially helpful to patients who have spent a substantial amount of time researching their treatment options and who are confused about why they are receiving conflicting recommendations. Should further editions of this book be published, a chapter on the medical oncologist's perspective would be helpful, because an increasing number of patients consult a medical oncologist to help make the choice between surgery and radiation therapy.
A second feature of this book is its practical approach to the management of prostate cancer and the complications of treatment. In the chapter entitled "Contemporary Technique of Radical Retropubic Prostatectomy," Klein, Licht, and Jhaveri provide a good description of their surgical technique and discuss its pros and cons. The chapter has many detailed illustrations. The discussions of cost containment and "collaborative care pathways" in the chapter on perioperative management show how continuous-quality-improvement programs can influence practice patterns and improve both the quality of care and the education of medical providers. The chapters on therapy for voiding dysfunction and sexual rehabilitation provide very useful discussions of diagnostic evaluations and therapeutic options. Knowledge of treatment choices is especially important for primary care physicians who provide routine care for men with prostate cancer. A chapter on management of the complications of progressive prostate cancer would have been useful. Although there are many common problems associated with advanced cancer, such as fatigue, anemia, and weight loss, there are certain complications that, if not unique to prostate cancer, are more commonly encountered with this type of cancer than with other types. Suggested evaluations and potential interventions for spinal cord compression, gross hematuria that cannot be controlled or that is difficult to control, urinary frequency, disseminated intravascular coagulation, diffuse bone pain, and pancytopenia would have been helpful.
The third feature of this book is its emphasis on new horizons. In their chapter on gene therapy, Rashid and Sanda discuss vectors for gene delivery, molecular targets, and the results of preclinical and phase 1 trials. Many patients assume that gene therapy will soon be available and will provide a nontoxic cure, but these authors make it clear that gene therapy is only in its infancy and that expectations about it need to be realistic. In "Monoclonal Antibodies for Imaging and Therapy of Prostate Cancer," Bander discusses antibodies to the extracellular domain of prostate-specific membrane antigen. These antibodies bind with high affinity to prostate-cancer cells, are internalized, and have been genetically engineered to be nonimmunogenic. They have a substantial antitumor effect in preclinical models, and there is optimism about the planned clinical trials. Finally, Kamradt and Pienta describe the newest approaches to hormone-refractory prostate cancer, with the use of antiangiogenesis agents, differentiating agents, and antimetastatic therapies. These novel approaches reflect our expanding knowledge of the mechanisms underlying cell proliferation and disease progression in cancer and the renewed trend toward translational research.
Management of Prostate Cancer is an informative review, and most of the chapters should be readily understood by patients and physicians alike. The last two chapters, on the surgeon's and radiation oncologist's perspectives, would be valuable reading for any man with prostate cancer who must decide whether to undergo surgery or radiation therapy. The chapter on screening provides important insights for primary care physicians facing the problem of whether to recommend screening.
Nancy A. Dawson, M.D.
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