Prostate Cancer: Principles and Practice

It is a challenging enterprise to assemble a comprehensive textbook on prostate cancer that goes beyond what other books afford. Although there have been at least a dozen other treatises on the same or similar subjects, Prostate Cancer: Principles and Practice has achieved the goals outlined in its preface: a summary of basic science and its relation to clinical medicine and a state-of-the-art summary of the management of prostate cancer. The student of the science of prostate cancer and the physician who treats men with the disease are challenged by an almost insurmountably complex disease process. This cancer affects one man in six and causes the death of 3 to 4 percent of all men, but it is apparent histologically in more than half of men during their lifetime. A number of key questions pervade clinical practice and provoke seemingly unending conversations between clinicians and basic scientists. What are the factors that precipitate the histologic event? Which tumors are biologically significant and require treatment? How does an individual patient balance the risks entailed by the disease with the risks involved in treatment, given our inability to predict the outcome of untreated disease? The reader of this book will understand the complexity of the disease, not just at the most basic, cellular level but at the level of the patient-physician interaction. The editors have selected outstanding authorities to contribute to this book. The crown jewel is its first section, entitled "Biology." These seven chapters are not only comprehensive but also insightful. Robert Myers's chapter on gross and applied anatomy, for example, traces the historical advances in prostatic embryology as it relates to anatomy and function. His integration of observations by American and European anatomists -- including the often-forgotten yet seminal work of Gil-Vernet in Barcelona, Spain -- provides a clear understanding of functional anatomy, an essential element in comprehending the effects of treatment on urinary and sexual function. Similarly, the depth of detail in the chapters on the molecular biology and genetics of prostate cancer is superb. The paired chapters 5 and 6 provide one of the most comprehensive discussions of the evolution of the hormone-resistant cell and potential therapeutic targets. In addition to the first section, the first two chapters of the epidemiology section (8 and 9), which are comprehensive and well written, should be required reading. Many of the clinical sections make repeated references to the same few clinical trials, some of which are discussed in detail in four separate chapters. Such repetition occurs because few clinical trials have been initiated, and even fewer have been completed. At least three chapters, for example, discuss the role of adjuvant radiotherapy after radical prostatectomy. The only randomized trial comparing adjuvant radiation with observation after radical prostatectomy began in 1987, and because the trial is concerned with survival, results will not be available until about 2004. Many clinical trials of patients with prostate cancer have compared treatments that are quite similar (e.g., radiotherapy with and without hormones), but challenging studies that compare dissimilar treatments are only now beginning to be undertaken (Figure). The trial of the American College of Surgeons Oncology Group and the National Cancer Institute comparing radical prostatectomy with brachytherapy has only recently begun; results may be a decade away. Thus, the clinical sections of the book suffer from the lack of data resulting from inherent challenges to clinical trials: the hesitancy of physicians and patients to offer or enter such trials, the large numbers of patients required for prostate-cancer trials, the long follow-up required, the lack of validated surrogate end points, and the very real risk that treatments may change dramatically long before study end points are reached. Nonetheless, there is much good counsel in this book. Since many physicians treat patients from the inception of the disease until death, managing the multitude of age-related and disease-related symptoms and complications, quality-of-life issues are exceptionally important. The chapters on the management of urinary incontinence and erectile dysfunction, neurologic and orthopedic considerations, and psychosocial considerations are important reading for clinicians. I must draw special attention to chapter 44 on pain and symptom management. I was so impressed by it that I have made it mandatory reading in our training program. Ian M. Thompson, M.D.
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