The Clinical Problem of Prostate Cancer

Abstract

Prostate cancer is the most common non-cutaneous malignancy and the second leading cause of cancer death in men. It is estimated that in 1999, 179,300 new cases of prostate cancer will be diagnosed and 37,000 men will die of the disease in the United States alone. One in every six men born in the United States will develop clinically significant prostate cancer in their lifetime [1]. These sobering and staggering statistics speak to the enormous clinical problem that prostate cancer represents in our society, not to mention the tremendous financial cost for diagnosis and treatment that is brought to bear on our already overburdened health care system. In recent years, there has been a decline in the mortality rate from prostate cancer, which some experts argue reflects the success of early detection programs combined with effective local therapy [1, 2]. The sobering truth remains that a patient’s potential for cure lies more in the underlying biologic virulence of their prostatic neoplasm, rather than in early intervention. The observation that fewer men are dying of metastatic prostate cancer is clearly not the result of a significant advance in treatment efficacy, as there hasn’t been one. Instead, this decline in the mortality from prostate cancer more reflects a stage migration, where the cancer is found at an earlier stage and is thus perhaps more amenable to local therapy with surgery or radiotherapy. There remains no effective systemic therapy for prostate cancer that reliably provides a cure when the cancer has progressed beyond the confines of the prostate gland. The biology of prostate cancer is heterogeneous and unpredictable, which contributes to the paucity of effective therapies for aggressive disease. As we enter a new millennium, the standard of care for the treatment of metastatic prostate cancer remains hormone ablation therapy, which was initially described as an effective palliative treatment at the beginning of this century [3]. In the intervening years, we have remained relatively in the dark about the complex biological processes that result in prostate carcinogenesis and progression. This ignorance has directly hampered the development of novel therapeutic approaches. However, with increased funding for basic science research, increased public awareness of the problem, and an increased commitment from the academic, public, and private sector, it is believed that this disease can ultimately be conquered.