Conservative Management of Carcinoma of the Prostate

Abstract

Conservative management of carcinoma of the prostate is based on the assumption that the natural course of the disease, i.e., the course of the disease if no treatment were to be given, is extremely slow or is not influenced by the treatments available. Autopsy studies (Franks and Durh 1956; Sakr et al. 1993) indicate a high prevalence of so-called latent prostatic carcinomas in men above the age of 50. It is well known that most of these men will succumb to other diseases and will die with their prostatic carcinoma rather than from it. In the Western world there is an increase in the incidence of prostatic carcinomas and this increase in incidence is mainly due to the detection of localized disease. Especially in countries where case finding or screening programs have been launched, this increase in incidence is dramatic. Information on the natural history of prostatic cancer before the era of hormone therapy is available from a few studies (Nessit et al. 1946; Barnes and Ninan1972; Whitmore 1973). In his paper in Cancer, Whitmore wrote: “In the face of the variable and unpredictable natural history of prostatic cancer the end results of uncontrolled treatment regimens are subject to varying interpretations. It is morally and ethically impossible in the present era to obtain data regarding the natural history of the disease which might resolve some of the existing questions regarding therapy but, as in the remarkably analogous problem of female breast cancer, controlled clinical trials would answer some of the legitimate therapeutic questions.” Unfortunately, 22 years later there is still only one published randomized controlled study with a primary untreated control arm (Graversen et al. 1990), but randomized controlled studies are in progress both in Scandinavia (Norlén1994) and in the United States (Prorok 1994).