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Foreword
This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinical use of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines, if they exist, are presented. The article ends with the author's clinical recommendations.
Stage
A 69-year-old man undergoes a follow-up evaluation after testing showed an elevated serum prostate-specific antigen (PSA) level. One year previously, he had requested serum PSA testing after receiving counseling regarding its advantages and disadvantages. His serum PSA level at that time was 8.0 ng per milliliter, and prostatic intraepithelial neoplasia was detected on biopsy. His serum PSA level is now 11.0 ng per milliliter, and the apical prostate is indurated (clinical tumor stage, T2a). Transrectal prostatic ultrasonography shows a prostate gland 70 ml in size (twice normal size), needle biopsy reveals adenocarcinoma with a Gleason score of 7, and cancer staging shows no sign of spread beyond the prostate. A specialist recommends high-dose, image-guided external-beam radiotherapy.
The Clinical Problem
One in six American men receives a diagnosis of prostate cancer during his lifetime, usually after 60 years of age.1 With approximately 234,000 new cases expected in 2006, prostate cancer is the most common noncutaneous malignant disease and is the third leading cause of cancer-related death in men.1 The established risk factors for the disease include race, age, and family history.2
The prognosis for patients with prostate cancer is variable and depends on the tumor-related characteristics at diagnosis. In practice, the clinical tumor stage at presentation (according to the classification of the American Joint Committee on Cancer),3 the histologic appearance (according to the Gleason score; scores range from 2 to 10, with higher scores indicating a poorer prognosis), and serum PSA values are used to assess the risk of spread of microscopic tumor beyond the prostate,4 -6 determine the risk of recurrence (Table 1 ),4 and estimate the likelihood of therapeutic success.5 The interaction among these factors can be assessed with the use of a predictive instrument, such as a nomogram,7 that quantifies the risk for the individual patient.6 -8 Patients with higher Gleason scores, higher PSA levels, and rapidly rising PSA values...