Perineal discomfort in prostatic adenocarcinoma

Prostate cancer is the most frequent malignancy of men of all races and is the biggest cause of cancer deaths in men but there is continuing controversy surrounding screening for prostate cancer even though the seriousness of prostate cancer is unquestioned with 0.6% of cases diagnosed as early as 35–44 years of age. The limitations of PSA use and, more specifically, false positives and false negatives are well known and some investigators have tried to improve the method’s sensitivity and specificity, including PSA adjusted by age, as well as PSA density, velocity and fractions, i.e. free/total PSA ratio (%fPSA). Despite imperfections which limit their interpretation, the recently published large randomized screening trials show there is only a small – or no – improvement in survival from early detection over the first 10 years. However, in the recent European Randomized Study of Screening for Prostate Cancer (ERSPC) by Schröder et al., most centres involved in the trial used a PSA cut-off value of 3 ng/mL (range of 3.0– 10.0 ng/mL depending on the country involved) as an indication for biopsy; in the large American randomized study by Andriole et al. the standard US threshold of 4 ng/mL was used. Using their PSA values, Schröder et al. concluded that PSAbased screening reduced the rate of death from prostate cancer by 20% in their 55–69 year age group of men at entry to the trial. The Andriole et al. trial concluded that, after 7–10 years of follow-up, the death rate was very low, not differing significantly between their two study groups. Significant prostate cancer can exist with PSA levels of 2.5–4 ng/mL. Thompson et al. looked at the prevalence of prostate cancer, including high-grade cancer, with PSA levels of 4.0 ng/mL and found 15% had prostate cancer despite ‘normal PSA levels’, i.e. levels generally thought to be in the normal range (4.0 ng/mL or less). A transrectal ultrasound (TRUS) guided biopsy of the prostate gland is the only way that prostate cancer can be diagnosed with certainty. However, TRUS alone has poor test characteristics for the diagnosis of prostate cancer with a positive predictive value of 52.7%, a negative predictive value of 72%, and an accuracy of 67%. Biopsy cancer tissue is graded microscopically using the Gleason score with a possible total rating from 2–10. Fast-growing (i.e. ‘high-grade’ cancers with a Gleason score of 7–10 usually need more radical treatment. Prostate cancer frequently originates from the peripheral zone and only approximately 24% arise from the transition zone where they are difficult to diagnose. Barry refers to many available treatment options including surgery, radiation, cryotherapy, and expectant management, and Jang et al. state it is essential for men to have access to balanced information before choosing a particular therapy. Hoffman et al. highlight the importance of an informed and shared decision-making process between the patient and urologist for prostate cancer screening, treatment decisions, and their possible sequelae. DECLARATIONS