The clinical management of prostate cancer continues to be one of the most controversial areas in medicine, with no consensus on the need for cancer screening, choice of diagnostic tests for pretreatment evaluation, and the need for and appropriateness of treatment for any stage of disease.<sup>66 Quinlan D.M., Partin A.W., Walsh P.C. Can aggressive prostatic carcinomas be identified and can their natural history be altered by treatment? Urology 1995 ;  46 (3 suppl A) : 77  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> Controversies in management can be attributed to several unique biologic features of the disease.<sup>77 Slawin K.M., Ohori M., Dillioglugil O., Scardino P.T. Screening for prostate cancer: An analysis of the early experience CA Cancer J Clin 1995 ;  45 : 134  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> For example, many prostate cancers do not lead to serious morbidity or death. Autopsy studies have shown that 30% to 46% of men older than age 50 have microscopic prostate cancer, yet less than 20% of men develop clinical prostate cancer in their lifetime.<sup>36 Kabalin J.N., McNeal J.E., Price H.M. , e al. Unsuspected adenocarcinoma of the prostate in patients undergoing cystoprostatectomy for other causes: Incidence, histology and morphometric observations J Urol 1989 ;  141 : 1091

Cliccare qui per andare alla sezione Riferimenti, 66 Quinlan D.M., Partin A.W., Walsh P.C. Can aggressive prostatic carcinomas be identified and can their natural history be altered by treatment? Urology 1995 ;  46 (3 suppl A) : 77  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> Unlike other cancers (e.g., lung, colon, breast, or ovarian cancer), which behave aggressively and are more rapidly and uniformly fatal if untreated, prostate cancer behaves in a less predictable manner. Some cancers are small, well differentiated, and unlikely to cause clinically significant disease, whereas others are large, poorly differentiated, and likely to metastasize, causing death. Despite recent advances in the diagnosis, pretreatment evaluation, and treatment of prostate cancer, significant gaps in knowledge of the underlying pathophysiology of this disease remain.

Several major obstacles impede the optimal clinical management of prostate cancer. The first obstacle, related to early detection, is the inability of screening tests to differentiate subclinical disease from clinically significant prostate cancer. Although there is evidence suggesting that most (85% to 90%) cancers detected through prostate cancer screening programs represent clinically significant rather than insignificant disease and are detected at an earlier stage of disease, the feasibility of prostate cancer screening in the general population remains controversial, and the costs of undertaking screening in all men over age 50 years far exceeds presently available health care funds.<sup>40 Krahn M.D., Mahoney J.E., Eckman M.H. , e al. Screening for prostate cancer. A decision analytic view JAMA 1994 ;  272 : 773

Cliccare qui per andare alla sezione Riferimenti, 54 Ohori M., Wheeler T.M., Dunn J.K. , e al. The pathological features and prognosis of prostate cancer detectable with current diagnostic tests J Urol 1994 ;  152 (5 pt 2) : 1714

Cliccare qui per andare alla sezione Riferimenti, 77 Slawin K.M., Ohori M., Dillioglugil O., Scardino P.T. Screening for prostate cancer: An analysis of the early experience CA Cancer J Clin 1995 ;  45 : 134  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 85 Waterbor J.W., Bueschen A.J. Prostate cancer screening (United States) Cancer Causes Control 1995 ;  6 : 267

Cliccare qui per andare alla sezione Riferimenti</sup> The second obstacle is related to treatment planning. There are limitations of currently available tumor prognostic factors in differentiating indolent from aggressive disease. Although a number of tumor prognostic factors (e.g., tumor volume, grade, and stage) can generally predict disease at either end of the spectrum, most cancers fall into an intermediate range, where it is difficult to distinguish those cancers likely to progress from those that can be observed.<sup>55 Ohori M., Wheeler T.M., Scardino P.T. The New American Joint Committee on Cancer and International Union Against Cancer TNM classification of prostate cancer. Clinicopathologic correlations Cancer 1994 ;  74 : 104  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 79 Stamey T.A., Freiha F.S., McNeal J.E. , e al. Localized prostate cancer. Relationship of tumor volume to clinical significance for treatment of prostate cancer Cancer 1993 ;  71 (3 suppl) : 933  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> There continues to be intense debate about the ability of currently available tumor prognostic factors accurately to assign patients to appropriate risk and treatment categories.<sup>77 Slawin K.M., Ohori M., Dillioglugil O., Scardino P.T. Screening for prostate cancer: An analysis of the early experience CA Cancer J Clin 1995 ;  45 : 134  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup>

Prostate cancer is usually suspected due to an abnormal digital rectal examination (DRE) or elevated serum prostate-specific antigen (PSA) level (Figure 1). American Cancer Society recommendations for the annual cancer prevention check-up includes DRE and serum PSA testing for men older than 50 years or for younger men at increased risk (black race or family history of prostate cancer) for the disease.<sup>47 Mettlin C., Jones G., Averette H. , e al. Defining and updating the ACS guidelines for the cancer related check-up: Prostate and endometrial cancer CA Cancer J Clin 1993 ;  43 : 42  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> Imaging provides additional information in patients with a histologic diagnosis of prostate cancer, but imaging findings alone are not sufficient for the primary diagnosis of prostate cancer. The diagnosis of prostate cancer depends on the histopathologic evaluation of tissue specimens obtained from digitally or transrectal ultrasound (TRUS)–guided prostate biopsies (see Figure 1).<sup>39 Klein L.A. Prostatic carcinoma N Engl J Med 1979 ;  300 : 824  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> Systematic (sextant) core biopsies of the prostate are recommended to maximize the diagnostic yield of biopsy and to allow estimation of tumor grade and volume.<sup>60 Peller P.A., Young D.C., Marmaduke D.P. , e al. Sextant prostate biopsies Cancer 1994 ;  75 : 530

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