LWBK1006-21 LWW-Govindan-Review December 12, 2011 19:6
292 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Reviewthe phase III intervention study (SELECT) of selenium and vitamin E
to prevent prostate cancer demonstrates that vitamin E use is actually
associated with an increased risk of developing prostate cancer (JAMA
2011;306:1549).Answer 21.19. The answer is A.
The decision to screen for and diagnose prostate cancer always needs to
be accompanied by a discussion between the physician and the patient
regarding risks and benefits of screening. To this end, it should be rec-
ognized that the median survival of an average 70-year-old man without
significant comorbidities is more than 10 years, and that such a patient
could benefit from the treatment of localized disease. Nonetheless, there
is a risk of treating disease that will never become clinically significant
within the patient’s lifetime. It also needs to be recalled that the sensi-
tivity and specificity of all PSA-based screening methods are limited, and
there are no absolute “normal” criteria. Therefore, no single test can
determine the absolute need for a biopsy. Predictors of cancer on biopsy
include PSA greater than 4.0 ng/mL, PSA greater than age-adjusted PSA
norms (based on normal increasing PSA with age), free-to-total PSA ratio,
and PSA velocity. Of these, and in this case, the rapid increase in the PSA
is most predictive of malignancy, and this is also predictive of aggressive
disease.Answer 21.20. The answer is D.
On the basis of the high Gleason score, the aforementioned rapid PSA
doubling time, and the tumor in all cores, this patient is at a high risk
for locally advanced disease and systemic recurrence. As such, staging
CT scan and bone scan are reasonable, although not generally neces-
sary in patients with lower-risk disease. Because of the presence of high-
risk features and the general good health of the patient, watchful wait-
ing is probably not an appropriate option in this case. Radiotherapy,
with external beam radiotherapy or interstitial brachytherapy, or surgical
prostatectomy is equally appropriate for patients with clinically localized
disease. The choice is dependent on a discussion of expected risks and
benefits.Answer 21.21. The answer is B.
Rapidly increasing PSA before diagnosis, high Gleason score, PSA nadir
of greater than 1.0 after radiotherapy, short interval between defini-
tive local therapy and biochemical recurrence, and rapid PSA increase
once recurrence is identified are all associated with a poor progno-
sis. The probability of locally recurrent disease alone is extremely low,
and there is not much value to pelvic MRI for assessing local recur-
rence. Despite the poor prognosis, the role of chemotherapy in patients
whose testosterone axis is intact is controversial. Although timing of
androgen ablation is not clearly defined, some retrospective data sug-
gest that “early” ablation in high-risk patients such as this provides a
long-term survival advantage over “later” ablation.