PROSTATE-CANCER - MORTALITY AND MORBIDITY AFTER NON-CURATIVE TREATMENT WITH ASPECTS ON DIAGNOSIS AND TREATMENT

Aims of the study: To investigate the mortality, need for hospital car e and palliative treatments in patients with prostate cancer (PC) trea ted with non-curative intention (i.e. deferred or hormonal treatment). To evaluate acceptance by patients and complications of a new diagnos tic procedure for PC - transrectal ultrasound (TRUS) and core biopsies . To investigate if knowledge of prostate volume enhances the accuracy of prostate specific antigen (PSA) to indicate non-palpable PC. Final ly, to investigate how neo-adjuvant hormonal treatment before radical prostatectomy affected PSA and tumour volume. Methods: In a retrospect ive analysis of all 536 patients with a known diagnosis of PC who died in the city of Goteborg during the years 1988-90, age at diagnosis, s urvival time, need for hospital care and cause of death were registere d (I and II). A questionnaire was sent to 511 patients who underwent T RUS with or without prostatic biopsies (III). In 120 consecutive patie nts admitted for TURF due to presumed benign prostatic hyperplasia, a comparison was made between PSA and prostate-volume-adjusted (measured via TRUS) PSA (PSADensity) to indicate the presence of non-palpable P C (IV). Of 56 patients who underwent radical prostatectomy, 28 receive d 3 months' pretreatment with a GnRH-agonist. The effects on tumour vo lumes (assessed by the planimetric method on whole mount slides) and P SA were studied (V). Results: Overall, 62% of patients with a known di agnosis of PC died of the disease when all patients were followed from diagnosis until death (up to 25 years). Of patients in stage MO at di agnosis, 50% died of PC. However, in patients who survived for more th an 10 years the mortality reached 63% (I). The average PC patient need ed 27 days of hospital stay (geriatric wards excluded) and 185 patient s needed at least one palliative TURF, 103 patients palliative radiati on therapy and 55 patients procedures due to upper urinary tract obstr uction. The lion's share of these resources was consumed by patients w ho later succumbed to PC (II). Ninetyfive per cent of patients reporte d none or minor discomfort after TRUS of the prostate and 92% if TRUS was combined with transrectal core biopsies of the prostate. Haematuri a for > 2 days occurred in 13%, haematospermia > 2 days in 9% and bloo d in stool > 2 days in 3% among patients who underwent core biopsies b ut none of these patients needed active treatment. Overall, 4.1% of bi opsied patients experienced urinary tract infection (III). The use of PSADensity with a cut-off value of 0.10 ng/ml/cc rendered both higher sensitivity (75 vs 50%) and positive predictive value (0.33 vs 0.15) f or indicating non-palpable PC in symptomatic patients with benign find ings on digital rectal examination (IV). Pretreatment with a GnRH-agon ist resulted in a significant PSA decrease not explained by changes in tumour volume. Tumour volume reduction was found in 36% of the patien ts. Conclusions: According to these studies, PC is a progressive disea se with considerable mortality and morbidity when managed by non-curat ive intention. Since new diagnostic and therapeutic methods described in this thesis are well accepted by patients and may increase the chan ce of radical surgery, it is reasonable to offer younger patients with long life expectancy the chance of early detection and treatment with curative intention.