Conclusions

Recent developments suggest that prostate disease (especially cancer) is at last being taken seriously, and welcome additional funding has been announced by the Government. This will contribute towards research into the causes and will accelerate the search for reliable methods of early detection.

In this context, expert opinion on the usefulness of the PSA test remains divided. Its wider use will undoubtedly throw up many false positives, and will detect tumours which are not in need of immediate attention. The subsequent emotional burden on individuals and the demand for early treatment will be considerable. But it may detect many treatable cases and give those men the chance of a longer or fuller life. Alternatives to the PSA test may well emerge, but they are likely to be even more distant and will in turn need careful evaluation.

The search for more effective treatments for prostate disease has met with many real successes. Although surgery remains the mainstay of treatment for BPH, alpha-blocking medicines and the 5-alpha reductase inhibitor finasteride provide valuable and generally well-tolerated alternatives. The development of a medicine that blocks both types of 5-alpha reductase enzyme should add considerably to our understanding of BPH and provide new avenues for medicines discovery.

In early prostate cancer, medicines have little place, but radical prostatectomy, external beam radiotherapy, conformal radiotherapy and brachytherapy are all potentially curative. Brachytherapy in particular has the potential to offer a high success rate, with convenience, relative simplicity and fewer side effects, but remains available in only a few hospitals.

In more advanced disease, the newer hormone therapies (LHRH agonists and antiandrogens) are a significant advance on the earlier hormone products. At best, they can greatly extend life and do so while retaining a more acceptable quality of life. Recent studies show that their use in combination with prostatectomy and radiotherapy improves response rates and long-term survival even further. The performance of the new LHRH antagonists will be watched with interest, as it will enable clinicians to gauge the true significance of the testosterone flare seen with LHRH agonists and may provide a genuine alternative form of therapy.

The greatest unmet need, though, is for more effective treatment for hormone-resistant prostate cancer, where radiotherapy and surgery are only of palliative value. Favourable reports have appeared for both paclitaxel, taxotere, and mitoxantrone, but extended controlled trials are needed. Trials with tyrosine kinase inhibitors offer the best hope in the area, at least for the present.

An exciting new avenue is the potential for blocking angiogenesis and cell growth. Several companies, including AstraZeneca, Novartis, and Schwarz Pharma, have leads in this area and their new compounds may be useful in treating several kinds of solid tumour, including prostate cancer.

The most advanced scientific approaches are those seeking to exploit vaccination and gene therapy. Though these are still early days, there are hints that vaccines may work and may be both curative and preventive. The problem of delivering genes to cells inside solid tumours still remains a big challenge, but the prostate provides some opportunities here that are not possible in other organs. Gene therapy products for general use are still a long way off, though.

Finally, now that men’s diseases have started to emerge from the twilight, there is a need to spread the positive messages. Prostate cancer is often very slow growing and with early detection can be successfully treated. Even in the later stages, both prostate cancer and BPH can be managed to minimise discomfort and with the preservation of dignity that people with these conditions deserve.