Men who are diagnosed with prostate cancer often find themselves in a situation of choosing between unfamiliar and often complex treatment choices, while facing the psychological distress of a cancer diagnosis. In this context decision-related distress is common and persistent . Population-based studies suggest that the medical treatments received by men with localised prostate cancer are influenced by age and by socio-economic factors that affect access to medical services. For example, assessed 3,073 North American men six months after treatment for localised prostate cancer. Conservative management was predicted by later stage disease, physical co-morbidity, older age, and being unmarried. As well, radical prostatectomy was received more frequently by Hispanics compared with non-Hispanic Caucasians and less frequently by men with lower education and income levels.

utilised cancer registry data about 2,941 patients diagnosed with prostate cancer in the Netherlands and found that the presence of co-morbidities such as cardiovascular disease or diabetes had little effect on what medical treatments men received. Rather, men were more likely to receive radical prostatectomy if they were younger, had a small clinically localised tumour that was moderately differentiated and when they had been diagnosed in a hospital with a high clinical case load. These researchers concluded that treatment was mostly determined by the patient’s age and the extent of the urologist’s surgical experience. assessed clinical and socio-demographic factors to identify predictors of treatment choices amongst 1,809 North American men, predominantly white middle class and affluent, who were diagnosed with prostate cancer as a result of a screening program. Younger age, a higher cancer stage and PSA level and being of non African-American race predicted receiving curative treatments. Men with normal sexual function were more likely to receive watchful waiting whereas men with normal urinary function were more likely to receive radical prostatectomy.

Several studies have found that the clinician’s recommendation strongly influences men’s treatment choice . As well, lay health beliefs, such as the view that surgery is the best way to cure a cancer are a strong influence, with the use of such beliefs acting as a short cut to more effortful systematic processing . As one example, found only 13% of men made their decision about treatment for localised prostate cancer by weighing up the risks and benefits of each different medical treatment. Thus, there is a need for care to be taken in supporting informed and patient oriented choice.

In order to support men’s decision making, as a minimum men should be provided with evidence-based patient decision support materials to provide them with an opportunity to become well informed about their treatment options. A recent Cochrane review provides guidance on acceptable attributes of evidence based decision aids and some of these can be web accessed ( www.prostatehealth.org.au; www.ohri.ca/decisionaid). As well, a generic decision aid, the Ottawa Personal Decision Guide is available that can be adapted for use for most patient populations (www.ohri.ca/decisionaid). Two of the present authors (SKS and RAG) are currently validating a revised version of the Ottawa Personal Decision Guide within a randomised control trial of a multi-component intervention targeted to the specific challenges men experience in the early diagnostic and treatment phase of prostate cancer. This approach integrates psychoeducation and decision support in a novel approach . The psycho-educational component is informed by the stress and coping model and problem solving therapy . Structured counselling protocols and patient education materials underpin a telephone based nurse delivered support intervention that commences at diagnosis and extends 6 to 8 weeks after treatment.

Peer support may also be helpful to men at the time of deciding about treatments. Peers can provide support from the perspective of shared personal experience . In this regard, men who have been previously diagnosed with prostate cancer can provide first hand advice about what it is like to live with the effects of treatments, practical advice about ways to cope, and ongoing social support. A range of peer support programs are available world wide, with research suggesting they are positively received by men . Peer support programs work well when they are integrated into a broader support framework and are linked to clinicians, and many are available that do this (table 7).

Because there was a pronounced increase in the number of men diagnosed with prostate cancer following the introduction and widespread use of the PSA blood test, concern arose that a proportion of these patients had insignificant disease which did not warrant treatment. As a result, Epstein et al (1994) (334) developed criteria to identify insignificant prostate cancer. These included a PSA density <0.15, a biopsy Gleason score <6, the presence of disease in fewer than 3/6 biopsy cores and <50% prostate cancer involvement in each of these cores.

Bastian et al (2004) (335) reported on the analysis of these criteria in relation to 237 patients who had RRPs between December 2002 and August 2003. The large majority (67%) had only one TRUS biopsy core positive and most (89.9% had Gleason 6 in the RRP specimen. However, 9.7% had Gleason 7 or 8 tumours and 8.4% had non-organ confined disease, illustrating the problem of ‘undercalling’ when relying on biopsy information for stratifying patients into a good prognostic group.

The presence of any cancer cells outside the prostate locally or at distant sites following treatment with curative intent, is regarded as a portent for ultimate treatment failure. The likelihood of cancer becoming evident after prostatectomy and radiotherapy increases with pathologic stage (336, 337), both these therapies being potentially curative for men with localized (T1 and T2; N0; M0) prostate cancer (336-338). Because these treatments are considerable undertakings and may cause problems in terms of their unwanted effects, it is imperative that, as far as possible, pre-treatment staging excludes any evidence of locally-advanced or metastatic disease.

However, the clinical staging of prostate cancer is inexact and this imprecision continues to be a serious limitation in the overall management of patients with this malignancy. PSA serology is a poor predictor of pathologic stage and needle biopsies can misrepresent - usually understate - the volume, histology, and thus the expected behaviour of a patient’s tumour (339, 340). In addition, the presence of extraprostatic extension is easily underappreciated by digital palpation, and conventional imaging studies can fail to detect metastatic spread (341). Approximately 25% of men with clinically localised disease experience an early relapse despite successful treatment of the primary lesion, and up to 50 percent of men with clinically organ-confined lesions are discovered to be understaged at time of surgery (15, 342-346).

Cancer cells, particularly in the case of higher grade tumours, are apt to change phenotype and be motile. Facilitated by enzymic breakdown of the extracellular matrix, infiltration of motile cancer cells proceeds into extracellular tissues with intravasation into vascular and lymphatic channels, occurring much earlier than was appreciated previously. However, the rate-limiting steps in terms of metastasising are extravasation from the circulation into tissues remote from the primary lesion and the ability to grow and thrive in these new environments which, for prostate cancer, are particularly the bone of the axial skeleton and pelvic and retroperitoneal lymp nodes. A very recent report indicates that bone marrow-derived haemopoietic progenitor cells expressing vascular endothelial growth factor 1 (VEGFR1) home to tumour-specific pre-metastatic sites and form clusters, preceding the arrival of tumour cells. These VEGFR1+ cells also express VLA-4 which binds to fibronectin, upregulated in resident fibroblasts by tumour-specific growth factors, to provide a permissive niche for incoming tumour cells. Thus a favourable environment for secondary tumour cells to become established is pre-arranged even before arrival or the tumour cells themselves (347).

One important though easily neglected role of clinicians is to inform patients of the potential that RRP or radiotherapy, including brachytherapy, may not result in cure. To help with this task, the Partin Tables may be used (248, 260). Initially published in 1993, these were subsequently updated to accommodate an earlier stage of presentation at diagnosis for the majority of patients (348). The Partin Tables have been validated by others in multicentre studies ( 349 ) although not all reports have confirmed an improvement from earlier versions ( 350 ). In addition, Steuber at al ( 2005 ) found that the Partin Tables were less predictive for predominantly transition zone tumours. They attributed this variance to the different biological tumour characteristics of transitional zone lesions ( 351 ).

First published in 1993, subsequently modified (352) and validated in a number of centres (353), nomograms have been created to summarize a multivariate logistic regression analysis for the prediction of pathologic stage using the combination of DRE, serum PSA and Gleason score. While these estimations do not predict whether or not a given patient will be cured with surgery, they do provide an indication of likelihood of disease-free recurrence at 5 years. Stratifying patients is often a helpful exercise in this regard. The use of nomograms based on age have been extended recently to include the use of percentage free PSA for determining the presence of prostate cancer ( 354 ).

Problems with the application of tables and nomogram findings to individual patients are that PSA is a labile enzyme with serum levels affected by factors other than prostate cancer, TRUS biopsies tend to understate cancer both in terms of the extent of tumour and its Gleason score and clinical staging is subjective and relatively insensitive. Nevertheless, tables and nomograms based on pre-operative findings are useful to a degree. Post-operatively, however, incorporation of more definitive and comprehensive parameters obtained from pathology of the RRP specimen itself, enable formulation of more predictive nomograms (355).

A number of studies have stratified patients with respect to likelihood of tumour progression with recurrent disease, if it does become evident, likely to do so for the first time within 5 years after RRP. Partin et al were the first to develop a simple biostatistical model equation which allowed categorisation of cases after RRP into 3 risk groups reflecting a low, intermediate and high likelihood of PSA recurrence (356). After an extensive multifactorial regression analysis, they identified only 3 variables viz. a sigmoidal transformation of PSA, Gleason sum of the RRP specimen and margin status or tumour confinement within the prostate. Other studies have confirmed the importance of these parameters and the prognostic value of the 3-group categorisation approach (357, 358).

A combination of the following parameters is used routinely to estimate whether a prostate cancer is localized: