The past decade has seen a 20% drop in prostate cancer mortality. It is claimed that it is not yet possible to attribute this drop in mortality to prostate specific antigen (PSA) screening and early intervention. However, the evidence that the drop in mortality is related to screening and early intervention is accumulating, in particular with reference to the recently published Holmberg study. This study showed a definite survival advantage and also a significant reduction in metastatic disease development for men treated with radical prostatectomy. We await with interest the results of the Prostate Cancer Intervention versus Observation Trial (PIVOT) and Prostate, Lung, Colorectal and Ovarian (PLCO) trials, which are due to report in 2007. These are large prospective randomised cont rolled studies comparing watchful waiting with definitive therapy. In the meantime, men with early prostate cancer are keen to know what treatment options are available and the consequences of such treatments . In any discussion of prostate cancer it is important to be cognisant of the grade of cancer. The Gleason score is an attempt by pathologists to categorise prostate cancers into low-, intermediate- and high-grade malign ancy. The natural history of the three groups is quite distinct and the clinician must be cognisant of the Gleason grade of the prostate cancer when making treatment recommendations .

Radical prostatectomy is indicated for men with a life expectancy in excess of 10 years who have organ-confined prostate cancer. When performed by an experienced urological surgeon, radical prostatectomy is a low morbidity operation with a realistic expectation of return to usual employment within a fiveweek period. The operation is perf o rmed via a lower midline muscle separating incision. The pelvic lymph nodes are bilaterally sampled. The prostate and seminal vesicles are removed en bloc. The bladder neck is reconstructed with mucosal eversion and anastomosed to the membranous urethra. Great care must be taken with the apical dissection and with the vesicourethral anastomosis in order to maintain the integrity of the distal urethral sphincter mechanism. Utilising modern sphinctersparing techniques, anatomical radical prostatectomy now has excellent continence preservation. In experienced surgical hands, there is now only a 3% risk of major postoperative incontinence. Pre- and postoperative intensive pelvic floor training improves long-term continence results. Negative surgical margins, non-invasion of the seminal vesicles and negative lymph nodes portend an excellent long-term prognosis. Men who have good quality erections prior to radical prostatectomy have at least a 50% chance of maintaining potency postoperatively when an anatomical nerve-sparing operation is performed. Men with waning erections are unlikely to maintain erectile activity postoperatively. This, of course, accounts for at least half of men undergoing radical p rostatectomy as the average age for the operation is 64. Six weeks postoperatively it is important to start men on penile injection therapy as it is now well recognised that erectile function is more likely to be restored when erections are stimulated early in the postoperative period. Erectile function can continue to improve for up to three years post nervesparing radical prostatectomy. Radical prostatectomy is an excellent management option for men with localised prostate cancer and significant obstructive urinary symptoms. Men with obstructive symptoms do not do well with radiation therapy in any form as the postradiation morbidity is significant.

Watchful waiting is appropriate for men with a life expectancy of less than 10 years, and especially for men with a low-grade prostate cancer. In the mid-1990s, Canadian prostate cancer researcher, Labrie, noted that a man has to be older than 75 before having at least a 50% chance of dying with, rather than from, prostate cancer.

It has been shown that the natural history of prostate cancer, when treated conservatively, is to steadily progress and, more importantly, to upgrade. Therefore, a 50-year-old man who chooses not to treat his Gleason 6 prostate cancer can expect over the ensuing decade for it to become a higher-grade, higher-stage malignancy with a significant chance of death or metastasis at 10 years. The ideal patient in whom to consider watchful waiting is the elderly man with low-grade prostate cancer, who will die with, rather than from, prostate cancer. The younger man managed conservatively will suffer the inevitable consequences of both local and systemic prostatic cancer, including recurrent bladder neck obstruction, ureteric obstruction, bony metastasis, pathological fractures and possibly spinal cord compression.

For decades external beam radiotherapy has been a mainline treatment for localised prostate cancer, however, it is waning in popularity. External beam radiotherapy suffers from dose limitation and potentially significant morbidities associated with radiation damage to the bowel and bladder.

Accurate prostatic brachytherapy has been made possible by the introduction of the transrectal ultrasound probe. Both iodine seed brachytherapy and high dose rate brachytherapy are gaining popularity in Australia.

Patients suitable for iodine seed brachytherapy must have a PSA value less than 10 ng/mL and must have Gleason 6 or less disease. Patients with a large nodule protruding into the rectum are not suitable for iodine seed implantation, nor are men who have undergone transurethral prostatectomy. The aim of iodine seed brachytherapy is to implant 80-100 radioactive iodine seeds into the prostate using transrectal ultrasound imaging under spinal or general anaesthesia. The seeds a re implanted according to a computerised treatment program pre-determined by a medical physicist. Accurate seed placement is critical in order to avoid cold spots or under- treated regions of the prostate gland. If the physicist is not satisfied with the integrity of the implant, additional external beam radiotherapy may be necessary. Iodine seed brachytherapy is able to achieve very high intraprostatic radiation dosages while minimising the exposure to the rectum and bladder. For three months post-operatively it is usual for the patient to experience frequency, urgency and dysuria, but these irritative symptoms inevitably settle. The iodine seeds emit radiation for three months and then become inert and incorporated within the prostatic parenchyma. During this three months, the patient is advised to avoid close contact with pregnant women or small children. In reality, however, radiation emitted from a man with an iodine implant is minimal and radiation exposure to next of kin is not considered clinically significant. Should the prostate gland not meet certain planning volume requirements, a 6-9 month course of cytoreductive hormone ablation therapy is indicated prior to iodine seed brachytherapy. In the US, it is estimated that up to onethird of men with localised p rostate cancer are treated with iodine seed brachytherapy.

High dose rate brachytherapy is indicated for men with higherstage, higher-grade prostate cancer who are not suitable for radical prostatectomy. It is usual for these men to have a 6-9 month course of cytoreductive hormone therapy in combination with daily finasteride when prostate volume needs considerable reduction. Once the patient meets volume criteria, they are admitted and 18-20 needles are inserted into the prostate under spinal or general anaesthesia. The radiation physicist then administers the therapy utilising iridium wire as a radioactive source. After a 36-hour inpatient stay, the needles are removed from the perineum and the patient is discharged. Ten days later lowdose external beam radiotherapy is applied for half an hour a day, five days a week, over a five-week period. High dose rate brachytherapy is able to achieve the radiobiological dose equivalence of 80 Gray. This compares with 66 Gray for external beam radiotherapy. It is possible to administer high dose rate brachytherapy with significant reduction in radiation toxicity to bladder and bowel.1 The worldwide experience with brachytherapy is only out to seven years. Hence, it is not usual to offer it to younger men with prostate cancer, especially to those whose life expectancy exceeds 15 years. This therapy is best avoided in men with significant obstructive symptoms. MO Reference available from Medical Observer upon request