world cancer report - iarc

Management
The dramatic division between localized
curable prostate cancer versus the
advanced incurable disease has provoked
heated controversies regarding the impact
of early diagnosis and appropriate management.
For localized disease in patients with
a reasonable life expectancy, cure is the
ultimate goal [10]. Radical prostatectomy
(retropubic, perineal or laparoscopic) is
usually recommended for patients with a
life expectancy of greater than ten years.
Although the cure rate is very high, side
effects may include incontinence (2-10%)
and impotence (30-90%). Due to subsequent
incapacity to produce semen, men
who wish to father children may be advised
concerning sperm-banking or retrieval.
Radiotherapy is effective and may be recommended
for patients who are not suitable
for surgery. Proctitis (inflammation of
the rectum) is, however, a common side
effect of conventional external beam therapy
(occurring severely in 3-5% of patients),
as is erectile dysfunction (6-84%) [11].
Alternatives include conformal radiotherapy
or brachytherapy. Locally advanced disease
is frequently managed by a combination
of endocrine therapy and radiotherapy,
while endocrine treatment is the mainstay
for metastatic disease. Such endocrine
treatment may comprise luteinizing hormone-releasing
hormone agonists, antiandrogens
or orchidectomy. The initial
choice of treatment is best done after
counselling the patient and with access to
a multidisciplinary team. Endocrine treatment
almost invariably achieves a remission
of the disease for a period, followed by
a relapse and the development of
endocrine unresponsive cancer. This type
of disease needs aggressive but compassionate
management, depending upon the
general health status of the patient. More
research is, however, essential to establish
specific optimal treatment for the individual
patient.
Stage and grade determine the outcome of
the disease in both localized and advanced
disease. The limiting factor to cure is the
presence of extraprostatic extension of the
disease, a frequent companion to surgical
treatment due to the uncertainty of detecting
extracapsular perforation before the
operation. The TNM staging system (Box:
TNM, p124) is universally recognized. The
differentiation or grade of the tumour is a
well-recognized dominant prognostic factor
that predicts the outcome of disease in all
stages and independently of the applied
therapy. The Gleason grade scoring system
is now widely accepted as a means to
assess the histological degree of differentiation.
Serum PSA values and tumour size
are valuable indicators; other promising
potential prognostic factors include
kallikreins, microvessel density, epidermal
growth factors and androgen receptors.
Tuning or integrating the different prognostic
factors into a nomogram, or an analysis
by artificial neural net system may provide
better probabilities for the individual
patient in the future [12].
Survival time after diagnosis is significantly
longer in high-risk countries (80% in the
USA compared to 40% in developing countries),
although this more favourable prognosis
could well be due to the greater numbers
of latent cancers being detected by
screening procedures in these countries.
CANCER OF THE TESTIS
Definition
The most common malignant tumours of
the testis (>90%) are germ cell tumours,
< 0.5 < 0.8 < 1.5 < 4.0
Age-standardized incidence/100,000 population
which are classified as seminoma or
nonseminoma. Less common testicular
tumours are Leydig cell tumours, Sertoli
tumours, rhabdomyosarcoma and, in the
elderly, non-Hodgkin lymphoma.
Epidemiology
Cancer of the testis accounts for 1.5 % of all
male cancers in most markedly affected
populations and about 0.5% elsewhere.
About 49,300 new cases are diagnosed
each year. A rapid increase in incidence has
been observed in most countries, such that
in some populations testicular cancer is the
most common malignancy among young
men at age 15-34. The reasons for this
trend are not well understood, although
improved diagnostic procedures may be
partially responsible. The highest incidence
is in Central Europe (Denmark, Norway and
Germany) and generally in Caucasian populations
of developed countries (Fig. 5.51). In
the USA and Western Europe, the lifetime
incidence of germ cell tumours is one in
500 or 15-20 per 100,000 males per
annum. Incidence is low in Africa and Asia,
including Japan, with only Israel having an
intermediate rate.
Cancer of the testis can occur at all ages,
risk being maximal during the third and
fourth decades of life and declining after
age 50; the median age at diagnosis for
testicular nonseminoma is 24 years and a
< 10.4
Fig. 5.51 Global incidence of testicular cancer. The highest rates are in affluent Caucasian populations.
Cancers of the male reproductive tract 211