Effective prevention, diagnosis and management of prostate problems are often hampered by the perception that they are the inevitable consequences of aging and the misconception that little can be done for the affected men and their respective prostate problems. It is clear that there is a need for far greater education among men and their care-giving physicians to increase their knowledge not only about the prostate but also about prostate health in order to encourage men to consult with their physicians, thus improving screening and disease prevention, facilitating early diagnosis and allowing the appropriate treatment of prostate diseases and improving men's health in general.
Based on the latest cancer statistics in the United Kingdom, the European Union, and the United States, White et al [1] argue that services should target men more effectively. Statistically the increased risk is compounded by the possibility that men delay seeking both preventive health care services and early appointments following onset of symptoms. The burden of death from cancer could probably be reduced with heightened surveillance and more rapid access to health care. Men have a nearly threefold higher rate of death from bladder cancer and a twofold higher rate of death from kidney cancer than women [2]. This trend extends beyond the urogical cancers to the majority of cancers that should affect men and women equally.
Prostate cancer is the most common non-cutaneous cancer in men and the second most common form of cancer death. Marberger [3] in this issue of jmh provides a state-of-the-art review on managing benign prostatic hyperplasia (BPH) and prostate cancer, stressing the vital role the primary care physician should play. He points out that many men who reach average life expectancy will experience BPH or prostate cancer at some stage in their life and these conditions account for a considerable amount of ill-health and distress for men and their, often neglected, partners. The goal for any cancer should be to understand an individual patient's risk of developing the disease and to detect the cancer while it is still localized and treatable. Thus, Marberger rightly points out, and stresses, that the first to encounter patients with symptoms or risk factors for these conditions, the primary care physician, is in an unique position to provide counseling and intervention which can make a significant contribution towards achieving these goals.
One of the foremost challenges for primary care physicians is, therefore, to achieve an accurate assessment of an individual man's risk of prostate cancer and to ensure referral to secondary care if necessary. Since early prostate cancer is very rarely symptomatic it can only be detected by active investigation including digital rectal examination (DRE) and prostate-specific antigen (PSA) level, both associated with certain limitations. The newest, and the most methodologically sound, study of PSA-based screening for prostate cancer, the ERSPC trial, demonstrated a significant improvement in mortality using a PSA cut-off value of 3–4
ng/ml with a high risk of over-diagnosis [4]. It is recommended that patients be fully informed of the risks and limitations of the test before making their own choice, thus again making it evident that greater and better education of the public, as for instance in the case of breast cancer and the use of mammography, is desperately needed.
For those patients in whom prostate cancer has been ruled out, Marberger suggests that the primary care physician has a responsibility to choose the most appropriate treatment option for benign prostatic disease by knowing and understanding the burden of the disease and, furthermore, its impact on the patient's quality of life and that of his family. Marberger provides, in his excellent review, a very practical treatment algorithm. More than ever, prostate decision aids could help to increase knowledge, on the patient's side, about his condition as well as its treatment, and this should result in increased satisfaction for the patient with the decision-making on treatment options.
We believe that raising awareness of prostate health and prostate disease will empower and motivate men to consult their physician and it will also be a promoter and catalyst for detecting many other existing or even underlying conditions and co-morbidities. The most important goals are to empower men to finally manage their own health and to talk about their worries regarding their health.
The data from Sharpley et al [5] from Australia on the incidence and nature of anxiety–depression co-morbidity in prostate cancer provide some evidence that patients have a higher incidence during treatment procedures and the following period than has been previously suggested.
The authors stress that anxiety and depression can impair prostate cancer patients’ decision-making abilities, and early identification of the presence of these affective disorders is a necessary aspect of a complete treatment protocol for prostate cancer. Their data suggest that 1 in 6 prostate cancer patients might be expected to have clinically and personally relevant anxiety and depression. If these data are confirmed not only future protocols but also the clinical treatment of men with prostate cancer will have to be reevaluated.
Men's lower life expectancy may be explained in part by clinical factors such as the higher incidence of cardiovascular disease and cancer. In the context of public health, raising awareness of prostate health, and further consideration of preventive and early detection/intervention programs could be a new and effective way to reduce premature death and improve men's health.
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