Samir S. Taneja, MD, Consulting Editor

In the 1990s, during my residency training and early practice, I watched an enthusiastic groundswell behind the introduction of PSA, the transition from digital-guided biopsy to ultrasound-guided biopsy, and the description and refinement of the nerve-sparing radical prostatectomy. We strived to diagnose disease earlier and earlier because we believed we were advancing the disease further and further away from the horrible oncologic outcomes of the 1970s and 1980s.

In the 2000s, the focus turned to the side effects of therapy and its impact on quality of life, and slowly we began to question whether earlier diagnosis and treatment were really beneficial to our patients. Studies were completed that demonstrated modest reductions in mortality, but a substantial cost, measured in dollars and patient investment, associated with the process of diagnosing and curing the disease.

In part, our ability to be so critical of our own practice stemmed from the fact that we rarely now see men coming to us debilitated from the disease. With the memory of spinal cord compressions, bone pain, and surgical orchiectomy so far behind them, our colleagues from other specialties began to treat the disease as an innocuous entity.

As we entered the current decade, I believe we come in with tremendous confusion about how to approach prostate cancer. The medical establishment would advise we don’t look for the disease unless the patient is symptomatic. In this way, I am well trained. Having experienced the 1980s, I am very capable of recognizing the pain of advanced disease and managing symptoms without hope of cure. I think, we are not eager, as urologists, to return to that time.

We remain mindful that the disease continues to remain a killer of American men and has the potential to grow in its ability to kill if left unattended. We also recognize that the current one-size-fits-all paradigm of prostate cancer diagnosis followed by radical treatment is unacceptable because not every prostate cancer will kill, and because the secondary consequences of treatment are substantial. This approach is not sustainable. In my view, the decisions we make about prostate cancer detection in the near future are perhaps the most critical in determining the eventual fate of our patients, and of urology practice in general.

The ability to successfully treat patients with cancer as individuals, and to prescribe therapies of true benefit, has several a priori requisites. First, one must be able to contextualize the disease within the setting of an individual host. Learning to assess comorbidities and predict longevity is only part of this. The patient’s expectations and pre-existing urologic quality of life must be determined. Second, one must be able risk-stratify the disease and make effort to determine its lethality and its speed. In recent years, several methods of tumor assessment have emerged ranging from predictive biomarkers to noninvasive imaging to genetic assessment of tumor tissue. Finally, one must have a menu of efficacious treatment options that can be tailored to the patient and the tumor. In doing so, side effects can be accepted when necessary, but not imposed on all.

In this most important issue of Urologic Clinics , two of the most thoughtful opinion leaders in the field of prostate cancer, Drs Stacy Loeb and Matthew Cooperberg, have constructed a comprehensive overview of the current state of prostate cancer screening, detection, and molecular risk stratification. In doing so, they have offered insight into the tools available to construct future, individualized, approaches to the disease. Our guest editors have constructed a broad table of contents to include articles on the most relevant aspects of the prostate cancer controversy from some of our community’s most respected colleagues. The issue offers the reader a chance to be well versed in those approaches to disease detection and risk stratification most likely to be utilized in redefining the current approach to prostate cancer.

I am deeply indebted to Drs Loeb and Cooperberg for taking on this arduous task, and to each of the contributors for a job extremely well done. I sincerely hope that the readers will use this issue as a means of leaping forward into the next decade of prostate cancer management.