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The practice of radical prostatectomy for treating prostate cancer has evolved remarkably since its general introduction around 1900. Initially described using a perineal approach, the procedure was later popularized using a retropubic one, after it was first described as such in 1948. The open surgical method has now largely been abandoned in favour of the minimally invasive robot-assisted method, which was first described in 2000. Until 1980, the procedure was hazardous, often accompanied by massive blood loss and poor outcomes. For patients in whom surgery is indicated, prostatectomy is increasingly being used as the first step in a multitherapeutic approach in advanced local, and even early metastatic, disease. However, contemporary molecular insights have enabled many men to safely avoid surgical intervention when the disease is phenotypically indolent and use of active surveillance programmes continues to expand worldwide. In 2020, surgery is not recommended in those men with low-grade, low-volume Gleason 6 prostate cancer; previously these men — a large cohort of ~40% of men with newly diagnosed prostate cancer — were offered surgery in large numbers, with little clinical benefit and considerable adverse effects. Radical prostatectomy is appropriate for men with intermediate-risk and high-risk disease (Gleason score 7–9 or Grade Groups 2–5) in whom radical prostatectomy prevents further metastatic seeding of potentially lethal clones of prostate cancer cells. Small series have suggested that it might be appropriate to offer radical prostatectomy to men presenting with small metastatic burden (nodal and or bone) as part of a multimodal therapeutic approach. Furthermore, surgical treatment of prostate cancer has been reported in cohorts of octogenarian men in good health with minimal comorbidities, when 20 years ago such men were rarely treated surgically even when diagnosed with localized high-risk disease. As medical therapies for prostate cancer continue to increase, the use of surgery might seem to be less relevant; however, the changing demographics of prostate cancer means that radical prostatectomy remains an important and useful option in many men, with a changing indication.In this Perspectives, a pioneer in the field of robotic radical prostatectomy describes the history of the technique and changing indications for its use, from an operation once considered useless, to one offered to almost all patients with low-risk disease, to a procedure that now has a role in advanced disease as part of a multimodal approach.

This essay draws attention to the prostate-specific antigen (PSA) discovery's lack of Nobel Prize acknowledgement despite its significance for prostate cancer (PCa) clinical practice. The Nobel Prize committee gives more weight to discoveries in basic research than to applications in medicine, which may account for PSA's lack of recognition. The prize has been dominated by the identification of cancer-causing viruses. Considering the subject from our -urologists- side, numerous pioneer researchers have uncovered PSA's presence and function, and its overuse in PCa screening has sparked debates about issues like overdiagnosis and overtreatment. We must concur that the factors contributing to PSA's underappreciation include the lack of a clear pioneer in its discovery and the contradictory opinions around its use. As a conclusion, PSA may have to wait for a better application before it receives recognition in the Nobel Prize.

The Gleason scoring system is widely used for the grading and prognostication of prostate cancer. A Gleason pattern 4 subtype known as cribriform morphology has now been recognized as an aggressive and often lethal pattern of prostate cancer. The vast majority of published and ongoing prostate cancer studies still do not acknowledge the prognostic differences between various Gleason pattern 4 morphologies. As a result, current treatment recommendations are likely to be imprecise and not tailored towards patients who are most likely to die from the disease. Use of active surveillance for patients with Gleason score 3 + 4 prostate cancer has been suggested. However, the success of such paradigms would require cribriform morphology to be reported at the time of prostate biopsy, as patients harbouring such a pattern are poor candidates for surveillance. To date, only a limited number of studies have described the molecular alterations that occur in the cribriform morphological pattern. Further refinement of prostate cancer grading paradigms to distinguish cribriform from noncribriform Gleason pattern 4 is essential.

BackgroundProspective evidence supports active surveillance/watchful waiting (AS/WW) as an efficacious management option for low-risk prostate cancer that avoids potential treatment toxicity. AS/WW schedules require regular follow-up and adherence, and it is unknown to what extent patient socioeconomic status (SES) may impact management decisions for AS/WW. We sought to determine whether AS/WW use in the United States differs according to patient SES.DesignUsing the Surveillance, Epidemiology, and End Results Prostate with AS/WW Database, all adult men diagnosed with localized low-risk prostate cancer (clinical T1–T2a, Gleason 6, and prostate-specific antigen <10 ng/mL) and managed with either AS/WW, radical prostatectomy, or radiotherapy were identified between 2010 and 2015. SES tertile was measured by the validated Yost Index (low: 0–10,901; middle: 10,904–11,469; high: 11,470–11,827). AS/WW trends were defined across SES tertiles from 2010 to 2015. Logistic multivariable regression defined adjusted odds ratios (aOR) for receipt of AS/WW by SES tertile.ResultsIn 50,302 men, AS/WW use was higher with increasing SES tertile (24.6, 25.3, and 30.5% for low, middle, and high SES tertiles, respectively; PTrend (SES) <0.001). From 2010 to 2015, AS/WW use in the low, middle, and high SES tertiles increased from 11.2 to 37.3%, 14.1 to 45.8%, and 17.6 to 46.4%, respectively (PTrends <0.001). By 2015, likelihood of AS/WW became comparable among the middle vs. high SES tertiles (aOR 0.96, 95% confidence interval (CI): 0.83–1.11, P = 0.55), but remained lower among the low vs. high SES tertile (aOR 0.73, 95% CI: 0.64–0.83, P < 0.001).ConclusionsAS/WW use for low-risk prostate cancer in the US differs by SES. Despite increases in AS/WW across SES from 2010 to 2015, patients from low SES received significantly lower rates of AS/WW compared with higher SES groups. SES may therefore influence management decisions, where factors associated with low SES might act as a barrier to AS/WW, and may need to be addressed to reduce any disproportionate risk of unnecessary treatment to lower SES patients.

Background Breast cancer in women and prostate cancer are the first and second leading tumour respectively in terms of incidence world-wide. Our objective is to ascertain the similarities and differences between mortality trends in breast cancer among women and prostate cancer in Spain using age-period-cohort models, and analyse the correlation between incidence of breast and prostate cancer at cancer registries locally and world-wide. Methods We analysed the independent effects of age, period of death and birth cohort on mortality rates for breast cancer in women and prostate cancer in Spain across the period 1952–2011. Segmented regression analyses were performed to detect and estimate changes in period and cohort curvatures. Correlation among age-adjusted incidence rates at 246 population cancer registries world-wide was analysed for the period 2003–2007. Results The mortality trend displayed common characteristics in terms of the annual number of deaths due to these tumours, their adjusted mortality rates and the change points detected in the cohort and period effects. The trend in incidence was very different to that in mortality, due to early detection and progressive improvement in survival. Correlation between the incidence rates of both tumours recorded by registries around the world proved to be a generalised phenomenon. Conclusions This study shows that breast cancer mortality in women and prostate cancer mortality and their trends in Spain display visible similarities in terms of the number of deaths due to these tumours, their adjusted mortality rates and the changes experienced by mortality over time. The effects of advances in the diagnosis of both tumours correspond to a decline in mortality which becomes evident after a lag of approximately eight years. Correlation between breast and prostate cancer incidence rates is very high in Spain and at registries on all continents.

The increased incidence of prostate cancer has led to remarkable changes in diagnosis and treatment over the past century. What were the first ways in which prostate cancer was treated, and how did these evolve into the variety of therapeutic strategies from which patients have to choose today?

The Bowery series, open perineal biopsies performed on more than 1200 alcoholic men recruited from homeless shelters in New York City’s Bowery section, began in 1951 and persisted for more than a decade. If frozen sections revealed prostate cancer, men typically underwent radical perineal prostatectomy, orchiectomy, and diethylstilbestrol treatment. This poorly informed, vulnerable population was subjected to health risks that investigators knew others would not accept. Although the knowledge produced had little impact on practice, the Bowery practices foreshadowed and have troubling continuities with later developments. Currently, more than a million American men each year undergo prostatic biopsies. But the efficacy of prostate-specific antigen screening and the treatment that typically follows has never been established. The Bowery series and subsequent developments are part of one continuous story of how medical and lay people came to believe in the efficacy of population screening followed by aggressive treatment without solid supporting scientific evidence.

Background The aetiology of urological cancers is poorly understood and variations in incidence by ethnic group may provide insights into the relative importance of genetic and environmental risk factors. Our objective was to compare the incidence of four urological cancers (kidney, bladder, prostate and testicular) among six ‘ non-White ’ ethnic groups in England (Indian, Pakistani, Bangladeshi, Black African, Black Caribbean and Chinese) to each other and to Whites. Methods We obtained Information on ethnicity for all urological cancer registrations from 2001 to 2007 (n = 329,524) by linkage to the Hospital Episodes Statistics database. We calculated incidence rate ratios adjusted for age, sex and income, comparing the six ethnic groups (and combined ‘ South Asian ’ and ‘ Black ’ groups) to Whites and to each other. Results There were significant differences in the incidence of all four cancers between the ethnic groups (all p < 0.001). In general, ‘non-White’ groups had a lower incidence of urological cancers compared to Whites, except prostate cancer, which displayed a higher incidence in Blacks. (IRR 2.55) There was strong evidence of differences in risk between Indians, Pakistanis and Bangladeshis for kidney, bladder and prostate cancer (p < 0.001), and between Black Africans and Black Caribbeans for all four cancers (p < 0.001). Conclusions The risk of urological cancers in England varies greatly by ethnicity, including within groups that have traditionally been analysed together (South Asians and Blacks). In general, these differences are not readily explained by known risk factors, although the very high incidence of prostate cancer in both black Africans and Caribbeans suggests increased genetic susceptibility. g.