For men who have a limited life expectancy (less than ten years) either due to advanced age at diagnosis (typically greater than age 75) or significant co-morbidity, are therefore not candidates for treatment of localized prostate cancer with intent to cure. For patients who have mild co-morbidities and life expectancy greater than ten years, the risks and benefits of treatment should be balanced and the patient informed of his options including watchful waiting, radiation, and surgery. For men who have no significant co-morbidities, are young, and have a greater than 10- to 15-year life expectancy, all available data suggest that treatment is likely to be effective. Watchful waiting to determine if a cancer will progress is limited by the sensitivity of digital-rectal exam to detect cancer growth and the uncertain nature of PSA changes as patients have local cancer progression.

Despite its epidemic proportion of incidence, prostate cancer treatment still generates controversy. Prostate cancer treatment is associated with some degree of morbidity, may be applied to patients who have micrometastatic disease, and many patients at the time of diagnosis will have local disease that cannot be cured. Until 10- to 15-year data are available from early detection (PLCO) or treatment (PIVOT) studies for localized cancer, we will not have definitive information as to whether aggressive or conservative treatment should be provided for men with localized prostate cancer. However, the vast majority of prostate cancers that are detected as localized disease at this point are clinically important (Gardner et al., 1998). Slow but inevitable progression of clinically detected localized cancer occurs without treatment. Surgical treatment appears to be quite effective if cancers are detected early.