Clinically significant and non significant prostate cancer an ongoing question

One of the most important problems in urological practice is how to differentiate clinically significant and non significant prostate cancer (Pca) i.e. how to avoid over treatment of tumors with low malignant potential in one hand, and inappropriate less aggressive treatment of significant tumors, on the other hand. At the first place, one should estimate precise local clinical stage and the grade of the disease. Transrectal ultrasound--guided prostate biopsy id the golden standard, but there are few dilemmas concerning prostate biopsy: the number of biopsy cores, inter and intra-observer variations in the grading, the significance of PIN, multifocal character of Pca etc. Our opinion is that sextant or octan biopsy is quite sufficient for the exact detection of clinically insignificant cancers. An additional problem is the discrepancy in grade between biopsy and radical prosatectomy specimen. Second, the treatment should not be the same for every patient and it is guided by the age and general condition of the patient. The aggressive treatment is recommendable for younger patients, younger than 70-72 years, even for tiny area of cancer in one of the biopsy samples. On the other hand, it is an ethical question, should we insist on detection of small cancer foci at older patients, and make them anxious and unhappy in their last years of life.