Diagnosis and Treatment by Clinical State The disease continuum—from the appearance of a preneoplastic and invasive lesion localized to the prostate, to a metastatic lesion that results in symptoms and, ultimately, mortality from prostate cancer—can span decades. Management at all points is centered on competing risks that are defined by considering the disease as a series of clinical states (Fig. 91-1). The states are defined operationally, on the basis of whether or not a cancer diagnosis has been established and, for those already diagnosed, whether or not metastases are detectable on imaging studies and the measured level of testosterone in. | Chapter 091. Benign and Malignant Diseases of the Prostate Part 2 Diagnosis and Treatment by Clinical State The disease continuum from the appearance of a preneoplastic and invasive lesion localized to the prostate to a metastatic lesion that results in symptoms and ultimately mortality from prostate cancer can span decades. Management at all points is centered on competing risks that are defined by considering the disease as a series of clinical states Fig. 91-1 . The states are defined operationally on the basis of whether or not a cancer diagnosis has been established and for those already diagnosed whether or not metastases are detectable on imaging studies and the measured level of testosterone in the blood. With this approach an individual resides in only one state and remains in that state until he has progressed. At each assessment the decision to offer treatment and the specific form of treatment is based on the risk posed by the cancer relative to competing causes of mortality that may be present in that individual. It follows that the more advanced the disease the greater the need for treatment. For those without a cancer diagnosis the decision to undergo testing to detect a cancer is based on the probability that a clinically significant cancer may be present. For those with a prostate cancer diagnosis the clinical state model considers the probability of developing symptoms or dying from disease. Thus a patient with localized prostate cancer who has had all cancer removed surgically remains in the state of localized disease as long as the PSA remains undetectable. The time within a state becomes a measure of the efficacy of an intervention though the effect may not be assessable for years. As many men with active cancer are not at risk for developing metastases symptoms or death the states model allows a distinction between cure the elimination of all cancer cells the primary therapeutic objective when treating most cancers and cancer control in which
