DOI: 10.1097/COC.0b013e318185fa10
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PMID: 19346819
Issn Print: 0277-3732
Publication Date: 2009/04/01
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Excerpt
Would that strategy be suitable for his elevated blood pressure? Should antihypertensive medications be withheld until the appearance of retinopathy? Such an approach was considered appropriate 50 years ago. Although the relationship between hypertension and cardiovascular disease had been posited early in the 20th century,2 ambivalence regarding intervention persisted until relatively recently. Hypertension was classified as either “malignant” (associated with renal failure and cerebral hemorrhage; think FDR) or “benign” (asymptomatic; typically with diastolic reading of <110). Based on uncontrolled retrospective studies, it was concluded that “benign” hypertension resulted in little, if any, reduction in quality or length of life.3–5 It was deemed “essential,” reflecting its idiopathic origin and inherency to the subject's homeostasis; indeed, it was suspected that moderate hypertension was “essential” for perfusion of ischemic organs, and that attempts to lower it were misguided. Physicians were advised that even monitoring blood pressure would engender neurosis3,4,6 (actuaries, however, were not persuaded; they set higher life insurance premiums for applicants with even modest blood pressure elevations). Passivity was reasonable when evidence of morbidity was lacking, especially as the available antihypertensive agents were marginally beneficial. But, resistance to intervention persisted even after the relationship of hypertension to ischemic heart disease was confirmed,7 effective medications were introduced, and the benefit of therapy demonstrated.8 Concern was expressed that treatment was detrimental to quality-of-life (resulting in urinary and sexual dysfunction) and that the detection and management of hypertension would impose an unmanageable burden upon the medical system.9 As recently as 1977, the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC) suggested that therapy for mild-to-moderate hypertension may not be indicated for patients older than 50.10 Indeed, reluctance to treat elderly hypertensives continued into the 1990s, when it was demonstrated that geriatric patients benefited equally from therapy.11
Has low- and moderately-differentiated prostate cancer become our generation's “benign essential” malady? The parallels are compelling. Despite a randomized study demonstrating improved survival from immediate therapy with curative intent,12 the notion persists that surveillance is an appropriate option for a young man with prostate cancer. Despite several large studies suggesting a 30%–60% reduction in mortality among screened populations,13–15 there remains ambivalence toward prostate-specific antigen (PSA) screening.16
The perception of prostate cancer has changed dramatically over the last 100 years. It was considered all but incurable for much of the 20th century.17 Prior to effective screening, fewer than 5% of newly diagnosed cases were organ-confined; Hugh Young, the originator of the radical prostatectomy, barely saw a single operable case annually.18 Leading urologists (Young,19 Barringer,20 Flocks,21 Carlton,22 and Whitmore23) developed brachytherapy as an intervention for the majority of their patients, for whom surgery was futile.
How did this once-feared malignancy become the “Rodney Dangerfield” of oncology? In 1941, Huggins demonstrated that even metastatic disease responded to castration.24 Autopsy studies revealed that subclinical cancer is ubiquitous, suggesting that the large majority of cases pursue an indolent course.25,26 Several retrospective studies demonstrated that most men with untreated prostate cancer apparently fared well (died of unrelated causes). Taken together, these developments resulted in a new paradigm: Neoplasia is an inherent (“essential”?), generally indolent condition of the aging prostate, for which intervention is unnecessary.
