FR02-01\u2003WILLET F. WHITMORE JR: FOUR QUESTIONS AND THE NATURAL HISTORY OF PROSTATE CANCER

Abstract

INTRODUCTION AND OBJECTIVES: As the Father of Urologic Oncology, Dr. Willett F. Whitmore Jr presided over a dynamic period regarding the diagnosis and treatment of prostate cancer. His commitment to evidence based medicine is documented in many publications involving clinical research of prostate cancer, and was verified in his daily practice. Using a “Four Question” approach to the natural history of prostate cancer, he defined critical selection criteria for therapeutic intervention versus observation based on the likelihood of morbidity and mortality. We review his contributions, which created the foundation of the modern era of conservative management of prostate cancer. METHODS: A comprehensive literature review and internet search concerning Dr. Whitmore s observations and approach to prostate cancer management. RESULTS: One hundred years after the first description of prostate cancer and on the eve of the discovery of DNA in 1953, Dr. Whitmore described the natural history of prostate cancer. He noted that not all disease was clinically significant but hypothesized an “unknown activating power to release its malignant potential.” Three years later, he published on the role of hormone therapy in prostate cancer applying a novel alphabetical staging system, as well as considerations for patient age and life expectancy. This Whitmore staging system was later revised to include subclassifications yielding the Whitmore-Jewett staging system, the pre-eminent American staging system until TNM staging in 1992. In 1974, he published his observations, updated with the incorporation of tumor grading, on the variability of prostate cancer progression and mortality in Lancet. Despite clinical and research experience with androgen deprivation therapy, and the popularity of prostatic brachytherapy and nerve-sparing radical prostatectomy, he remained an advocate for active surveillance and watchful waiting. The era of the adoption of PSA screening and widespread use of ultrasound guided prostate biopsy was marked by a 3-fold increase in rates of radiation and prostatectomy for prostate cancer. Throughout this time, he continued to ask, “If cure is necessary, is it possible, and if cure is possible, is it necessary?” At the age of 74, he was diagnosed with prostate cancer and ultimately pursued a conservative management course, a final testament to his convictions regarding prostate cancer treatment, which are now the standard of care. CONCLUSIONS: Dr. Willett F. Whitmore Jr. was a progressive, evidence-based proponent of active surveillance in prostate cancer in an intervention driven era of aggressive management. Source of Funding: None