Recentemente, pesquisas vêm claramente demonstrando que xenobióticos podem apresentar efeitos deletérios sobre o sistema endócrino e passam a ser de grande importância toxicológica à medida que se tornam contaminantes ambientais. Tais substâncias passaram a ser denominadas de desreguladores endócrinos (DEs). Entre os diferentes DEs identificados, muitos são praguicidas, amplamente utilizados no meio agropecuário em todo o mundo. Atualmente, já são bem estabelecidas as metodologias para avaliação do potencial efeito DE de diferentes substâncias em roedores; porém uma busca na literatura deixa clara a falta de estudos e de protocolos para avaliação de DEs em animais de produção ruminantes, os quais certamente estão expostos a um grande número de agentes tóxicos com estas características. Assim, foi objetivo desta pesquisa dar início ao desenvolvimento de um protocolo para avaliação de efeitos DEs de xenobióticos em ruminantes. Para tal, estudou-se o bisfenol A (BPA), o qual é, classicamente, um DE para roedores. Além disto, avaliou-se o potencial efeito DE da I. carnea, uma planta tóxica de grande importância para ruminantes no Brasil e em outros países. O estudo foi realizado em duas etapas, na primeira avaliou-se os efeitos do BPA e da planta nos caprinos machos púberes; na segunda etapa propôs-se avaliar os efeitos tóxicos da exposição in utero de caprinos machos púberes a estas mesmas substâncias. Os resultados obtidos mostraram que os bodes púberes expostos ao BPA apresentaram redução significante dos níveis séricos de tiroxina, e da qualidade espermática. Também observou-se nestes mesmos animais degeneração vacuolar na rete testis. Já os caprinos machos púberes que receberam a I. carnea apresentaram aumento significante do numero de espermatozoides com alterações morfológicas e degeneração vacuolar testicular. Ainda, estes mesmos animais apresentaram diminuição estatisticamente significante dos níveis séricos dos hormônios tireoidianos (T3 e T4). O protocolo empregado para avaliação dos efeitos da exposição in utero a I. carnea ou ao BPA em machos púberes, não evidenciou nenhuma alteração hormonal e/ou reprodutiva. Conclui-se que o protocolo empregado para avaliação de possíveis efeitos DEs de xenobióticos, em ruminantes foi eficaz, no entanto, futuras metodologias deverão ser introduzidas neste protocolo, para detectar alterações mais sutis no sistema endócrino. / Recently, many studies clearly showed that xenobiotics may have deleterious effects on the endocrine system. These substances are termed endocrine disruptors (EDs), and have great toxicological significance when they become environmental contaminants. Many of EDs are identified as pesticides, which were widely used in agriculture and livestock worldwide. Currently, there are already well-established methodologies for assessing the potential effect of endocrine disruptor (ED) of different substances in rodents; however, a literature search shows clearly the lack of studies and protocols for assessing EDs in ruminant livestock, which are indubitably exposed to a large number of these substances. Thus, the objective of the present research was to start developing a protocol for evaluation of possible effects of EDs in ruminants. For this, it was studied bisphenol A (BPA), a classic ED and also I. carnea, an important toxic plant to ruminants in Brazil and other countries. The study was conducted in two stages, in the first, it was evaluated the effects of BPA and I. carnea in pubescent male goats, and in the second stage it was studied the effects in pubescent male goats from mothers exposed, during pregnancy, to BPA or the toxic plant. The pubescent male goats treated with BPA showed significant reduction in serum thyroxine levels and in the sperm quality. Those animals also presented vacuolar degeneration in the rete testis. Pubescent male goats exposed to I. carnea showed many alterations: significant increase in morphological changes in the sperm, decrease in serum levels of thyroid hormones (T3 and T4) and testicular vacuolar degeneration. The used protocol for evaluation of the effects of in utero exposure to BPA or I. carnea in pubescent male goats showed no hormonal or reproductive changes in male goats evaluated at the puberty. In conclusion, the protocol used in the present study showed to be worthy to evaluate EDs effects in ruminants; however future methodologies should be introduced to detect more subtle changes in the endocrine system.

Recentemente, pesquisas vêm claramente demonstrando que xenobióticos podem apresentar efeitos deletérios sobre o sistema endócrino e passam a ser de grande importância toxicológica à medida que se tornam contaminantes ambientais. Tais substâncias passaram a ser denominadas de desreguladores endócrinos (DEs). Entre os diferentes DEs identificados, muitos são praguicidas, amplamente utilizados no meio agropecuário em todo o mundo. Atualmente, já são bem estabelecidas as metodologias para avaliação do potencial efeito DE de diferentes substâncias em roedores; porém uma busca na literatura deixa clara a falta de estudos e de protocolos para avaliação de DEs em animais de produção ruminantes, os quais certamente estão expostos a um grande número de agentes tóxicos com estas características. Assim, foi objetivo desta pesquisa dar início ao desenvolvimento de um protocolo para avaliação de efeitos DEs de xenobióticos em ruminantes. Para tal, estudou-se o bisfenol A (BPA), o qual é, classicamente, um DE para roedores. Além disto, avaliou-se o potencial efeito DE da I. carnea, uma planta tóxica de grande importância para ruminantes no Brasil e em outros países. O estudo foi realizado em duas etapas, na primeira avaliou-se os efeitos do BPA e da planta nos caprinos machos púberes; na segunda etapa propôs-se avaliar os efeitos tóxicos da exposição in utero de caprinos machos púberes a estas mesmas substâncias. Os resultados obtidos mostraram que os bodes púberes expostos ao BPA apresentaram redução significante dos níveis séricos de tiroxina, e da qualidade espermática. Também observou-se nestes mesmos animais degeneração vacuolar na rete testis. Já os caprinos machos púberes que receberam a I. carnea apresentaram aumento significante do numero de espermatozoides com alterações morfológicas e degeneração vacuolar testicular. Ainda, estes mesmos animais apresentaram diminuição estatisticamente significante dos níveis séricos dos hormônios tireoidianos (T3 e T4). O protocolo empregado para avaliação dos efeitos da exposição in utero a I. carnea ou ao BPA em machos púberes, não evidenciou nenhuma alteração hormonal e/ou reprodutiva. Conclui-se que o protocolo empregado para avaliação de possíveis efeitos DEs de xenobióticos, em ruminantes foi eficaz, no entanto, futuras metodologias deverão ser introduzidas neste protocolo, para detectar alterações mais sutis no sistema endócrino. / Recently, many studies clearly showed that xenobiotics may have deleterious effects on the endocrine system. These substances are termed endocrine disruptors (EDs), and have great toxicological significance when they become environmental contaminants. Many of EDs are identified as pesticides, which were widely used in agriculture and livestock worldwide. Currently, there are already well-established methodologies for assessing the potential effect of endocrine disruptor (ED) of different substances in rodents; however, a literature search shows clearly the lack of studies and protocols for assessing EDs in ruminant livestock, which are indubitably exposed to a large number of these substances. Thus, the objective of the present research was to start developing a protocol for evaluation of possible effects of EDs in ruminants. For this, it was studied bisphenol A (BPA), a classic ED and also I. carnea, an important toxic plant to ruminants in Brazil and other countries. The study was conducted in two stages, in the first, it was evaluated the effects of BPA and I. carnea in pubescent male goats, and in the second stage it was studied the effects in pubescent male goats from mothers exposed, during pregnancy, to BPA or the toxic plant. The pubescent male goats treated with BPA showed significant reduction in serum thyroxine levels and in the sperm quality. Those animals also presented vacuolar degeneration in the rete testis. Pubescent male goats exposed to I. carnea showed many alterations: significant increase in morphological changes in the sperm, decrease in serum levels of thyroid hormones (T3 and T4) and testicular vacuolar degeneration. The used protocol for evaluation of the effects of in utero exposure to BPA or I. carnea in pubescent male goats showed no hormonal or reproductive changes in male goats evaluated at the puberty. In conclusion, the protocol used in the present study showed to be worthy to evaluate EDs effects in ruminants; however future methodologies should be introduced to detect more subtle changes in the endocrine system.

Background. Angiogenesis is essential for tumour growth. Vascular endothelial growth factor (VEGF) and its isoforms were investigated in relation to the clinical course in a large number of patients with renal cell carcinoma (RCC). Methods. RCC subtypes and behaviour were established by clinicopathological criteria and surveillance. VEGF expression was analysed in serum by enzyme-linked immuno-sorbent assay (ELISA) and in tumour tissue by reverse transcription polymerase chain reaction (RT-PCR), immunohistochemistry (IHC), and Western blot (WB). Results. Serum VEGF (S-VEGF) was increased in RCC compared to control group. S-VEGF correlated with tumour stage and grade and was associated with survival in men but not in women. S-VEGF correlated with blood platelet counts, which were inversely correlated to increasing age in women, and they were decreased in chronically medicated patients, particularly in men. In contrast to S-VEGF, platelet counts associated with survival only in patients free of medication and chronic diseases. RT-PCR showed a correlation between VEGF121/VEGF165 mRNA and between VEGF165/VEGF-R1 mRNA. There was no association between different VEGF mRNA isoforms and S-VEGF. Conventional renal cell carcinoma (CRCC) had higher VEGF165, VEGF121, and VEGF-R1 mRNA levels compared with papillary renal cell carcinoma (PRCC). IHC VEGF staining was strong in kidney cortex. Kidney tumour showed a considerable variation in cytoplasmatic VEGF expression, which correlated with tumour size. Although, there was no difference in VEGF expression between the RCC types, VEGF expression was associated with survival only in CRCC. WB showed a strong protein expression of both VEGF189 and VEGF165 in kidney cortex. In kidney tumour, expression of VEGF189 varied the most, VEGF165 less so, and VEGF121 was rarely detected. Both CRCC and PRCC expressed low levels of VEGF189 and VEGF165 compared with kidney cortex. Chromophobe renal cell carcinoma (ChRCC) expressed VEGF189 levels comparable to those from kidney cortex, while VEGF165 was lower. In PRCC and ChRCC, VEGF189 levels correlated inversely with advancing tumour stage, and in PRCC, VEGF165 levels correlated inversely with increasing tumour size. VEGF189 was an independent prognostic factor for survival in patients with PRCC. Conclusions. S-VEGF has a stronger association to progression in RCC than platelet count. CRCC showed high levels of VEGF mRNA isoforms and VEGF-R1 mRNA compared to PRCC. VEGF mRNA isoforms expression decreased with advancing stage. IHC demonstrated VEGF expression in cell cytoplasm related to tumour growth, particular in CRCC. Different VEGF isoform patterns were found in different RCC types. Protein VEGF189 expression was associated with tumour stage and was an independent prognostic factor in PRCC. Protein VEGF165 expression was generally low and had no prognostic value. The trend for decreasing levels of VEGF isoforms in advanced tumour stages may indicate that angiogenic activity is an early event in tumour growth induced by VEGF, but that during later tumour progression the role of VEGF is less clear.

<p>This thesis deals with problem solving of general practitioners (GPs), which is explored with different methods and from different perspectives. The general aim was to explore and describe rules of thumb and to analyse the management of respiratory and urinary tract infections (RTI and UTI) in general practice in Sweden. The results are based upon focus group interviews concerning rules of thumb and a prospective diagnosis-prescription study concerning the management of patients allocated a diagnosis of RTI or UTI. In addition unpublished data are given from structured telephone interviews concerning specific rules of thumb in acute sinusitis and prevailing cough.</p><p>GPs were able to verbalize their rules of thumb, which could be called tacit knowledge. A specific set of rules of thumb was used for rapid assessment when emergency and psychosocial problems were identified. Somatic problems seemed to be the expected, normal state. In the further consultation the rules of thumb seemed to be used in an act of balance between the individual and the general perspective. There was considerable variation between the rules of thumb of different GPs for patients with acute sinusitis and prevailing cough. In their rules of thumb the GPs seemed to integrate their medical knowledge and practical experience of the consultation. A high number of near-patient antigen tests to probe Streptococcus pyogenes (Strep A tests) and C-reactive protein (CRP) tests were performed in patients, where testing was not recommended. There was only a slight decrease in antibiotic prescribing in patients allocated a diagnosis of RTI examined with CRP in comparison with patients not tested. In general, the GPs in Sweden adhered to current guidelines for antibiotic prescribing. Phenoxymethylpenicillin (PcV) was the preferred antibiotic for most patients allocated a diagnosis of respiratory tract infection.</p><p>In conclusion, the use of rules of thumb might explain why current practices prevail in spite of educational efforts. One way to change practice could be to identify and evaluate rules of thumb used by GPs and disseminate well adapted rules. The use of diagnostic tests in patients with infectious illnesses in general practice needs critical appraisal before introduction as well as continuing surveillance. The use of rules of thumb by GPs might be one explanation for variation in practice and irrational prescribing of antibiotics in patients with infectious conditions.</p> / On the day of the public defence the status of the articles IV and V was: Accepted.

<p>The natural history of localized prostate cancer is not fully understood. In most patients the tumor will never progress to a lethal disease, while a subset of patients will ultimately die of the disease. Efficient tools to separate indolent from lethal disease is currently lacking which means that many patients will be offered treatment without any benefit, but still be at risk of experiencing treatment related side effects.</p><p>The aims of these studies were to get more insight into the natural history of untreated localized prostate cancer, to assess the prognostic value of established clinical parameters such as Gleason score, nuclear grade and tumor volume and, moreover, some new prognostic markers Ki-67, AMACR and MUC-1. We also aimed to study time trends in the detection of incidental tumors in Sweden.</p><p>Patients with localized disease (n=223) and no initial treatment were followed for 21 years. Most patients had a favorable outcome. However, a subset of patients developed lethal disease even beyond 15 years of follow-up and these patients define the group that may benefit most from treatment with curative intent. Patients with poorly differentiated tumors experienced a 9 time higher risk of dying in prostate cancer.</p><p>The studies on prognostic markers are based on a cohort of patients (n=253) with incidental prostate cancer detected by transurethral resection for presumed benign hyperplasia. All patients were left without initial treatment. Gleason grade, nuclear grade and tumor volume turned all out to be independent prognostic factors. MUC-1, AMACR and Ki-67 also carried prognostic information. However, after adjustment for Gleason grade, nuclear grade and tumor volume only MUC-1 and AMACR remained as statistically significant prognostic factors. When tested for sensitivity and specificity they all failed and, consequently, they seem to be of less value in daily practice for cancelling an individual patient regarding the choice of treatment.</p><p>Time trends in incidental prostate tumors in Sweden were analyzed in a cohort of patients with prostate tumors detected by transurethral resection (TUR-P). Through linkage of the national registration number (NRN) with several registers, e.g. the Swedish Cancer Registry, the National Inpatient registry and the Cause of Death Registry we identified, during the period 1970 through 2003, in total 23288 patients with incidental prostate cancer, who constituted the study group. As comparison group we choose all patients diagnosed with prostate cancer between 1970-2003 excluding those with incidental cancer, in total 112204 patients. Our result confirms earlier findings that there has been a dramatic change over time in incidence of incidental prostate cancers in Sweden, which parallels the introduction of prostate specific antigen. We also found that the cumulative incidence of prostate cancer death is high in the incidental group, opposing earlier findings that incidental tumours are a non-lethal disease.</p> / issn 1642-4063

This thesis deals with problem solving of general practitioners (GPs), which is explored with different methods and from different perspectives. The general aim was to explore and describe rules of thumb and to analyse the management of respiratory and urinary tract infections (RTI and UTI) in general practice in Sweden. The results are based upon focus group interviews concerning rules of thumb and a prospective diagnosis-prescription study concerning the management of patients allocated a diagnosis of RTI or UTI. In addition unpublished data are given from structured telephone interviews concerning specific rules of thumb in acute sinusitis and prevailing cough. GPs were able to verbalize their rules of thumb, which could be called tacit knowledge. A specific set of rules of thumb was used for rapid assessment when emergency and psychosocial problems were identified. Somatic problems seemed to be the expected, normal state. In the further consultation the rules of thumb seemed to be used in an act of balance between the individual and the general perspective. There was considerable variation between the rules of thumb of different GPs for patients with acute sinusitis and prevailing cough. In their rules of thumb the GPs seemed to integrate their medical knowledge and practical experience of the consultation. A high number of near-patient antigen tests to probe Streptococcus pyogenes (Strep A tests) and C-reactive protein (CRP) tests were performed in patients, where testing was not recommended. There was only a slight decrease in antibiotic prescribing in patients allocated a diagnosis of RTI examined with CRP in comparison with patients not tested. In general, the GPs in Sweden adhered to current guidelines for antibiotic prescribing. Phenoxymethylpenicillin (PcV) was the preferred antibiotic for most patients allocated a diagnosis of respiratory tract infection. In conclusion, the use of rules of thumb might explain why current practices prevail in spite of educational efforts. One way to change practice could be to identify and evaluate rules of thumb used by GPs and disseminate well adapted rules. The use of diagnostic tests in patients with infectious illnesses in general practice needs critical appraisal before introduction as well as continuing surveillance. The use of rules of thumb by GPs might be one explanation for variation in practice and irrational prescribing of antibiotics in patients with infectious conditions. / On the day of the public defence the status of the articles IV and V was: Accepted.

Hypoxia Inducible Factor-1α in Renal Cell Carcinoma Departments of Surgical and Perioperative Sciences, Urology and Andrology; Radiation Sciences, Oncology; Medical Biosciences, Pathology; and Medical Biosciences, Clinical Chemistry, Umeå University, Umeå, Sweden Background: Renal cell carcinoma (RCC) accounts for approximately 2-3% of all human cancers. A distinguished feature of RCC is vascularisation and among the three dominating RCC types conventional RCC (cRCC) generally is more vascularised than papillary RCC (pRCC) and chromophobe RCC (chRCC). Angiogenesis is a critical step in tumour progression controlled by a balance involving molecules that have positive and negative regulatory activity. A balance distorted by metabolic stress such as hypoxia, acidosis, and inflammation. Hypoxia-Inducible Factor 1α (HIF-1α) is a key transcription factor in angiogenesis and tumour progression, targeting more than a 100 genes involved in vascular growth and regulation, iron metabolism and erythropoesis, collagen matrix formation, regulation of extracellular pH, glucose uptake and metabolism, proliferation, apoptosis, differentiation, and cell viability. Methods: Tumour tissue and corresponding kidney cortex from nephrectomised RCC patients was used in order to characterize HIF-1α expression and one of its target genes, Glucose Transporter 1 (GLUT-1). All tumour samples were thoroughly described regarding tumour type, TNM stage, nuclear grade, tumour size, vein invasion, and patient survival. Utilizing RT-PCR, Westen Blot and Tissue micro array (TMA) we studied HIF-1α mRNA and protein expression as well as GLUT-1 protein expression, correlating them to each other and clinicopathological parameters. Results: Using Western Blot, HIF-1α protein expression differed significantly between the different RCC types and kidney cortex. In cRCC, high expression of HIF-1α was an independent prognostic factor for favourable prognosis. TMA is a useful method to analyze HIF-1α protein expression in RCC. HIF-1α levels were significantly lower in locally aggressive cRCC and patients with high levels of HIF-1 tended to have a better prognosis. GLUT-1 levels were higher in cRCC than in other RCC types and for cRCC a correlation to HIF-1α was seen. HIF-1α mRNA levels were significantly lower in cRCC compared to other RCC types and kidney cortex. An inverse correlation between HIF-1α protein expression and mRNA levels was observed. Summary: These results demonstrate a discrepancy between RCC types, highlighting the need to separately evaluate biological events in different RCC types. Overexpression of HIF-1α protein is not necessarily all bad and translational regulation appears more critical than anticipated. Further studies are encouraged to clarify angiogenic pathways in RCC.

Background: Renal cell carcinoma (RCC) is most lethal of the urological cancers, with more than 40% dying of the disease. About 30% of the patients have metastases at initial diagnosis and up to 40% undergoing nephrectomy for localized RCC develop metastasis. A follow-up protocol based on accurate prognostic variables allows identification of low and high risk patients and selection of those most likely to benefit from adjuvant therapy. I have studied a number of prognostic patient-related factors, including tumour stage and grade, angiogenetic factors and tumour markers, in order to improve follow-up guideline as well as to try to predict prognosis and clinical outcome for individual patients. Material and Methods: The studies are based on patients treated for RCC between 1982 and 2002. All patients eligible for surgery with or without metastasis were treated with nephrectomy and were followed according to a scheduled follow-up programme. Serum samples were collected after obtained informed consent. Multiple clinicopathological, laboratory variables and preoperative radiological examinations were analyzed. Results: Study I- After nephrectomy in 187 patients with non-metastatic RCC, 30% developed metastases during the follow-up. The risk for metastases was greater for more advanced stage and was adjusted by size and DNA ploidy. The median time to the diagnosis of metastases was 14.5 months. Metastases occurred in 43% of the patients within one year, within 2 years in 70% and 80% in 3 years. Patients with tumours less than 5 cm and diploid pT1&gt;5cm and pT2 tumours survived longer than those with larger and aneuploid tumours. The 5-years survival rate for pT1, pT2, pT3 tumours were 95%, 87%, and 37% respectively. In pT3 tumours DNA ploidy had no relation to survival time. Study II and IV- The median survival time for patients with metastatic RCC was 7 months. Cytoreductive nephrectomy was associated with longer survival time. Factors including performance status (PS), number of metastatic sites, erythrocyte sedimentation rate (ESR), calcium in serum, vein invasion, capsule invasion had independent prognostic value with Cox multivariate analysis. Study III- The incidence of adrenal tumour involvement was 5.3 %, unaffected of RCC type, tumour location or side. Gender (male) and locally advanced tumours (pT3 &gt; 5cm) were factors predicting adrenal involvement. The presence of adrenal involvement was a significant adverse prognostic variable, indicating a significantly shorter survival in patients both with and without distant metastases. Conclusion: Optimal follow-up guidelines are important from both medical and economic perspectives. The risk for progression depends mainly on stage, which in combination with other prognostic factors may allow more individualized and cost effective follow-up, in some cases by avoiding unnecessary examinations in a third of the patients. Cytoreductive nephrectomy in patients with good PS, metastases limited to one organ, low ESR, normal calcium and no vein invasion were factors associated to long survival time. Soluble angiogenic factors in serum gave no prognostic information. Ipsilateral adrenalectomy in conjunction with radical nephrectomy should be performed if an adrenal lesion cannot be cleared of suspicion during preoperative work up. Ipsilateral adrenal involvement is a highly adverse prognostic factor and should be staged as M1a in the TNM staging system.

The natural history of localized prostate cancer is not fully understood. In most patients the tumor will never progress to a lethal disease, while a subset of patients will ultimately die of the disease. Efficient tools to separate indolent from lethal disease is currently lacking which means that many patients will be offered treatment without any benefit, but still be at risk of experiencing treatment related side effects. The aims of these studies were to get more insight into the natural history of untreated localized prostate cancer, to assess the prognostic value of established clinical parameters such as Gleason score, nuclear grade and tumor volume and, moreover, some new prognostic markers Ki-67, AMACR and MUC-1. We also aimed to study time trends in the detection of incidental tumors in Sweden. Patients with localized disease (n=223) and no initial treatment were followed for 21 years. Most patients had a favorable outcome. However, a subset of patients developed lethal disease even beyond 15 years of follow-up and these patients define the group that may benefit most from treatment with curative intent. Patients with poorly differentiated tumors experienced a 9 time higher risk of dying in prostate cancer. The studies on prognostic markers are based on a cohort of patients (n=253) with incidental prostate cancer detected by transurethral resection for presumed benign hyperplasia. All patients were left without initial treatment. Gleason grade, nuclear grade and tumor volume turned all out to be independent prognostic factors. MUC-1, AMACR and Ki-67 also carried prognostic information. However, after adjustment for Gleason grade, nuclear grade and tumor volume only MUC-1 and AMACR remained as statistically significant prognostic factors. When tested for sensitivity and specificity they all failed and, consequently, they seem to be of less value in daily practice for cancelling an individual patient regarding the choice of treatment. Time trends in incidental prostate tumors in Sweden were analyzed in a cohort of patients with prostate tumors detected by transurethral resection (TUR-P). Through linkage of the national registration number (NRN) with several registers, e.g. the Swedish Cancer Registry, the National Inpatient registry and the Cause of Death Registry we identified, during the period 1970 through 2003, in total 23288 patients with incidental prostate cancer, who constituted the study group. As comparison group we choose all patients diagnosed with prostate cancer between 1970-2003 excluding those with incidental cancer, in total 112204 patients. Our result confirms earlier findings that there has been a dramatic change over time in incidence of incidental prostate cancers in Sweden, which parallels the introduction of prostate specific antigen. We also found that the cumulative incidence of prostate cancer death is high in the incidental group, opposing earlier findings that incidental tumours are a non-lethal disease.

Quality-of-life and functional outcomes are important in the choice of treatment for men with localized prostate cancer. These issues were investigated in the present thesis. All living 400 men randomized to radical prostatectomy or watchful waiting from 1989 to 1999 in the Scandinavian Prostate Cancer Group Number 4 (SPCG-4) were included. An additional 281 men compromised an age-matched control group. Physical symptoms, symptom-induced stress, sense of well-being and self-assessed quality of life were evaluated by a study-specific questionnaire. Results showed that prostate cancer men, regardless if they were allocated to radical prostatectomy or watchful waiting were suffering of long term adverse effects, mainly erectile dysfunction, urinary leakage and voiding symptoms. In the prostatectomy group, erectile dysfunction and urinary leakage were often consequences of surgery; in the watchful waiting group the side-effects could be caused by tumor progression. The quality of life deteriorated over time. High self-assessed quality of life was reported by 35 % in the radical, 34 % in watchful-waiting, and 43 % in the control groups after a median follow-up time of 12.2 years. The SPCG-4 men significantly more often reported anxiety than did controls. Erectile dysfunction was associated with the most negative influence on quality of life in both SPCG-4 groups. Men in the prostatectomy group were more distressed by erectile dysfunction than watchful waiting. Androgen deprivation therapy had negative effects on all psychological parameters, including quality of life, for the watchful waiting but not for the prostatectomy group. Information about the prostate-cancer disease was significantly higher in the radical-prostatectomy group than in watchful waiting. Check-ups were associated with worry, especially for those on androgen deprivation therapy. Open radical prostatectomy led to an increased rate of inguinal hernia compared with robot-assisted technique. In conclusion, the data of this thesis emphasize that it takes more than a decade to understand the patterns of adverse effects and time dimension of their occurrence for each treatment. Consideration of quality of life has a high priority to aid the ageing man through the shifting scenarios of localized prostate cancer.