Prostate cancer is the most common tumour in men after the age of 50. Early detection is crucial for its cure. In Germany, preventive medical checkups are offered from the age of 45 onwards. Therapeutically, surgery, brachytherapy, radiotherapy and active surveillance are available, among others, such as hormone therapy. The chances of recovery are very good in the early stages of the disease. In the further monitoring of the success of treatment, the determination of the PSA level in the blood is of decisive importance.
What is prostate cancer?
Prostate cancer is the malignant new formation of prostate gland tissue. It usually develops in the outer region of the gland, so that it can often be palpated with a finger from the rectum during the examination. In the early stages, however, the palpation findings can be completely inconspicuous and no symptoms occur, so that the preventive examination with determination of the PSA value and its course is of great importance. The prostate carcinoma tends to spread beyond its own limiting capsule, along the nerve fibres, into lymph channels and nodes and into the bones. In the latter, metastases form, which can lead to spontaneous bone fractures. The haematopoietic bone marrow is thereby displaced. In addition to this spreading behaviour, the fine tissue characteristics (differentiation) of the prostate carcinoma also plays a decisive role in the later choice of therapy, which is why the physician aims to take a tissue sample. The prostate carcinoma is more or less subject to hormonal control by male sex hormones and can be influenced by a withdrawal of these hormones.
Is prostate cancer curable?
A diagnosis at an early stage is decisive for the success of a cure for prostate cancer. In this case, a cure can often be achieved by complete surgical removal or radiotherapy. If the tumour can only be detected within the prostate capsule, the long-term healing probability is about 90 percent. If the tumor has broken through the capsule, the probability of recovery is about 50 percent. If, at the time of diagnosis, the tumour has already settled in lymph nodes or other organs, healing is no longer possible. Nevertheless, modern forms of drug treatment can prevent the tumour from growing for several more years.
Early detection of prostate cancer before symptoms appear is one of the decisive factors for the chances of a cure, because symptoms are usually already an indication of an advanced stage. In principle, the first step towards early detection should be a screening examination from the age of 45. Patients with an increased risk (hereditary load) should already have a preventive examination from the age of 40. This includes palpation of the prostate through the rectum, determination of the PSA level in the blood and an ultrasound examination of the prostate through the rectum. If the results of the examination lead to the suspicion of a prostate carcinoma, tissue samples should be taken from the prostate using a biopsy. This procedure can usually be performed under local anaesthesia, but in some cases it can also be performed under a short anaesthetic on an outpatient basis. A new method of taking biopsies of the prostate is known als fusion guided biopsy which is offered since many years at our clinic. If a prostate cancer is detected in the tissue samples, further examinations follow if necessary to clarify the possible spread. Nuclear medical examinations of the skeleton (skeletal scintigraphy), as well as radiological examinations of the abdominal and pelvic area by means of computer tomography (CT) or magnetic resonance imaging (MRT) are considered. Based on the findings, an optimal and individual therapy can then be planned.
The therapy of early-stage prostate carcinoma
As already described at the beginning, there are several treatment options depending on the tumor stage. Therapeutically, surgery, brachytherapy, radiotherapy and active surveillance are available among others, such as hormone therapy. The chances of recovery are very good in the early stages of the disease.
The surgical procedure - radical retropubic prostatectomy
The standard procedure is the radical removal of the prostate with removal of the lymph nodes in the pelvis. The operation is usually performed with an incision below the navel; alternatively, it can be performed through an incision at the perineum or laparoscopically (keyhole surgery). In suitable patients with an early tumor stage, this operation can be performed while preserving the vascular-nerve bundle. In this way, potential side effects such as impaired urinary incontinence and potency can be favourably influenced. It is crucial for the success of the surgical procedure that the tumour is safely confined to the prostate and that there are no metastases at the time of surgery.
There are basically two possibilities here: firstly, the permanent implantation of small radiation sources, so-called "seeds", with a low dose rate, which remain in the body, and secondly, the temporary implantation of hollow needles, which are loaded for a short time with radiation sources of high dose rate, the "high-dose-rate brachytherapy".
External radiation of the prostate
Irradiation of prostate cancer requires exact radiation planning in order to keep the side effects of radiation as low as possible. CT-guided 3D-conformal radiation makes it possible to keep the side effects of radiation to a minimum. If necessary, the lymphatic drainage channels can also be recorded. The total radiation dose is divided over about 40 days, so that the entire treatment lasts for about eight weeks.
Active Surveillance is a monitoring concept in which therapy is delayed by close, even invasive, diagnosis by means of repeated prostate biopsies until therapy is indispensable. A sufficient safety of the concept has not yet been sufficiently confirmed and is to be evaluated in a large German study. However, meaningful results can only be expected in ten years at the earliest. Therefore, this treatment concept will only be offered to patients with low risk prostate cancer.
In older patients and less aggressive prostate carcinoma, a wait-and-see approach is also possible at first; only when a clear tumor growth is visible, therapy is initiated.
Side effects of the treatment
In some cases, side effects may occur after the surgical treatment as well as the radiation treatment. In this context, the partial loss of continence (ability to retain urine) and the loss of potency are particularly noteworthy. Impairment of this function by therapy is caused by the close proximity of the prostate to the outer sphincter muscle (urinary incontinence) and to the vascular-nerve bundle (urinary incontinence/potency). If the tumour is detected early and if it is possible to spare the outer sphincter muscle and the vascular-nerve bundle, good postoperative continence can be expected and, especially in younger patients, good rehabilitation of the erection.
Therapy of prostate cancer in advanced stages
If the tumour has spread to surrounding organs or if there are metastases in the lymph nodes or other organs, healing is no longer possible. Nevertheless, it usually takes years before life-threatening cancer-related symptoms occur. The prostate tumour grows under the influence of the male sex hormone testosterone. The growth of the tumour and its daughter tumours can be stopped or curbed for a certain period of time by hormone withdrawal. The aim is to prevent the effect of the growth-promoting hormones (androgens) on the prostate carcinoma.
If, despite "hormone withdrawal" with a defined serum testosterone level (15<20 ng/dl), progression of the disease occurs, this is known as "castration-resistant" prostate cancer. In recent years, intensive clinical research has led to the development of numerous new drugs that are used at this stage and are associated with a prolongation of life with a good quality of life. The therapeutic spectrum ranges from chemotherapy (docetaxel/cabacitaxel) to "new" hormone preparations (abiraterone/enzalutamide) and systemic therapy with radioactive substances (Summarium/Alpharadin) for bone metastases.
If there are metastases in the bones (bone metastases), special drugs (zoledronic acid or RANKL inhibitors) are also used, which have a positive effect on bone metabolism. These lead to an alleviation of pain and also protect against undesirable skeletal events such as bone fractures. If localized pain occurs in the course of the disease, focused radiation therapy of the bone metastasis can provide relief, and radioactive substances (such as Alpharadin) can also be used.
Aftercare treatment of the prostate cancer
The physical, especially urological examination, together with the determination of the PSA blood value are the focus of the aftercare. After therapy has been carried out, the initially usually elevated PSA value drops continuously to a "low" (nadir). Depending on the type of therapy, different "lows" apply. After complete removal of the tumour-affected prostate, the PSA value should drop to a value close to zero (there are various PSA determination procedures with different limits). After radiotherapy or brachytherapy, individual "lows" apply, since the existing prostate tissue still produces residual amounts of PSA. If there is still a detectable PSA level after the operation, or if the level rises again after reaching the nadir, it is suspected that either residual tumour tissue has remained locally or daughter tumours are present in other regions of the body (mainly in lymph nodes or the skeleton).
If you have further questions, please contact your family doctor or urologist or make an appointment for one of our consultation hours at +49 (0)89 1797-2603.
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