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Clinical trial tests the concept of "active surveillance" as an alternative therapy option
Thanks to refined examination methods, more and more prostate carcinomas are being detected at an early stage. At the same time, there is growing uncertainty as to whether all diagnosed tumors actually require invasive therapy, such as radical surgery. Alternatively, patients with low-risk prostate cancer can be monitored closely. Whether the concept of "active surveillance" actually works is currently the subject of a large international study.
For patients with low-risk prostate cancer, "active surveillance" is another treatment option, namely "non-treatment". For the first two years, the tumor is actively monitored every three months by PSA level, palpation and imaging, and every 12 months by repeat prostate biopsy. If the PSA value remains stable, the examination period is extended to six months. However, if the first signs of disease progression appear, appropriate therapeutic measures are taken. "The aim is to achieve a good quality of life with Active Surveillance, while leaving open the possibility of therapy at a later date," explains Dr. Pedram Derakhshani, urologist at the West German Prostate Center in Cologne.
More than 30 percent of patients are treated after three to four years
Überprüft wird das Behandlungskonzept derzeit in einer großen internationalen Studie1, deren erste Ergebnisse anlässlich der diesjährigen Tagung der Europäischen Gesellschaft für Urologie (EAU) in Wien vorgestellt wurden. In die Studie eingeschlossen wurden rund 1600 Patienten, die ein Prostatakarzinom mit einem geringen Risiko aufwiesen (PSA<10; PSA/Prostatavolumen<0,20; Gleason-Score = 6; T1c oder T2). Die Ergebnisse sind schlechter als vermutet: Immerhin jeder dritte Patient musste aufgrund erhöhter PSA-Werte oder einem verschlechterten Biopsiebefund innerhalb von drei bis vier Jahren einer aktiven Behandlung unterzogen werden. Dabei wurden auch immer wieder aggressive Tumore gefunden, die bereits die Kapselgrenze überschritten hatten. Eine Behandlung ist in solchen Fällen dann oftmals zu spät, da sich bereits Absiedelungen des Tumors (Metastasen) gebildet haben können.
Treatment with few side effects: brachytherapy
"Today, we are not yet able to monitor patients with a low-risk tumor so reliably that we can always intervene in time if the disease progresses," emphasizes the Cologne urologist. "Therefore, our only option at present is to make the therapy less side-effective." Radical treatment approaches such as surgical removal of the prostate are not justified in many cases, he says, because of the complications that frequently occur, such as incontinence and erectile dysfunction.
In contrast, brachytherapy (internal radiation) has proven to be a particularly gentle yet effective treatment for prostate cancer. Here, tiny radiation sources are introduced directly into the prostate. "By precisely distributing the radiation dose, we can irradiate the tumor without damaging surrounding tissue such as the urethra, intestine or sphincter," Derakhshani explains. As a result, several studies show that erectile dysfunction as well as urinary incontinence occurs significantly less frequently compared to prostate surgery (14% vs. 70%; 0.3-3% vs. 50%).2
Living with the tumor: strain on the psyche
In addition, active monitoring of the tumor leads to psychological stress for many patients, which may significantly reduce their quality of life. "Patients live with the knowledge that there is a tumor in their body that can change in size, extent and aggressiveness every day," Derakhshani sums up. And in his experience, not all patients can deal with that calmly.