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9th Uro-oncological Update Symposium in Cologne, Germany
Prostate cancer is sometimes treated even though it would never have caused problems throughout life. On the other hand, many patients whose tumor is already advanced do not receive adequate therapy. Experts from the West German Prostate Center recently discussed ways out of the dilemma between over- and under-treatment at the 9th Uro-oncological Update Symposium in Cologne.
Prostate cancer is the most common malignant tumor in men: every year, more than 58,000 men in Germany develop the disease, and 11,000 die as a result. "Thanks to improved early detection methods, we are now able to detect tumors in the prostate at an increasingly early stage," said Dr. Pedram Derakhshani at the 9th Uro-oncology Update Symposium in Cologne. However, it is often impossible to say with certainty whether a diagnosed tumor will actually lead to death if it is not treated. To avoid the risk of overtherapy, Derakhshani said it makes sense to decouple diagnosis from therapy. "Even in the preliminary stages, we need to better identify patients at risk," the urologist emphasized. New test procedures from laboratory and imaging diagnostics, such as the PCA3 gene test and ultrasound-assisted elastography, are already a valuable addition to the conventional PSA test.
The risk of overtreatment should always be included in therapy considerations, "especially since prostate cancer patients sometimes have to put up with serious side effects, especially after radical surgery," said Dr. Stephan Neubauer, also a urologist at the West German Prostate Center. Especially the surgical removal of the prostate, which is still the most frequently performed procedure in Germany, is sometimes associated with a high incontinence and impotence rate. For example, one in 10 patients can no longer hold their urine after the operation, and almost two-thirds suffer from erectile dysfunction. The focus in the treatment of prostate cancer patients must therefore increasingly be on achieving optimal cure rates with minimal side effects, says Neubauer.
Tumor stage not clear
If prostate cancer is detected early, the cure rate is 80 to 90 percent, regardless of whether internal radiation (brachytherapy), radical prostatectomy or external radiation therapy is performed. "However, as soon as the tumor has grown into the surrounding prostate capsule or lymph nodes have already been affected, the probability of cure drops dramatically," Neubauer emphasized. However, the distinction between the different tumor stages is not always clear-cut. For example, after a prostate removal, it may turn out that the tumor has already invaded the capsule.
If the tumor has a higher risk of breaking through the capsule or forming metastases, radical removal of the prostate is no longer recommended as the therapy of choice, according to the tenor at the symposium. "Here, radiotherapeutic methods perform better," explained Dr. Gregor Spira, radiotherapist at the West German Prostate Center. In contrast to surgical treatment, where a single incision separates healthy from malignant tissue, radiotherapy always includes a safety margin around the tumor that covers possible metastases that cannot be detected in the diagnosis. The radiation dose is gradually reduced from the tumor site to the risk organs of the bladder, rectum and urethra.
More safety through radiation therapy
Brachytherapy has proven to be particularly effective and gentle. During seed implantation, up to 80 tiny radiation sources (seeds) are inserted into the prostate under constant ultrasound control. "The seeds remain in the patient's body and develop their radiation effect on the prostate carcinoma over months," explained Dr. Carsten Weise, also a radiation therapist at the West German Prostate Center. The tumor tissue is destroyed from within by the high-dose, targeted radiation. While seed implantation is used for a tumor diagnosed early, HDR afterloading is the most effective and useful treatment for advanced or aggressive prostate cancer. In this procedure, special hollow needles are inserted into the prostate through which a highly active radiation source passes that irradiates the tumor directly on site " The afterloading procedure is usually combined with external radiation. This ensures that the peripheral areas of the prostate, where tumor cells can settle, are also irradiated," summarized Spira.
The advantage of "internal radiation" is also that patients have to accept significantly fewer side effects for the treatment. Another advantage of seed implantation and HDR afterloading is that patients are able to resume professional and private activities after just a few days.