Prostate Cancer

No! Even though prostate cancer is diagnosed much more frequently in men over the age of 60, younger men from the age of 40 can also be affected, as the latest figures from the Robert Koch Institute show: In about one in ten men, the malignant tumor occurs before the age of 60. In addition, younger men are more likely to develop a more aggressive prostate carcinoma. These are tumors that tend to grow quickly, form metastases, and can lead to death if detected too late. The current guideline for the early detection, diagnosis and treatment of prostate carcinoma therefore recommends that men visit their urologist for an early detection examination at the age of 40. Only if the tumor is detected early by means of PSA testing, ultrasound and palpation can prostate cancer be completely cured in most cases.

Anyone who suffers from a constant urge to urinate or a weak urinary stream should not immediately panic. In most cases, this is due to a benign enlargement of the prostate. It affects every second man over 50 and almost all 80-year-olds. In benign prostatic hyperplasia (BPH), the glandular tissue of the prostate grows into the area of the urethra. As a result, the strength of the urinary stream decreases and residual urine remains in the bladder. In addition to effective medications to improve bladder emptying, today there are gentle laser procedures that vaporize excess tissue with little bleeding. Prostate cancer, on the other hand, usually remains without typical symptoms in the early stages. In order to detect a possible tumor at an early stage and to treat it optimally, it is therefore important to have regular early detection examinations with a urologist.

Prostate cancer is not a hereditary disease in the classical sense. If the father suffered from prostate cancer, this does not automatically mean that the son will also develop the disease. Nevertheless, men with a family history of prostate cancer have a significantly increased risk of also developing prostate cancer in the course of their lives. The risk is greater the younger, the more closely related and the more numerous the affected relatives. For this reason, men with a family history of prostate cancer should take the recommendations of the German Society of Urology seriously and undergo an early detection examination from the age of 40.

For many cancers, the earlier the tumor is detected, the greater the chances of cure. This is particularly true for prostate cancer. Once a year, therefore, every man over the age of 40 should have a cancer screening examination by a urologist. During this examination, the doctor asks about the patient's medical history, any complaints or symptoms, and examines the genital organs and lymph nodes. In addition, he or she palpates the prostate from the rectum to detect possible indurations that could indicate a tumor. However, palpation can only detect superficial tumors that have already reached a certain size. The disease may then already be in an advanced stage and can only be cured to a limited extent. According to the current guidelines of the German Society of Urology, an effective early detection examination therefore includes, in addition to palpation with the finger, an ultrasound examination of the prostate and checking the PSA level in the blood. If this results in a suspicion of cancer, tissue samples (biopsies) from the prostate gland provide a reliable diagnosis. The pathologist examines the tissue sample for the presence of tumor cells. The pathological findings, the PSA value and the physician's examination findings form the basis for the necessity, type and extent of any treatment that may be required.

Despite controversial discussions about the PSA test as a suitable method for the early detection of prostate cancer, the current guideline on prostate cancer leaves no doubt about its effectiveness: The introduction of the PSA test has led to prostate tumors being detected on average about five years earlier. This is the crucial time when curable disease stages can become incurable disease. Thus, since the introduction of the PSA test, the proportion of curable stages has increased from about 40 to 80 percent and prostate cancer mortality has been significantly reduced.

No way! PSA is produced by every prostate cell. Not every patient whose blood exceeds the "threshold" of 4 ng/ml has prostate cancer. This is because benign prostate enlargement, cycling, inflammation of the prostate and sexual intercourse can cause the PSA in the blood to rise for a short time. It is therefore all the more important not to panic in the event of a one-time increase in PSA levels, but to repeat the test and use additional diagnostic procedures such as ultrasound and palpation of the prostate.

Since prostate cancer usually does not appear as a single tumor but in the form of many small foci that are difficult to detect, imaging techniques are still of secondary importance for the initial diagnosis. Nevertheless, ultrasound and magnetic resonance imaging provide valuable information on prostate volume and the localization of suspicious areas. In particular, state-of-the-art multiparametric magnetic resonance imaging (mpMRI) currently represents the most accurate method for visualizing prostate cancer.

MRI-guided biopsy takes advantage of modern imaging and combines it with the actual tissue sampling that ALWAYS has to be done to prove the diagnosis of prostate cancer. The advantage: prostate cancers can be detected and hit with a much higher sensitivity and specificity than is possible with the transrectal ultrasound (TRUS) used in conventional biopsy. Especially for patients whose PSA levels continue to rise despite a negative biopsy and the suspicion of cancer remains, the MRI-guided biopsy is a useful and important extension of the diagnostic spectrum.

But imaging techniques also play an important role in cases of suspected recurrence of the disease (relapse). For example, new tumor sites or prostate cancer cells that have spread in the body can be detected with a PSMA-PET-CT. Molecules that have previously been coupled to a radioactive substance bind specifically to the membrane of the prostate cancer cells. By detecting the molecules using a special camera, the researchers know where other prostate cancer cells are located in the body. The examination by means of PSMA PET/CT not only improves recurrence diagnostics, but also further therapy planning. In this way, it is possible to distinguish precisely whether a patient with a prostate cancer recurrence should again undergo local treatment such as radiation, or systemic treatment such as chemotherapy or hormone therapy.

In order for the physician to select the right treatment and provide a correct prognosis, the tumor must be classified. The different tumors show highly different behavior in growth and spread. The so-called TNM classification - also known as staging - indicates the local size of the tumor (T), the spread to the lymph nodes (N) and possible metastases in other organs (M).

For T (tumor) there are the following designations:

• T0 = no evidence of primary tumor
• T1 = the tumor is small and not palpable or cannot be detected
• T2 = the tumor is confined to the prostate and has not broken through the prostate capsule
• T3 = the tumor spreads over the prostate capsule
• T4 = tumor involves adjacent structures (e.g. bladder, bowel, pelvic wall)

The designations to N (Nodi = nodes) are:

• N0 = no adjacent lymph nodes affected
• N1 = Involvement of adjacent lymph nodes

For M (metastases), there is the following classification:

• M0 = no clinical evidence of daughter tumors (distant metastases)
• M1 = distant metastases detectable

The Gleason score describes the differentiation of tumor tissue. It determines how much the tumor cells differ from normal, healthy tissue. A total of five different growth patterns are described and evaluated according to increasing deviation from normal tissue from 1 (= slight) to 5 (= strong). The score is assigned separately for the primary (predominant) and the secondary (further) pattern. The two cell scores are then added together, e.g. 3+4 gives a Gleason score of 7. If the Gleason score is below 7, the prognosis is rather favorable. However, if the score is above 7, the prognosis tends to be less favorable.

If no tumor cells are found in the biopsy, but the PSA value remains high, prostate carcinoma cannot be ruled out with certainty. Therefore, the first step is to conduct a detailed interview and clinical examination of the patient to look for other possible causes of the elevated PSA levels. These include, for example, mechanical stress on the prostate caused by cycling or inflammation of the organ.

However, if the suspicion of prostate cancer remains, the current guidelines recommend a repeat biopsy within 6 months. Prostate biopsy is an established and safe procedure and is currently the only way to definitively diagnose prostate cancer.

However, in order to improve the detection of a possibly existing prostate carcinoma after negative tissue sampling, the West German Prostate Center uses the so-called MRI-assisted biopsy. Prior to the actual tissue removal, the patient's prostate is scanned in a special magnetic resonance imaging (MRI) scanner, the so-called multiparametric 3 Tesla MRI. This creates a kind of "map" in which areas suspected of having a tumor are marked, which the urologists then use to orient themselves precisely when removing the tissue. The actual biopsy then takes place in a second step under the control of a high-resolution transrectal ultrasound. By combining both diagnostic procedures, we increase the hit rate and can thus spare the patient possible further biopsies.

If prostate cancer is detected in time, several treatment options are available to the patient: Surgery, brachytherapy (internal radiation) and external radiation. For a long time, surgical removal of the tumor was considered the treatment of choice, despite considerable side effects. In the meantime, a large number of studies comparing the three procedures show that brachytherapy, alone or in combination with complementary radiation or hormone therapy, is at least equivalent or even superior to radical surgery in all disease stages of localized prostate carcinoma. The scientific confirmation of the high effectiveness of brachytherapy necessitates a rethink in the treatment of localized prostate carcinoma. The trend is increasingly moving away from surgery towards radiation.

Many men opt for surgery with the argument: "What's gone is gone". This is one of the most common misconceptions we encounter in daily practice. This is because in about one third of all patients, despite surgery, the disease recurs after a certain period of time, a so-called recurrence. The risk of developing a recurrence depends on the probability that individual tumor cells may have already left the prostate at the time of diagnosis. This means that after the operation, the tumor is gone if there are not already tumor metastases outside the prostate. The success of treatment and thus the prospect of cure are thus directly dependent on the probability of whether there is already capsular overgrowth or metastases.

Numerous studies show that surgery is not a good choice, especially for advanced tumors. The reason: If the prostate is surgically removed and there are already extensions of the tumor outside the incision margin, these will continue to grow after the operation. Therefore, treatments such as brachytherapy are more suitable for advanced stages (so-called intermediate or high-risk tumors), since peripheral areas of the prostate are also included in the radiation. The likelihood of the tumor recurring in the prostate area (local recurrence) is therefore much lower after combined brachytherapy than after radical surgery. The most effective and useful treatment for advanced or aggressive prostate cancer is brachytherapy (e.g. HDR afterloading) combined with external beam radiation. Prostate cancer is said to be advanced when the tumor may have already left the organ but is still confined to the immediate area around the prostate, without evidence of lymph node or bone metastases. The advantage of combined brachytherapy over external radiation alone is that the highest possible amount of radiation can be administered by targeting the prostate, while reducing the radiation dose to the surrounding organs at risk, especially the rectum and urinary bladder.

For patients with a low-risk prostate carcinoma, "active surveillance" is another option available, namely "non-treatment". In this case, no therapy is initially performed and the patient waits to see whether the tumor grows. For the first two years, the tumor is actively monitored every three months by means of PSA levels, palpation and imaging procedures, and every 12 months by means of a new prostate biopsy. If the PSA value remains stable, the examination period is extended to six months. However, if the first signs(symptoms) appear that indicate progression of the disease, appropriate therapeutic measures are taken. The aim of Active Surveillance is to achieve a good quality of life while leaving open the possibility of therapy at a later stage.

Life expectancy does not depend on age alone, but on a number of additional factors: For example, chronic concomitant diseases, physical fitness, but also independence and mental agility play an essential role. Many seniors are still in the midst of life beyond the age of 75, are physically active, have a wide range of interests and enjoy good health. It would be fatal to forego effective therapy in such cases. For this reason, the Society for Geriatric Oncology (SIOG) also recommends that healthy older people should receive the same therapy as younger prostate cancer patients. Here, too, the goal should be to avoid possible limitations in quality of life caused by the disease and to prolong the patient's life. This is all the more important if the prostate cancer is aggressive and fast-growing and can become threatening for the patient without treatment.

Hormone treatment is the best therapy for prostate cancer that has already spread to other organs (metastases). It has long been known that testosterone promotes the growth of prostate cancer. While in the past the testicle was removed to treat prostate cancer, today testosterone levels can be effectively lowered with drugs called antiandrogens. Even if no cure can be achieved with hormone therapy, tumor growth can be stopped for a long time - often for years - and symptoms alleviated in 80 percent of patients. If only single metastases are present, supplementary local therapy of the prostate by means of radiation or surgery has recently been considered. For men with very aggressive and fast-growing tumors, however, it may also make sense to combine hormone withdrawal with chemotherapy.