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Prostate carcinoma

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The prostate carcinoma

In industrialised countries, prostate carcinoma is the most common cancer in men and the second most common cause of cancer death. In particular, the introduction of the tumour marker PSA led to an increased diagnosis of prostate carcinomas in early stages (keyword overdiagnosis). When prostate cancer is diagnosed, both the patient and his treating physician are often faced with a difficult decision. The therapy recommendation for prostate carcinoma is based on specific criteria. For early-stage tumours confined to the prostate, various standard treatment options (active surveillance, surgery, radiation) are available. However, the optimal treatment strategy is unclear.

Relevance of the general condition

Before a decision for or against a form of therapy is made, the general condition, life expectancy and tumour characteristics of each patient should be assessed. Life expectancy plays a greater role than biological age.

With advanced patient age or reduced life expectancy, the patient's concomitant diseases reduce the risk of dying from prostate carcinoma. This means that patients die with the prostate carcinoma, but not from the tumour. Of course, the treatment wishes of the affected men must also be taken into account.

Side effects

The proven therapy methods, radiation and surgical removal of the prostate offer excellent local tumour control, but can be associated with sometimes considerable side effects.

The consistent further development of surgical techniques using laparoscopy and robot-assisted surgery (Da Vinci) has led to an improvement in terms of blood loss, wound pain and length of hospital stay. However, there are contradictory data regarding a significant reduction in side effects and improved tumour control.

In the case of less aggressive tumours, active surveillance is now an established procedure. As part of active surveillance, the patient must undergo follow-up examinations (PSA, palpation of the prostate and rebiopsies) at regular intervals. If the disease process progresses, the person is advised to switch to definitive therapy.

For patients, active surveillance can be a psychological burden. They therefore opt for a radical therapy with all its consequences and side effects (keyword overtherapy). Furthermore, men who no longer formally fulfil the criteria for continued surveillance in the course of active surveillance receive definitive radical therapy.

The aim of focal therapy is to offer these patients a possible middle way between radical therapy on the one hand and active surveillance on the other.

Therapy options for locally limited prostate carcinoma

1. active monitoring

In active monitoring, active therapy is dispensed with. Patients are monitored at regular intervals. This includes the determination of the PSA value, palpation examinations of the prostate, imaging (MRI) and biopsies. Active therapy is only initiated when the tumour progresses. Active surveillance is suitable for patients with a low risk profile.

2. radical prostatectomy

In this operation, the entire prostate is removed, including the seminal vesicles. Nowadays, the operation is preferably performed minimally invasively robot-assisted with the Da Vinci System at centres. Depending on the tumour characteristics, the operation can be performed in a nerve-sparing manner (e.g. to preserve erectile function). At the same time, depending on the risk profile, removal of the pelvic lymph nodes may be necessary.

3. external beam radiotherapy (EBRT)

External percutaneous radiotherapy (EBRT) is an alternative therapy to radical prostatectomy for organ-confined prostate cancer. The therapy is carried out on an outpatient basis and lasts several weeks. Depending on the risk profile, this treatment is combined with hormone deprivation therapy and the pelvic lymph nodes are also irradiated.

4. focal therapy

In contrast to surgery and radiation, the focal therapy of prostate carcinoma does not pursue the approach of treating the entire organ, but only the tumour itself. Due to the lack of long-term data, focal therapy is not yet an established standard of treatment.

"The diagnosis of prostate cancer is hard - for men, it often means the end of the world. That is why it is particularly important for my colleagues and me to work on new methods for the benefit of our patients. Precise diagnostics is the prerequisite for choosing the best method."

Prof. Dr. med. Gernot Bonkat
alta uro AG, Basel