FAQ about prostate cancer

Do only older men suffer from prostate cancer?

No! Even though prostate cancer is diagnosed significantly more frequently in men over the age of 60, younger men aged 40 and over can also be affected, as the current figures of the Robert Koch Institute show: In about one in ten men, the malignant tumour occurs before the age of 60. In addition, younger men are more likely to develop more aggressive prostate cancer. These are tumours 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 cancer therefore recommends that men as early as 40 years of age should take advantage of the early diagnosis examination at their urologist. Because only if the tumor is detected early enough by means of PSA test, ultrasound and scanning can the prostate cancer be completely cured in most cases.

Do constant urge to urinate and a weak stream of urine indicate prostate cancer?

If you suffer from a constant urge to urinate or a weak stream of urine, do not panic. The reason for this is usually a benign enlargement of the prostate gland. She meets every second man over 50 and almost all 80-year-olds. In benign prostatic hyperplasia (BPH), the glandular tissue of the prostate grows in the area of the urethra. As a result, the strength of the urine stream decreases and residual urine remains in the bladder. In addition to effective medication to improve the emptying of the bladder, there are now gentle laser procedures that vaporize excess tissue with low blood flow. Prostate cancer, on the other hand, usually does not show any typical symptoms in the early stages. In order to detect a possible tumour at an early stage and to treat it optimally, it is therefore important to regularly take part in an early diagnosis examination by the urologist.

My father died of prostate cancer. Will I also fall ill as a son?

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 fall ill. Nevertheless, men with a high incidence of prostate cancer in the family have a significantly increased risk of developing prostate cancer in the course of their lives. The younger, the more closely related and the more numerous the relatives affected, the greater the risk. For this reason, especially men with a family predisposition should take the recommendations of the German Society of Urology seriously and undergo an early diagnosis examination from the age of 40.

How often should urological precautions be taken?

In many cancers, the earlier the tumor is detected, the greater the chances of recovery. This is particularly true for prostate cancer. Once a year, every man over the age of 40 should therefore have a cancer screening examination performed by an urologist. In this case, the doctor asks for the patient's medical history, any symptoms or symptoms and examines the genital organs and lymph nodes. In addition, it scans the prostate from the rectum to detect possible hardening that could indicate a tumor. However, the examination by touch can only detect superficial tumours that have already reached a certain size. The disease may then be at 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 screening for early detection is therefore not only a finger examination, but also an ultrasound examination of the prostate and the control of the PSA value in the blood. If this leads to the suspicion of cancer, tissue samples (biopsy) from the prostate provide a reliable diagnosis. The pathologist examines the tissue sample for the presence of tumor cells. The pathological findings, the PSA value and the examination findings of the physician form the basis for the necessity, type and extent of the possibly necessary treatment.

How important is the PSA test for the early detection of prostate cancer?

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 an average of five years earlier detection of prostate tumors. This is the crucial time in which curable disease stages can turn into incurable diseases. Since the introduction of the PSA test, the proportion of curable stages has increased from around 40 to 80 percent and mortality from prostate cancer has been significantly reduced.

Does a PSA value above four automatically mean prostate cancer?

Not at all! PSA is produced by every prostate cell. Not every patient whose blood exceeds the "threshold" of 4 ng/ml suffers from prostate cancer. Benign prostate hyperplasia, cycling, inflammation of the prostate and sexual intercourse can cause the PSA in the blood to rise for a short time. This makes it all the more important not to panic with a single increase in PSA values, but to repeat the test and to use additional diagnostic methods such as ultrasound and prostate palpation.

Can prostate cancer be diagnosed using imaging techniques?

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

MRI-assisted biopsy takes advantage of modern imaging and combines it with actual tissue harvesting, which must ALWAYS be performed to prove the diagnosis of prostate cancer. The advantage: prostate carcinomas can be detected and treated with a significantly higher sensitivity and specificity than is possible with the transrectal ultrasound (TRUS) used in conventional biopsies. MRI-assisted biopsy is a useful and important extension of the diagnostic spectrum, especially for patients whose PSA values continue to rise despite negative biopsies and who are still suspected of having cancer.

However, imaging methods also play an important role in cases of suspected recurrence of the disease. PSMA-PET-CT can be used to detect new tumour centres or prostate cancer cells that have spread throughout the body. Molecules previously coupled to a radioactive substance bind specifically to the membrane of the prostate cancer cells. By detecting the molecules using a special camera, we know where other prostate cancer cells are located in the body. The PSMA PET/CT examination not only improves the diagnosis of relapses, but also further therapy planning. Thus it can be exactly differentiated whether for a patient with a prostate cancer relapse a local treatment such as irradiation or a systemic treatment such as chemotherapy or hormone treatment can be considered.

How important is the classification of the tumor into T, N and M?

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

For T (tumor) there are the following terms:

T0 = no indication for primary tumor
T1 = the tumour is small and not palpable or cannot be detected
T2 = the tumour is restricted to the prostate gland and has not penetrated the prostate capsule
T3 = the tumour spreads via the prostate capsule
T4 = the tumor detects adjacent structures (e. g. bladder, intestine, pelvic wall)
The designations for N (Nodi = node) are as follows:

N0 = no neighbouring lymph nodes affected
N1 = Infestation of neighbouring lymph nodes
For M (metastases) there is the following classification:

M0 = no clinical proof of metastases (remote metastases)
M1 = Remote metastases detectable

What does the Gleason score mean?

The Gleason score describes the differentiation of tumor tissue. It is determined how much the tumor cells differ from normal, healthy tissue. A total of five different growth patterns are described and evaluated after increasing deviation from normal tissue from 1 (= low) to 5 (= strong). The score is awarded separately for the primary (predominant) and secondary (additional) pattern. The two scores of the cells are then added together, e. g. 3+4 gives Gleason score 7, and if the Gleason score is less than 7, the prognosis is rather favourable. However, if the score is above 7, the forecast is rather less favourable.

Negative biopsy, continued increase in PSA value - What happens next?

If no tumour cells are found in the biopsy, but if the PSA level remains unchanged high, prostate carcinoma cannot be excluded with certainty. For this reason, a detailed questioning and clinical examination of the patient is first carried out to find other possible causes of the increased PSA values. This includes, for example, mechanical stress on the prostate caused by cycling or inflammation of the organ.

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

However, in order to improve the detection of a possibly existing prostate carcinoma after negative tissue removal, the West German Prostate Center uses the so-called MRI-supported biopsy. Prior to the actual tissue removal, the patient's prostate is examined in a special magnetic resonance tomograph (MRI), the so-called multiparametric 3-Tesla-MRI. In this process, a kind of "map" is created in which areas suspected of being tumor are marked, on which the urologists orientate themselves precisely when removing tissue. The actual biopsy then takes place in a second step under the control of a high-resolution transrectal ultrasound. By combining both diagnostic methods, we increase the hit rate and thus save the patient from further biopsies.

What is the best therapy for a localised tumour of the prostate gland?

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

Is the tumor gone after the operation?

Many men choose surgery with the argument:"What's gone is gone". This is one of the most common mistakes we encounter in daily practice. This is because about one third of all patients suffer from recurrence of the disease, a condition known as recurrence, despite surgery. The risk of developing a relapse depends on the likelihood of individual tumor cells having already left the prostate at the time of diagnosis. This means that the tumor has disappeared after surgery if there are no tumor metastases outside the prostate gland. The success of the treatment and thus also the prospect of cure are therefore directly dependent on the likelihood of a capsule overrun or metastasis.

What is the best treatment for advanced prostate cancer?

Numerous studies have shown that surgery is not a good choice for advanced tumors. The reason for this is that if the prostate gland is removed by surgery and there are already tumor outgrowths outside the incision margin, they will continue to grow after the operation. Therefore, in advanced stages (so-called intermediaries or high-risk tumours) treatments such as brachytherapy are more suitable, since peripheral areas of the prostate are also included in the irradiation. The likelihood of the tumour reappearing in the area of the prostate (local recurrence) is therefore much lower after combined brachytherapy than after radical surgery. The most effective and sensible treatment for advanced or aggressive prostate cancer is brachytherapy (e. g. HDR afterloading) combined with external radiation. It is said to be an advanced prostate carcinoma if the tumor may have already left the organ, but is still limited to the immediate vicinity of the prostate gland without being able to detect lymph node or bone metastases. The advantage of combined brachytherapy over external radiation alone lies in the fact that the targeted irradiation of the prostate allows the highest possible amount of radiation to be administered, while at the same time reducing the radiation dose to the surrounding risk organs, especially the rectum and bladder.

What does Active Surveillance mean?

For patients with low-risk prostate carcinoma, Active Surveillance offers a further option, namely "non-treatment". Initially, no therapy will be carried out and the tumor will wait until it grows. During the first two years, the tumour is actively monitored every three months by means of PSA, 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 there are first signs that the disease is progressing, appropriate therapeutic measures are taken. The aim is to achieve a good quality of life with active monitoring and at the same time to leave the possibility of therapy open at a later date.

Is it true that men over 75 years of age should no longer be treated?

Life expectancy does not depend solely on age, but on a number of additional factors: Chronic accompanying illnesses, physical fitness but also independence and mental agility play an essential role. Many seniors are also beyond the age of 75 still in the middle of life, are physically active, have a wide range of interests and enjoy good health. It would be fatal to dispense with effective therapy in such cases. Therefore, the Society for Geriatric Oncology (SIOG) recommends that healthy elderly people receive the same treatment as younger prostate cancer patients. The aim should also be to avoid possible quality of life restrictions caused by the disease and to prolong patients' lives. This is all the more so when it comes to aggressive, fast-growing prostate cancer, which can become a threat to the patient without treatment.

How is prostate cancer treated that has already spread?

In prostate cancer, which has already spread to other organs (metastases), hormone treatment is the best therapy. It has long been known that testosterone promotes the growth of prostate cancer. Whereas in the past the testicles were removed to treat prostate cancer, testosterone levels can now be lowered effectively with drugs known as anti-androgens. Even if no cure can be achieved with hormone therapy, in 80 percent of patients tumour growth can be stopped for a long time - often for years - and the symptoms alleviated. In the presence of only individual metastases, complementary local therapy of the prostate by means of radiation or surgery has recently come into consideration. For men with very aggressive and fast-growing tumours, it can also be useful to combine hormone withdrawal with chemotherapy.

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