Top 10 Misconceptions about Prostate Cancer

Surgery, radiation or just wait and see? Hardly any other type of cancer has as many misunderstandings, prejudices and misinformation as prostate cancer therapy. Numerous false claims have been made about radiation treatment for prostate cancer in particular. This results in deeply insecure men looking for the best therapy for them. With the "10 Errors About the Treatment of Prostate Cancer", the West German Prostate Center wants to eliminate knowledge deficits and contribute to a better education of men.

Fallacy No. 1: The best therapy for prostate cancer is surgery.

Patients are still being suggested that radical prostatectomy is the only way to cure cancer. This is clearly wrong. On the contrary: In the past, radical removal of the prostate gland was regarded as a preferred solution to completely remove the carcinoma and to prolong its life span. Today, current long-term studies show other ways of doing so: They not only show better healing rates for modern radiotherapy, but also significantly lower side effects such as incontinence and impotence1.

Fallacy No. 2: After the operation, the tumor is gone.

Approximately one third of all patients relapse after a certain period of time, known as recurrence. The risk of developing a relapse depends on the likelihood of individual tumor cells having already left the prostate at the time of diagnosis. Therefore, the statement should be correct:"After the operation, the tumor is gone if there are no tumor metastases outside the prostate gland. The success of the treatment and thus also the prospect of cure is therefore directly dependent on the probability that metastases are already present.

Fallacy No. 3: If the prostate cancer is advanced, the operation offers the best chances of recovery.

A fatal error that many men believe. Numerous studies have shown that surgery is not a good choice for advanced tumors. The reason for this is that if surgery is performed, it is possible that the tumor's offshoots may be located outside the incision margin and grow again after the operation. For this reason, organ-crossing treatments such as internal radiation (brachytherapy) are more suitable. The advantage over surgery is that the marginal areas of the prostate are also included in the irradiation. The likelihood of the tumor reoccurring in the prostate (local recurrence) is therefore lower after brachytherapy than after radical surgery.

Fallacy No. 4: After diagnosis, therapy should start quickly

Prostate cancer is usually a slow-growing cancer. For this reason, men who have just been diagnosed with a tumour should take sufficient time to make a coherent decision with the treating physician. According to the recommendation of the guidelines, it can often even be sufficient for men with a low risk prostate carcinoma to monitor the tumor closely (Active Surveillance). If treatment should become necessary, however, it is important to steer the focus more strongly towards achieving optimal healing rates with minimal side effects.

Fallacy No. 5: Younger patients should be better operated on

This is simply wrong: especially younger men benefit from the essential advantages of modern brachytherapy/radiotherapy. These are: Better chances of recovery, a lower incontinence rate and a significantly lower impotence rate. These are all factors which, in younger men and men who are usually even more active sexually, mean a great gain in quality of life. Significantly lower treatment and downtimes of brachytherapy compared to surgery are also a further plus point for men who are still in professional life.

Fallacy No. 6: Men over 75 should no longer be treated

Life expectancy does not depend on age alone but on a number of additional factors. Chronic concomitant illnesses, physical fitness, but also independence and mental agility play an important role in determining how many years a patient has ahead of him/her. 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 an effective therapy here. 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.

Fallacy No. 7: The insertion of mini-implants (seeds) into the prostate causes "radiation gaps".

Within the framework of irradiation planning, it is determined how much radiation dose the tumour or organ is "prescribed". This is also referred to as the "organ-enclosing dose" or "prescription dose". The subsequent seed implantation guarantees that all areas of the prostate and tumor receive at least this amount of radiation. "Gaps" arise only with inexperienced therapists and poor therapy planning. Therefore, the choice of an experienced treatment team is always recommended.

Fallacy No. 8: After radiotherapy, it is no longer possible to operate.

The prejudice after irradiation can no longer be operated on in the case of a relapse is wrong in two respects. Firstly, tissue adhesions caused by radiation treatment, which are regarded as an obstacle to surgery, are nowadays significantly reduced by targeted irradiation and can therefore be easily controlled by an experienced surgeon. Secondly, the likelihood of the tumor reappearing in the prostate (local recurrence) is less than two percent. 98 percent of the recurrences after brachytherapy are not isolated local recurrences but metastases in other organs (remote metastases). Surgery is not indicated in such cases anyway.

Fallacy No. 9: Radiation therapy of the prostate favours the occurrence of bladder and colon cancer.

The fear that after successful radiation treatment of prostate cancer, a second tumor will develop is deep in many men. Wrongly, as numerous studies have now shown. For example, an American cohort study3 has shown that the risk of developing bladder or rectal cancer after irradiation of the prostate using brachytherapy as a second tumor is lower than after complete removal of the prostate. Newer and more precise techniques mean that most men's intestines and bladder are hardly exposed to radiation. State-of-the-art computer technology and the use of imaging methods make it possible to detect the target area with millimetre precision and irradiate it with pinpoint accuracy.

Fallacy No. 10: Robotic prostate surgery reduces the risk of incontinence and impotence.

The modern robot-assisted surgery, which is regarded biased as a "gentle" treatment option for the patient, has more side effects than previously advocated. For example, a cohort study has shown that the "robotic operation" is associated with an increased occurrence of late risks such as impotence and incontinence, which can be even more pronounced than with the conventional surgical procedure4, despite the minimally invasive technique, and that surgeons who perform a robot-assisted removal of the prostate must also have extensive experience.

Literature:

  1. Grimm P, Ignace Billiet I, Bostwick D et al. Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJUI 109, Suppl. 1, 22-29, 2012
  2. Barmer GEK Krankenhausreport 2012
  3. Zelefsky MJ, Pei X, Teslova T, Kuk D, Magsanoc JM, Kollmeier M, Cox B, Zhang Z: Secondary cancers after intensity-modulated radiotherapy, brachytherapy and radical prostatectomy for the treatment of prostate cancer: incidence and cause-specific survival outcomes according to the initial treatment intervention. BJU Int. 2012 Aug 13.
  4. Jim C. Hu, MD, MPH; Xiangmei Gu, MS; Stuart R. Lipsitz, ScD; Michael J. Barry, MD; Anthony V. D’Amico, MD, PhD; Aaron C. Weinberg, MD; Nancy L. Keating, MD, MPH: Comparative Effectiveness of Minimally Invasive vs Open Radical Prostatectomy; JAMA. 2009;302(14):1557-1564.

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