Treat or wait and see?

Clinical study examines the concept of "active monitoring" as an alternative therapy option

More and more prostate carcinomas are being detected at an early stage thanks to more sophisticated examination methods. At the same time, there is growing uncertainty as to whether all diagnosed tumours actually require invasive therapy, such as radical surgery. Alternatively, patients with low risk prostate cancer can be closely monitored. Whether the concept of "Active Surveillance" actually works is currently the subject of a major international study.   

For patients with a low-risk prostate carcinoma, the "Active Surveillance" is a further therapy option, namely the "non-treatment". 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 leave the possibility of therapy open at a later stage,"explains Dr. Pedram Derakhshani, urologist at the West German Prostate Center in Cologne.

More than 30 percent of patients are treated after three to four years

The treatment concept is currently being examined in a large international study1, the first results of which were presented at this year's conference of the European Society of Urology (EAU) in Vienna.  The results are worse than expected: After all, every third patient had to undergo active treatment within three to four years due to increased PSA values or a deterioration in the biopsy findings. Thereby, aggressive tumors were found again and again that had already crossed the capsule boundary. In such cases, treatment is often too late because metastases may have already developed.

Low side-effect treatment: brachytherapy

We have not yet been able to monitor patients with a low-risk tumor so reliably that we can always intervene in time if the disease progresses,"said the urologist from Cologne. That's why we're left with only one option at present: to make the therapy less prone to side effects. Radical treatment approaches such as surgical removal of the prostate gland are not justified in many cases because of the frequent complications such as incontinence and erectile dysfunction.

Brachytherapy (inner radiation) has proven to be a particularly gentle but effective treatment for prostate cancer. Smallest radiation sources are introduced directly into the prostate. The exact distribution of the radiation dose allows us to irradiate the tumour without damaging the surrounding tissue such as the urethra, intestine or sphincter,"said Derakhshani. Several studies have shown that erectile dysfunction and urinary incontinence occur much less frequently than prostate surgery (14% vs. 70%; 0.3-3% vs. 50%). 2 

Living with the tumor: a burden on the psyche

In addition, the active monitoring of the tumor leads to psychological stress in many patients, which can considerably reduce the quality of life of those affected. Patients live with the knowledge that there is a tumour in their body that can change in size, extent and aggressiveness every day,"said Derakhshani. In his experience, not all patients are able to deal with this calmly.

  1. Source: 26th Annual congress of the European Association of Urology (EAU) 2011
  2. Chen R. C.; Clark J. A., Talcott J. A.,: Individualizing Quality-of-Life Outcomes Reporting: How localized prostate cancer treatments affect patients with different levels of baseline urinary, bowel and sexual function; Journal of Clinical Oncology, 2009,27 (24), 3961-3922

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