Prostate carcinoma: Wait and see and do nothing?
Active monitoring as an equal treatment option for prostate cancer
Thanks to improved early detection, more and more prostate carcinomas are being detected at an early stage and, in Germany in particular, radical surgical therapy is still being applied. Many of these tumors would never cause any discomfort, let alone death. Defensive strategies such as "active monitoring" or therapies with few side effects such as brachytherapy are becoming increasingly important in order to counteract "over-therapy".
The therapy recommendation for Heinz L. from Bornheim is "wait and see". Two weeks ago, the 58-year-old businessman was diagnosed with prostate cancer as part of a preventive examination. Every three months, he has to go to his treating physician to check whether the tumor has changed by means of a PSA test and palpation. In the case of a very early stage of prostate carcinoma with low tumor load and a very favorable, non-aggressive prostate carcinoma, it may be sufficient to carry out regular examinations first and to observe the tumor "actively". However, as soon as there are initial indications that the tumor disease is progressing, appropriate therapy measures will be taken,"explains Dr. Pedram Derakhshani, urologist at the West German Prostate Center.
Radical surgery usually not justified
One in six men over the age of 50 is diagnosed with prostate cancer. However, 90 percent of patients have a tumor that is limited to the prostate gland and has not formed metastases. Due to the favorable nature and nature of the tumour or due to its age, no clinically relevant tumour growth is to be expected in many patients. Against this background, the question arises as to whether a radical approach to treatment is justified in any case,"says Derakhshani. Recent studies show that the operation is sometimes associated with considerable side effects. Up to 50 percent of those undergoing surgery suffer from stress incontinence and 30 to 100 percent from erectile dysfunction. 12 The German Society of Urology (DGU) drew its conclusions from this and recommends that in the current guidelines for cancer patients who are eligible for local curative treatment, in addition to conventional therapy methods such as radiotherapy or radical prostate removal in special cases, the so-called Active Surveillance (in German: Active Monitoring) should also be considered as a possible alternative.
Active monitoring is not an actual therapy, but rather a strategy. The tumor is to be controlled in the first two years by PSA determination and the digital rectal examination every three months. If the PSA value remains stable, the period is extended to six months. Furthermore, it is recommended to perform a biopsy every 12 months. Signs of progression of the tumor disease are given if the PSA value doubles in less than three years or if the degree of aggressiveness deteriorates significantly after evaluation of the tissue sample (Gleason score > 6).
Psychological stress caused by "active surveillance"
The knowledge of a tumour in the body, however, can lead to a considerable psychological burden,"said Derakhshani. The quality of life may be considerably reduced as a result. In addition, patients have to meet the exact examination appointments with their urologist in order to ensure that they do not miss the progression of the disease and the resulting need for therapy.
A solution to this dilemma is provided by therapies that are considerably gentler than surgery while at the same time maintaining the quality of life. Despite the same chances of recovery, there are considerably fewer side effects with the so-called brachytherapy, for example, than with the radical removal of the prostate. 3 This internal radiation has a major advantage over surgery:"By exactly distributing the radiation dose, we can irradiate the tumour without damaging surrounding structures such as the urethra or sphincter muscle," explains Dr. Gregor Spira, radiotherapist at the WPZ. Several studies have shown that erectile dysfunction occurs after radical surgery at 70 percent and after seed implantation at 14 percent4, while urinary incontinence, which is up to 50 percent after radical removal of the prostate, is also negligible at 0.3 to 3 percent after seed implantation. This allows the patient to combine the advantage of optimal tumor healing with fewer side effects compared to surgery.
- Consultation version of the S3 guideline on prostate cancer 2009, German Society of Urology (DGU)
- Thompson I, Thrasher JB, Out of G, Burnett AL, Canby-Hagino ED, Cookson MS, D' Amico AV