PSA test remains standard

Focus on treatment with few side effects

The PSA test for early detection, prognosis and assessment of the course of therapy will continue to be indispensable in the future. The experts and the German Society of Urology (DGU) agree on this. Rather, more attention should be paid in the future to effective yet gentle treatment in order to avoid serious side effects such as incontinence and impotence,"says Dr. Pedram Derakhshani, urologist at the West German Prostate Center.

Prostate cancer is the most common malignant tumour in men: Every year, more than 58,000 men in Germany fall ill and 11,000 die from the consequences of the disease. Thanks to improved early detection methods, we are now able to detect tumors in the prostate at an ever earlier stage,"said Dr. Derakhshani. In addition to the legal early detection by touch examination, a simple blood test for the determination of the prostate specific antigen (PSA test) has been available for more than 20 years now. In the case of prostate gland tumours, the PSA is often elevated and, in addition to scanning the prostate gland and ultrasound examinations, gives the greatest possible security to detect prostate cancer at a stage that is still curable,"said the urologist from Cologne.

Despite its success story, the PSA test is currently under discussion. This is the result of two studies recently published in the journal "New England Journal of Medicine". The European study1 with 182,000 participants showed that by using the PSA test across the board in healthy men aged 65 to 69 years, the probability of dying from prostate cancer could be reduced by 20 percent. In the much smaller American investigation2, on the other hand, no tangible difference in the mortality rate was found. According to the experts, the different study results may be attributed to the fact that in the American study almost half of the patients in the control group had a PSA test carried out in contrast to the study protocol. The American investigation is therefore only of limited significance,"explains Derakhshani.

More harm than good?

Statistically, according to European data, a total of 48 men must be treated in order to prevent the death of prostate cancer. These figures are quite comparable to the accepted methods for breast or colon cancer. Since prostate cancer often occurs at an advanced age, grows slowly in general and may therefore never cause symptoms, there is sometimes the risk of "over-therapy". This should be included in the considerations, especially since prostate cancer patients have to accept serious side effects depending on the type of treatment,"says Dr. Stephan Neubauer, also a urologist at the West German Prostate Center. Radical prostate surgery, which is still the most common treatment in Germany, is often accompanied by a high incontinence and impotence rate. Every 10th patient can no longer hold the urine after surgery, almost two thirds suffer from impotence.

However, it is not a solution to remove the PSA test from the early detection inventory,"said Neubauer. Rather, we should have methods at our fingertips in the future to be able to identify dangerous tumours more effectively in order to avoid unnecessary biopsies. In addition, the focus in the treatment of prostate cancer patients must be increasingly on achieving optimal cure rates with minimal side effects. Modern radiotherapy methods such as brachytherapy are particularly suitable for this purpose. In contrast to radical removal of the prostate, the prostate gland remains intact. The ultrasound-guided introduction of radioactive pencils (seeds) directly into the prostate gland destroys the tumour and at the same time protects the surrounding tissue. According to Gregor Spira, radiotherapist at the West German Prostate Center,"Incontinence is virtually non-existent after brachytherapy and impotence is observed much less frequently. The advantage of "internal irradiation" is that patients have to accept significantly lower side effects for the treatment without fearing any loss of healing.

Despite all the criticism, we must not forget that the PSA test can also save lives,"says Neubauer. However, it is still the case that PSA values are interpreted incorrectly and acted prematurely, according to the Cologne urologist, for example, that due to briefly increased PSA values a biopsy is initiated instead of initially observing the course of the values in a short period of time. The patient must also be informed in detail about the benefits, but also about the risks and possible consequences of PSA testing,"says Neubauer.

Literature:

  1. Schröder FH et al.: Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009 Mar 26;360(13):1320-8. Epub 2009 Mar 18.
  2. Andriole GL et al.: Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009 Mar 26;360(13):1310-9. Epub 2009 Mar 18.

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