Treatment in the early stages
Treatment in the early stages, When the diagnosis of prostate cancer is established and the extent and stage of the disease have been determined, the doctor decides together with the patient which options of treatment are used. Here you will find information about the following treatment methods in the early stages:
- Local therapy
- Hormone therapy
- Curative or palliative therapy
Prostate carcinoma is one of the types of cancer, which is often slow to grow and is not always a direct threat to those affected. In addition, more and more tumors are discovered at a very early stage, so that therapy may be initiated, although carcinoma would never have caused any problems. It is therefore necessary to consider whether the benefit of a treatment is in a sensible relationship to its risks and to the expected side effects . Therefore, waiting strategies for prostate carcinoma are of paramount importance. One differentiates between two different procedures: “Watchful Waiting” and “Active Surveillance”.
In the case of waiting, the tumor is not treated for the time being – independent of the tumor stage. The palliative treatment begins only when symptoms occur. Patients whose tumors could potentially be cured should only be waited if their life expectancy is less than ten years due to age or other diseases, and the Gleason score is not above 7.
In the case of active monitoring (“active surveillance”), patients are closely monitored in order to be able to initiate a curative treatment in good time. If the tumor remains unobtrusive, it is not treated. If, however, the disease progresses, a radical prostatectomy usually takes place, alternatively an irradiation.
Active monitoring is also suitable for younger patients without severe other diseases that meet the following criteria:
- Life expectancy> 10 years
- PSA value ≤ 10 ng / ml
- Gleason Score ≤ 6
- Localized prostate carcinoma (cT1-2a),
- Tumor in ≤ 2 punchings
- Tumor incidence per stanza ≤ 50%.
The regular controls include the determination of the PSA value and a digital-rectal examination every three months. If the PSA value remains stable for two years, the control interval can be extended to 6 months. In addition, a biopsy should be carried out after half a year, every 12 to 18 months for the next three years, and then every three years if the results are stable.
The criteria for the termination of the waiting strategy and the start of active therapy are not uniformly defined. Evidence that the disease progresses rapidly gives rise to increasing PSA levels, worsened Gleason scores, and higher tumor levels in control biospies. And, of course, at any time, the patient can decide not to wait any longer, but to actively take action against the tumor.
If the cancer is confined to the prostate, it can be eliminated by surgical removal of the prostate . In the so-called radical prostatectomy, the prostate and seminal vesicles are removed. Various surgical techniques can be used:
- Retropubic : cut in the abdomen
- Perineal : section through the perineum (perineum) between the anus and the penis root
- Laparoscopic : endoscopic operation through several accesses in the abdomen (often robot-assisted)
The three procedures are currently considered to be equivalent in terms of the success of the operation, the frequency of complications, and the rate of undesirable sequelae.
Sometimes the lymph nodes in the pelvis are also removed during the operation (lymphadenectomy). This is done in order to determine the extent to which the disease has spread and which further treatment is necessary during the microscopic examination.
How effective is the operation?
The chances for a permanent cure are very good by a radical prostatectomy, especially if the tumor can be completely removed (“R0-resection”). However, the further the cancer has progressed, the lower the possibility of achieving R0 resection and thus higher is the risk of relapse.
What are the consequences of the surgery?
Despite the ever-improved surgical technique, undesirable consequences of radical prostate removal such as loss of erectile ability (impotence) and unwanted urination (urinary incontinence) can not be completely avoided. It is difficult to say how often these complications occur, since different surgical procedures and different tumor stages have been investigated in the studies, which is why the results differ greatly.
Intermittent urinary incontinence is relatively frequent (low: up to 50% of patients, high: up to 15%). It usually takes a few weeks or months until the holding function of the urethral sphincter is completely restored, especially when stressed as coughing or sneezing. Through a targeted training, so-called Beckenbodentraining, a long-term incontinence can successfully be counteracted. A permanent incontinence occurs in about 5 to 10 percent of the operated patients.
The limitation or loss of erectile dysfunction (erectile dysfunction, impotence) is due to the prostate removal that damages the nerve cords responsible for the erection. These nerve cords run right and left along the prostate. Depending on how far the cancer has spread, one or both nerve bundles can be spared during surgery. Nevertheless, up to 80% of the patients undergoing surgery can remain permanently impotent, depending on the tumor spread and the experience of the surgeon.
Rare side effects of radical prostatectomy are scarcity narrowings of the bladder neck (anastomotic stricture), injuries of the rectum and fecal incontinence.
In radiation therapy , radioactive radiation is targeted directly at the tumor. As a result, the cell nuclei of the cancer cells are so severely damaged that cancer cells can no longer divide and perish. Basically, radiotherapy is used for localized and locally advanced tumors, the latter in combination with a supporting (neoadjuvant) hormone therapy.
In some patients radiotherapy is performed as an additional measure after surgery (adjuvant radiotherapy). This is intended to reduce the risk of recurrence ( recurrence ).
There are two different types of irradiation: from the outside (percutaneous: lat. “Through the skin”) and from the inside (brachytherapy: Greek “short, near”).
In percutaneous radiotherapy, the tumor is irradiated by a radiation source outside the body. The prostate is first accurately imaged with the aid of computer tomography . On the basis of this, the area can be determined which is to be hit by the radiation.
The radiation source is then directed from several sides exactly to the tumor. The effective radiation dose is reached only where the rays cross over from the various directions; The surrounding healthy tissue is spared.
A total dose of 74 to <80 Gy (Gray = energy dose of radiation) is administered over several weeks; The single radiation dose is 1.8-2 Gy per day.
As an alternative to external irradiation, the radiation source can also be brought directly to the tumor. In this method called brachytherapy, small radioactive particles are implanted directly into the prostate. These radiation sources remain in the prostate at short notice (afterloading) or permanently (“seeds”).
In the case of the seed implantation (also LDR brachytherapy: “low dose rate”), the smallest radiation sources with short radiation, the so-called seeds, are inserted into the prostate. Seeds are placed with the aid of puncture needles: under ultrasound control, the short radiolaryts are placed at specifically selected points of the prostate. The radioactive radiation emitted by the seeds destroys the cancer cells directly from the inside. The placement of the seeds takes about two hours and takes place under a light general anesthesia or a spinal anesthesia. In early stage prostate cancer, brachytherapy is as effective as radiation from the outside; It is not recommended for locally advanced or aggressive prostate cancer.
In the case of afterloading (“recharge procedure”, also HDR brachytherapy: “high-dose rate”), a radioactive radiation source is inserted into the prostate via a hollow needle. For example, high local doses (HDR) can be administered precisely, while at the same time the surrounding tissue is spared. This form of treatment is currently always combined with external radiation.
How effective is radiation therapy?
Information on the efficacy of radiotherapy is difficult because of different dosages and procedures. In addition, as in the case of prostatectomy, the results are dependent on the tumor stage and other risk factors. On the whole, surgery and radiation are seen as equivalent procedures, especially in early tumors. In practice, therefore, the different side effects to be expected are often a decisive criterion for the choice between surgery and irradiation.
What are the consequences of radiotherapy?
Despite modern irradiation techniques, discomfort due to radiation therapy is possible, such as inflammation of the bladder and intestine. These symptoms can occur acutely, ie during therapy, or shortly thereafter, but there are also late episodes, which only cause months or even years after irradiation problems.
Radiation therapy also often leads to potency problems in up to 60% of patients, but less frequently than after surgery. Incontinence occurs less frequently after irradiation than after radical prostatectomy.
Other local therapy procedures
There are several newer methods currently being tested. However, since not enough results are available, they are not yet recommended, or only in the context of studies.
In cryotherapy or cryosurgery, cells are killed by subcooling. For this, the physician places 12-15 cryonadules under ultrasound control in the prostate. These are then cooled twice to -40 ° C. and thawed again.
In the case of High Intensive Focused Ultrasound (HIFU), high-energy sound waves are transmitted to the prostate via an ultrasound probe placed in the ultrasound. As a result, the tumor tissue heats up to above 65 ° C and dies.
The only hormone therapy is not a curative treatment and is therefore generally not used in curable prostate carcinomas – unless the patients wish it explicitly. However, there are also situations with local or locally advanced prostate cancer, in which hormone therapy can be used. Then she has the goal to improve the effect of curative local therapy:
- Two to three month (neo) adjuvant hormone therapy has been shown to be beneficial in patients with locally advanced prostate cancer who receive radiation therapy.
- A two to three-year adjuvant hormonal therapy is useful for patients with locally advanced tumor, high progressive risk and / or lymph node metastases after radiation therapy.
- If lymph node metastases are discovered, at least two years of adjuvant hormonal therapy can be performed after radical prostatectomy.
However, most patients receive hormone therapy if metastases are already present at the time of diagnosis or if their cancer has progressed after a previous curative therapy trial.
As for many other types of cancer, there are also different national and international guidelines for prostate cancer that are developed and regularly updated based on the latest research results. They help the doctors in decision-making in specific situations. The most important treatment recommendations for prostate cancer are:
- S3 Guideline of the German Cancer Society and various specialist companies
- Guidelines of the European Society of Urology (EAU)
- Clinical Practice Guidelines of the American National Comprehensive Cancer Network ( NCCN )
In addition to these specialist publications, patient guidance lines are also presented which, in a generally understandable language, reflect the current recommendations.
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