Prostate cancer: treatment

Possibilities of Prostate Cancer Treatment

In recent decades, the possibilities of prostate cancer treatment have greatly evolved. In principle, the treating physician may recommend one or more of the following strategies after the diagnosis of prostate cancer:

• Controlled watchful waiting
• Active Surveillance (“actice surveillance”)
• Surgery: removal of the prostate (“radical prostatectomy = total prostatectomy”)
• Radiotherapy (prostate cancer radiation from outside or inside)
• Hormone therapy
• chemotherapy
• Other therapies such as cold therapy and HIFU therapy (“High Intensity Focused Ultrasound”)

Individual therapy planning

The prostate cancer treatment is individually adapted to you as a patient. First and foremost, how far your prostate cancer has progressed and how aggressively it is growing is crucial for the planning of therapy.

The attending physician will explain in detail which form of prostate cancer treatment he thinks most appropriate in your case. This conversation should take place in peace and without time pressure. You can also take your partner, family member, or friend to talk: Many patients are in a state of emergency following the diagnosis of cancer and can barely absorb the amount of new information in this situation. According to experience, “four ears” absorb more of such a conversation. You can also take notes during the conversation. Do not be afraid to ask if you did not understand something. Do not let yourself be pushed to a therapy.

The following is an overview of the various options for prostate cancer treatment: You will learn how the various procedures are performed, when they are used and what are the advantages and disadvantages.

Controlled watchful waiting

Sometimes a prostate carcinoma grows very slowly and less aggressively. Instead of a prostate cancer treatment, doctors sometimes choose the strategy of controlled waiting: the tumor is monitored at regular intervals. If complaints arise, they are treated in a targeted manner. A prostate cancer treatment with the goal of a cure (surgery, radiation, etc.) is not initiated.

For example, “wachtful waiting” is useful for patients who are already quite old or whose life expectancy is probably less than ten years. Even in patients who also have other illnesses (high blood pressure, heart disease, etc.), one decides in a small, less aggressive prostate cancer often for the “watchful waiting”. This will save you the burden and potential side effects of a cure-oriented prostate cancer therapy.

Active surveillance

Similar to controlled waiting is the concept of active monitoring. This route is only possible if the patient fulfills certain requirements. This includes, for example, that the prostate carcinoma is very small and limited to the prostate and grows little aggressive. The patient then has to go to the doctor every three months for the first two years to have the tumor checked: this includes talking about possible complaints, palpation of the prostate (digital rectal examination, DRU) and determining the PSA value. At certain intervals, the doctor will also initiate a magnetic resonance imaging (MRI) and the removal and analysis of a tissue sample (prostate biopsy).

This close monitoring allows early detection as prostate cancer progresses. Then you can initiate a treatment.

Note: Discuss with your doctor if active monitoring is appropriate in your case.

Prostate cancer treatment: surgery

If the tumor is still completely confined to the prostate and has not spread beyond the prostate capsule, it can usually be completely cured by surgery. To do this, the prostate, along with the capsule surrounding it, the part of the urethra that runs through the prostate, the seminal vesicle, the vas deferens, and part of the bladder neck, must be removed. This procedure is called Radical Prostatectomy or Total Prostatectomy designated.

Access to the prostate can be done in three different ways:

• Lower abdominal incision between pubis and navel (retropubic radical prostatectomy)
• Laparoscopy (minimally invasive laparoscopic prostatectomy, “keyhole technique”)
• Perineal cut (perineal radical prostatectomy)

If necessary, additional adjacent lymph nodes are removed (lymphadenectomy), if they are suspected of being affected by tumor cells. This usually requires a lower abdominal incision or a laparoscopy. In the case of an episiotomy, an examination of the lymph nodes is only possible to a very limited extent. This approach is therefore chosen only in prostate cancer at a very early stage of the disease, when the lymph nodes are probably not yet affected by tumor cells.

The removed lymph nodes are examined histologically. If cancer cells are actually found, additional measures for prostate cancer treatment are required in addition to the surgery.

Attention: radical prostatectomy should not be confused with TURP (transurethral resection of the prostate gland). The prostate is “peeled out” of the urethra (urethra) from its capsule, the prostate capsule remains in the body. The TURP is only used for the treatment of benign enlargement of the prostate (Benign Prostatic Hyperplasia, BPH).

Prostate cancer surgery: side effects

Thanks to new surgical techniques, side effects and complications of prostate cancer surgery are much rarer today than they used to be. Nevertheless, patients should inform themselves about the risks before the procedure. Urinary urgency (urinary incontinence) and impotence (“erectile dysfunction”) are most common after surgery.

Urine dripping (incontinence)

When prostate cancer surgery weakens the sphincter, which is responsible for opening and closing the bladder (“sphincter”), resulting in urinary incontinence: Affected can no longer hold the urine. So uncontrolled go from smaller or larger urine quantities.

Urinary incontinence can severely limit daily life: many sufferers are ashamed and withdraw from social life. However, the weakened sphincter can also be trained again after the operation (for example with pelvic floor training). So twelve months after the radical prostate cancer surgery about 95 percent of men can hold the urine again.

If not, you can strengthen the sphincter surgically (“artificial sphincter”). In addition, sufferers can use deposits that catch the urine. This can reduce the restrictions in everyday life.

Impotence (erectile dysfunction)

In prostate cancer surgery, two nerve cords that are necessary for a normal erection of the penis can be injured. The nerve cords run on both sides directly along the prostate. They can only be spared during prostate cancer surgery if the tumor is still small and has not yet spread to the surrounding tissue. Before surgery, the surgeon can roughly estimate whether such a “nerve-sparing operation” will be possible – but he can not promise it. The full extent of the tumor spread is only apparent during the operation. For optimal chances of recovery the whole tumor tissue must necessarily be removed – if necessary even under damaging of said nerves. If the patient actually suffers from erectile dysfunction in the episode, various medications and adjuvants can lead to a largely normal erection ability.

Prostate Cancer Treatment: Radiotherapy

In radiation therapy (radiotherapy), the tumor is “bombarded” with ionizing radiation (X-rays). While the surrounding healthy cells can usually recover by repair mechanisms, the tumor cells die off.

Radiation is sometimes used in prostate cancer treatment when surgery is not possible (poor general condition) or rejected by the patient. However, it may also be performed in addition to surgery to remove tumor cells that could not be removed by the procedure.

Irradiation from the outside or from the inside

If one speaks of a radiation therapy for cancer, one usually means one Irradiation from the outside over the skin (external or percutaneous radiotherapy). With a so-called linear accelerator, the X-rays can be aligned very precisely on the tumor in order to preserve healthy tissue as far as possible. Most prostate cancer patients are irradiated several times a week (on weekdays) for seven to nine weeks. A single irradiation session takes a few seconds to minutes. Treatment is usually performed on an outpatient basis.

Meanwhile, in prostate cancer (and some other forms of cancer) is also one Irradiation from the inside possible. In this so-called brachytherapy The radiation source (radioactive substances) is introduced into the tumor. Treatment may be Low Dose Rate Brachytherapy (LDR) or High Dose Rate Brachytherapy (HDR):

In the LDR become so-called “seeds“These are small radioactive metal particles that remain permanently in the prostate gland, which emits radiation over a very short distance, and this radiation stops within a few weeks.” The then no longer radiating metal particles must remain intact in the body so not be surgically erased.

In the HDR Also, metal particles are introduced into the prostate. Unlike the seeds, they release a higher dose of radiation (at a short distance) and are removed after a few hours. This is usually done twice at intervals of several days. For this time, patients usually stay in the hospital. In addition to HDR, they usually receive conventional external radiation therapy.

Note: High Dose Rate Brachytherapy (HDR) is also called brachytherapy with afterloading procedures.

Irradiation: side effects

The side effects of radiotherapy arise from the fact that not only cancer cells are damaged, but to varying degrees, the healthy neighboring tissue. A distinction is made between acute and chronic side effects.

The acute side effects occur during radiotherapy. It includes irritation and redness of the skin. The mucous membrane in the bladder and urethra can also be irritated by the radiation and ignite. This is noticeable, for example, by a burning sensation when urinating. Also irritation and inflammation of the mucous membrane in the rectum is possible. This can cause pain in bowel movements, minor bleeding and diarrhea.

The acute side effects usually disappear after the end of radiotherapy. For relief, the doctor can often prescribe medication.

In some patients, prostate cancer radiotherapy causes chronic side effects respectively Long-term consequences, These may be, for example, an increased tendency to diarrhea and persistent bowel changes. Also permanent changes of the bladder and urethra as well as urinary incontinence are possible. Some patients also develop erectile dysfunction as a result of radiation. Last but not least, any radiotherapy can lead to a second tumor developing in the irradiated area years or decades later. In former prostate cancer patients, for example, this can be rectal cancer.

Note: The likelihood and extent of side effects depend on the type and intensity of radiotherapy.

Prostate Cancer Treatment: Hormone Therapy

Prostate cancer is hormone dependent in most patients: the male sex hormone testosterone promotes tumor growth. This fact uses the hormone therapy in prostate cancer: the testosterone is removed from the body or its effect is slowed down to prevent tumor growth. This can stop prostate cancer for many months or years. A cure is not possible with a sole hormone therapy. However, it may be useful in combination with other therapies (for example radiotherapy) in advanced prostate cancer.

Hormone treatment in prostate cancer can be done in different ways:

Operative castration

Testosterone is produced in the testicles. By surgically removing the testicles, the testosterone levels can be permanently and irreversibly lowered. But this radical intervention is rarely done.

Chemical (drug) castration

The patient receives medication that prevents testosterone formation in the testes. In contrast to surgical castration, chemical castration is completely reversible – after discontinuation of the medication, the testes resume testosterone production.

The drugs used include so-called GnRH agonists (also called LHRH agonists): They are structurally similar to the natural hormone GnRH (gonadotropin-releasing hormone), which is formed in the hypothalamus in the brain. It binds to special receptors of the pituitary gland (pituitary gland) and stimulates them to release the hormones LH and FSH. These two hormones in turn stimulate the testicular tissue to produce testosterone.

GnRH agonists intervene in this regulatory cycle: they can also bind to the corresponding receptors of the pituitary, but longer and stronger than the natural GnRH. This briefly increases the secretion of LH and FSH from the pituitary gland and, consequently, testosterone production. After a short time but it comes to a “depletion” of the pituitary gland: It releases no more LH and FSH, making the testes no longer testosterone. GnRH agonists are thus administered depot injection under the skin. Their effect lasts for a long time.

Also suitable for chemical castration are so-called GnRH antagonists, also called GnRH blockers or LHRH antagonists. They block the receptors of the natural GnRH in the pituitary gland. Thus, the signal for LH and FSH release is missing – the testosterone production in the testes decreases. GnRH antagonists are injected under the skin as a regular injection at regular intervals (a sustained release depot syringe is not available).

Treatment with antiandrogens

Sometimes hormone treatment for prostate cancer is called antiandrogens: androgens are the male sex hormones, with testosterone being their main agent. Antiandrogens are drugs that occupy the docking sites of androgens in the prostate. Testosterone and other androgens can not dock and exert their effect. Some antiandrogens can also block some of the testosterone production.

Overall, antiandrogens thus reduce the testosterone effect in the body. The growth of prostate cancer is affected. Antiandrogens are taken daily as a tablet.

Treatment with abiraterone

In certain cases, the drug abiraterone can be used to treat prostate cancer hormones. It inhibits the formation of a protein that is necessary for the production of testosterone. This not only works in the testes, where most of the testosterone is produced. Even the slight formation of testosterone in the adrenals and the cancer cells themselves is suppressed by abiraterone. The drug is taken daily as a tablet.

Treatment with female sex hormones

In principle, one can also inhibit the testosterone effect by administering female sex hormones (estrogens) to prostate cancer patients. Because of the possible side effects (such as thrombosis) but you hardly do that.

Hormone therapy: side effects

If the amount or effect of testosterone is significantly reduced, this will not be without undesirable consequences. Possible side effects of prostate cancer hormone therapy include (depending on the type of treatment) hot flashes, chest pain and breast enlargement (gynecomastia), weight gain, muscle loss, bone loss (osteoporosis), and anemia. There is also a risk of decreased sexual desire (loss of libido), impotence (erectile dysfunction) and loss of fertility.

In the longer term, hormone treatment for prostate cancer may also increase the risk of cardiovascular disease. This is under discussion but still discussed.

Prostate Cancer Treatment: Chemotherapy

Like hormone therapy, chemotherapy works throughout the body (systemic therapy). Certain medicines (so-called cytostatic drugs) are administered via the vein, which prevent the growth and division of cells. Especially fast-growing cells such as cancer cells are particularly sensitive to this.

Prostate cancer chemotherapy may be considered if the tumor has already formed daughter (metastasis) in other parts of the body. It can also be used with hormone therapy. In patients with advanced prostate cancer who are unresponsive to hormone therapy, chemotherapy may be a viable alternative.

Chemotherapy: Side effects

Cytostatic agents also affect healthy cells, especially those that normally divide rapidly. This explains the side effects of chemotherapy such as hair loss, skin problems, nail changes, nausea and vomiting, as well as changes in the blood count (such as lack of white and red blood cells). In part, such side effects can be alleviated with countermeasures, such as special medication for nausea and vomiting (antiemetics).

Other therapy procedures

If the prostate cancer has not yet spread over the connective tissue capsule, there is a possibility of a cold therapy (Cryotherapy). The tumor tissue is iced up. According to current expert opinion, cold therapy is not suitable for the treatment of locally limited prostate cancer.

Another possibility of prostate cancer treatment in a locally limited tumor is a special ultrasound therapy, the so-calledHIFU (High Intensity Focused Ultrasound), The tissue is strongly heated with ultrasonic waves and destroyed in this way. The ultrasound is directed either to the whole prostate (whole gland therapy) or only to the limited tumor (focal therapy). The HIFU is still considered an experimental method, for which there are not so many empirical values ​​(long-term experience). For this reason, HIFU therapy should initially only be used in clinical trials.

Also, some other methods of prostate cancer treatment have so far been recommended only in studies such as Irreversible Electroporation (IRE) and Vascular Photodynamic Therapy (VTP).

Treatment of metastases

In the advanced stage, a malignant prostate tumor has already formed settlements in other body regions (metastases). Most commonly, these are bone metastases, In some patients, they cause no discomfort. Often, however, they cause pain and make the affected bones more fragile. Then you can specifically irradiate the bone metastases. This can stop the decomposition of the bone, reduce the pain and prevent bone fractures.

In addition, the doctor may prescribe medications such as analgesics and bisphosphonates (anti-bone grafting agents). In certain cases, so-called radionuclide therapy may also be considered for bone metastases. This is a kind of radiation from the inside: The patient gets radiant chemicals that the body specifically builds into the bone metastases. The short-range radiation destroys the cancer cells.

Sometimes bone metastases (if possible) are also surgically removed. In addition, patients usually receive radiotherapy.

In addition to bone metastases, advanced prostate cancer can also be Metastases in the liver, lungs or brain form. The Prostate Cancer Treatment As far as possible, this also includes measures aimed specifically at the secondary tumors (radiotherapy, chemotherapy, possibly surgery, etc.).