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Prostate Carcinoma: Just wait and see, and not do anything?

Thanks to improved early detection methods, prostate carcinoma are more often discovered at an early stage, and especially in Germany this still leads to radical surgical procedures. At the same time, many of these tumors would never cause any problems, let alone cause death. In the battle of this “overtreatment“, the defensive strategies such as the „active surveillance“ or the low-risk brachytherapy with few side effects become very essential therapies.

Wait and see – observation of the tumor was the treatment recommended to Heinz L. from Bornheim, Germany. Two weeks ago, the 58-year-old businessman was diagnosed with prostate cancer during a preventive medical checkup. Heinz L. will now undergo PSA testing and palpation every three months at the office of his treating physician, in order to determine whether or not the tumor has changed. „In a very early stage of prostate carcinoma with low tumor burden and a favorable-risk, non-aggressive prostate carcinoma, it can be sufficient to undergo regular tests and to observe the tumor „actively”. If the cancer is seen to be growing or becoming more aggressive, further treatment may be called for“, explains Dr. Pedram Derakhshani, urologist at the West-German Prostate Center.

Radical surgical procedures are often not justified
Every sixth male over the age of 50 is currently diagnosed with prostate cancer. However, 90 per cent of the patients have a tumor that is confined to the prostate, and which has not formed metastases. Based on the favorable characteristics of the tumor or the patient’s age, in quite a few cases a clinically relevant tumor growth is not to be expected. „Against this background, it is questionable whether a radical treatment approach is justified in each and every case“, says Derakhshani. Recent studies show that some of the surgical procedures bear high risks and often involve considerable side effects. For example, almost 50 per cent of the patients undergoing radical surgery suffer after the procedure from stress incontinence, and 30 to 100 per cent of the patients suffer erectile dysfunction. The German Society of Urology (Deutsche Gesellschaft für Urologie, DGU) responded immediately to these studies. In its current guidelines, the DGU recommends for cancer requiring localized curative treatment in addition to the conventional therapy methods, e.g. radiotherapy or the radical prostate removal, in special cases also the so-called active surveillance as a possible alternative. The active surveillance is not an actual therapy, but rather a strategy. The tumor will be monitored every three months during the first two years by means of PSA tests and digital rectal examinations. If the PSA level remains stabile, the testing is prolonged for a period of six months. Additionally, the guidelines recommend that a biopsy be performed every 12 months. Indications for the progression of a tumor are presents, if the PSA level doubles in less than three years or if the tissue samples show that the cancer has clearly worsened, e.g. reached a higher degree of aggression (Gleason-Score > 6).

Psychological stress resulting from „Active Surveillance“
„The knowledge that there is a tumor inside the body, can nevertheless cause extensive psychological stress“, so Dr. Derakhshani. The life quality can in some cases become restricted, since patients must make numerous visits to the treating urologist at exactly the times scheduled in the treatment plan in order not to miss any progression of the decease and the needed therapy resulting from the changes.

Solutions to this dilemma are therapies that are clearly more gentle than surgical procedures, and which allow for maintaining the desired life quality. These are internal radiation therapies. Although the chances of recovery are equal, one form of internal radiation therapy, the so-called brachytherapy bears considerably fewer side effects than the radical removal of the prostate. Internal radiation offers an essential advantage in comparison to the surgery: „with an exact distribution of the radiation dose, we can administer radiation to the tumor without damaging the surrounding structures such as the urethra or the sphincter “, explains Dr. Gregor Spira, radiotherapist at the West-German Center. A number of studies show that an erectile dysfunction after a radical surgery procedure occurs in 70 per cent of the patients, and occur after a seed implantation in 14 per cent of patients. In addition, urinary incontinence, which after the radical removal of the prostate occurs in 50 per cent of the cases, proves with 0.3 to 3 per cent after a seed implantation relatively small. This allows the patient to meaningful combine an optimal tumor treatment with relatively few side effects that may occur in comparison to radical surgery.


1 Consultation Issue of the S3 Guideline for Prostate Carcinoma 2009 (Konsultationsfassung der S3-Leitlinie zum Prostatakarzinom 2009), Deutsche Gesellschaft für Urologie (DGU)

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