HIFU: "Lack of sufficient Data"

Despite the growing interest in HIFU therapy it remains an experimental procedure in localized prostate cancer. Focused ultrasound waves are directed through a bundling lens into the prostate. At the "hot spots" temperatures of around 90 degrees Celsius are achieved, which should destroy the tumor tissue. The HIFU technology (high intensity focused ultrasound) is increasingly asked for to treat localized prostate cancer. However, the method remains highly controversial among experts.

Laser are safer than conventional resection of the prostate

“Men diagnosed with prostate cancer are still not thoroughly informed about urinary incontinence as a consequence of surgery prior to undergoing the procedure,”complains Dr. Stephan Neubauer, Urologist at the West German Prostate Center. Many men are affected by the involuntary loss of urine despite more advanced surgical techniques. However, details of the actual incidence are still incomplete. "For example the statistical numbers for urinary incontinence often differ vastly depending on the type of study they were derived from, e.g., how and when they were determined. Usually these numbers are far removed from realty," says Dr. Neubauer.

MRT: Ist die Biopsie überflüssig?

Vor allem Patienten, deren PSA-Werte trotz negativer Biopsie weiterhin steigen und der Krebsverdacht bestehen bleibt, profitieren von der MRT-gestützten Biopsie.
Diagnose ganz ohne Biopsie? Immer wieder wird Patienten mit Verdacht auf Prostatakrebs suggeriert, dass eine Gewebeentnahme heute überflüssig ist. Stattdessen reiche eine Kernspintomographie (MRT) der Prostata aus, um den Krebsverdacht zu bestätigen.

Prostate Cancer: Is biopsy still necessary?

Especially patients whose PSA level continues to rise despite a negative biopsy and for whom the suspicion of cancer remains do still benefit from the MR-guided biopsy.
Diagnosis entirely without a biopsy? Time and again, it is proposed to patients with suspected prostate cancer that nowadays a tissue sample is unnecessary, and that instead, a magnetic resonance imaging (MRI) of the prostate can sufficiently confirm the suspicion of cancer.

Laser are safer than conventional resection of the prostate

“Men diagnosed with prostate cancer are still not thoroughly informed about urinary incontinence as a consequence of surgery prior to undergoing the procedure,”complains Dr. Stephan Neubauer, Urologist at the West German Prostate Center. Many men are affected by the involuntary loss of urine despite more advanced surgical techniques. However, details of the actual incidence are still incomplete. "For example the statistical numbers for urinary incontinence often differ vastly depending on the type of study they were derived from, e.g., how and when they were determined. Usually these numbers are far removed from realty," says Dr. Neubauer.

“Men diagnosed with prostate cancer are still not thoroughly informed about urinary incontinence as a consequence of surgery prior to undergoing the procedure,”complains Dr. Stephan Neubauer, Urologist at the West German Prostate Center. Many men are affected by the involuntary loss of urine despite more advanced surgical techniques. However, details of the actual incidence are still incomplete. "For example the statistical numbers for urinary incontinence often differ vastly depending on the type of study they were derived from, e.g., how and when they were determined. Usually these numbers are far removed from realty," says Dr. Neubauer.

Recent study assessing the realities of care

How many patients actually experience incontinence after prostate surgery has now been shown by a study that was published recently in the medical journal “Der Urologe.” In this study, a team of scientists assessed the medical records of all patients who received follow-up treatments in 2009 at the Klinik am Kurpark in Bad Wildungen following surgical removal of the prostate. Evaluated were 1750 patients with an average age of 65. Recorded were the age of the patient, PSA levels prior to surgery as well as the surgical procedure selected.

The result of the investigation cannot be any clearer: Three months after surgery, two-thirds of the patients were unable to hold their urine, despite the rehabilitation measures such as pelvic training. The degree of incontinence differed and ranged from urine leaks and wearing inserts and pessaries up to the permanent use of diapers. Conversely, only one third of the men left the rehab facility as continent. “The figures reflect the results we know from our daily practice," says the Cologne urologist. When and if at all, affected men can overcome their incontinence, remains currently still unknown. Generally, we can assume that the longer the duration of incontinence, the higher the probability that the patient cannot keep the urine even after 12 months.  Noticeable was also that no matter what the operating method had been, there was no difference in how frequent urinary incontinence occurred. Even the propagated particularly safe robot-assisted surgery did not protect against the dreaded loss of urine.

"The high incidence of urinary incontinence as a result of the surgery is all the more serious considering that many men with prostate cancer still undergo surgery unnecessarily," says Dr. Neubauer. As recommended in the guidelines for men with prostate cancer at low risk, it might therefore often be sufficient to monitor the tumor closely (Active Surveillance). “Should surgical procedures become necessary, it will be important to shift the focus more on achieving the best cure rates with the most minimal side effects,” so the urologist from Cologne. “It is therefore our duty,” continues Neubauer, “to alert the patient before the therapy to more effective but less invasive treatments, such as brachytherapy (internal radiation)."
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Literature: 
¹Lent V.Schultheis H.M., Strauß L. et al.: Belastungsinkontinenz nach Prostatektomie in der Versorgungswirklichkeit; Urologe 2013 – 52:1104-1109

Prostate cancer with 75

Who benefits from a treatment and who does not?

Is it worthwhile for 75-year-old men to undergo a therapy of prostate cancer or are the elderly better off with a wait and see approach? Experts demand in addition to the age factor that the decision for treatment should be based on the health condition, the size, and type of the tumor as well as the individual needs of patients. Prostate cancer is after all not called for nothing the cancer of old men.  Fact is that every fourth patient affected is older than 75 at the time the diagnosis is made. Although prostate cancer is particularly prevalent in the elderly, men above the age 70 regularly slip through the cracks of preventive strategies. "The decision whether the patient receives a “curative” therapy or not is unfortunately often still made ??exclusively dependent on the patient's age," criticizes Dr. Stephan Neubauer, Urologist at West German Prostate Center in Cologne.

Who benefits from a treatment and who does not?

Is it worthwhile for 75-year-old men to undergo a therapy of prostate cancer or are the elderly better off with a wait and see approach? Experts demand in addition to the age factor that the decision for treatment should be based on the health condition, the size, and type of the tumor as well as the individual needs of patients. Prostate cancer is after all not called for nothing the cancer of old men.  Fact is that every fourth patient affected is older than 75 at the time the diagnosis is made. Although prostate cancer is particularly prevalent in the elderly, men above the age 70 regularly slip through the cracks of preventive strategies. "The decision whether the patient receives a “curative” therapy or not is unfortunately often still made ??exclusively dependent on the patient's age," criticizes Dr. Stephan Neubauer, Urologist at West German Prostate Center in Cologne.

As shown by multiple studies in an impressive way, life expectancy does not only depend on the age itself but on a number of other factors. Thus, chronic comorbidities, physical fitness but also mental agility, and independence play a significant role in how many years a patient’s life expectancy is extended¹. "Many seniors are still, also beyond 75, in the middle of life, are physically active, interested in many things, and enjoy good health," concludes Neubauer, thereby referring to experience from his daily practice. The Cologne urologist certifies the majority of his 75-year-old patients an average life expectancy of at least 10 to 15 years. Why should they not enjoy an effective therapy?

Patients over 70 are less likely to receive curative therapy

The Society for Geriatric Oncology (SIOG) recommends that healthy older people with prostate cancer should receive the same treatment as do younger prostate cancer patients. However, as is shown in a number of popular studies¹, in practice that this is not the case. According to these evaluations, actually older patients with localized prostate cancer receive curative therapies such as brachytherapy, radiation, or surgery less frequently than younger patients do. Instead, older men are often treated with a hormone therapy or are subjected to active surveillance.

“This could backfire,“ explains Neubauer who maintains that also in men over 75 years of age, aggressive forms of the tumor are more common than previously suspected. These are tumors that grow very rapidly, forming secondary tumors (metastases). If they are detected too late, they can lead to death. However, as recently published in the prestigious British Journal of Urology wurde², if older men with a high-risk tumor are treated by established therapies, the death rate decreases by nearly half.

Focus on gentle minimal invasive therapies

"The goal of any prostate cancer therapy should be to avoid potential limitations to the quality of life arising from the disease and to prolong the life of the patient. Once the decision for a therapy is made, the focus should be on a gentle therapy procedure," emphasizes Neubauer. An especially suitable treatment is the internal radiation, referred to as brachytherapy. Under continuous ultrasound guidance, up to 80 smallest radiation sources (seeds) are inserted directly into the prostate. The seeds remain in the body of the patient and develop their radiation effect on prostate cancer over months. The tumor tissue is destroyed with the highest accuracy by a high-dose radiation from the inside Whereby neighboring organs such as the bowel, bladder, and urethra are spared. Neubauer maintains that this is what brings about patient satisfaction and a beneficial factor in maintaining the desired quality of life.  He concludes, "By no means should old age be a compelling reason for not treating prostate cancer. “

Literature:

1. Rockwood K, StadnykK, McKnight C et al: A brief clinical instrument to classify fraility in elderly people, Lancet 353.205-206; 1999

2. Brassell SA, et al.: Prostate cancer in men 70 years old or older, indolent or aggressive: clinico-pathological analysis and outcomes. J Urol. 2011 Jan;185(1):132-7. Epub 2010 Nov 12.

Prostate Cancer: Surgery is often not justified

In Germany, the majority of patients with localized prostate cancer are still being operated. That this approach is obsolete is again shown by a study that has recently been published in the journal "European Urology". The investigation showed that men with a low-risk tumor or men who are older than 70, surgery is not the most beneficial treatment method. On the contrary, the operation is associated in part with significant side effects.

In Germany, the majority of patients with localized prostate cancer are still being operated. That this approach is obsolete is again shown by a study that has recently been published in the journal "European Urology". The investigation showed that men with a low-risk tumor or men who are older than 70, surgery is not the most beneficial treatment method. On the contrary, the operation is associated in part with significant side effects.

Due to improved early detection more prostate cancers are discovered at an early stage. At the same time the uncertainty whether all tumors diagnosed require invasive therapy, such as radical surgery, grows because now we know that many of these tumors would never cause problems, let alone lead to death. Swedish and U.S. scientists have attempted to clarify in a model calculation, for which men with a tumor limited to the prostate the operation is actually beneficial and for which men it is not beneficial. They analyzed data from a total of 695 men who either underwent surgery or whose tumors were monitored without active treatment (Active Surveillance).

Questionable benefits of the surgery

The study2 showed that a majority of men do not, as previously believed, benefit from the surgery. Foremost included were prostate cancer patients with non-palpable, less aggressive tumors (T1 tumors with Gleason score 6) and men over 70 years of age. But also for patients whose tumor condition were less favorable (T1 tumors with Gleason score 7 and T2 tumors with Gleason score 6), the value of a surgery cannot according to the scientist clearly be evidenced. The situation is different for young men who have an aggressive tumor. Here the risk to die from the effects of prostate cancer is reduced by an invasive therapy.

This raises the question whether radical treatment is warranted in every case? "It makes little sense to those affected, who, because of the favorable condition of their tumor or based on their age do not have to expect a clinically relevant tumor growth, to have the prostate removed completely", says Dr. Derakhshani, urologist at the West German Prostate Center. A radical prostate surgery is the wrong approach here, especially since the procedure can be associated with significant side effects. For example, up to 50 percent of the operated patients suffer after surgery from stress incontinence and 30 to 100 percent from erectile dysfunktion.1

If at all, the goal of treatment should be to achieve the best possible cure with minor side effects. Suitable for this purpose, are especially minimally invasive treatment methods like internal radiation. In the so-called brachytherapy ultrasound guidance smallest radiation sources (seeds) are placed directly into the prostate. Thus the brachytherapy has a significant advantage over radical prostatectomy: "Through a precise distribution of the radiation dose, we can irradiate the tumor without damaging surrounding structures such as urethra or sphincter", says Dr. Derakhshani.

Moreover, the equivalence of brachytherapy compared with radical surgery has to be considered in terms of the recovery rate, says the urologist. Thus, a current meta-analysis3 was able to demonstrate that brachytherapy alone or in combination with an additional radiation or hormonal therapy in all disease stages of localized prostate cancer compared to radical surgery is at least equivalent or even better. "The patient can combine the advantage of an optimal tumor treatment with the in comparison to the operation, fewer occurring side effects", concludes Derakhshani.

1 Naselli A, Simone G, Papalia R, Gallucci M, Introini C, Andreatta R, Puppo P: Late-onset incontinence in a cohort of radical prostatectomy patients. Int J Urol. 2011 Jan;18(1):76-9.

2Vickers A, Bennette C, Steineck G, Adami HO, Johansson JE, Bill-Axelson A, Palm-gren J, Garmo H, Holmberg L. :Individualized Estimation of the Benefit of Radical Prostatectomy from the Scandinavian Prostate Cancer Group Randomized Trial.Eur Urol. 2012 Apr 19. [Epub ahead of print]

3Grimm P, Ignace Billiet I, Bostwick D et al. Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJUI 109, Suppl. 1, 22-29, 2012