How is prostate cancer treated? Individual choice of therapy
Various forms of therapy are available for the treatment of prostate cancer. How the tumor is treated in individual cases depends mainly on the age of the patient and on how far the cancer has already progressed and how aggressively it is growing.
The following factors enter into the treatment decision:
General condition: Other existing diseases such as cardiovascular diseases may significantly limit life expectancy. In addition, diseases such as heart failure make certain forms of treatment for prostate cancer, such as surgery, impossible.
PSA value: A very high or rapidly rising PSA value is an argument for a rapid start of therapy, because it suggests a high activity of the tumor.
The attending physician will explain to you in detail which form of prostate cancer treatment he considers most suitable in your case. This discussion should take place calmly and without time pressure. You can also bring your partner, a family member or friend along for the discussion:
Don’t be afraid to ask questions if you don’t understand something. Also, do not let yourself be pushed into a therapy.
A diagnosis of prostate cancer is not an emergency! Take enough time to inform yourself and, together with your doctor, make a decision about the therapy that is right for you!
What are the treatment options for prostate cancer?
The options for treating prostate cancer have developed considerably in recent decades. Several treatments are now available that completely cure the tumor or curb tumor growth. If the cancer is already far advanced and has metastasized, treatment aims to prolong life and alleviate symptoms.
The following treatment options are currently available:
- Controlled waiting (“watchful waiting”)
- Active surveillance
- Surgery: removal of the prostate gland (“radical prostatectomy = total prostatectomy”)
- Radiation therapy (prostate cancer radiation from the outside or inside)
- Hormone therapy
- Chemotherapy
- Nuclear medicine therapy (radio-ligand therapy)
How good are the chances of cure for prostate cancer?
Prostate cancer grows very slowly compared to other cancers. If the tumor is confined to the prostate, it can usually be completely cured.
If the cancer has already metastasized, the disease can no longer be cured. However, hormone deprivation treatment (with or without chemotherapy or radiotherapy) can slow the progression of the disease, so that many men live with their tumor disease for a long time. Metastases can be treated specifically.
Prostate cancer treatment: surgery
To do this, the prostate must be removed along with the capsule surrounding it, the part of the urethra that runs through the prostate, the seminal vesicles, the vas deferens, and part of the bladder neck. Doctors refer to this procedure as a radical prostatectomy or total prostatectomy.
The prostate can be accessed through three different ways:
- Lower abdominal incision between the pubic bone and the belly button (retropubic radical prostatectomy).
- Perineal incision (perineal radical prostatectomy)
If there is a suspicion that neighboring lymph nodes are also affected with cancer cells, these are additionally removed (lymphadenectomy) and then examined under the microscope (histopathologically). If cancer cells are found in them, further treatment measures are necessary.
Risks of the surgery
Thanks to new surgical techniques, side effects and complications of prostate cancer surgery are much less common today than in the past. However, it is still important to know about the risks of the surgery. Urinary dribbling (urinary incontinence) and impotence (“erectile dysfunction”) may occur after surgery.
Urinary dribbling (incontinence)
Not being able to hold your urine severely limits your quality of life: Many sufferers feel ashamed and withdraw from social life. However, there are ways to train the weakened sphincter muscle:
Impotence (Erectile Dysfunction).
Prostate cancer surgery can injure two nerve cords that are necessary for normal penile erection. The nerve cords run directly along the prostate on both sides. They can be spared during prostate cancer surgery only if the tumor is still small and has not yet spread to the surrounding tissue.
For optimal chances of recovery, the entire tumor tissue must be removed – if necessary also by damaging the nerves mentioned. If the patient does suffer from erectile dysfunction as a result, various drugs and aids can help to restore erectile function to a largely normal level.
Prostate cancer treatment: hormone therapy
Hormone therapy is used when prostate cancer has already metastasized to lymph nodes, bones or other organs. A cure is not possible with hormone therapy alone, but it is useful in combination with other therapies such as radiation therapy for advanced prostate cancer. The aim of treatment is to delay the progression of the disease and alleviate symptoms.
There are different forms of hormone therapies. Their common goal is to slow tumor growth. This is achieved by different means: some hormone treatments block the production of testosterone in the testes, others stop the effect of the hormone on the tumor cells.
Surgical hormone withdrawal (surgical castration)
Chemical hormone withdrawal (hormone withdrawal therapy, chemical castration).
In this form of treatment, the testosterone level is lowered with medication. It is used when the tumor is already advanced and has metastasized or surgery is not possible. It is usually combined with radiotherapy or chemotherapy.
The following hormones are suitable for the treatment of prostate cancer:
GnRH analogs act like natural GnRH. If the patient is given GnRH, the pituitary gland releases LH and FSH, and the testosterone level initially increases. However, with long-term use, the pituitary gland becomes insensitive to GnRH and releases less LH, causing the testes to produce less and less testosterone. After a few weeks, testosterone levels drop significantly. GnRH analogues are administered monthly or every three (or six) months as a depot injection.
“Androgens” is the medical term for male sex hormones, the main representative of which is testosterone. Antiandrogens cancel out the effect of these sex hormones. They block the docking sites for testosterone in the tumor cells of the prostate and thus prevent its growth-promoting effect. Antiandrogens are administered as tablets and are divided according to their chemical structure into steroidal and non-steroidal antiandrogens.
The active ingredient abiraterone not only inhibits testosterone production in the testes, but also in the adrenal glands (where small amounts of testosterone are produced) and in the tumor tissue itself. Thus, all testosterone production is suppressed. This form of treatment is only used in metastatic, castration-resistant prostate cancer. Abiraterone is taken daily as a tablet.
Hormone therapy: side effects
In addition to the desired effect of hormone withdrawal, hormone therapy is also associated with side effects. The symptoms are roughly comparable to those experienced by menopausal women.
Possible side effects include:
- Hot flashes
- Breast pain or breast enlargement (gynecomastia)
- Weight gain
- muscle loss
- bone loss (osteoporosis)
- anemia (lack of blood)
- Decreased sexual desire (loss of libido)
- Infertility (Infertilität)
Talk to your doctor about any side effects that may occur! Some of these adverse effects, such as hot flashes or breast enlargement, are easily treated!
Prostate Cancer Treatment: Radiation Therapy
Radiation therapy (radiotherapy) involves “bombarding” the tumor with ionizing radiation (X-rays). The goal of the treatment is to damage the cancer cells so that they lose their ability to divide and die.
Irradiation from the outside or from the inside
Radiation of the prostate is possible from the outside and from the inside.
In the case of radiation from the inside (brachytherapy), the principle is different: Here, the physician introduces the radiation source (radioactive substances) directly into the tumor. Brachytherapy is considered if the tumor is still localized and has not metastasized. There are two options for this form of treatment:
In “high-dose rate brachytherapy” (HDR), metal particles are also introduced into the prostate. This is done using hollow needles that remain in the prostate tissue only for the duration of the treatment. In contrast to the “seeds”, the metal particles in HDR deliver a higher radiation dose over a very short distance and are removed again via the lying hollow needles after a few minutes of irradiation.
“High Dose Rate Brachytherapy” (HDR) is also called brachytherapy with afterloading procedure.
Radiation: Side effects
With the help of radiation therapy, it is possible to kill cancer cells in a targeted manner. However, it cannot be ruled out that healthy neighboring tissue may also be affected.
The acute side effects usually subside after radiation therapy is completed. The doctor may prescribe medication to alleviate them.
Last but not least, any radiation therapy can lead to the development of a second tumor in the irradiated area years or decades later. In former prostate cancer patients, this can be rectal cancer, for example.
The likelihood and extent of side effects depend on the type and intensity of radiation therapy.
Controlled waiting (“watchful waiting”)
In contrast to “active monitoring”, controlled waiting does not involve any check-ups. The physician only initiates treatment when symptoms occur. This could be pain caused by metastases in the bones, for example.
Active surveillance
The principle of active surveillance is similar to that of controlled waiting: Initially, no treatment is given, but the physician checks the behavior of the tumor at short intervals. If the tumor is growing very slowly, it may not be necessary to treat it at all.
In the first two years after diagnosis, the doctor checks every three months (or every six months if the PSA level remains constant) to see whether the tumor is changing. To do this, he palpates the prostate (digital-rectal examination) and determines the PSA level (blood sample).
Through this close monitoring, the doctor detects early if the prostate cancer is progressing and initiates appropriate treatment.
Discuss with your doctor whether active surveillance is an option in your case.
Prostate cancer treatment: chemotherapy
However, chemotherapy not only reaches tumor cells, but also other fast-growing cells such as hair follicles, which leads to hair loss in many patients. Chemotherapy for prostate cancer is considered when the tumor has already metastasized. It is often combined with hormone therapy.
Chemotherapy: side effects
Prostate Cancer Treatment: Nuclear Medicine Therapy
Nuclear medicine works with radioactive substances that specifically destroy tumor cells. Doctors refer to this as radio-ligand therapy (RLT).
The radioactive substance is coupled to a carrier molecule (PSMA ligand). According to the lock-and-key principle, this ligand fits the prostate-specific membrane antigen (PSMA) that most prostate cancer cells carry on their surface.
The patient receives the drug every five to seven weeks as an infusion via the vein or as an injection. It is possible to repeat the treatment up to six times.
PSMA ligand therapy is used in patients whose prostate cancer is already advanced. It is suitable for patients with metastatic prostate tumors in whom the disease continues to progress despite hormone withdrawal or chemotherapy.
Side effects of nuclear medicine prostate cancer therapy.
Radio-ligand therapy can cause side effects in some patients. For example, patients most commonly report feeling tired after therapy and having less appetite than usual or a dry mouth. In addition, nausea and diarrhea can sometimes occur.
Other therapy methods
If the prostate cancer has not yet spread beyond the connective tissue of the prostate capsule, there is in principle the possibility of cold therapy (cryotherapy). This involves freezing the tumor tissue. According to current expert opinion, however, cold therapy is not suitable for the treatment of localized prostate cancer. It is currently only carried out as part of studies.
Some other prostate cancer treatment procedures have also been recommended only within trials, such as Irreversible Electroporation (IRE) and Vascular Photodynamic Therapy (VTP).
Treatment of metastases
In addition, it is possible that the doctor prescribes medication. These can be painkillers or bisphosphonates – active substances against bone resorption.
In certain cases, a so-called radionuclide therapy may also be considered for bone metastases. This is a type of radiation from the inside: The patient receives radiating chemicals by infusion, which the body incorporates specifically into the bone metastases. The radiation emitted at a short distance destroys the cancer cells.
In addition to bone metastases, advanced prostate cancer may also form metastases in the liver, lungs or brain. If possible, prostate cancer treatment in these cases also includes measures that specifically target the metastases (radiation therapy, chemotherapy, possibly surgery, etc.).
Aftercare
Follow-up usually begins twelve weeks after the end of therapy. In most cases, it is sufficient to determine the PSA level in the blood. If this remains stable, no further examinations are necessary. It is important to have these check-ups regularly. They take place every three months in the first and second years after completion of treatment, every six months in the third and fourth years, and then once a year.
