In industrialised countries, prostate cancer is the most common form of cancer affecting men and the second most frequent cause of cancer-related deaths. In particular, the use of PSA as a tumour marker has led to more cases of prostate cancer being diagnosed at an early stage (overdiagnosis). Following a prostate cancer diagnosis, both the patient and his doctor are often faced with a difficult decision. Prostate cancer treatment is recommended on the basis of special criteria. Various standard treatment options, ranging from active surveillance to surgery and radiotherapy, are available for early-stage tumours restricted to the prostate. However, the optimal treatment strategy is unclear.
Before opting for or ruling out a particular form of treatment, it is crucial to assess a patient’s general state of health and life expectancy as well as the characteristics of the tumour. Life expectancy plays a more important role here than biological age.
In patients of an advanced age or with a reduced life expectancy, concomitant diseases reduce the patient’s risk of dying from prostate cancer. In other words, patients die with, but not from, prostate cancer. A patient’s desire for a particular treatment must of course also be taken into account.
Although the tried-and-tested treatment methods of radiotherapy and surgical removal of the prostate are excellent options for local tumour control, they sometimes cause significant side effects.
Ongoing advances in surgical procedures using laparoscopy and robot-assisted surgery (da Vinci) have resulted in improvements in terms of blood loss, postoperative pain and the time spent in hospital. However, there is conflicting data concerning whether this progress has brought about a considerable reduction in side effects and improved tumour control.
Active surveillance is now an established approach for less aggressive tumours. During active surveillance, patients need regular check-ups (PSA, palpation and repeat biopsies). If the disease is found to be progressing, the patient is advised to switch to a definitive course of treatment.
Active surveillance may be a cause of psychological stress among patients. As a result, they may opt for radical treatment despite all its consequences and side effects (overtreatment). Furthermore, men who no longer formally meet the requirements for continued active surveillance receive a definitive radical treatment.
The objective of focal therapy is to give these patients an option which forms the middle ground between radical treatment on the one hand and active surveillance on the other.
During active surveillance, patients do not receive any actual treatment. Instead, they are monitored at regular intervals. This could involve PSA tests, palpation of the prostate, medical imaging (MRI scans) and biopsies. Active treatment is only initiated if it is discovered that the tumour has progressed. Active surveillance is suitable for patients with a low risk profile.
This operation involves removing the entire prostate gland including the seminal vesicles. These days, the surgery is preferably performed as a minimally invasive, robot-assisted procedure that uses the da Vinci system. Depending on the characteristics of the tumour, it may be possible to avoid damaging the nerves during the operation (to preserve the patient’s erectile function). The patient’s risk profile may also mean that the pelvic lymph nodes need to be removed at the same time.
External beam radiation therapy (EBRT) is an alternative treatment option to radical prostatectomy in cases where the cancer has not spread beyond the prostate. The therapy is performed on an outpatient basis over a period of several weeks. Depending on the patient’s risk profile, it may be combined with hormone therapy and it may also be administered to the pelvic lymph nodes.
In contrast to surgery and radiotherapy, focal therapy does not treat the entire organ, but rather targets just the tumour itself (plus a safety margin) or just the affected part of the prostate. Due to the current lack of long-term data, focal therapy has not yet become an established standard treatment.