Treatment of prostate cancer

What are the options?

There are various therapeutic options for treating prostate cancer. Which approach is followed in the individual case depends on the tumor stage, general condition and age of the patient. Surgical removal of the prostate is the treatment of choice for tumors that are locally limited and have not yet formed metastases (radical prostatovesiculectomy). Other options are radiotherapy (radiation therapy) or hormone treatment. In palliative situations, especially when distant metastases are present, chemotherapy can be initiated.
Especially in older patients, in whom the cancer does not lead to a significant reduction in life expectancy (tumor-independent life expectancy <10 years), the tumor does not necessarily have to be treated. With this palliative measure, one speaks of a controlled waiting (“watchful waiting”). Even small, low-risk findings can initially only be observed waiting ("active surveillance") and do not have to be treated immediately. However, there is then the risk that a possibly necessary therapy can no longer be initiated in time.

Also read the article on the topic: What are the chances of a cure for prostate cancer?

surgery

In preparation for the prostate operation, the patient is admitted to the hospital the day before the operation. This is where the first examinations (e.g. ultrasound examination of the prostate), a blood sample and an informative discussion about the upcoming procedure by the attending physician take place. Furthermore, the patient is informed about the anesthesia by the anesthetist. their initiation and possible risks clarified. The patient then has to sign a document confirming that they consent to the operation.

Before the operation, the lower abdomen is generously shaved by the nursing staff. Since the procedure takes place under general anesthesia and ventilation (intubation), the patient must be sober. This means that on the day of admission no more solid food may be fed from midday. On the day of the operation, the patient is also not allowed to drink or smoke.

Also read the article on the topic: What is the terminal stage of prostate cancer?

Procedure of the operation

In a radical prostate vesiculectomy to treat prostate cancer, the entire prostate, including adjacent seminal vesicles and pelvic lymph nodes, is completely removed. The goal of the operation is to completely remove the tumor. Doctors refer to this as an "R0 procedure", where R0 stands for "no residual tumor tissue" (i.e. no tumor tissue that remains).

There are several ways in which the surgery goes. Usually the patient has a general anesthetic. Either the prostate is removed via an incision in the front of the abdominal wall (retropubic prostatectomy), via a small perineal incision (perineal prostatectomy) or minimally invasively with the "keyhole technique" (laparoscopic prostatectomy). In certain cases, a minimally invasive robot-assisted procedure (prostatectomy with the Da Vinci operating system) can also be considered.

The surgeon decides on the basis of the tumor findings, the general condition and the age of the patient which surgical technique is to be used in each individual case. During the operation, the tumor tissue is removed along with the prostate. Since the prostate is anatomically located between the urinary bladder and the erectile tissue of the penis, a new connection must then be made between the urethra and the urinary bladder. Medically this is called an "anastomosis". During the procedure, the surgeon tries to preserve all the nerves and blood vessels that are important for continence and potency.

Also read the article on the topic: Prostate cancer therapy

Aftercare

Immediately after the operation, the patient is transferred back to the ward during the day, where his condition and vital signs (blood pressure, temperature and pulse) are monitored. For the duration of the stay, the patient has a urinary catheter in place so that the surgical wound on the urethra can heal. On the first day after the operation, the patient can get up and move slowly under supervision. Medication is administered to relieve the pain as needed. In the following days, regular pelvic floor exercises and urination training with a physiotherapist are carried out, as these measures are important for the development of continence. As a rule, a patient has to stay in the hospital for 14 days after prostate surgery.

Within six to twelve weeks after the operation, the tumor marker PSA (prostate-specific antigen) is checked in the blood and examined to see whether it has decreased sufficiently. The PSA value should be below the detection limit. If the values ​​are normal, blood samples are then taken every quarter.

Read more about PSA level in prostate cancer

What are the risks / side effects of the operation?

A prostatectomy is a major procedure and, like any surgery, has a number of risks and side effects. One complication is that after the prostate has been removed, the patient suffers from urinary incontinence, i.e. involuntary loss of urine. It is completely normal for patients to experience incontinence for several days or weeks immediately after the procedure. Usually this can be treated very well with medication and will subside after a while. Permanent incontinence is much less common. In such a case, a small follow-up operation has to be carried out to restore the function of the urethral sphincter.

In addition, sexual disorders such as erectile dysfunction (erectile dysfunction) or orgasm disorders are also possible. This can happen if nerves or vessels that are important for erectile function are severed during the operation. The disorders are either temporary or permanent and can be treated well with medication. Since prostate vesiculectomy removes both the prostate and the seminal vesicles, the patients are sterile after the operation and can no longer father children. In addition, complications such as excessive bleeding during the operation, wound infections, and fever can occur with a prostatectomy.

What happens during irradiation?

Patients diagnosed with localized prostate cancer can be treated with radiation therapy (radiotherapy). The aim of the therapy is a curative treatment, which means that the patients are cancer-free afterwards. During irradiation, the tumor tissue is destroyed by radioactive rays and the tumor shrinks. The rays do not differentiate between healthy tissue and tumor cells, which is why it is important that only the tumor tissue is irradiated if possible. In order to protect the healthy tissue as much as possible, the radiation dose that is necessary to destroy the tumor is divided into several sessions (fractions).

Read more about this topic here: Treatment with radiation therapy

Procedure / follow-up treatment of radiation therapy

The tumor can be irradiated from “inside” or “outside”. Classic irradiation occurs from the outside through the skin (percutaneous irradiation). The patient is irradiated every day for seven to nine weeks, and the patient can go home after each treatment (outpatient treatment). The irradiation is carried out by a specific machine, a linear accelerator. Using the latest computer technology, the radiation dose and the radiation field are calculated and the tumor is precisely irradiated. Percutaneous radiation is painless and usually only takes a few minutes.

Brachytherapy is an alternative irradiation option. Here, so-called seeds are introduced directly into the prostate. Seeds are small radioactive particles that are inserted into the tissue via a long needle and emit radioactive radiation from within. The implantation is a small procedure that takes place under local anesthesia. Then the patients are discharged again. The radiation from the seeds lasts for a few weeks. This is followed by a follow-up treatment in which the result is examined. If the treatment was successful, the seeds do not have to be removed again.

Find out all about the topic here: Radiation for prostate cancer.

Risks / side effects of radiation

The acute side effects of radiation therapy for prostate cancer mainly result from damage to healthy tissue. Percutaneous irradiation can lead to reddening of the skin and inflammation in the irradiated area.Since the bladder and rectum are in close proximity to the prostate, irritation of the mucous membranes in these organs can also occur. The patients then suffer from cystitis or inflammation of the lower intestines. In most cases, however, these are temporary events that will quickly subside after treatment is completed. The side effects of brachytherapy or seed implantation are minor. After the seeds have been implanted, the bladder or intestines may be slightly irritated.

The treatment can lead to permanent damage to the bladder, the lower urinary tract or the rectum much less often. The long-term effects include incontinence, potency problems and chronic diarrhea. Unfortunately, it cannot be said before the start of therapy whether there will be long-term damage.

When do you get chemotherapy?

Chemotherapy is suitable for patients with advanced prostate cancer. In these cases the tumor has mostly already metastasized. Local treatment by surgery or radiation then usually no longer makes sense, as the tumor cells may have already spread throughout the body. Because of the relatively strong side effects, chemotherapy is only used for prostate cancer if hormone therapy has previously shown no effect and all other options have been exhausted.
Chemotherapy can slow tumor growth and alleviate symptoms, such as bone pain from spinal metastases. The aim of chemotherapy for the treatment of prostate cancer is to extend the life span and improve the quality of life for the patient. However, chemotherapy does not provide a cure. The doctor decides together with the patient whether chemotherapy makes sense, because due to the serious side effects, this treatment option is not suitable for everyone.

Read more on the subject at: What is the terminal stage of prostate cancer?

How long does chemotherapy last?

There are several ways that chemotherapy is given to patients with prostate cancer. The therapy is administered in so-called cycles, with one cycle corresponding to a treatment interval. Each cycle is followed by a break in treatment of several weeks so that the body can recover from the stress of chemotherapy.

The patient usually receives his medication in the form of an infusion every three weeks per cycle. It usually takes about an hour for the infusion to finish. After giving the infusion, the patient can go home.

This article might also interest you: Conducting chemotherapy

How many cycles do you need?

How many cycles of chemotherapy a patient with prostate cancer needs is decided jointly by the doctor and patient. The number of cycles depends on the general health of the patient and the stage of the cancer. Chemotherapy usually lasts four to six cycles. The success of the treatment is then checked using the tumor marker PSA and further treatment is determined.

Chemotherapy side effects

It is very likely that you will experience more or less severe side effects during chemotherapy. During chemotherapy, drugs are administered that primarily inhibit the growth of rapidly dividing cells. The rapidly multiplying tumor cells are primarily affected, but healthy tissue that frequently regenerates is also destroyed. The mucous membrane of the digestive tract, the hair root cells and the blood-forming cells in the bone marrow are particularly affected. As a result, the patients suffer from diarrhea, nausea and vomiting.

Due to the damaging effect on the hair root cells, the scalp hair, pubic hair and other body hair gradually fall out. In addition, there are changes in the blood count: the number of white blood cells, which make up the human immune system, can decrease and patients become more susceptible to infections. The red blood cells can also decrease and anemia (anemia) develops. The result is headache, tiredness and paleness.

During chemotherapy, patients are closely monitored and side effects are treated as best as possible. There are medications that help relieve nausea and vomiting against the symptoms of the gastrointestinal tract. The blood count is checked regularly and, in the event of severe complications, the dose of chemotherapy drugs is reduced accordingly.

Read more on the topic: Chemotherapy side effects

Hormone therapy

Hormone therapy (antiandrogenic therapy) is indicated, especially if the prostate cancer is already at an advanced stage. Hormone therapy for prostate cancer can be used either alone or in combination with surgery or radiation therapy. The patient is given certain hormones, so-called antiandrogens, which ensure that the tumor cells no longer divide and the cancer does not spread any further.

Antiandrogens are preparations that neutralize the effects of male sex hormones (androgens) and thus lead to hormone withdrawal in the patient's body. Since prostate cancer is a type of cancer that almost always grows hormone-dependent (especially testosterone-dependent), anti-hormonal treatment slows down tumor growth. Tumors that do not respond to hormone withdrawal therapy and still continue to grow are referred to as "hormone-deaf". Approved drugs that are used in anti-androgen therapy are, for example, androgen receptor blockers (bicalutamide, flutamide), GnRH antagonists (Defarelix, Abarelix) or GnRH analogues (goserelin, leuprorelin). Nowadays, estrogens (Fosfestrol) are rarely used in the hormone therapy of prostate cancer. The hormones are either taken in tablet form or injected under the skin as a depot syringe. Alternatively, there is also the possibility of an orchiectomy (castration), since the majority of male sex hormones are formed in the testicles.

Hormone therapy can only inhibit the growth of the tumor, but not lead to a complete cure. Hormone therapy is therefore the therapy of first choice for inoperable findings, metastases (scattered tumor settlements in the body) or lymph node involvement. However, it must be borne in mind that after two to three years the majority of tumors become resistant to hormone withdrawal and the treatment therefore does not more appealing.

Read more about the topic here: Hormonal preparations and Hormone therapy for prostate cancer

Which treatment is the best for me?

The treating medical team decides which treatment is the best therapy option for the patient in each individual case. Affected persons should seek comprehensive advice from their doctor as to which treatment option is best for them and which side effects they are most likely to cope with. It can often make sense to get a second opinion in another clinic before deciding on treatment.

The type of treatment depends primarily on the stage of the tumor and how aggressively it is growing. In the case of locally limited tumors with a low risk profile that are still in the prostate and have not spread to the surrounding tissue, the cancer does not necessarily have to be treated. One waits in a controlled manner ("active surveillance") and examines the tumor at regular intervals. This strategy is particularly suitable for older patients.

Find out more at: What are the stages in prostate cancer?

Only when the tumor marker PSA continues to rise or the cancer causes symptoms can surgery or radiation therapy be considered. Patients who are in poor general condition and are not stable enough to undergo surgery can be treated with hormone therapy. Advanced prostate cancer is treated with surgery or radiation in combination with much more aggressive chemotherapy. If metastases are already present and lymph nodes or other organs in the body are affected, there is the option of anti-androgenic hormone treatment or chemotherapy.

Read more on the subject at: Metastases in prostate cancer

What if I don't treat prostate cancer?

Prostate cancer is not always treated immediately. Especially with small tumors with a low risk profile, the doctor may recommend waiting first. This treatment strategy is called "active surveillance" and means something like "active surveillance". The prostate is checked at regular intervals and treatment is only initiated when the disease progresses. Studies have shown that in such cases, patients have no disadvantage compared to immediate initiation of therapy.

In contrast, a more advanced tumor must always be treated immediately, as otherwise the disease spreads quickly and leads to a significant impairment of the quality of life. Life expectancy in prostate cancer depends primarily on the size, type and spread of the tumor.

What is the end-stage treatment like?

In the end-stage prostate cancer, in most cases only palliative treatment is possible. This means that the patient can no longer be cured, instead improving the quality of life is the primary therapeutic goal. Palliative therapy is intended to prevent the tumor from growing further and improve the patient's symptoms. Often end-stage patients experience pain, weight loss, exhaustion, and anxiety. The tumor can press on the urethra, causing urination problems. In the final stage, prostate cancer has formed metastases that can spread throughout the body and lead to pain and discomfort in the respective organs (for example the spine, the liver or the kidneys).

The doctor, together with the patient and his / her relatives, draws up a suitable therapy plan that serves to treat the physical and psychological complaints appropriately. In addition to comprehensive pain therapy and the administration of anti-anxiety medication, this also includes close medical care and support. Seriously ill patients are either cared for in the home environment by relatives or by an outpatient care service. There is also the option of palliative care in a hospital or a specialized day clinic.

Find out more about the topic: End-stage prostate cancer

Methadone

Methadone is a drug from the group of opioids and is known as a substitute for heroin addicts. Methadone has an analgesic and sedative effect. The use of methadone in cancer treatment has been discussed for some time. There is some evidence that cancer patients who take methadone have a longer survival time. However, there are currently no clear studies that prove the effectiveness of methadone for cancer therapy. For this reason, respected organizations such as the German Cancer Aid Foundation come to the conclusion that the use of methadone in cancer is not justified due to possible risks (such as increased mortality).

How long will the treatment take?

The duration of the treatment depends on the respective form of therapy. A locally limited prostate tumor without metastases can be treated surgically. The patient is ideally cured after the procedure and the removal of the prostate and seminal vesicles. Radiation is usually carried out for several weeks, with the patient being treated for a few minutes every day. After a successful irradiation, the patient is then tumor-free and the treatment is completed.

Hormone withdrawal therapy prevents tumor growth, but used alone does not lead to a cure. With hormone therapy, the patient either has their testicles removed or has to take medication at regular intervals. For the duration of the therapy, the growth of the tumor is stopped, which can be for months or years.

The last station in the fight against an advanced prostate tumor is chemotherapy. The medication is administered over several cycles, with the duration of the treatment depending on the individual findings of the person affected. If the side effects are very severe, it may also be necessary to reduce the dose or to stop treatment early.