Prostate carcinoma is a malignant tumour of the prostate gland in men.

Prostate carcinoma is the most common tumour disease in men in Germany with over 60,000 new cases every year. The disease mainly occurs at an older age, although the incidence rate has continued to rise in recent years due to the increasing age of the population as a whole, increased public awareness and consistent screening using prostate-specific antigen (PSA/blood test).
Every year, over 15,000 men in Germany die from this tumour. This makes prostate cancer the third most common cause of death among men suffering from cancer in Germany, although a large number of tumours are not the actual cause of death due to advanced age, or are not even discovered during a man's lifetime.

The exact cause of prostate cancer is not known. Various factors, in particular genetic influences and changes in hormonal balance, appear to play an important role.

Increasing age and overweight (obesity) are considered risk factors, as are certain life circumstances such as eating habits and environmental factors.

The risk of PCA is also increased if there is a positive family history, although this also depends on the degree of relationship. If a first-degree relative has the disease, the risk is higher than if a second-degree relative is affected. The highest risk of PCA exists when 1st and 2nd degree relatives are affected.

Prostate carcinoma usually only becomes noticeable very late through clinical symptoms in the form of urinary tract obstruction, visible blood in the urine (macrohaematuria) or bone pain. Early diagnosis (screening) is therefore crucial and should be carried out routinely by a urologist in all men aged 50 and over, or even better from the age of 45.

The following examination methods are used to clarify the stage of the tumour before a possible therapy:

Medical history and physical examination

The medical history and physical examination are performed to document the patient's complaints, previous illnesses and previous operations. The physical examination is carried out to assess the patient's general condition, to exclude other diseases and to determine the extent of the tumour.

In particular, the dorsal surface of the prostate is palpated from the anus (rectum) during the digital rectal examination. The healthy prostate has a furrow (sulcus) in the centre and can be easily delineated to the right and left. Any abnormalities, such as a rough, bumpy lump and varying consistency within the prostate or lack of delimitation, are further clarified by taking a tissue sample (biopsy).

Transrectal sonography (TRUS)

A transrectal (through the bowel) ultrasound examination (sonography) in which a special transducer in the form of a rod is inserted through the rectum and the prostate is sonographed longitudinally and transversely. A prostate carcinoma nodule typically appears on the ultrasound image as a dark (hyporeflexive) area, although this is not very specific, as benign enlarged prostate (benign prostatic hyperplasia), vessels, cysts or inflammatory processes can also look similar. However, if a hyporeflexive area is found in the outer (peripheral) zone, a biopsy should be performed in any case. In addition, the volume of the prostate can be determined with a transrectal ultrasound examination.

Chest X-ray examination

Chest X-ray examination to rule out metastases in the lungs.

Bone scintigram

The bone scintigram to rule out skeletal metastases. A weak radioactive substance is injected into the patient's venous system, which preferentially accumulates in diseased bone due to the increased mineral metabolism. The accumulation of the radionuclide is visualised with the aid of a gamma camera.

Computer tomography

Computed tomography to detect affected lymph nodes in the pelvic area.

MRI

MRI (magnetic resonance imaging) is becoming increasingly important in the diagnosis of prostate carcinoma.

Liver sonography

Liver sonography to rule out metastases in the liver.

Sonography of the upper urinary tract

Sonography of the upper urinary tract to detect existing urinary retention.

PSA blood test

Determination of the concentration of prostate-specific antigen in the serum, using a limit value of 4 ng/ml. In recent years, in addition to total PSA, free, unbound PSA has also been determined and the ratio of total to free PSA calculated.

Punch biopsy

A standardised punch biopsy is carried out in the event of abnormal findings in the above-mentioned examinations.
This examination can be carried out by your urologist in private practice and without anaesthetic.

During this examination, tissue samples are taken from the prostate under ultrasound guidance using a biopsy needle through the anus (transrectally). A punch with 10 to 12 biopsy samples is usually carried out.

Only if standard diagnostics fail and the presence of prostate carcinoma is still suspected can a targeted biopsy of abnormal areas be performed using an MRI/TRUS-fused prostate biopsy. By fusing the MRI images with the transrectal ultrasound images, areas suspected of being prostate cancer can be precisely biopsied in the MRI.

The classification of prostate cancer, also known as staging, is based on the TNM system, which is also used for other cancers

Grading describes the pathological differentiation by describing the histological image. In addition to the stage of spread, the degree of malignancy is the most important value for the prognosis of prostate carcinoma. The most common classifications are the WHO classification and the Gleason classification:

On the other hand, it is important for further treatment whether the tumour could be completely removed.

Various types of therapy are available for the treatment of prostate carcinoma, which can vary depending on the stage of the tumour.

Firstly, clinical examinations should determine whether the tumour is localised (the carcinoma is confined to the prostate) or systemic (there are lymph node metastases or distant metastases). If the carcinoma is localised, a curative treatment approach can be used.

Watchful waiting and active surveillance

Patients with well to moderately differentiated, organ-confined small prostate carcinomas (e.g. incidental carcinomas after TURP, pT1a) do not always require treatment. In older men in particular, a watchful waiting strategy or the concept of "active surveillance" can be applied. With active surveillance, a PSA check and a new biopsy of the prostate should be carried out at certain intervals. The aim is to detect whether the growth pattern, i.e. the aggressiveness of the known tumour, is changing.

Curative therapy

In the case of a prostate carcinoma that is limited to the prostate, a total removal of the prostate or radiotherapy can be carried out.

Radical prostatectomy

In a complete removal of the prostate (radical prostatectomy), the regional lymph nodes and then the prostate are completely removed surgically and the bladder outlet and urethral stump are then joined together.

Radical prostatectomy can be performed either by open surgery via an abdominal incision below the navel or laparoscopically (often robotically assisted).

Brachytherapy

One form of radiotherapy is brachytherapy, in which the radiating material is placed in the prostate in the form of small samples, so-called seeds, under ultrasound guidance. The aim is to deliver the highest possible dose of radiation to the affected organ while sparing the sensitive surrounding tissue.

Percutaneous radiotherapy

Another option for radiotherapy is external radiotherapy. This involves carrying out a computer tomography scan of the prostate. A computer uses this data to create a three-dimensional view of the prostate. A computer is then used to control the radiation beam, which irradiates the patient from the outside, so that it adapts exactly to the size of the prostate in every position. In this way, the radiation only hits the target object - the prostate - and the surrounding tissue is spared. This procedure is repeated several days a week for 6-8 weeks. To optimise the radiation planning, so-called gold seed markers can be placed in the prostate beforehand.

Other local therapy methods

The following procedures are currently still being tested and are therefore only recommended as part of clinical studies.

HIFU

In high-intensity focused ultrasound (HIFU), sound waves are applied via a transrectal ultrasound probe, causing the tumour cells to die.

Cryotherapy

In this method, cells are killed by supercooling; this is done using so-called cryo needles, which the doctor places in the prostate under ultrasound control.

Other forms of therapy

Advanced stage/residual tumour

Additional radiotherapy after surgery (adjuvant radiotherapy) can reduce the probability of cancer regrowth in the surgical area in the case of locally advanced tumours and residual tumours (residual tumour). Small tumour remnants that may still be present after the operation should be destroyed in this way.

Locally advanced tumours that have already exceeded the limits of the prostate and where surgery is no longer possible with the prospect of a cure can be irradiated if symptoms are present. As a rule, the tumour region and possibly also the lymph nodes in the pelvic area are irradiated from the outside (external radiation).

Recurrence (recurrence of the tumour after a previous curative therapy approach)

Local recurrence (in the former tumour area)

The type of previous therapy plays a decisive role: if the tumour was surgically removed by radical prostatectomy, the second therapy may consist of radiotherapy. The size of the irradiated area can now be adjusted very precisely and depends on the extent of the recurrent tumour. In addition to the immediate vicinity of the (removed) prostate, the pelvic region can also be irradiated if necessary. Affected lymph nodes can also be included. The nodes next to the abdominal aorta and the nodes in the groin region are the main candidates. In most cases, radiotherapy is not carried out until the recurrence becomes noticeable through symptoms, but as soon as the PSA values rise again after the operation.

If the initial therapy consisted of radiotherapy, this is usually followed by hormone therapy. In many cases, this results in a long-lasting reduction in PSA levels. In rare cases where the recurrence is localised, surgery may also be an option if the patient's age and condition allow. However, the tissue is usually heavily scarred after radiotherapy and surgery can be associated with a higher rate of possible complications.

Metastases in the bone (bone metastases)

Bone metastases in the context of recurrences are very common in prostate carcinoma and can cause pain and complications such as bone fractures or narrowing of the spinal cord. Bones at risk of fracture should be surgically stabilised if possible. Additional radiotherapy reduces the growth of metastases and bone pain, as does the administration of certain drugs, especially bisphosphonates or the antibody denosumab. Of course, adequate pain therapy is necessary if required.

Systemic therapy

Hormone deprivation therapy can be initiated immediately or after a delay. This can be achieved either by irreversible removal of the testosterone-producing testicular tissue (orchiectomy) or by drug therapy with the same effect. The latter has the advantage that it is not irreversible and can therefore also be used intermittently. The aim of such therapy is to keep the prostate cancer under control.

Castration-resistant prostate cancer (CRPC) (prostate cancer that progresses despite hormone deprivation therapy)

Some prostate carcinomas become castration-resistant earlier, others at a later stage and the disease progresses despite hormone deprivation therapy. In many cases, switching to a different anti-hormonal therapy can again successfully influence tumour growth. In some patients, the PSA level drops temporarily after stopping hormone therapy (anti-androgen withdrawal syndrome), but this is a temporary effect.

In castration-resistant prostate cancer, the substances abiraterone and enzalutamide are available for further hormone therapy.

For patients with symptomatic osseous metastasised CRPC without organ metastases, the radionuclide radium-223 chloride is available. This is increasingly incorporated into bone metastases and is intended to inhibit the growth of bone metastases.

In the case of castration-resistant tumours (hormone-intensive carcinoma), the focus is on the patient's quality of life and the regression of bone pain, urinary retention kidneys and lymphoedema of the lower extremities. At least a short-term subjective improvement can be achieved with chemotherapy in the majority of patients. However, a curative effect of cytostasis (regimens based on docetaxel or cabazitaxel as second-line therapy) is not to be expected.

After surgery or radiotherapy and also after the initiation of anti-hormonal therapy, regular follow-up examinations are carried out. They serve to detect side effects or consequences of the treatment, but also a recurrence or progression of the tumour disease.

In the first two years after surgery or radiotherapy, follow-up examinations are recommended every three months, then every six months and then every year.

The physical examination by the doctor with palpation of the prostate region from the rectum (digital rectal examination) and the determination of the PSA value are part of the routine programme. If there are indications that the disease is progressing, for example if the PSA value rises over several measurements, additional ultrasound and X-ray examinations, a biopsy and bone scintigraphy are used.

So-called PSMA ("prostate-specific membrane antigen") PET/CT (combination of positron emission tomography and computer tomography) is playing an increasingly important role in the diagnosis of tumour recurrence. PSMA is expressed more strongly in prostate carcinoma tissue than in normal prostate tissue. It therefore represents an interesting target structure in diagnostics, particularly in cases of suspected recurrent tumours.

The recurrence of the disease after radical prostate surgery is usually signalled by an increase in the PSA value: It should initially fall to barely detectable levels (<0.1µg/l) within a few weeks after complete removal of prostate and tumour tissue. After radiotherapy of the prostate, prostate tissue is often retained and it can take up to a year, sometimes even longer, for the PSA to fall to its lowest level. A rebound phenomenon can also often be observed (a brief rise in PSA followed by a subsequent drop), but this does not indicate a tumour recurrence. Here too, however, significant increases in the PSA level in the blood with multiple measurements indicate possible tumour growth.

PSA progression

If the PSA level rises again over time after initially successful treatment, it is important to clarify whether this is due to a localised relapse following surgery. If this is the case, early radiotherapy may be advisable after a previous total operation. In the event of a localised relapse after previous radiotherapy, radiotherapy cannot be repeated. Surgery is associated with a higher risk of complications. For this reason, hormone therapy is usually given if PSA rises after radiotherapy. If metastases are discovered, usually in the bones, hormone therapy is also carried out.

Rehabilitation

In order to regain as much capacity as possible after treatment, to be able to cope with everyday life and to minimise the long-term consequences of an illness, most insured persons are entitled to rehabilitation services. This can take place directly after hospital treatment as follow-up treatment (AHB), some time after the initial treatment as inpatient treatment or as a bundling of outpatient measures if the patient does not wish to return to hospital.

You can find tips on how to cope better with the disease on websites such as http://www.prostatakrebs-bps.de/

In general, prostate cancer is a slow-growing tumour. The treatment alternatives are varied and therefore the prognosis is often very favourable, especially in the case of newly diagnosed tumours at an early stage, i.e. limited to the prostate.