The type of treatment for prostate cancer depends largely on how far the cancer has progressed. In addition, the growth rate of the tumor as well as the general condition, age and surgical risk of the patient play a major role. There are numerous different treatment options available, which may also be used in combination with each other. It is therefore advisable to get a second opinion from another doctor before starting therapy.
Basically, the following treatment approaches are available:
- Surgical intervention
- Hormone therapy
Stages of prostate cancer
The treatment options and prospects for cure vary greatly depending on the stage of prostate cancer:
Limited prostate cancer
In this stage of prostate cancer, the tumor is still located exclusively in the prostate tissue. The therapy with the best chances of cure is a complete surgical removal of the prostate. If the tumour is still small, radiotherapy can be performed as an alternative instead of surgery.
For patients over the age of 75, or for those with small, barely aggressive tumors, the option of no treatment at first and watching how quickly the cancer progresses should be considered. Otherwise, the cancer therapy could cause far greater discomfort than the cancer itself.
Advanced prostate cancer
At this stage, the prostate tumor has already broken through the capsule of the prostate and is infiltrating the surrounding tissue. Since in many cases the cancerous tissue can no longer be completely removed by surgery, a cure for the prostate cancer is only possible to a limited extent.
As an additional treatment after surgery, an attempt can be made to kill any remaining tumour cells with the help of radiotherapy. It is also possible to inhibit the growth of the remaining cancer cells by withdrawing the growth-promoting hormone testosterone from the cells.
If the prostate cancer has metastasized to other organs, such as the lungs or bones, it is usually no longer possible to cure the patient. A so-called palliative therapy is carried out, in which the treatment goal is to improve the cancer patient's quality of life. The further growth of the prostate tumour is inhibited by radical hormone withdrawal. In addition, an attempt is made to destroy the cells of the metastases by means of cytostatic drugs.
Therapy options at a glance
If the prostate tumour is small and growing very slowly, the therapy can be postponed if necessary. This option should be considered especially in older patients over 75 years of age or in patients with poor health. Otherwise, the cancer therapy could cause far greater discomfort than the cancer itself. The further development of the prostate carcinoma is regularly examined and closely monitored.
Radical prostatectomy (complete removal of the prostate) is the recommended procedure if the spread of the tumour is limited to the prostate gland and the surrounding tissue has not been infiltrated. At this stage of cancer, surgery offers the highest chance of cure. In addition to the prostate gland, the vesicular glands below the prostate gland and, in some cases, nearby lymph nodes are surgically removed.
If the cancer has already affected the surrounding tissue, the operation will at least relieve the symptoms. In addition to the prostate and the vesicular glands, all nearby lymph nodes must be removed.
In the conventional surgical procedure, the prostate is removed through an abdominal incision approximately 12 centimeters long above the pubic hairline. The minimally invasive laparoscopic procedure is an alternative method in which the surgical device is introduced into the abdominal cavity through five approximately 1.5-centimeter-long incisions. A complete opening of the abdominal wall is not necessary - the operation is performed with the help of a video camera inserted into the abdominal cavity. According to studies, however, the laparoscopic procedure is not necessarily gentler for the patient. Wound pain, recovery time and late effects such as impaired continence (ability to hold back urine) and erectile function are not always less than with conventional surgical procedures. The reason for this is that postoperative complaints depend less on the access route than on the individual circumstances of the operation and the skills of the surgeon.
A frequent late consequence of surgical removal of the prostate is loss of potency. Since certain nerves that are important for erection run directly along the prostate capsule, there is a great risk that these nerves will be damaged during the operation. Despite nerve-sparing surgical procedures, about 80 percent of men suffer from erection problems after the procedure. Stress incontinence occurs in about 3 to 5 percent of cases. In this case, coughing, sneezing or laughing can lead to an involuntary leakage of urine.
Radiation therapy can be given to a prostate tumor from the outside (percutaneous radiation therapy) or directly from the inside (radionuclide implantation, brachytherapy):
- Radiation therapy from the outside: Usually, five radiation sessions are given per week over a period of about eight weeks. A single radiation session lasts about 15 minutes.
- Radiation therapy from the inside: In a one-time procedure, radioactive grains about the size of grains of rice are placed inside the prostate. These radioactive particles continuously emit radiation a few millimeters deep into the surrounding prostate tissue over a period of about one year. Subsequent removal of the grains is not necessary.
Just like surgery, internal or external radiation therapy can also cause erectile dysfunction. This is because the radioactive radiation can also damage tissue that is necessary for the erection. About 50 percent of those affected suffer from erection problems after radiation therapy. The incidence of late effects of treatment, such as impaired potency or erection, is similar between nerve-sparing surgery and radiation therapy - differences are mainly the result of individual circumstances and the skills of the treating physician.
The radioactive radiation can also damage the intestines and urethra, which is why some patients experience problems with urination or digestion (for example diarrhoea).
Cryotherapy involves freezing the prostate tissue over the intestine, which then causes it to die. However, current evidence suggests that cryotherapy is less effective than other established treatments, so it is not an equivalent alternative in prostate cancer treatment.
In many prostate tumors, the male sex hormone testosterone promotes the growth as well as the spread of the cancer. In about 80 percent of cases, inhibiting testosterone production can slow tumor growth and relieve the pain caused by the tumor. However, the extent to which prostate cancers respond to hormone withdrawal varies from patient to patient. In addition, the therapy loses effectiveness over time and the cancer can then grow independently of testosterone, making treatment more difficult thereafter.
Complete drug inhibition of testosterone has the same effects on the body as castration. The patient suffers from impotence, a decrease in libido (sex drive), hot flashes, weight gain, breast enlargement, and an increased loss of bone and muscle mass, leading to an increase in the risk of osteoporosis. Bone densitometry should therefore be carried out regularly as part of hormone withdrawal therapy and osteoporosis therapy may need to be initiated.
LHRH analogues and GnRH analogues can be used to lower testosterone levels. The effect is based on the fact that the active substances correspond to the body's own hormones, which have the effect of reducing testosterone production.
Antiandrogens , on the other hand, shield the prostate carcinoma from the hormone testosterone without affecting the production of the hormone. The drugs cause significantly fewer side effects because they do not lower the level of testosterone in the blood. However, antiandrogens are less effective than testosterone blockers.
Oestrogens (female sex hormones) can lower testosterone levels in the blood within seven days. However, they cause much more severe side effects in men than testosterone blockers. In addition, they should not be used in patients with cardiovascular disease.
Removal of the testicles
Because most testosterone production occurs in the testes, removing them can provide rapid relief from pain in late-stage prostate cancer by quickly lowering testosterone levels. Because removal of the testicles cannot be reversed and it is therefore a psychologically very stressful procedure for the patient, this procedure is now rarely performed for prostate tumors.
If the prostate cancer does not respond or no longer responds to testosterone withdrawal, chemotherapy is given to kill the cancer cells. However, cytostatics (cancer drugs) are primarily used to damage fast-growing tumor cells. Because a prostate tumour sometimes grows very slowly, chemotherapy for prostate cancer is difficult. A life-prolonging effect of cytostatic therapy has only been proven for fast-growing forms of prostate cancer. Since cytostatic drugs kill not only cancer cells but all rapidly dividing cells in the body (for example intestinal cells or hair root cells), chemotherapy causes severe side effects.
In many cases of an advanced, metastatic prostate tumour, those affected suffer severe pain. Since a cure can usually no longer be achieved, effective pain control is an important therapeutic goal.
Late-stage prostate cancer often leads to the formation of metastases in bone tissue, which can cause severe pain and bone fractures. The risk of bone fractures can be reduced by radiation therapy. In addition, certain drugs such as bisphosphonates can be administered, which inhibit the breakdown of bone substance.
Since there is only a chance of a cure if prostate cancer is diagnosed early, annual cancer screening is very important for men from the age of 45. If there have been cases of prostate cancer in the family, screening examinations should be carried out earlier.