Prostate cancer: causes, diagnosis, treatment

Overview

Prostate cancer is the most common malignancy of the male in our latitudes. It occurs primarily with increasing age and arises depending on certain risk factors such as a genetic predisposition as well as environmental and lifestyle factors.

Foresight is worthwhile

Prostate cancer has slow growth in most cases and does not become symptomatic until it has become dislocated to other organs or has become significantly larger. For this reason, men from the age of 45 are annually reimbursed by the statutory health insurance.

As part of the precaution, but also on the appearance of prostate-specific symptoms, a palpation of the prostate is first performed. If these indications indicate the presence of a malignant tumor, further examinations may follow, such as the measurement of the PSA value, an x-ray of the lumbar spine, a CT or an MRI examination of the pelvis and a tissue biopsy of the prostate gland. In summary, the findings can then be used to estimate the stage of the disease and initiate therapy.

Treatment according to prognosis

For the treatment of prostate cancer, different options are available. In general, a distinction is made between a curative therapy concept for non-metastatic tumors and a palliative approach for metastatic tumors.

The curative approach aims at healing and can be achieved through surgery or radiation, while the palliative approach does not pursue the goal of healing, but seeks to facilitate a symptom-free existence. Hormone and chemotherapy as well as the "watchful waiting" approach are used. Prostate carcinoma is monitored and intervened only when it causes discomfort - which is never the case in many cases.

definition

Prostate cancer is a malignant growth of prostate cells. It is the most common cancer in Germany and the third leading cause of cancer death after lung and colon cancer. On average, men around the age of 70 suffer from prostate cancer, although the number of unreported cases of prostate cancer appears to be much higher. In more than 50% of all autopsies performed on over 80s, there is a so-called latent prostate carcinoma, a prostate cancer that has not become clinically abnormal during his lifetime.

causes

There are no reliable triggers for the development of prostate cancer. However, various risk factors could be ascertained that appear to be associated with the onset of cancers of the prostate gland. According to the guideline of the European Association of Urology, there are three main risk factors for the development of prostate cancer:

  • Age: Age seems to play a crucial role in the development of prostate cancer. For example, 80% of men who develop cancer are 60 years or older.
  • Location: If the global world is considered, there is a north-south as well as a west-east gradient for the occurrence of prostate cancer. This means that prostate cancer is more prevalent in the US and Northern European countries than in the Asian and Southern European countries. The reasons for this have not yet been finally clarified. However, it is believed that socio-economic factors as well as different dietary habits play a role.
  • genetic predisposition: Familial preloading plays an important role, especially for early forms of prostate cancer. Thus, the risk of becoming ill even when a relative of the first grass (for example, father or brother) is affected and tenfold increases when two or more first-degree relatives suffer from prostate cancer. For this reason, men with a significant genetic predisposition are offered early and regular urological check-ups.

Avoidable: smoking and unhealthy eating

Other risk factors that are positively correlated with the occurrence of prostate cancer are the following:

  • chronic diseases such as chronic inflammation of the prostate gland (prostatitis) or venereal diseases
  • High-fat and meat-rich diet with simultaneous lack of selenium and fish and vegetable-poor diet
  • chronic nicotine consumption

Although a positive correlation between the side-risk factors and the occurrence of prostate cancer has been demonstrated in various studies, it has not been shown that prevention of these risk factors has a preventive effect on carcinogenesis.

Read also:
Important questions about causes & risk

symptoms

Prostate cancer causes no symptoms for a long time and is often not noticed until it is well advanced. This makes it a very treacherous tumor that is often difficult to treat. In early stages, most prostate cancer is detected in the context of screening, which are reimbursed once a year from the statutory health insurance in men from the age of 45 years.

Allerweltsbeschwerden

Disorders caused by prostate cancer not only occur at a very advanced stage, but are also less characteristic, as they can also occur in many other harmless diseases of the prostate gland.

In detail, possible symptoms are:

  • Problems with urination (dysuria) to the urinary retention, which is caused by the laying of the urethra by the prostate
  • frequent urination, which is especially noticeable at night (nocturia)
  • slightly bloody urine (hematuria)
  • Incontinence, due to the cancerous involvement of the sphincter
  • Impotence due to infestation of nerves and vessels responsible for an erection, as well as pain in ejaculation
  • Defecation difficulties

Especially in the context of a benign prostate enlargement as well as a urinary tract infection or inflammation of the prostate, it can also come to the above-mentioned complaints. Only about a tenth of the men who present with these symptoms to a urologist actually suffer from prostate cancer. For all the others, the cause is far more harmless and often good to deal with.

Here it is already suspicious

An indication that prostate cancer is responsible for your condition is the following additional symptoms:

  • Pain in the bones and especially in the lower back, the legs or the hip, caused by a dislocation of secondary tumors (metastases) from the primary tumor
  • Weight loss by more than 10% of body weight in the last six months
  • Night sweats that force you to change your pajamas and bedding at night
  • fever

You'll find more about it here:
Questions and answers about the symptoms

diagnosis

Blessing and curse of early detection

In many cases, prostate cancer is diagnosed not first when it is already causing symptoms, but at a latent stage during a check-up. However, although the introduction of early detection measures far more tumors of the prostate are detected and treated, so far no clear advantage on survival has been shown. On the contrary, the question must be asked as to whether an early therapy will lead to an over-therapy because a considerable part of the discovered prostate carcinomas would not have become symptomatic throughout their lifetime.

In the current guidelines, therefore, the recommendation to inform about the advantages and disadvantages of diagnostics and preventive examinations and to act individually. While in many cases gratuitous precautionary measures are of no benefit, there is an opportunity for individual cases to recognize prostate cancer at an early stage and to treat it at a stage in which the chances of recovery are still very good.

Whether symptomatic or not, the diagnosis always results from different components. Your doctor or urologist will start by taking an anamnesis. This is followed by a digital examination of the prostate gland and possibly a blood sample to measure the PSA value. As a supplementary diagnostic, further examinations may be necessary in case of conspicuous findings.

1. Anamnesis

During the first consultation with the doctor, your doctor will first ask you about existing complaints. He will also discuss with you the risk factors for prostate cancer and ask you about your family history. It is especially important if a first-degree relative, father or brother, suffers from a prostate cancer, because in such a case increases the likelihood for you to get yourself in your life.

Following the anamnesis interview, the palpation of the prostate (digital-rectal examination) is performed.

1. Digital rectal examination (DRU)

What is often very uncomfortable in mind and makes many men shy away from having a screening test is rectal palpation of the prostate. Your doctor will insert the gloved index finger into the rectum and will feel the surface structure of the prostate through the intestinal wall.

In the healthy state, the prostate is about the size of a chestnut and of firm-elastic consistency.Especially in the early stages of prostate cancer, certain rough areas within the normal prostate tissue can be delineated. In later tumor stages, the prostate is grossly deformed, asymmetrically and painlessly enlarged.

At maximum relaxation of the sphincter, the examination is not painful and takes no more than 1-2 minutes. If you are insured by law, you have a yearly entitlement to DRU from the age of 45.

3. PSA value

If noticeable palpation findings occur during the DRU, your doctor may arrange for a blood test from which the PSA value is obtained for further diagnostics. PSA, the prostate-specific antigen, is a marker that is formed only by the prostate and may increase in certain diseases of the prostate gland. Typically, increases in value are found in benign and malignant tumors, but also in inflammation or after manipulation of the prostate.

The costs are your own

The PSA value is expressed in nanograms (ng) per milliliter (ml) and is used as a screening method in the early detection of prostate cancer. Since its predictive value as a precautionary instrument is however controversial and so far could not be clearly demonstrated that the determination of the PSA value, the prostate cancer mortality was declining, the PSA screening is not covered by the statutory health insurance and is an individual health service (IGeL), the If you want to have the PSA value determined during a check-up, you must wear it yourself.

After a first determination of the PSA value from the age of 45 years, depending on the level of the determined value, the further procedure results:

  • for a PSA <1ng / ml, the next assessment after four years is recommended. After the age of 70, no further controls are necessary.
  • If the PSA value is between 1-2 ng / ml, the next value control should be done after two years.
  • at values> 2 ng / ml, the value can be determined at yearly intervals.

Follow-up takes over the cash register

In addition, PSA will be used to monitor the progression of PSA-positive prostate cancer to assess the efficacy of the therapy and to detect recurrence early. In the course of control examinations after diagnosed or treated carcinoma, the costs for the determination of the PSA value are borne by the health insurance.

Overall, various situations are considered suspect and should be further clarified. These include, among others:

  • a total PSA of> 4 ng / ml
  • an increase in PSA within one year of more than 0.35-0.75 ng / ml
  • a proportion of less than 20% free PSA in total PSA

PSA determination remains controversial

But beware, even though this information seems to be very clear, it must always be kept in mind that PSA levels may be elevated, for example, when the prostate has been manipulated (anal intercourse, prostate massage) or other prostate disease (for example inflammatory diseases of the prostate or a urinary retention).

Furthermore, an increase in PSA level is not mandatory for every carcinoma. Certain forms as well as very slowly growing tumors do not have to lead to abnormalities in the PSA value and thus elude this diagnostic agent.

Further information can be found here:
Questions and answers about the PSA test

4. Sonography & prostate biopsy

In the case of suspicious findings in basic diagnostics, further instruments are used to secure the diagnosis. The drug of choice is transrectal sonography-guided prostate stance biopsy. Under ultrasound-guided vision and local anesthesia 10 to 12 tissue samples are taken from the prostate. The sampling instruments are inserted rectally and the prostate is punctured through the intestine.

In case of conspicuous findings or a further strongly increasing PSA value, another biopsy may be necessary after about six months. Tissue samples are scored under the microscope and scored using the Gleason score.

5. Further staging examinations

If the diagnosis of a malignant tumor of the prostate can be confirmed, further investigations, so-called staging examinations, follow, with which the extent of the tumor at its primary place of origin should be assessed and also investigated for secondary tumors.

From the head to the feet

The most important investigations on staging diagnostics are:

  • Ultrasound examination of the abdominal organs: A sonography of the abdominal organs is mainly used for the elucidation of metastases in the liver and the detection of urinary tract disorders.
  • Whole-body scintigraphy: for the assessment of bone status or for the detection of bone metastases
  • X-ray of the spinal column: X-ray is a procedure that provides rapid information about possible metastases of the lumbar spine, especially in back pain.
  • Laparocopy: As part of a laparoscopic examination, lymph nodes can be removed from the pelvis and examined for tumor cells. The so-called laparoscopic pelvic lymphadenectomy serves to assess the degree of metastasis in the regional lymph nodes.
  • MRI of the pelvis: MRI can clarify the question of the extent of the tumor as well as the operability in case of unclear findings.

Which staging examinations are used in detail is always an individual decision and depends to a large extent on the preliminary examinations that were performed on you.Based on the available results, your doctor can assess the tumor stage and plan the subsequent therapy. This is chosen very individually and decisively influenced by you. So let yourself be well informed about all procedures and their advantages and disadvantages.

Learn more about diagnostics here:
Investigations of suspected cancer
spread diagnostics

classification

Different systems can be used to classify prostate cancer. The TNM classification is internationally valid and refers to the macroscopic spread of the tumor, while the Gleason score is used to assess the microscopic changes in the prostate tissue that are visible under the microscope.

TNM classification

Following the diagnosis, the classification of the tumor is based on the TNM stage. The TNM classification is an internationally used classification system used to describe malignant tumors. Its features can be identified by the TNM classification of a tumor. Doctors can estimate which therapy is needed or how good the prognosis of the respective cancer form is.

  • T: The "T" of the TNM classification refers to the source or primary tumor itself. It describes its size or local extent.
  • N: The "N" indicates the number of affected lymph nodes that are already interspersed with tumor metastases.
  • M: "M" stands for distant metastases and refers to progenitor tumors that have moved away from the primary tumor in other organs.

For a description of prostate cancer, the TNM classification looks like this:

T0 There is no evidence of a prostate tumor.
T1 The primary tumor is clinically indistinguishable (there are no symptoms, the tumor is neither palpable nor visible).
T1a: In the surgically removed prostate tissue, <5% of the examined tissue is tumorous.
T1b: In the surgically removed prostate tissue,> 5% of the examined tissue is tumorous.
- T1c: Ultrasound and palpation of the prostate are unremarkable, but with the help of tissue sampling, a tumor is still detectable.
T2 The carcinoma is confined to the prostate, the capsule surrounding the prostate is intact.
- T2a: The tumor has affected <50% of a prostate side lobe.
- T2b: The tumor has attacked> 50% of a side lobe of the prostate.
- T2c: The tumor has affected both lobes of the prostate.
T3 The prostate carcinoma has broken through the capsule and spread outside the prostate.
- T3a: The spread is outside the prostate capsule, without infestation by neighboring organs.
- T3b: The spread of carcinoma affects the seminal vesicle.
T4 Prostate cancer has spread to neighboring organs such as the urinary bladder, the rectum or the pelvic wall.
N1 Lymph nodes in the pelvic area have metastases of prostate cancer.
M1 There are distant metastases.
- M1a: Metastases outside the small pelvis
M1b: there are bone metastases.
- M1c: distant metastases are present in all other organs.

Gleason score

The Gleason score is used to assess tissue samples obtained from a biopsy or organ harvesting from the prostate. Under the microscope, it can be assessed how much the carcinoma cells differ from the healthy cells of the prostate.

Furthermore, it can be estimated by means of the microscopic examination or the Gleason score, how fast the tumor grows and whether it has already broken through the capsule of the prostate. In summary, prognostic parameters can be determined which may play a role in the choice of therapy.

5 degrees, 10 values

To determine the Gleason score, the cancer cells are first divided into 5 groups. A Gleason grade of 1 corresponds to barely altered tissue, while a Gleason grade of 5 corresponds to tissue degeneration so severe that the prostate output tissue is barely recognizable. The Gleason score is calculated by adding two Gleason grades, resulting in a value between 2 and 10:

  • If the assessed tissue sample is from a prostate biopsy, the most common Gleason grade is added to the one that is the least well-differentiated, and thus the most different from healthy tissue.
  • However, if the assessed tissue sample comes from a prostate resected, the Gleason score is calculated by adding the most common to the second most common tumor cell type.

Low scores indicate a slow-growing, well-differentiated tumor, while high scores indicate the dangers and rapid growth of prostate cancer.

Read also:
Understand examination findings

treatment

Often, waiting is enough

For the treatment of prostate cancer, various options are available. In addition to classical methods such as surgical removal of the prostate and radiation of the tumor tissue, there is also the option of active surveillance ("Active Surveillance"). Here, the prostate cancer is monitored at short intervals and only started with the progression of the disease with a definitive tumor therapy.

If distant metastases are present or your life expectancy is below 10 years regardless of cancer, palliative therapy may be considered.This provides, inter alia, the concept of watchful waiting, whereby mitigating measures are initiated only when symptoms of the disease show up.

In general, a distinction can be made between two situations: therapy of non-metastatic and metastatic prostate cancer therapy.

1. Therapy of non-metastatic prostate cancer

For the treatment of non-metastatic prostate cancer, two equivalent alternatives are available, each of which has a curative therapeutic goal, ie to lead to the cure of the disease.

A matter of taste: surgery or radiation

First, the entire prostate can be surgically removed. In addition to the prostate including its capsule, the adjacent seminal vesicle and adjacent parts of the vas deferens are removed. As a rule, additional adjacent lymph nodes are removed and examined histologically for metastases present. Furthermore, the cut edges of the removed tissue are examined and checked for freedom from tumors. In the case of tumor-affected cut edges of the resected lesion, the surgery should be followed by irradiation of the tumor bed in order to destroy any remaining tumor cells.

Although surgical removal of the prostate gland is not a very big procedure, there can be complications that can seriously affect quality of life afterwards. These include primarily stress incontinence and erectile dysfunction, which occurs in about 50% of cases.

Alternatively to surgery, external radiation can be used as a therapeutic option. This is done in several sessions with a total radiation dose of 74-80 Gray. If lymph nodes are affected radiotherapy can be combined with hormone therapy.

Keep the ball flat: Active Surveillance

For very small, locally and slowly growing prostate carcinomas, there are two other treatment strategies: On the one hand, radiolucent material (so-called 125-iodine seeds) can be inserted into the prostate and locally destroy the tumor cells there.

On the other hand, there is the option of "active surveillance", in which the tumor or tumor growth is monitored closely and treated only as the disease progresses. This variant has the advantage that no unnecessary treatment is carried out. The disadvantages are very close-meshed examination appointments, which often cause great uncertainty regarding one's own health.

2. Therapy of metastatic prostate cancer

If the prostate carcinoma has already formed settlements in other parts of the body, or if your life expectancy is less than 10 years independent of the tumor disease, palliative therapy procedures are regularly used.

The hormone supply caps the tumor

On the one hand, combined hormone chemotherapy can be used. This combines a classic chemotherapy drug such as docetaxel with a GnRH analogue such as buserelin or a GnRH blocker such as Abarelix, as well as an antiandrogen such as flutamide.

The goal of hormone therapy is to achieve a complete androgen blockade and to deprive the tumor of its hormonal growth stimulus in this way, as many prostate cancers grow androgen dependent. Combined chemotherapy is intended to prevent the formation of new tumor cells and thus further restrict the growth of degenerated prostate tissue.

A sensible alternative: Watchful Waiting

Another option of the palliative therapy concept is the "Watchful Waiting". Here, the tumor growth is observed in the long term and intervene only when you develop symptoms that lead to a reduction in quality of life. In contrast to "Active Surveillance", these are not measures to cure the disease, but rather to relieve symptoms of progressive tumor disease.

No matter which treatment concept is chosen, it is very important that you know the pros and cons of each and every one of them, in order to weigh for themselves which of the therapeutic options you want to use and which not. Trust not only the medical statements, but also your own gut feeling.

More about this topic can be found here:
Frequently asked questions about the treatment

forecast

The prognosis of prostate cancer depends on different factors. Decisive are the Gleason score as well as the TNM stage of the initial tumor, but also the operative findings. Removal of the tumor in the healthy, for example, has a significantly better prognosis than if residual components of the tumorous tissue remain in the healthy.

Read more here:
Questions and answers about history and prognosis

Author: Lisa Wunsch

sources

M. Stephan et al .: Urology, Springer Medizin Verlag, 2016.

Guideline oncology: S3 guideline for the early detection, diagnosis and treatment of the various stages of prostate cancer, http://www.awmf.org/uploads/tx_szleitlinien/043-022OLl_S3_Prostatakarzinom_2018-04.pdf, last accessed on 22.05.2018.

N. Mottet et al .: Guidelines on Prostate Cancer, https://uroweb.org/wp-content/uploads/09-Prostate-Cancer_LR.pdf, last accessed on 22.05.2018.