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Prostate cancer: “Wait and see?”

One in six men contracts prostate cancer

Unlike BPH (Benign Prostatic Hyperplasia), prostate cancer doesn't usually produce any symptoms.

Although they occur frequently, many prostate cancers are relatively harmless. Many men live with undiscovered prostate cancer that remains asymptomatic and does not shorten their life expectancy.

When a physician suspects prostate cancer, a punch biopsy is usually recommended. If it is positive for prostate cancer, most men are advised to have their prostate surgically removed (radical prostatectomy) with the explanation that this is the only method by which there is certainty that the carcinoma has been prevented from spreading to other parts of the body.

What often remains unsaid is that this method, justifiably called “radical”, causes serious collateral damage: 70% of all men are impotent after the operation, 10-50% incontinent.

But for many men this prostatectomy is totally unnecessary. Between five and 30 men have to be treated before one man's life is saved (depending on tumor stage, age and time elapsed after diagnosis). The problem is that no one knows which carcinoma will remain harmless and which will not.

In many cases, it would be best to simply not perform any type of therapy. For older men with small, only slightly aggressive prostate carcinomas, it is often sufficient to observe how the carcinoma develops—so-called “active surveillance”. This is because, in older men, many prostrate carcinomas grow very slowly and never form metastases.

An alternative could be a gentle focal treatment with the goal of sparing erectile function and continence. In such treatment, only the part of the prostate that is affected by the tumor is destroyed. It is even sufficient if only the index lesion—the largest cancerous area—is destroyed, because this is the most important factor in the patient's further prognosis.

A prerequisite for an optimal therapy choice is an exact assessment of the spreading of the tumor and its aggressiveness. Transperineal 3D biopsies play a central role in this assessment. Unlike standard biopsies through the rectum, they produce exact evidence of the carcinoma's aggressiveness and distribution in the prostate (Gleason score). The diagnosis is complemented by imaging procedures and, if appropriate, lymph node examinations.

Therapy options range from doing nothing (“watchful waiting” or “active surveillance”) to minimally-invasive focal treatment procedures or antihormonal treatment, all the way to an operation and radiation therapy. The optimal therapy can be determined on an individual basis taking into account staging, grading, laboratory results, state of health, life expectancy, social and sexual life, psychological factors and personal preferences.

In this process, two goals should be foremost: avoiding metastases and avoiding collateral damage, because impotence and incontinence are usually irreversible. On the other hand, prostate cancer is usually a slow process. And because, due to the rapid advances being made in medicine, new, effective and substantially less traumatic therapy procedures can be expected in the next five to ten years, it really makes the concept of “waiting and seeing” worthy of discussion.

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