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Ten misconceptions about the treatment of prostate cancer

Surgery, radiotherapy or just wait and see? Prostate cancer like no other type of cancer, creates so many misconceptions, biases, and wrong information concerning the causes, treatment methods, and possible cures. False rumors circulate especially around radiation therapies for prostate cancer. False rumors circulate especially around radiation therapies for prostate cancer.

The consequence is a severe insecurity in men who search for a therapy best suiting their individual needs. By addressing the "10 misconception about the treatment of prostate cancer," the West German Prostate Center wants to close a knowledge gap and contribute to a better awareness for men concerned with the issue.

Misconception # 1: The best therapy for prostate cancer is surgery

Currently, patients are still suggested that radical prostatectomy is the only way to cure the cancer. Clearly, this is wrong. On the contrary: If previously radical removal of the prostate was known as a favored solution to completely remove the cancer and prolong the lifetime, recent long-term studies show that there other ways. The methods of the modern radiation therapy have not only proven a higher cure rate, but they have also evidenced significantly lower side effects such as incontinence and Impotenz1.

Misconception # 2: After surgery, the tumor has disappeared

About one third of all patients do experience a return of the disease after a certain time, a so-called recurrence. The risk of developing a recurrence depends on the probability that individual tumor cells may have already left the prostate at the time of the diagnosis. Therefore, the statement should really be that the tumor is gone after surgery, if it has not already moved beyond the prostate tumor metastases. The success of the treatment, and thus the chance for recovery are thus directly dependent on the probability, whether metastases are present or not.

Misconception # 3: If prostate cancer has progressed, surgery offers the best chance for recovery

A fatal error believed by many men. Numerous studies have established that surgery is not a good choice especially when it comes to advanced tumors. The reason for this is that the tumor may already have spread outside the edge of the incision and grows again after the surgery. This is why internal radiation (brachytherapy) that targets the organ or tissue involved comprehensively, extending beyond a sharply defined incision, are more appropriate. The advantage compared to the surgery is that the peripheral regions of the prostate are included in the irradiation. The probability that the tumor in the prostate (local recurrence) occurs again, is thus less after brachytherapy than after radical surger1.

Misconception # 4: After the diagnosis treatment should start rapidly

In most cases, prostate cancer is a slow-growing cancer. When a tumor was just diagnosed, men should take enough time to make a decision as to an appropriate treatment with the attending physician. As recommended by the guidelines, it may even be sufficient for men who have a low risk prostate cancer, to have the tumor monitored closely (active surveillance). However, if a treatment is necessary, it is important to focus on achieving an optimum cure rate with minimal side effects.

Misconception # 5: Younger patients should be better operated

This is simply wrong: Especially younger men benefit from the significant advantages of a modern brachytherapy / radiotherapy. The benefits are a new therapy concept, a lower rate of incontinence, and a significantly lower rate of impotence. All these factors mean that young and sexually active men affected by prostate cancer, can regain their good quality of life. In addition, the significantly shorter treatment and sick leave times of the brachytherapy – when compared to conventional treatments – are an additional benefit for men who are in the middle of working life.

Misconception # 6: Men over 75 should not be treated

Life expectancy does not just depend on age but rather on a number of additional factors. Chronic diseases, physical fitness, independent life style, and mental agility play an essential role in how many years a patient will still enjoy life. Many seniors even if they are beyond 75, are still in the midst of life. They are physically active, interested in many things and enjoy good health. Here, it would be fatal to forgo an effective therapy. The Society of Geriatric Oncology (SIOG) therefore recommends that otherwise healthy elderly people be afforded the same treatment as provided younger prostate cancer patients. The goal should be, to avoid potential restrains to the quality of life arising from the decease, and to prolong the lives of the patients.

Misconception # 7: Upon introduction of mini-implants (seeds) in the prostate, it comes to 'rays gaps '.

As part of a treatment plan it will be determined what radiation dose is “prescribed” to the tumor or the organ. This is also called the “comprehensive organ dose" or "prescription dose." The subsequently performed seed implantation ensures that all areas of the prostate and the tumor are provided at least this amount of radiation. "Gaps" occur only with inexperienced therapists and/or poor treatment planning. Consequently, it is always advisable to choose an experienced treatment team is chosen.

Misconception # 8: Surgery is no longer possible after radiotherapy

The assumption that after irradiation surgery can no longer be performed in the event of a recurrence is wrong on two counts. Firstly, adhesions of the tissue resulting from a radiation therapy that are considered a hindrance to the surgery are today because of precisely targeted irradiation significantly lower and therefore easily manageable by an experienced surgeon. Secondly, the probability of the tumor recurring in the prostate (local recurrence) is less than two percent. In 98 percent of the cases, recurrences after brachytherapy are not isolated local recurrences but rather metastases in other organs (distant metastases). A surgery is not indicated in such cases anyway.

Misconception # 9: Radiotherapy of prostate favors the occurrence of bladder and colon cancer

A great fear that many men have is that after successful radiation treatment of prostate cancer a second tumor develops. As has meantime been shown in numerous studies, this fear is not justified. Thus, an American cohort study3 showed that the risk of a second bladder or rectum cancer developing after irradiation of the prostate via brachytherapy is less than after a complete resection of the prostate. More recent and more targeted techniques today avoid in most men that intestines and bladder are within the radiation field. State of the art computer technology and the use of imaging techniques make it possible to detect the target area with millimeter precision and to irradiate with utmost accuracy.

Misconception # 10: A surgery of the prostate using a robot reduces the risk of incontinence and impotence

The modern robot-assisted surgery, which is considered prejudgmentally as a "gentle" treatment option for the patient, has more side effects than previously publicized. Thus, a cohort study showed that the "robotic surgery" is accompanied by an elevated incidence of late risks such as impotence and incontinence, which despite the minimally invasive technique can even be more pronounced than the conventional surgical processes4. In addition, surgeons who perform robotic-assisted radical prostatectomies must have extensive experience.

Literature:

1Grimm P, Ignace Billiet I, Bostwick D et al. Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJUI 109, Suppl. 1, 22-29, 2012

2 Barmer GEK Krankenhausreport 2012

3Zelefsky MJ, Pei X, Teslova T, Kuk D, Magsanoc JM, Kollmeier M, Cox B, Zhang Z: Secondary cancers after intensity-modulated radiotherapy, brachytherapy and radical prostatectomy for the treatment of

 

ESTRO: Brachytherapy achieves excellent results

Internal radiation – more effective, safer, and cost effective than radical surgery

 

Urinary incontinence, erectile dysfunction, impotence?

Especially for younger patients with prostate cancer, the expected adverse effects play a crucial role in the selection of a therapy. Brachytherapy, a special form of "internal" radiation has not only proven to be highly effective, but also has proven to have fewer side effects. A recent study, which was presented at the annual meeting of the European Society of Radiology and Oncology (ESTRO), clearly demonstrates: patients, who are treated with brachytherapy instead of traditional surgery, can expect a much better quality of life after surgery, without having to compromise healing. Moreover, the brachytherapy is in comparison to the radical removal of the prostate much more cost effective.

Whether surgery, brachytherapy, or external irradiation - the cure rates for patients with the cancer limited to the prostate, are with 90% very regardless of the type of treatment. "Once the decision for a therapy is made, the primary concern should be on selecting the less invasive and most gentle procedure," said Dr. Neubauer from the West German Prostate Center in Cologne. Nevertheless, unfortunately the reality, at least in Germany, is still different, criticized the urologist. Invasive surgery is still number one on the list of conducted therapies for localized prostate cancer. And, this regardless of significant side effects, such as erectile problems, lack of sex or urinary incontinence. One in five patients also confirmed surgery-related complications, such as severe bleeding or bowel injury.

 

Best results for brachytherapy

Increasingly more studies proof that brachytherapy has the the highest score with regard to the quality of life and patient satisfaction. In this ultra-modern form of radiation therapy, the tumor in the prostate is destroyed with utmost precision from within and neighboring organs such as bowel, bladder, and urethra are protected. The superiority of brachytherapy compared to the radical prostatectomy  was again evidenced by a systematic analysis encompassing data of 55.000 patients. This study was just recently presented at the annual meeting of the European Society of Radiology and Oncology1.

Analyzed was the healing rate, health-related criteria for quality of life, and cost of treatment over a period of 10 years. The results were clear: Both the seed implantation in patients with a low risk as well as the HDR afterloading in combination with external radiotherapy in prostate cancer at a more advanced stage were in comparison to the surgical removal of the prostate associated with a significantly higher quality of life.

 

Lower costs for  brachytherapy

Another advantage is that brachytherapy is the most cost-effective option in the treatment of localized prostate cancer. Not only are long recovery times after surgical removal especially costly to the patient, but also for employers and health insurers. The patient is at a minimum 104 days on sick leave after a radical prostatectomy, while a patient following brachytherapy, can resume work as early as the day following the treatment. The costs are extremely high since time-consuming treatment-related complications and side effects of surgery, such as total urinary incontinence and impotence, have to be added in.

"The goal of the treatment for patients with a tumor limited to the prostate should always be to achieve a cure and to prevent the disease from degrading the quality of life," says Dr. Neubauer. "Here the United States is already a big step ahead of us," says the urologist of the West German Prostate Center.  While in Germany only 8 percent of all  patients are treated with brachytherapy, in the US 25% of the men with prostate cancer already benefit from this less invasive therapy.

 

Literature.

1 Steuten LMG. Comparative cost / QALY of guideline-recommended treatments prostate cancer: a UK cost perspective. PD 0371; 2nd ESTRO Forum, Geneva, Switzerland, 2013.

 

 

Second Tumar after Prostate Cancer Therapy?

Less occurrence of bladder and colon cancer after brachytherapy than after surgery and radiation

The risk to develop a bladder or colorectal cancer as a secondary tumor after radiation, e.g., brachytherapy, is lower than developing a second cancer after complete removal of the prostate. This is the result shown in a current U.S. study that has recently been published in the renowned British Journal of Urology.

Read more: Second Tumar after Prostate Cancer Therapy?

   

Prostate Cancer is operated too often

Recent studies confirm overtreatment / Serious side effects for patients after surgery

The majority of patients in Germany diagnosed with localized prostate cancer are still undergoing radical surgery. That this procedure has been obsolete for quite some time has meanwhile been evidenced by numerous studies. Especially for men with low risk tumors or men over the age of 70, radical prostatectomy might not be a wise decision. On the contrary: Many patients complain of significant side effects after the surgery—and this, although vessel and nerve-sparing surgical techniques are used more frequently.

 

Read more: Prostate Cancer is operated too often

 

Fewer complications after laser therapy

Recent meta-study shows benefits for advanced laser procedures in the treatment of benign prostatic hyperplasia

Despite the possible complications, the enucleation of the prostate (transurethral resection / TURP) remains the standard procedure for the treatment of benign prostatic hyperplasia. A recent meta-study published in the European Journal of Urology, showed that the photo-selective laser therapy (PVP) in comparison to TURP resulted in fewer postoperative complications. "Conventional prostate enucleation can now be replaced in most cases by the less invasive laser procedure”, commented Dr. Stephan Neubauer of the West German Prostate Center in Cologne, the current results of the largest comparative study.

Read more: Fewer complications after laser therapy

   

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