Prostate cancer treatment in Germany
What every man should know about prostate cancer
Prostate cancer is the most common cancer in men. The number of new cases of prostate cancer diagnosed in Germany each year is an average 57,000.
One in eight men will develop prostate cancer during their lifetime. About 90% of patients live for at least another 10 years. Many of them thanks to active monitoring. The mortality rate for prostate cancer is significantly lower than for lung or colon cancer.
In the early stages, the disease does not show any symptoms. As the disease progresses, pain in the pelvic area and back may occur, as well as bladder and bowel dysfunction.
How not to lose time
Prostate cancer prevention offers significant advantages: if the tumor is confined to the prostate gland, it is easier to treat. In this case, the chances of recovery increase significantly.
In Germany, prostate cancer screening begins at age 45. During the screening, a blood test is taken to measure the level of PSA (prostate-specific antigen), a significant increase in which may be associated with prostate cancer. Then, a urologist performs digital rectal exam (DRE) of the prostate and also examines the testicles, penis, and inguinal lymph nodes.
When the results of the DRE and PSA level in the blood indicate the oncological process, a transrectal biopsy with a special thin needle is indicated. A procedure may be done using transrectal ultrasound or MRI guidance under short-term anesthesia. Next, the pathologist examines the tissue obtained during a biopsy under a microscope to look for cancer cells.
If cancer cells are found during laboratory examination of the tumor material, histomorphological analysis of the cells is performed to find out the grade of the cancer using the Gleason score.
To get the exact location of the tumor and how far it's spread, the following tests are applied:
- Ultrasound, MRI, and PSMA PET-CT scans: imaging procedures which are used to detect prostate cancer cells that have spread outside the prostate, lymph nodes, into the bones, or other organs.
- Bone scintigraphy: bone scan to check bone tissue for metastases.
Depending on the results of a comprehensive investigation and the patient's age, the necessary therapy or recommended preventive examinations every 1-4 years are indicated. Removal of prostate cancer is the main method of treating this pathology. Prostate cancer surgery in Germany is most often performed using a minimally invasive technique (MIS).
PSMA PET-CT scan
PSA is a prostate-specific antigen that can be detected in the blood of any man and is produced by a healthy prostate. A prostate tumor also produces PSA, and much more than a healthy organ. If the prostate gland is removed together with the tumor, the PSA level drops to zero. This is not the case after radiation therapy, because the prostate remains in the body.
When the PSA level increases again after surgery, this is not normal, because the prostate has been completely removed. A high PSA level detected in the blood must be caused by prostate cancer. Although the tumor has been removed, some cancer cells probably remain in the body and continue to produce prostate-specific antigen. Where these cells are located is unclear.
Only when PSA levels reach a relatively high level (around 3-5 ng/ml), and the tumor has grown sufficiently large, it can be visible again on CT or MRI scans. In Germany, PSMA PET-CT scans are used to detect small tumors that cause an increased PSA level.
PSMA PET-CT is one of the most modern diagnostic methods for diagnosing prostate cancer. To find cancer cells, prostate-specific membrane antigen (PSMA) is used, a protein that attaches to prostate cancer cells. PSMA protein or PSMA ligands are loaded with a radioactive substance and injected into the patient's body. Once in the body, the ligands bind to prostate cancer cells and become visible during a PET scan.
While traditional CT, MRI, or bone scintigraphy tests have certain limitations, the PSMA marker can reveal tumor recurrence at PSA levels below 1.0. PSMA PET-CT is also significantly more sensitive in detecting very small bone metastases.
This diagnostic method has advantages not only for patients with recurrence, but also for those suspected of having prostate cancer, even if the biopsy analysis failed to detect a tumor. PSMA PET-CT scanning can also be used to test the possibility of treatment with PSMA ligands using lutetium-177 (Lu-177).
Source: https://www.uksh.de/strahlentherapie
MRI-Guided Fusion Prostate Biopsy
Fusion biopsy, or MRI-guided fusion biopsie of the prostate, is the most accurate and advanced prostate examination available, allowing for better diagnosis of the most aggressive prostate tumors and significantly improving treatment effectiveness.
A large study published in the respected medical journal New England Journal of Medicine (PRECISION Study) compared standard biopsy and fusion biopsy. The results showed that clinically significant tumors (38% vs. 26%) are much better detected with fusion biopsy. These results have been confirmed by other study groups, making MRI fusion biopsy an essential part of prostate cancer diagnosis in Germany.
In fusion biopsy, a 3D image of the prostate is created from conventional ultrasound images, which is then merged with a real-time ultrasound image (3D TRUS biopsy). At the same time, MRI images are combined with ultrasound images to produce a detailed 3D image of the organ. This information allows not only to identify even the smallest formations in the prostate, but also to take more precise tissue samples for histological analysis in the laboratory.
Source: https://www.martini-klinik.de/diagnostik/fusionsbiopsie
Prostate cancer treatment approaches in Germany
There are various approaches to treating prostate cancer in Germany. Once a diagnosis has been made, the optimal treatment plan is selected and agreed with the patient.
Active surveillance
If there are no indications for surgery, active monitoring is applied so that therapy can be started in time if the disease progresses.
Prostate cancer surgery
When the tumor is restricted to the prostate gland (cancer is found in the prostate only), surgery—radical prostatectomy—is an effective treatment option. During the surgical procedure, the prostate and, if necessary, nearby lymph nodes are removed. If the disease has not spread outside the organ's capsule, 97% of patients are completely cured after surgery. Additional treatment is only necessary if the tumor tissue has not been completely removed.
Specialized urology hospitals in Germany perform prostate removal using da Vinci robotic surgical system. Robotic-assisted radical laparoscopic prostatectomy da Vinci increases the effectiveness of treatment, minimizes risks, and reduces the rehabilitation period.
Robot Da Vinci Surgery
DaVinci® is the most advanced technology in the area of minimally invasive surgery. The system allows to perform minimally invasive laparoscopic surgeries with the highest 3D resolution and precision. A robotic-assisted radical prostatectomy (RARP) – is the most common surgery performed using the DaVinci® system.
German urology clinics started using the DaVinci® surgical technique back in 2004, so they've got enormous experience in this area. Since then, robot-assisted laparoscopic radical prostatectomy using the Da Vinci robot has become the standard surgical method for treating prostate cancer.
The DaVinci® surgical technique is based on the precise transmission of the surgeon's hand and finger movements to the surgical instruments. Therefore, the frequently used term “robotic surgery” is not really accurate. Rather, it is an automated telemanipulator that works on the so-called “master-slave” principle. The safety standards applied in this case are comparable to those in the aircraft industry.
As with conventional laparoscopy, when using the DaVinci® technique, instruments are inserted into the abdominal cavity through small tubes with a diameter similar to that of a ballpoint pen. At the same time, robotic surgery has a number of advantages over conventional laparoscopic surgery.
The robot's instruments are equipped with small mechanical “arms” that can be called a real technological marvel in terms of their precision and maneuverability. The surgeon’s finger and hand movements are transmitted to them with an accuracy of up to 7 degrees of freedom, allowing the surgeon to see a 3D image of the surgical field with the ability to smoothly zoom in on it. As a result, the surgeon can reliably identify even the most fine structures, such as nerve bundles and small vessels, in order to perform the operation accurately, carefully, and with minimal blood loss.
The advantages of da Vinci robotic surgery for patients are as follows:
- Quick and painless postoperative recovery
- Short stay in the hospital
- Excellent cosmetic results
- Fewer complications and infections
- Less pain and less scarring
- Leliable protection of erectile nerves during nerve-sparing surgery
The cost of robotic surgery in Germany ranges from €18,000 to €20,000
In the surgical technique developed at Heidelberg University Hospital, the first step is to remove the local lymph nodes of the prostate. During the operation, a histological examination of the lymph nodes (rapid biopsy) is performed to check for tumor cells.
Then, the prostate gland is separated from the bladder and connective tissues of the prostate bed while preserving the erectile nerves and, carefully controlling the sphincter muscles, is removed from the urethra.
After the prostate is placed in a small bag, the bladder is connected to the urethra with a thin continuous suture. At the end of the operation, the bag with the prostate is removed from the abdominal cavity and sent to the laboratory for histological analysis.
After the surgery, the patient will spend about three hours in the recovery room, where anesthesiologists monitor respiratory and cardiovascular functions and give pain medication.
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When all parameters return to normal, the patient is moved to a regular room, where relatives can visit him in the evening. Mobilization (the ability to sit, stand, and walk) begins the next day (the first postoperative day). On approximately the 4th or 5th postoperative day, the tightness of the connection between the urethra and the bladder is checked, after which the patient is discharged.
Source: https://www.klinikum.uni-heidelberg.de
Radiation therapy
In the early stages of cancer, if the tumor is confined to the prostate, radiation therapy is considered in addition to surgery. External or internal radiation is used to destroy the gland tissue affected by cancer cells.
In Germany, intensity-modulated radiation therapy (IMRT) is used, which is the most effective and modern method of external radiation therapy. IMRT technology allows high-power rays to target the cancerous tumor with extreme precision, while avoiding unwanted irradiation of healthy tissue.
Internal methods include interstitial brachytherapy, where the radiation source is placed inside the cancerous tumor. Radiation therapy can be combined with chemotherapy or hormone therapy.
Hormone therapy
In cases where other organs are affected or the treatment has not been successful, hormone therapy is used as an additional method. If the metastases have spread to other parts of the body, this is referred to as metastatic prostate cancer (MPC). Hormone therapy for metastatic prostate cancer is used as a primary treatment. This method is also called androgen deprivation therapy (ADT). Androgens, the main male hormones testosterone and dihydrotestosterone, stimulate the growth of cancer cells. Hormone therapy suppresses the action of testosterone, thereby slowing tumor growth.
Chemotherapy
In the later stages of the cancer, when it's spread to other parts of the body, they'll give you cytostatic anticancer drugs. Chemotherapy is often given together with hormone therapy.
PSMA therapy for prostate cancer with lutetium-177 isotope
PSMA therapy is the latest method for the precise and safe treatment of cancer cells, used to treat patients with metastatic prostate cancer.
Prostate-specific membrane antigen (PSMA) is a molecule that is found in large numbers on the surface of prostate carcinoma cells. PSMA ligands, pre-loaded with the radioactive isotope lutetium 177, have the ability to bind to PSMA molecules on tumor cells. When the ligands are injected into the patient's body, they find the affected cells, attach to them, and the radioactive substance begins to destroy them. This makes it possible not only to detect prostate cancer cells, but also to destroy them with minimal impact on surrounding tissues.
The half-life of the Lu-177 beta emitter is 6.7 days, so its effect lasts for several weeks. For this reason, the effect of the therapy is not immediately noticeable, but only becomes apparent over the following weeks. Since one procedure is often not enough to effectively suppress tumor growth, in most cases several procedures (usually 3) are performed at 8-week intervals.
PSMA therapy is well tolerated and side effects are usually mild.
The most common ones are:
- Fatigue and general malaise, which can last up to 2 weeks after treatment
- Changes in blood counts (anemia, decreased platelet or white blood cell counts)
- Dry mouth
- Nausea, fever, and pain are rare in bone metastases
PSMA therapy in Germany is performed in nuclear medicine centers on an inpatient basis with a stay in the clinic for 3-4 days.
Long-Term Monitoring
Not all men who develop prostate cancer during their lifetime have a poor prognosis or must face a decline in quality of life. Many patients may avoid treatment altogether. Active surveillance is considered, in particular, for older men with slow-growing disease. These patients have a 2-3% chance of developing life-threatening disease. In this case, there is no danger for life.
A wide range of modern prostate cancer treatments in Germany allows completely getting rid of the disease in its early stages and effectively slowing its development in stages 3 and 4.
Do not ignore the initial symptoms of the disease; make an appointment with an experienced German urologist. On our website, you will find information about the best urologists specializing in the treatment of prostate cancer in Germany, prices, and patient reviews.
