Urogenital Diseases

Current Diagnostic and Treatment Algorithm for Prostate Cancer

Prostate cancer (PC) is the most common cancer diagnosis made in men with more than 60,000 new cases each year in Germany. Although it often has an indolent course, prostate cancer remains the third-leading cause of cancer death in men. The death rate from Prostate cancer has declined in Germany in recent years.  This is due to greater awareness and screening, along with the advanced treatments that are available. The prognosis of prostate cancer is generally good in Germany with an estimated relative 5 and 10 years survival rate of more than 90 % (1). 

One of the key elements of this success in the treatment of cancer is the comprehensive and precise approach taken with each patient. It is the healthcare system in Germany that has made such an approach possible for all cancer patients, inclusive of those with breast cancer. 

An individualised risk-adapted strategy is the cornerstone of the successful treatment of cancers in Germany.  Each patient receives an individualised treatment plan depending on their tumour type and its stage of progression. In this process, the identification of tumour histology and staging of the tumour is of fundamental importance for a successful planning of the treatment. This is the key factor in German Health Advisors’ daily work. 

For each patient with a tumour, we attempt to initially fulfil these two aspects in collaboration with our patients and local colleagues.  We then discuss the case with the specialists, or, at the multidisciplinary tumour boards at our partner clinics in Germany.  If any problem appears, mostly when we get an incorrect or incomplete pathology or radiology report (discussed in details below), we communicate with our patients and try to move forward with their treatment plan.  

Initial Staging and Risk Assessment 

The staging for overseas patients is usually not complete when they contact us for a second opinion and any subsequent treatment recommendations. The system employed by German Health Advisors, however, allows for the completion of this stage while the patient is in his homeland. It is not necessary to come to Germany for cancer staging. You will be informed if there are any obstacles in the staging process. For the staging of prostate cancer, please bear in mind the following:  

  • Family history, physical examination, blood count and differential, tumour markers (PSA, PSA Velocity and doubling time), liver and renal function tests (see the request form for German Health Advisors). This will usually be carried out by our local colleagues and documented in the form of a doctor’s letter. 
  • A digital rectal exam and measuring the level of prostate-specific antigen (PSA) in the blood are the most effective means of detecting prostate cancer in early stages. These tests are usually performed by your doctor as part of screening for prostate cancer.  This important information should be documented in the doctor’s letter of our local colleagues.  
  • Next step is usually an ultrasoundor MRI guided prostate biopsy, which uses imaging guidance and a needle to remove tissue from the prostate for pathological evaluation. Please provide us with your pathology report if available. In some cases, when our specialists are not satisfied with the quality of a pathology report, we will contact you with a recommendation for further steps. You may have to send us the frozen/paraffin embedded tissue samples for further histology investigation at one of the German Health Advisors’ partner laboratories in Germany.   
  • For the detection of pelvic lymph node involvement and bone metastases. contrast-enhanced computerized tomography (CT) scanof pelvis is the most frequently performed, but the magnetic resonance imaging (MRI) is known to be the most sensitive alternative.You can send the DICOM files of CTscans using German Health Advisors’ secure data transfer system.
  • Bone scan is used to to rule out bone metastasis. Bone scintiscan findings are sensitive but nonspecific. 
  • Whole-body MRI and FDG-PET scanning are accurate techniques that are currently limited by their high cost and will not be covered by insurance (3). However, in some countries, such radiology tests are less expensive. You can obtain MRI or/and FDG-PET scanning and send the results using German Health Advisors’secure data transfer system. Such results would be greatly advantageous in assisting the staging.

Treatment of Prostate Cancer 

After a proper diagnosis is made, a personalized examination is suggested, and, depending on the disease staging, patient’s age at diagnosis, and many other variables, the most suitable therapeutic alternatives for each case are determined:

  • A localized or asymptomatic Prostate Cancer, for instance, demands active monitoring, radiotherapy, and radical prostatectomy. 
  • The radiation therapy eliminates cancer cells through high-powered energy either directed from X-rays or protons beams into the Prostate Cancer (external beam radiation) or in the form of radioactive seeds placed directly in the prostate tissue (brachytherapy).
  • Radical prostatectomy is known as the surgery to remove the prostate gland, along with the nearby tissue and some regional lymph nodes. There are two main methods to execute this operation. Robot-assisted surgery, is an innovative technology in which small-size instrumentation and a camera are inserted inside the patient´s body while the surgeon seats at a console and controls them via robotic arms that imitates the specialist’s hand motions with precision and accuracy. During retropubic surgery, the prostate gland is removed through an incision in the lower abdomen area.
  • For locally advanced or metastatic PC, on the other hand, androgen deprivation (surgical or pharmacological castration) is the first-line therapeutic therapy, consisting of cutting out testosterone sources from prostate cancer cells. Though this procedure is often effective at first, some genetic changes trigger the recurrence of cancer which is called castration-resistant prostate cancer (CRPC). 
  • Several researchers have identified new genetic biomarkers, enzymes - XIAP and SRD5A1, which can be targeted with inhibitors to overcome CRPC. 
  • Another finding, the PARP inhibitors, are medicines specially conceived to treat ovarian cancer, but have also shown satisfactory results when trialed for some prostate cancers.

Follow-Up After Treatment of Prostate Cancer 

Follow-up should be tailored to the individual patient and the stage of the disease. The German Health Advisors’ partner clinics will normally schedule follow-ups in this manner: 

  • The first follow-up control is usually scheduled two or three months after the treatment. The next follow-up controls will be done in every three to six months for the first 3 years. These controls usually include: assessment of treatment side effects (incontinence, erectile disfunction etc.) and  PSA test 
  • Three years after the treatment, the follow-up controls may be less often
  • Chronic bowel symptoms after radiotherapy should be investigated by a gastroenterologist. Men developing bowel symptoms after prostate radiotherapy may have inflammatory bowel disease, a primary colorectal malignancy or a treatable radiation enteropathy. 

Patients, who received their treatments in Germany, usually do not need to return to Germany for the follow-up visits. German Health Advisors will provide you with follow-up care through its Telemedicine platform.

References

1. Prostatakrebs (Prostatakarzinom), 2014, https://www.krebsdaten.de

2. Cancer of the prostate: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology 26.suppl_5 (2015): v69-v77#

3. Prostatakrebs-Leitlinien der European Association of Urology, Stand 2014, http://uroweb.org/guideline/prostate-cancer/