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Home » EU Health, Health, Prostate Cancer

Symptoms, treatment, follow-up & everything about PCa

Submitted by on 30 Mar 2016 – 17:16

Dr. Laurent Fossion, M.D., Urologist, FeBU, gives the whole picture on care, prevention and treatment of prostate cancer in Europe

Dr Laurent Fossion Exact causes for prostate cancer are still unknown, but dietary habits (Western feeding pattern) and genetic mutations seem to be related to the development of prostate cancer (PCa). In patients with two first line relatives ( <55 year) in their family with PCa, screening is advised.Screening for PCa can reduce PCa mortality (cfr. infra ERSPC-study)

Diagnosis and care

Serum markers, mainly PSA, still play the most important role in diagnosing PCa disease.

Physical digital rectal examination (DRE), ultrasound guided prostate biopsies and multiparametric MRI (mpMRI) are the main tools for local evaluation of prostate cancer.

The ERSPC-study showed 27% reduction in prostate cancer mortality among those men who participated in screening (PSA-measurement and DRE). Screening consists of a single PSA-test at the age of 40 years. If PSA < 1 ug/L, lifetime chance of development of PCa is minimal.  For older patients, PSA-measurement every 2-5 years till the age of 70 years is advised. In men with normal findings on mpMRI, the risk of clinically significant PCa is very low. mpMRI has a detection rate of 44-87% of clinically significant disease (that has influence on life expectancy). It can thus avoid over treatment.

Probably only 30% of the patients will need an MRI to improve sensitivity and specificity in PCa screening. The quality of mpMRI interpretation remains very important and should be centralised or supervised by experienced cancer centers (quality control).

In this stage the interdisciplinary interface between the oncologic trained urologist, the uro-radiologist and uro-pathologist plays an important role.

Treatment

The goal of PCa treatment is to cure patients from their (significant) prostate cancer or to delay/postpone metastases and their impact on health and survival. Active surveillance should be offered to all low risk PCa patients. This will help us to reduce over treatment and the accompanying costs and consequences for the patient.

Focal treatment is still under investigation but can be seen an alternative for surgery or external radiotherapy for localised (intermediate risk) disease, but it still has the chance to miss lymph node involvement.

Localised, significant PCa disease can be cured by open or minimal invasive surgery (laparoscopic or robotic assisted radical prostatectomy (RP)) or by radiation therapy (RT); the latter in combination with androgen deprivation hormonal treatment (ADT) for 2-3 years. The advantage of the surgical RP approach lies in the ability to perform both the lymph node staging and the treatment with curative intention in one operation and does not necessitate ADT.

The rationality for lymph node dissection remains adequate lymph node / disease staging, but the impact on survival is unknown. Risk prediction tools help us to predict the chance of lymph node involvement and confirm the need for certain intermediate and all high risk PCa patients. The ideal number of lymph nodes removed is yet to be determined, but lies around 18-20 lymph nodes. Overall lymph node involvement varies from 1-17%.

Quality control and definition of postoperative success is known as pentafecta (free surgical margins, no peri-and postoperative complications, continence, potency, survival). These quality parameters are measured in most European cancer centers and aid to optimise the quality of care. So it is clear that the surgeon does matter.

Recently even locally advanced prostate cancer seem to benefit from surgical treatment (RP + lymph node dissection), but often necessitate multimodal treatment, using (salvage) radiotherapy to be able to cure these patients.

Metastatic disease treatments consist of ADT hormonal treatment to suppress tumour progression and reduce the consequences of metastases. Focal radiotherapy (stereotactic RT) can help to control symptomatic bone metastasis. New insights in early adoption of chemotherapy in aggressive PCa show promising results on prolonged survival.

Follow-up

Standard follow up after local treatment with curative intention consists of 5 year follow up to evaluate oncologic outcome (immeasurable PSA) and treat functional and psychological consequences of local treatment. In metastatic disease or in case of biochemical recurrence (measurable PSA suiting remaining PCa) the follow-up is at least 10 years to lifetime long.

Cost effectiveness

Costs in PCa health care are caused by investigational aspects (PSA-test, biopsies, mpMRI, bone scan), treatment costs (operation or radiation therapy + lymph node operation + ADT) and the costs for the purchase of e.g. the operation robot (in contrast to laparoscopic and open surgery) or radiation device and finally the follow up costs and treatment costs for complications and consequences of treatment (early costs after surgery and late costs after radiation therapy).