Conditions Prostate cancer

Medical practitioners refer to malignant tumors that occur in a man’s prostatic gland (prostate) as prostate cancer or prostate carcinoma. The prostate is one of the internal sex organs in a man. 

There are different types of prostate cancer: most prostate tumors (95 out of 100) are known as adenocarcinomas. In addition, there are tumors known as neuroendocrine tumors (NETs) of the prostate – a very aggressive form of prostate cancer with a rather unfavorable prognosis: the tumor typically metastasizes very rapidly and grows independently of hormones. A key characteristic: A NET is not detected by an elevated blood PSA level. A tissue examination is necessary for a definitive diagnosis.

In Germany, just under 66,000 men developed prostate cancer in 2020. Doctors usually diagnose the disease at an early stage. At that point, patients generally have no symptoms. Even if the condition is more advanced, patients frequently do not have typical symptoms. This means that the symptoms they have could also be caused by other illnesses.

The symptoms of prostate carcinoma may include:

• difficulty urinating – the bladder cannot be spontaneously emptied
• difficulty urinating and frequent urination
• pain in the bones
• blood in the urine or seminal fluid
• problems during sexual intercourse (painful ejaculation or erectile problems)

Urination problems frequently occur as men get older: the prostate enlarges and can press against the urethra. This benign (harmless) enlargement of the prostate is known by experts as benign prostatic hyperplasia (BPH).

If the symptoms persist over several weeks, a visit to the doctor is recommended. General practitioners can already narrow down what is causing the symptoms and, if necessary, initiate further diagnostic steps with specialists. 

The risk of developing prostate cancer increases with age. As men age, genetic changes (mutations) increase in the cells of the prostate gland. The more mutations there are, the greater the risk of prostate cancer. Most men are between 70 and 80 years old when diagnosed. Prostate cancer occurs relatively rarely before the age of 50.

Another major risk factor for prostate cancer is family history. If a first-degree relative, such as a father or brother, has prostate cancer, your own risk of developing the disease increases compared to the rest of the male population. In this case, it may be useful to find out about prostate screening at a younger age than 45. You can find out about which options are available in the section of this article dealing with screening.

Prostate cancer progresses very differently in different men. Doctors differentiate between three tumor stages: 

• Localized: the cancer is only growing in the prostate.
• Locally advanced: the cancer cells are growing beyond the prostate, for example, into the seminal vesicles. 
• Advanced or metastatic: the cancer cells are spreading to the lymph nodes, bones or other organs.

In most men, prostate cancer grows quite slowly compared with many other cancers. These less aggressive carcinomas often remain undetected throughout a man’s life if he has no symptoms. This means that even with early-stage prostate cancer, many men have a normal life expectancy.

In other men, prostate cancer can progress quite quickly and the doctor also identifies secondary tumors (metastases) outside the prostate. This type of metastatic prostate cancer is usually incurable. Prostate cancer can also recur after therapy (relapse). In some cases, curative treatment can be administered again in the event of a relapse.

In Germany, national screening program for cancers of the sex organs starts at age 45. Men are entitled to an annual screening, in which their doctor asks about symptoms and examines their external sex organs. The doctor will also carry out a digital rectal exam (DRE), feeling the prostate with a finger.

Professional societies advise against manual examination for early detection and instead recommend an individually tailored screening program based on the PSA test. In this process, doctors measure the level of the protein “prostate-specific antigen” (PSA) in the blood. When such an early detection screening begins, how often it is repeated and whether further tests are needed depends on a man’s personal risk.

Men who are considering tailored PSA screening should find out about the benefits and drawbacks for themselves. Urologists and General Practitioners can provide detailed information about this. Someone who understands the benefits and potential risks that apply in their individual situation is better able to decide for or against having the test done.

Would you like to know more about early detection of prostate cancer through a tailored screening program, or more about the PSA test in general? And find out about the benefits and drawbacks of PSA screening? More information is available on the website of the German Cancer Research Center’s Cancer Information Service (in German).

If prostate cancer is suspected, there are various diagnostic procedures to clarify the diagnosis. The approach is based on a man’s individual risk of prostate cancer. Doctors assess this by:

• asking the patient about age, pre-existing conditions, symptoms, and family history (medical history)
• performing a physical examination and palpating the prostate: digital rectal examination (DRE)
• measuring the prostate-specific antigen (PSA) level in the blood and determining the prostate volume using transrectal ultrasound (TRUS). From this, they can calculate what is known as the PSA density.

If the PSA level at the initial examination is 3 nanograms per milliliter (ng/ml) or higher: Following the risk assessment, and prior to the tissue sample (biopsy), an imaging examination using multi-parametric magnetic resonance imaging (mpMRI) is performed and subsequently, if appropriate, further imaging procedures such as transrectal ultrasound (TRUS). 

General practitioners can take the first steps towards risk assessment themselves. Specialists in urology and radiology are responsible for subsequent testing. Specialist outpatient clinics also have trained staff and the equipment required.

Prostate tissue samples are required to verify the diagnosis. Men are given a local anesthetic for this. The procedure for tissue sampling is guided by the result of the previous MRI scan: 

• If a man has a high risk of prostate cancer and doctors find areas (lesions) suspicious for cancer during an MRI scan, 2 to 3 tissue samples are specifically taken from the relevant lesions during the biopsy and, where applicable, also in the immediate vicinity of these areas. 
• In addition, urologists systematically take 10 to 12 biopsies from 6 different areas of the prostate according to a set pattern. These biopsies are examined in the laboratory under a microscope for their histological (microscopic tissue) characteristics. 

The results of the biopsy, the PSA level and the PSA density indicate how likely it is that the tumor has spread beyond the prostate. Depending on individual risk, further examinations may then be added:

• computed tomography (CT)
• magnetic resonance imaging (MRI)
• bone or skeletal scintigraphy
• positron emission tomography (PET), in particular using a specific radioactive substance as a marker (i.e. PSMA-PET) – usually in combination with a CT scan (PSMA-PET/CT)
• tests known as molecular genetic tests are an option only if men already have advanced prostate cancer and the result would alter the further planning of therapy. This includes a test for the presence of a BRCA2 or BRCA1 mutation.

Would you like to know how doctors test for prostate cancer? And when further tests are used to determine how far the cancer has spread? You can read more about diagnostic procedures on the website of the Cancer Information Service of the German Cancer Research Center (in German).

Prostate cancer can be treated in a number of ways. The therapy can act locally on the prostate or throughout the body (systemically) against the tumor. The following five factors determine which treatment is best in each individual case:

• the stage of the disease
• the prostate-specific antigen (PSA) level in the blood
• how aggressive the tumor is
• the patient’s general state of health
• the patient’s own goals and values

Localized prostate cancer

If tumor growth is limited to the prostate, a long-term cure is often possible. The treatment options then depend on a man’s personal risk profile, that is whether he has a high, medium or low risk of disease relapse (recurrence). This risk depends on the likely course of the disease in a man – that is, whether and how quickly the cancer grows. Experts can assess this based on results from various studies.

Experts recommend active surveillance for men at low risk of disease progression. It means that no treatment is administered initially. Instead, regular check-ups are required. If the prostate cancer becomes more aggressive, doctors then begin curative treatment.

Patients can also choose from a range of standard treatments. According to modern medical knowledge, the different treatment options offer similar chances of recovery. However, they differ in terms of their side effects and long-term effects:

• complete surgical removal (radical prostatectomy): there are two types of surgical procedure – one with a robot and one without. Both cure prostate cancer equally well.
• external irradiation through the skin (percutaneous radiotherapy)
• internal irradiation (brachytherapy with radioactive sources in the prostate)

Minimally invasive focal (localized) therapies may also be considered under certain circumstances. However, it is not yet clear whether these are as effective as standard treatments.

In individual cases, doctors may also combine different types of therapy. For example, an operation may be followed by radiotherapy. Alternatively, urologists may administer radiotherapy in parallel with hormone withdrawal.

There are various techniques for surgical removal of the prostate (prostatectomy), i.e., open surgery, laparoscopic surgery or robot-assisted surgery. The following videos illustrate how these methods work.

What is an open prostatectomy?
What is a laparoscopic prostatectomy?
What is a robotic prostatectomy?

Advanced or metastatic prostate cancer

At this stage, it is usually incurable. Hormone therapy is a key part of treatment in this medical situation. It deprives prostate cancer cells of the male sex hormone testosterone, which they need to grow. In this way, doctors can suppress the prostate cancer and keep it in check for a certain time.

Treatment for patients with advanced and metastatic prostate cancer can be very complex. In addition to hormone therapy, there is now a range of other systemic treatments available for patients, some of which can be combined with one another. These include:

• Chemotherapy: These are medications (cytostatics) that slow down cell growth or prevent cell division.
• Targeted treatment: These are medications (PARP inhibitors) that specifically inhibit the repair of damaged genetic material in cancer cells.
• Radionuclide therapy: These are medications (radiopharmaceuticals) that accumulate selectively in prostate cancer cells and destroy them through nuclear radiation.
• Supportive treatment methods: They help to relieve or prevent side effects of the therapy. These include medications that act on the bones, or external radiotherapy. In the case of bone metastases, they can help to alleviate aching, prevent broken bones, and generally improve the man’s quality of life.

Sometimes it can also make sense to spare patients cancer therapy, especially when they have no symptoms. Doctors recommend this “watchful waiting” approach if the patient is of advanced age, for example, or if other health issues take precedence. Once affected individuals develop symptoms, these can be treated.

Do you want to learn more about the various treatment options for prostate cancer and their possible side effects? Which options are relevant to you and what is meant by medical terms such as “castration-resistant” or “oligometastatic”? You can find detailed descriptions of the treatments used on the German Cancer Research Center’s Cancer Information Service website (in German).

Cancer treatment can be physically and mentally exhausting. Medical rehabilitation (rehab) following cancer treatment can help patients regain their strength. It also aims to help them deal with the consequences of the disease and treatment in the best possible way.

Rehab for prostate cancer patients is specialized, i.e. the program includes specialized urological care. In general, urological rehab is tailored to the patient’s medical history, individual treatment, and any limitations or symptoms resulting from that treatment.

Urological rehab may include:

• pelvic floor exercise to help regain control of urination
• explaining possible treatments for weak erections
• exercise therapy to prevent complications from hormone withdrawal, such as metabolic disorders and osteoporosis
• psychological support
• nutritional counseling

What happens after treatment?

Prostate cancer aftercare is intended to detect any recurrence (relapse) at an early stage, as well as any long-term effects of treatment. Once treatment has been completed, patients are examined regularly, initially at short intervals, then at longer ones. Doctors ask about symptoms, carry out physical examinations, and measure the prostate-specific antigen (PSA) level in the blood.

Want to know more about prostate cancer rehabilitation and aftercare? How PSA levels fall at different rates after an operation and after radiotherapy? And how progression is monitored if the disease is at an advanced stage? Please visit the website of the Cancer Information Service of the German Cancer Research Center for additional information (in German).

Many prostate cancer patients want to be active in order to help themselves recover. There are a number of ways they can do this. What can help them to cope better with the disease and the consequences of treatment depends on the individual situation:

• Over time, rehab and physiotherapy can help improve or even eliminate incontinence.
• Patients find out how to deal with impotence and sexuality through rehab or by talking to doctors.
• Exercise can help overcome tiredness and exhaustion. This should be adapted to the patient’s physical ability.
• A balanced, healthy diet or even nutritional therapy can promote well-being and prevent poor nutrition.
• Psycho-oncological counseling can help if worry and anxiety dominate patients’ lives, or if they suffer from depression due to the illness.

If it is no longer possible to cure the cancer and it is becoming more advanced, good medical and nursing care are very important. Adverse symptoms such as pain and breathlessness can be alleviated. And psychosocial support can help maintain quality of life for as long as possible. In addition, there is the possibility of using various support services, such as outpatient care. It can also be helpful to share experiences with other affected individuals in a self-help group. 

When treating prostate cancer, doctors from different fields work together closely. Hospitals that are particularly experienced in treating patients with prostate cancer can get certification to prove this. The German Cancer Society (DKG) regularly checks their compliance with certain professional requirements.

You can find the addresses of the certified centers on the OncoMAP website.

You can search for urology practices and clinics on the Urological Health Foundation website.

Do you have further questions about dealing with the condition in everyday life and additional support options? You can find information about this on the website of the Cancer Information Service of the German Cancer Research Center (in German).

If you have any questions about prostate cancer, you can also contact the Cancer Information Service directly on freephone 0800 420 30 40 or by e-mail at krebsinformationsdienst@dkfz.de.