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.

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.

Around 60,000 men get prostate cancer every year in Germany. In most cases, the disease is detected at an early stage, when patients do not normally have any 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
• discomfort when urinating
• aching bones
• blood in the urine or seminal fluid
• difficulties during sex

Difficulty urinating often occurs as men get older. This is because the prostate gets bigger with age and presses on the urethra. This benign (harmless) enlargement of the prostate is known by medical practitioners as benign prostatic hyperplasia (BPH).

If the symptoms persist over several weeks, a visit to the doctor is recommended. The doctor can start narrowing down what is causing the symptoms and, if necessary, initiate further diagnostic steps by 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 close relative, such as a father or brother, has prostate cancer, the risk of cancer increases relative to the general 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.

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.

The national screening program does not include measuring the prostate-specific antigen (PSA) level in the blood. The statutory health insurance funds do not usually pay for PSA screening. Men can have this screening done as an individual health service (IGeL) and cover the cost themselves. The reason for this is that, to date, studies have not clearly demonstrated that nationwide PSA screening does more good than harm.

Men who are thinking of having their PSA tested 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 prostate cancer screening or PSA testing? 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).

Prostate cancer progresses very differently in different men.

In most men, prostate cancer grows quite slowly compared with many other cancers. Less aggressive prostate carcinomas often remain undetected throughout a man’s life if he has no symptoms. This means that many patients have a normal life expectancy even after receiving a diagnosis of prostate cancer.

In other men, prostate cancer can advance quite quickly and secondary tumors are also identified at the time of diagnosis. 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.

If prostate carcinoma is suspected, doctors can use a range of complementary diagnostic methods.

Initially, a basic diagnosis comprises the following steps:

• taking the patient’s case history, asking about pre-existing conditions, symptoms and family history
• performing a physical examination and feeling the prostate by means of a digital rectal exam (DRE)
• measuring the prostate-specific antigen (PSA) level
• scanning the prostate using multi-parametric magnetic resonance imaging (mp‑MRI)
• if necessary, using additional imaging techniques, such as transrectal ultrasound (TRUS)
• taking a tissue sample (biopsy) for histological examination

General Practitioners can take the first steps of a basic diagnosis themselves. Specialists such as urologists and radiologists 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. In most cases, urologists take 10 to 12 biopsies in accordance with a fixed (systematic) plan. These biopsies are subjected to a histological examination (i.e. examination on a cellular level) in a lab. In addition, specific samples can be taken from areas identified using imaging techniques.

These findings, together with the PSA level, indicate how likely it is that the tumor has spread beyond the prostate. If the risk is elevated, the following imaging methods can also be used:

• 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)

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 find out 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 treatment can act against the tumor in the prostate area or throughout the body. 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. Patients can choose from a range of standard treatments. Based on what is currently known, these 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)

Active surveillance may be equally beneficial. This method is considered if the prostate cancer is less aggressive. 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.

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.

For more detailed information about treatment of localized prostate cancer and about supports for sound decision-making, see the patient guide published by the Cancer Information Service.

There are various techniques for surgical removal of the prostate (prostatectomy), i.e., open surgery, laparoscopic surgery or robot-assisted surgery. The following videos explain what is involved in each of these types of surgery.

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

Advanced or metastatic prostate cancer

When the disease has reached this stage, it is usually incurable. In this situation, hormone withdrawal therapy is a key part of treatment. It removes the testosterone (male sex hormone) that the prostate cancer cells 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. Doctors and urologists therefore have a range of other systemic treatment options, some of which can be combined:

• Chemotherapy: doctors administer drugs (cytostatics) that slow down cell growth or prevent cell division.
• Targeted treatment: doctors administer drugs known as PARP inhibitors, which inhibit the repair of damaged genetic material in the cancer cells.
• Radionuclide therapy: doctors administer drugs (radiopharmaceuticals) that accumulate in the prostate cancer cells themselves and destroy them through nuclear radiation.
• Supportive treatment methods: these include drugs that act on the bones and 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.

In some cases, it may make sense to not treat patients who are symptom-free. Doctors recommend this “watchful waiting” approach if the patient is of advanced age, for example, or if other health issues take precedence.

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 both mentally and physically 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 based around the person’s medical history, the specific therapy and the limitations that exist.

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 advice

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? You can find more information on the website of the German Cancer Research Center’s Cancer Information Service.

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.

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. Psychosocial support can also help patients maintain a good quality of life for as long as possible.

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.

Urological university hospitals in Germany are listed on the urology portal (Urologenportal) website run jointly by the German Society of Urology (Deutsche Gesellschaft für Urologie) and the Association of German Urologists (Berufsverband der Deutschen Urologen).

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.