Prof. Dr. med. Alexander Muacevic

Today, I would like to answer some questions we have received from our patients on the topic of prostate cancer.

Question No. 1

You need a current PSA test and you need to know the so-called Gleason Score. You also need an MRI scan so that we can assess the prostate. These three things give us a lot of information. The PSA value should not be higher than 20 for our purposes. The Gleason score is part of the histological report of the prostate biopsy.

Taking a biopsy has gone out of fashion. However, without a biopsy, it is very hard to make a clear diagnosis. And without a clear diagnosis, I cannot make informed decisions about further treatment. Hence, it is crucial. What is very common these days, is an additional MRI scan. A few years ago, a CT scan would usually suffice. But we want to know precisely where the tumour is located in the prostate.

We are particularly interested in whether the tumour has grown beyond the prostate capsule. For our therapeutic approach, this should not be the case, which is why this additional diagnostic should be carried out in any case. If, in fact, the tumour has not grown too far, the PSA value is within the limits, the Gleason score ranges between six or seven and the tumour is limited to prostate, then we can consider whether a radiosurgical therapy is possible.

The therapy itself is pretty straightforward. Before we can start, our urologists must place some markers in the prostate. These three or four tiny gold plates must be placed in the prostate so that the robot can adjust to the prostate's movements during the treatment. That is one of the advantages of our therapy: The robot does not simply radiate in a single direction, but it adapts to every movement of the patient.

And there is a lot of movement in the prostate. Located at the front of the rectum, it moves up, down, left, right and it rotates. We can compensate for all of this with an accuracy of one millimetre. Thus, we do not need to radiate a big area – like in conventional radiation therapy – to make sure that we have hit the entire tumour. In fact, we can destroy the tumorous tissue with pinpoint accuracy, while sparing the surrounding tissue – in particular, the bowel and the bladder.

Question No. 2

Treating a prostate carcinoma with radiosurgery, usually comes with few side effects. Many patients experience some issues with urinating two or three weeks after the treatment. They need to urinate more frequently, during the day and at night. Some experience so-called ‘urge’ symptoms, i.e. a heightened urge to urinate. However, by the third week, these symptoms almost always recede and by week four or five, the patient usually goes back to normal.

Fortunately, we observe very few problems with the bowel. Some patients may experience some mild diarrhoea. But bigger side effects, which were once associated with radiation therapy, hardly ever occur. That is simply because the radiation only affects the front part of the bowel – not the entire bowel. And this minimal exposure of the rectum front wall significantly decreases side effects.

One of the most common questions we get is: What about potency? Of course, potency is difficult to measure. It depends on a whole range of factors – as we all know from our daily lives. However, the first studies on this topic have recently been published and they suggest that three years after Cyberknife therapy half of the patients experience a small decrease in potency. For the other half, potency is back to normal. This is a very good outcome, especially when compared to conventional methods such as surgery.

Question No. 3

The question is: What to expect in the long run? Will I experience some issues at a later stage, even though they did not appear at first?

For some patients, problems with urination may return after one or two years. Typically, this can be treated effectively with medication. So there is a good chance that it will not have significant impact.

In general, patients may feel some effects for up to two years. In most cases, we can see the final result after two years. And of course, we regularly perform PSA tests to evaluate the course of the therapy. The first test occurs after three months, then again after three months and then every six months. Regardless of how high the PSA level was before the treatment; we want it to decrease continuously to a level of one or even below one.

Question No. 4

The treatment currently takes five sessions. There is an appointment to implant the markers and then we have five radiosurgery sessions which take place from Monday to Friday. Each session takes about 25 minutes. After the treatments, you can basically go about your everyday life. There are no immediate side effects. They only occur a week or two later. So that is typically not a problem.

Nevertheless, we want to further improve how we treat prostate carcinomas with Cyberknife. We are currently developing a routine, in collaboration with some other universities in Germany, which would allow us to reduce the sessions from five to only three. That would give patients even more convenience and it would enable us to perform the entire treatment, i.e. marking, imaging and treatment, in one week. We expect to start this new concept in summer and we would be delighted if we would be the first to implement it here in Germany worldwide.

Question No. 5

To conclude, let us return to the topic of aftercare: What do patients have to look out for when the treatment is completed? To be frank, not much. They can go back to their everyday life. Every three to four months, we check their PSA level and have a short phone call. Depending on how the PSA level develops, further aftercare is provided over the next few months and years.

We stay in touch with all our patients over a long period of time and they can always contact us to ask questions. I would just like to give patients one advice: Do talk to your urologists if you have questions; but please also talk to us. We are responsible for your treatment, we prepared, planned and conducted the therapy. Together, we can almost always find a good solution.

In general, if you have any questions, just give us a call or send us an email. And if the circumstances allow for it, we will come together for a successful therapy.