Prostate cancer treatment in Germany: diagnosis, therapy and surgery

The approach to diagnosis and prostate cancer treatment in Germany differs from American clinics: European oncologists offer high quality services several times cheaper.

Prostate cancer is the most common malignancy among European men.

Thanks to the success of German oncology, this diagnosis accounts for only 10% in the structure of cancer mortality.

To timely identify prostate cancer, you do not need to make special efforts.

It is enough to visit your urologist at least once a year. Many tumors are palpable during digital rectal exam (DRE). PSA blood test, MRI and ultrasound can detect even small malignancies.

Risk factors for prostate cancer include age, genetic predisposition, and diet.

Up to 50 years, the disease occurs rarely; most cases are registered in elderly men over 70. There is no need to afraid the truth. The chances of recovery with timely diagnosis are very high: a five-year survival rate in Europe exceeds 90%, in early stages – 95-98%.

Due to the late onset, 5 out of 6 patients die from other causes associated with advanced age. Sometimes prostate tumors are diagnosed during post-mortem examination. Despite the slow growth, this cancer tends to spread beyond the capsule along the nerves, it occupies nearby lymph nodes and form secondary tumors (metastases) in pelvic bone.

Unfortunately, sometimes the disease is diagnosed only at the stage IV, when the metastases are manifested by pain or spontaneous fractures. Therapy at this stage is less effective.

You need to understand: the earlier the diagnosis is made, the higher your chances.

If the disease is detected at stage I, treatment for prostate cancer in Germany is limited by surgical removal (prostatectomy) or radiation therapy. The five-year survival rate exceeds 95%. In cases of metastatic cancer, oncologists can prolong life and relieve symptoms by using innovative drugs, radiotherapy, palliative surgery.

20 best prostate cancer hospitals in Germany

• University Hospital Charité in Berlin
• University Hospital of Heidelberg
• University Hospital of Magdeburg
• University Hospital of Erlangen
• University Hospital of Essen
• University Hospital of Aachen
• University Hospital of Munich (LMU)
• University Medical Center Freiburg
• University Medical Center Hamburg-Eppendorf
• Tubingen University Hospital
• Saint Lukas Clinic in Solingen
• Stuttgart Cancer Center (SCC)
• Alfred Krupp Hospital in Essen
• Nord Klinik Allianz in Bremen
• Nordwest Krankenhaus (Frankfurt)
• ASKLEPIOS Klinik Barmbek in Hamburg
• HELIOS clinics in Berlin and Schwerin
• Leopoldina Hospital in Schweinfurt
• Nuremberg Hospital North

To get the innovative treatment and second opinion of world-famous oncologists, we recommend university hospitals. These bastions of science and technology offer fantastic opportunities, which currently are not available in most European clinics.

Diagnosis of prostate cancer in Germany

Since the age of 50, almost every second man has abnormal changes in the prostate gland.



Most often it is benign prostatic hyperplasia (BPH), which compresses the urethra and causes discomfort during urination. This disease does not pose a threat to life. BPH is usually controlled by oral medications (like tamsulosin), but sometimes surgery is required.

Only your doctor can distinguish benign hyperplasia from malignant tumor.

Digital rectal exam

DRE (digital palpation) is a simple procedure that detects prostate tumors in about 20% patients. DRE is not considered as the main diagnostic method It is complemented by US and other tests.

PSA blood test

Prostate-specific antigen is a widely used but controversial biomarker. It is present in complexed form (cPSA) and free form. Men with BPH have a higher free PSA, but in malignant tumors cPSA is usually elevated. Blood test will tell your doctor if a biopsy is needed.

Transrectal ultrasound

In transrectal ultrasound (TRUS), the gland and surrounding tissues are visualized on the computer screen using transducer that is inserted into the rectum. It's painless, but uncomfortable procedure. TRUS is used in addition to digital rectal exam to determine the size, location and stage more accurately. A renal ultrasound helps the doctor to determine secondary problems.

Magnetic resonance imaging

Magnetic resonance imaging or computed tomography (rarely) provides the oncologist with some useful information about your prostate size and localization of the suspicious mass.

MRI is also used during preparation for surgery. This innovative visualization technique detects enlarged lymph nodes, which can be a sign of advanced cancer. If radiotherapy is planned, MRI is used to obtain high-quality images of the irradiated area. In doubtful cases, MRI is used after negative results of biopsy, if your doctor is still suspect a malignant tumor. The only major disadvantage of this diagnostic procedure is a high price.

Transrectal ultrasound-guided prostate biopsy

If DRE revealed a suspicious mass (or PSA level is elevated), biopsy will answer the question. During the prostate biopsy, doctor takes several tissue samples from different parts of the gland using a thin needle. Transrectal ultrasound makes this procedure accurate and safe. Biopsy is performed under local anesthesia; you don't need to stay in hospital.

Within a couple of days, specially trained doctors examine the tissue sample under a microscope (histological examination) for the presence of malignant cells.

Diagnosis of prostate cancer metastases

If a patient complains of bone pain, or PSA blood test and histological examination indicate advanced cancer, German clinics can offer a wide range of modern diagnostic procedures. In a few days doctor will answer the question whether metastases are present.

These tests and procedures include:

1. Tumor marker test helps determine the stage: an elevated alkaline phosphatase and calcium can be a sign of bone metastases. PSA test can tell how far the tumor has spread.
2. Skeletal scintigraphy is used as additional method for detection os bone metastases.
3. MR imaging and CT scan find the affected lymph nodes and small secondary tumors.
4. PET / CT is used only in exceptional cases or as a part of clinical studies.

5. Abdominal ultrasound allows excluding metastases in the liver.

Prostate cancer treatment in Germany: modern options

Prostate cancer is one of the few malignancies that grows slowly and does not always pose a direct threat to the patient’s life. More and more tumors are found in the early stages, when the doctor can take a wait-and-see attitude. Immediate surgery is not always an option. The benefits and risks of active treatment should be weighed, given the age and the patient’s health. When the results of biopsy and PSA indicate the progress of the disease, it’s time to treat.

The criteria that separate the observation from active treatment are not clearly defined. German oncologists constantly improve this strategy and always take into account the patient's opinion.

Prostate tumors: surgery (prostatectomy)

If the cancer is confined to the prostate, it can be removed surgically. With the so-called radical prostatectomy, the gland is completely removed along with seminal vesicles. For this purpose, surgeons use the incision in the perineum (between the anus and the root of the penis), the lower abdomen (retroperitoneal), as well as laparoscopic (keyhole) techniques.

Da Vinci robotic prostatectomy is the last word in urologic surgery.

Special manipulators (robotic arms) make the movements of the surgeon much more accurate. Complications after such surgeries are rare, blood loss is significantly reduced, and the duration of hospital stay is usually limited by 4-5 days.

Robotic prostatectomy is offered by leading German centers, including Nord Klinik Allianz (Bremen), Asklepios Klinik Barmbek (Hamburg), Nordwest Krankenhaus (Frankfurt am Main), Uniklinik Charite (Berlin), etc. This procedure costs 13000-18000 euros.

For comparison, the average cost of robotic prostatectomy in the US is 40000 dollars.

Early surgical treatment with high probability leads to complete cure of cancer (resection R0 in sano). The longer the disease is left untreated, the less likely the complete removal of malignant cells and, consequently, the higher the risk of recurrence. Complications of surgical treatment: despite the high skill of surgeons and perfect surgical technique, erectile dysfunction, urinary incontinence, and other complications happen. The most common complication is temporary urinary incontinence, which affects about 50% of patients. Normalization of the functions of the urethral sphincter takes several weeks or months. Permanent incontinence persists in about 5% of patients.

Erectile dysfunction is associated with damage to the nerves responsible for blood supply to the penis. These nerves pass around the gland, and can be affected by the tumor process. The risk of erectile dysfunction depends on the surgical skill and the stage of the disease.

Rare complications of prostatectomy include urethral stricture (narrowing of the urethra due to scarring), rectal damage and stool incontinence, surgical site infections, etc.

Radiation therapy

Radiotherapy is based on the use of high energy beams that destroy the tumor.

Rapidly dividing cancer cells are very sensitive to radiation, so it can stop the growth or even reduce the tumors. There are two main types of radiotherapy: external beam radiation therapy (the source is located outside the body) and internal (brachytherapy: the source is placed right into the tumor).

External beam radiation therapy

In recent decades, German cancer clinics actively use high-precision techniques like intensity-modulated radiotherapy (IMRT) guided by computed tomography. Sources of radiation are located from different sides and angles, which ensures the intersection of the rays directly in the tumor tissue, where an effective dose of radiation is achieved.

This technique minimizes damage to healthy tissues and risk of complications.

Brachytherapy (internal radiation)

Brachytherapy is a valuable alternative to external radiation.

The radioactive material can be transferred directly to the tumor. These sources are inserted through the catheters with millimeter accuracy, remaining in the gland for a certain period or permanently. Low-dose brachytherapy (LDR) involves the implantation of "seeds" into the prostate tissue. The procedure is performed using a thick needle guided by ultrasound. The implantation of seeds takes about two hours. Procedure requires mild general or spinal anesthesia.

At an early stage of the disease, brachytherapy is just as effective as external beam radiation therapy. This option is not recommended for the treatment of aggressive cancer. Comparing the effectiveness of the method is difficult due to the variety of doses and techniques used by different hospitals. As in the case of prostatectomy, the results of LDR and HDR therapy vary, depending on the stage and other risk factors.

These days, prostate cancer surgery and radiotherapy are considered equivalent options, especially in the early stages of the disease. Despite the cutting edge technology, inflammation of the bladder and intestines as well as other complications is still possible.

Targeted alpha therapy treats stage IV cancer

The German Cancer Research Center (DKFZ) is working on new therapeutic options. One of their latest discoveries is targeted alpha therapy (TAT) presented in 2016. This technology allows achieving long-term remission in patients with metastatic prostate cancer.

The study was carried out at the University Hospital of Heidelberg with tremendous results. Inoperable tumors completely disappeared after 3-4 sessions of therapy. Neoplasms were not manifested on PET / CT, and the PSA level dropped from 4000 to 0,1 ng/ml. After experimental treatment with actinium-225 compound, tumors just disappeared.

Instead of life expectancy of 2-3 months, these men live more than two years disease-free!



Such success stories from time to time appear on the pages of European scientific journals, reinforcing the belief in our victory over the deadly disease.

Other local prostate cancer treatments

Progress does not stand still, and now doctors are testing unusual therapeutic procedures. But because of insufficient evidence, they are usually recommended in the context of clinical trials.

Cryotherapy

Cryotherapy, or cryosurgery, is used to kill cancer with cold (hypothermia). During the procedure, your doctor inserts several cryomodules, freezes the tumor to -40 ° C, and then thaws is.

HIFU

The method called high-intensity focused ultrasound is based on directed high-energy sound waves. The procedure is performed using an endoscopic ultrasound probe under anesthesia. The tissues are heated up to + 65 ° C, which is deadly for tumor.

Hormonal therapy

This option is used in later stages, when it is already impossible to remove the tumor. Hormonal therapy inhibits the development of cancer for months and, it can alleviate the symptoms of the disease, reduce the size of the tumor and lower your PSA levels.

How does hormonal therapy work?

Prostate cells carry androgen receptors, where testosterone is attached. The male sex hormone triggers key biochemical processes and stimulates cell division. In prostate cancer, this mechanism is disrupted, leading to uncontrolled growth, invasion and metastasis. 95% of androgens are produced in testes, the remaining 5% - in the adrenal cortex. Testosterone production is regulated by the hypothalamic-pituitary control system (HPG axis) through a special gonadotropin-releasing hormone also called gonadoliberin, or GnRH.

These sensory mechanisms are the valuable targets for various types of hormonal (endocrine) therapy for prostate cancer.

German oncologists use three different approaches:

1. Suppression of androgen production in the testicles: surgical castration (orchiectomy), chemical castration (gonadorelin analogues goserelin, leuprorelin, triptorelin or GnRH antagonists abarelix, degarelix).
2. Suppression of androgen receptors: treatment with antiandrogens (flutamide, bicalutamide, nilutamide), monotherapy and combination with gonadorelin analogues. Enzaglutamide also interacts with intracellular signaling.
3. Suppression of androgen production in the adrenal cortex: abiraterone is prescribed since 2012 for the treatment of metastatic prostate cancer. It blocks the biosynthesis of testosterone in the testes, adrenal cortex and even malignant tumors.

Side effects of hormonal therapy

Since hormones control the most important processes in the male body, endocrine therapy causes numerous side effects. Among the most frequent consequences are: alopecia, loss of sexual interest (libido), a decrease in bone density with a risk of osteoporosis and fractures.

Patients on endocrine therapy tend to gain excess weight; their cognitive functions may be impaired. The risk of diabetes, heart attack and stroke is increasing.

Doctors recommend physical activity, which is good for somatic and mental health.

Prostate cancer immunotherapy

Sipuleucel-T is a kind of vaccine that initiates an immune response against malignant cells.

First, doctors collect certain blood cells (T-lymphocytes) from the patient, and then modify them in the laboratory, targeting against cancer, and return personalized vaccine into the body. Side effects of immunotherapy, such as body aches, chills and fever, are typical for acute immune reaction. Similar symptoms are observed during cold and flu.

Immunotherapy with sipuleucel-T has been approved in Europe since 2013. The method can be useful in castration-resistant cancer, but it is rarely used due to logistic problems and huge costs.

Prostate cancer chemotherapy in Germany

Cytotoxic drugs for the prostate cancer chemotherapy kill malignant cells throughout the body. This method is widely useful in the late stages of the disease, in case of inoperable metastases. Chemo is always associated with serious toxic effects, so it is administered only when endocrine therapy and other therapeutic options are unavailable or no longer effective. These agents are used to prevent paraplegia due to spinal metastases, to shrink secondary tumors in the lungs.

Today, the preferred chemo drug for prostate cancer is docetaxel (taxanes). In patients who previously received docetaxel, another drug carbazitaxel is recommended.

Prostate cancer chemotherapy in Germany costs from 2000 euros per course.

Side effects of chemotherapy

Unfortunately, chemo does not distinguish between healthy and cancer cells. Hair loss, anemia, diarrhea, nausea and vomiting, increased susceptibility to infections are often observed. German doctors do their best to mitigate unwanted side effects. Usually they pass after the end of chemotherapy course.

Treating bone metastases

At the stage IV, prostate cancer often forms bone metastases. This can cause severe pain and disrupt bone structure, leading to fractures. There are several ways to specifically treat bone metastases and relieve pain. Among them targeted radionuclide therapy (radium-223, samarium-153, and strontium-89).

Drugs based on monoclonal antibodies (denosumab) can delay the symptoms associated with metastases in bones. Treatment with bisphosphonates (zoledronic acid) prevents the fractures.

Pain management

At the last stage of cancer, men often suffer severe pain, which affects the quality of life more than the tumor itself. The role of effective pain management at this stage is especially important.



Cancer care in Germany is built in such a way that the comfort and well-being of the patient is priority # 1 for medical personnel. Smart pumps with opioids, electronic nerve stimulators and other cutting edge technologies help patients live the last few months with dignity. Modern pain management protocol ensures that the patient 24/7 has the necessary dose of analgesic. The situation when a dying person is able to leave the clinic and walk around the park is absolutely normal.

You do not have to live in pain!

Cost of prostate cancer treatment in Germany

For millions of medical tourists the journey to the European clinics begins with a preliminary online appointment. You must provide the doctor with a medical history, usually translated into German, as well as the results of all tests and diagnostic procedures (X-ray, MRI, CT, etc.)

Diagnosis of prostate cancer in Germany cost several thousand euros, including oncologist consultations, skeletal scintigraphy, MRI and lab tests:

• Oncologist consultation: 300 to 500 euros or more
• Prostate-specific antigen lab test: 400 euros or more
• Transurethral ultrasound (TRUS): 300 euros or more
• Complete blood count and urine test: 250 euros or more
• Ultrasound-guided prostate biopsy: 1100 euros or more
• Positron Emission Tomography: 2000 euros or more
• Magnetic resonance imaging: 1000 euros or more
• Computed Tomography (CT): 800 euros or more

The cost of prostate cancer treatment course depends on the stage of the disease:

• External radiotherapy: 8000 euros or more
• Brachytherapy (internal radiotherapy): 5000 euros or more
• High-intensity focused ultrasound (HIFU): 10000 euros or more
• Surgical treatment (prostatectomy): 8000 to 25000 euros or more
• Da Vinci robotic prostatectomy: 13,000 euros or more
• Chemotherapy: 2000 euros or more per course

© Analytical reviews and oncology news by K. Mokanov: clinical pharmacist and professional medical translator