Was ist zu viel, was ist zu wenig — beim Prostatakarzinom spielt heute die Frage nach dem sinnvollen, rationalen Einsatz der zur Verfügung stehenden und neuen Möglichkeiten des Screenings, der Diagnostik und der Therapie eine wichtige Rolle. Das war auch bei vielen Studien so, die auf dem Jahreskongress der amerikanischen Gesellschaft für Urologie (AUA) in New Orleans vorgestellt wurden.

In Haftungsprozessen sind medizinische Gutachten unentbehrliche Hilfen für die Urteilsfindung. Der Gutachter hat eigenverantwortlich und kompetent zu handeln und sollte immun gegen Interessen von Gerichten, Versicherungen oder Krankenkassen sein. Um diesem Spannungsfeld zu entgehen und gutachterliche Mängel zu vermeiden, bietet die aktuelle AWMF-Leitlinie zu den Grundlagen der medizinischen Begutachtung eine wichtige Hilfe.

Der weltgrößte Urologenkongress fand in diesem Jahr in Orlando statt und deckte das gesamte Spektrum der Urologie ab. Neben den „Klassikern“ Prostatektomie und Biopsie wurden auch Sitzungen zur Prävention von Prostatakarzinom und zu neuen Kombinationstherapien bei Symptomen des unteren Harntrakts veranstaltet.

Im Mittelpunkt des diesjährigen AUA-Kongress standen verschiedene Methoden, mit denen sich die Tumoreigenschaften beim Prostatakarzinom vorhersagen lassen. Zudem könnte ein neue medikamentöse Therapie für Patienten mit Induratio penis plastica eine Option sein.

Auf der anderen Seite des Atlantiks wird über dieselben kontroversen Themen diskutiert wie in Europa. Auf dem diesjährigen AUA-Kongress in Atlanta standen auch das PSA-Screening und die Roboter-assistierte retropubische Prostatektomie im Mittelpunkt der Debatte.

Background: Prostatic cancer (PCa) is the most common cancer in men in Germany. The goal of this review is to define the indication for hormonal treatment in patients over age 70.Methods: A selective search of the literature up to 2008 for the terms " prostate cancer" "androgen suppression and deprivation" "hormone therapy",, LHRH analogs" "antiandrogens" "active surveillance", and, watchful waiting" was performed in the Medline and Cochrane databases. The guidelines of the American Society of Clinical Oncology (ASCO, 2007) and the European Society of Urology (EAU, 2008) were also taken into account.Results: Hormonal therapy is not indicated for patients with organ-confined, well-differentiated or moderately differentiated tumors who are otherwise in good health. It is beneficial in the treatment of locally advanced cancer with an unfavorable Gleason score. For patients with organ-confined cancers who are in poor general condition, hormonal therapy is deferred until symptoms arise. The guidelines recommend hormonal therapy in case of PSA elevations greater than 1.5 ng/mL after attempted curative treatment. Symptomatic metastases require immediate hormonal therapy. Intermittent androgen deprivation is an attractive alternative.Conclusions: In patients over age 70, an attempt at curative treatment is only reasonable if the life expectancy exceeds 10 years. Hormonal therapy is the treatment of choice for patients with undifferentiated, locally advanced prostate cancer, recurrences as defined by PSA elevation, and symptomatic metastases.

BACKGROUNDAt present, one in six men over age 50 carries the diagnosis of prostate cancer, but only one in 33 will die of the disease. In view of these facts, conservative strategies such as active surveillance (AS) are important in the management of prostate cancer.METHODSTo obtain information on active surveillance, the Medline database was searched from January 2002 to April 2008 for the terms "prostate cancer" OR "prostatic neoplasms," AND "active surveillance" OR "expectant management". In addition a manual search was performed in the reference lists of relevant publications on the treatment of prostate cancer and on active surveillance.RESULTS88 relevant publications about active surveillance were found. The studies varied in methodological quality but consistently showed low rates of tumor progression and high rates of tumor-specific survival with active surveillance (99% to 100%). All 7 guidelines on the treatment of prostate cancer that have been published since 2006 list active surveillance in their recommendations as a therapeutic option for prostate cancer if there is a low risk of progression. In fact, the National Institute of Clinical Excellence (U.K.) recommends the active surveillance exclusively as the treatment strategy for such cases.CONCLUSIONSThe guideline recommendations reflect a changed attitude toward the treatment of prostate cancer in the light of the early detection of these tumors and the data now available regarding active surveillance. A corresponding change in actual medical practice would be desirable. The treatment of prostate cancer should always be adapted to the individual needs of the patient, and risky treatments should only be used when absolutely necessary.

Objective: Despite initial therapeutic success through androgen ablation in patients with advanced prostate cancer, the vast majority progress to androgen independence. Somatostatin (SST) analogs are a viable therapeutic modality before resorting to chemotherapy or immunotherapy. Their mechanism of action is related to a reduction in the IGF-1 (survival factor, reaction on neuroendocrine cells) appearing incrementally after long-term androgen deprivation and a possible suppression of GnRH receptors in prostate cancer following exposure to LHRH agonists. Methods: The computerized databases Medline, NCBI and OMIM were searched for the terms, somatostatin and prostate cancer, in parallel with printed bibliographic references. Forty-two studies were included and 267 patients with androgen-independent prostate cancer (AIPC) who were treated with SST analogs alone or in combination with other medications, e.g. dexamethasone, were analyzed. Results: In 42 studies with 267 AIPC patients, SST analogs were found to be effective, particularly when combined with estrogens or corticosteroids. The side effects are mild and related to the gastrointestinal tract. Conclusions: It would be interesting to study SST analogs in randomized trials including patients with well-defined AIPC. Whether SST analogs could be given earlier during sequential hormonal therapy remains to be studied.

This literature review discusses the theoretical background of 5α-reductase inhibitor (5ARI) treatment and the resulting clinical implications. A Medline-based search for peer-reviewed articles addressing 5ARIs, benign prostatic hyperplasia and prostate cancer was performed. The 5ARIs Finasteride and Dutasteride, which specifically inhibit the production of dihydrotestosterone by acting as competitive inhibitors of 5α-reductase, are clinically well tolerated and represent an effective treatment option for benign prostatic obstruction. Finasteride is the first compound which has a proven efficacy in chemoprevention of prostate cancer. The aim of this review was to elucidate, if there are sufficient data available to point out clinically relevant differences between the drugs. Both compounds achieve a significant reduction of prostate volume, an improvement of symptoms and a lower risk of acute urinary retention. Whether the different pharmacokinetic and pharmacodynamic properties of Finasteride and Dutasteride are of clinical importance cannot be judged at this time.

Due to the very high prevalence of prostate cancer (>20% among men aged 50–60), prevention is essential. In contrast to chemoprevention (e.g. with finasteride), which is not common practice, there is broad acceptance of dietary interventions. Analysis of epidemiological studies located via MEDLINE, EMBASE, and the World Cancer Research Fund (2007). Consuming milk products, calcium-rich foods, saturated fats, red meat, and multivitamin products (>7×/week) increases the risk of developing clinically manifest prostate cancer. This risk is reduced by consuming soy products (tofu), Brassica vegetables (e.g. broccoli), lycopene-rich foods (tomato products), selenium, tocopherol, linseed (lignans), red wine (resveratrol), and especially pomegranate products (e.g. ellagitannins). In secondary prevention, which is a key component in the current concept of active surveillance in prostate cancer, pomegranate products play the most important role. It is currently a matter of controversy whether lycopene is protective [Giovannuci, Exp Biol Med (Mayworrd) 2000;227(10):852–9.] or not [Kirsh et al., Cancer Epidemiol Biomakers Prev 2006;15(1):92–8]. Consistent prevention of prostate cancer has the added benefit of helping protect against other conditions, including cardiovascular disease and metabolic syndrome, and can thus be described as integrated prevention. Dietary prevention of prostate cancer requires a special nutritional regimen combined with nutritional supplements (e.g. neutraceuticals, functional food, and selenium).

You have accessJournal of UrologyWednesday, May 23, 2007, 10:40 am1 Apr 2007LBA1723: Intermittent Versus Continuous Androgen Suppression in Advanced Prostate Cancer - A Randomised Prospective Study Kurt Miller, Ursula Steiner, Anja Lingnau, Ulrich Witzch, Ahmad Haider, Udo Wachter, Christoph Rüssel, and Jens Altwein Kurt MillerKurt Miller More articles by this author , Ursula SteinerUrsula Steiner More articles by this author , Anja LingnauAnja Lingnau More articles by this author , Ulrich WitzchUlrich Witzch More articles by this author , Ahmad HaiderAhmad Haider More articles by this author , Udo WachterUdo Wachter More articles by this author , Christoph RüsselChristoph Rüssel More articles by this author , and Jens AltweinJens Altwein More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)32130-XAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "LBA1723: Intermittent Versus Continuous Androgen Suppression in Advanced Prostate Cancer - A Randomised Prospective Study." The Journal of Urology, 177(4S), p. 573 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 177Issue 4SApril 2007Page: 573 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Kurt Miller More articles by this author Ursula Steiner More articles by this author Anja Lingnau More articles by this author Ulrich Witzch More articles by this author Ahmad Haider More articles by this author Udo Wachter More articles by this author Christoph Rüssel More articles by this author Jens Altwein More articles by this author Expand All Advertisement PDF downloadLoading ...

Bladder cancer (Bc) with an incidence of 8.6% ranks fourth in males and with an incidence of 3.5% ranks eighth in females in Germany. The study of Cole demonstrating that coffee drinking poses a risk for developing Bc raised interest in primary prevention. In the meantime, however, 42 case-control studies could disprove this finding. Cigarette smoking raises the Bc risk threefold. Responsible are among others arylamines which are activated in the liver, but also detoxified. A genetically caused lack of transferases is responsible for every third Bc. Another risk factor is contributed by permanent hair dyes. Similarly to smoking, an arylamine is taken up by the body and has to be detoxified by transferases in the liver and skin. Furthermore, a chronic urinary tract infection may be related to Bc. Thus, the best prevention is the reduction of risk factors. A high fluid intake-irrespective of its kind-reduces the Bc risk by approximately 50%. Particularly smokers should realize that they can lower their risk of developing Bc by almost 70% with a high fluid intake. A connection between alcohol consumption and Bc development has never been shown. Vitamins A, B, and C were extensively investigated in epidemiological studies. Usefulness for primary prevention of Bc was not convincingly demonstrated. Interestingly, folic acid-containing food may reduce the Bc risk for smokers. Fruits and vegetables possess only a weak preventive efficacy. However, copious fruit consumption may reduce the risk for smokers by almost 50%. The trace element selenium does not possess a proven protection; however, it has been shown that persons with a high selenium plasma level have a lower incidence of Bc. Among probiotics yogurt containing Lactobacillus casei is particularly useful in smokers according to one study. Finally, the preventive action of NSAIDs is controversial. Surprisingly, users of analgetics have a low incidence of Bc.

Objective: To evaluate systematically the current endocrine treatment options for patients with biochemical recurrence after radical prostatectomy or radiation therapy for localized prostate cancer. Methods: Literature search of PubMed documented publications and abstracts from international meetings. Key items included timing and type of salvage hormone therapy, length of its application and handling of side effects. Results: The majority of patients with isolated prostate-specific antigen (PSA) relapse are not candidates for salvage treatment with curative intent. The PSA threshold that triggers initiation of hormonal therapy is debatable and should be based also on pretreatment risk assessment. Intermittent androgen suppression is an emerging concept to circumvent the unresolved controversy of early versus deferred endocrine therapy. Since the tumor load at time of recurrence is low, peripheral androgen blockade with an antiandrogen and a 5α-reductase inhibitor is an acceptable first choice. In case of progression, addition of a LHRH analogue would be the next step. Antiandrogen withdrawal and second-line antiandrogens are clinically of limited value. Conclusions: Biochemical-only progression after definitive treatment in curative intent is different from objective or even symptomatic relapse and allows for sequential hormonal therapy with a variety of compounds.

BACKGROUNDThe majority of patients receive HT after biochemical progression despite primary therapy of prostate cancer with curative intent. It is difficult to differentiate at a low rise in PSA level, e.g., <or=1 ng/ml, between local or systemic recurrence.MATERIAL AND METHODSThe PSA doubling time (DT) is the most reliable surrogate parameter to decide if HT should be initiated. In practice, however, the trigger PSA is used instead. The latter is closely related to the timing of HT. A high PSA is a contraindication for local salvage therapy. Intermittent HT is apparently as effective as continuous HT and shortens the time of HT exposure.RESULTSTraditional HT employs a LHRH agonist, however, the side effect profile is a disadvantage due to the long duration of this treatment, e.g., sarcopenia, osteopenia, or even cognitive impairment. The alternative is nontraditional HT: nonsteroidal antiandrogen (AA) alone such as bicalutamide 150 mg or peripheral androgen blockade (AA plus 5alpha-reductase inhibitor).CONCLUSIONEven after a long duration of the latter HT the side effects are less pronounced (gynecomastia) and treatable. Particularly in patients with high-risk primary tumors [Gleason score 7(4+3)-10 or an initially high PSA], nontraditional HT may be followed by secondary HT.