Expectant observation in prostate cancer
Especially in elderly patients with severe comorbidities, it may be advisable to refrain from incriminating tumor therapy and instead wait for tumor-related symptoms and to treat these palliative (soothing).
Expectant observation means long term to observe a tumor patients and initiate a palliative (palliative) therapy when the tumor causes symptoms.Whereas, a more active monitoring (engl. active surveillance, AS), under the close supervision postpone a fundamentally possible curative (healing) therapy until the tumor progresses or the patient's treatment wishes (see active surveillance in prostate cancer ). Both methods are also known as delayed treatment (engl. deferred treatment) or conservative procedure summarized, which expresses that one monitors the patients and only in the progression of the tumor on the further treatment decisions.
The aim of the wait-and-observation is to spare the person concerned an engaging therapy and their possible side effects. If the tumor causes symptoms before the person dies for other reasons, they are treated as far as necessary. Because prostate cancer often grows very slowly (see also the growth and spread ), such a strategy mainly offers when the life expectancy is not very long, either because of a higher age or additional diseases.
In which cases and under what conditions you can wait, the German S3 guideline for physicians by 2009 it can be seen (see also New prostate cancer guidelines ). For all studies were systematically collected on this subject and evaluated and derived from observations and recommendations for the wait-and-monitoring:
Expectant observation in a non-metastatic prostate cancer
As long as no metastases (secondary tumors) in the local lymph nodes (N0, the TNM system see the growth and spread of prostate cancer are available) or in other parts of the body (M0) are at localized (T1-2) or locally advanced prostate cancer ( T3-4) basically two approaches possible:
The first possibility is to try a curative treatment. These are the operation (see radical prostatectomy ), radiation (see radiation therapy ) or the first active surveillance .
The second option is to pursue a palliative strategy from the outset. This means an immediatehormone therapy or initiate first to observe waiting. When deciding on this possibility of desire, age and possible comorbidities of the patient and the risk of progression of the tumor must be observed. The wait-and-monitoring should be discussed with patients with a life expectancy of less than 10 years which are therefore older than 70 years or have severe comorbidities, so that curative therapy is questioned anyway. The T stage and PSA value are irrelevant, theGleason score should not be higher than 7.
To the patient chooses to curative therapy, so the second option, he should be informed of the immediate hormonal therapy and wait-watching. This is to address that both procedures are palliative, that hormone therapy can have undesirable effects and that with immediate hormone therapy Although (PFS) prolongs time to progression of the tumor, but it is still unclear whether this is also the time to death (overall survival) holds. Then the patient decides against an immediate hormone therapy and for the wait and observe, it is to be treated in case of complaints or on request.
Background of these recommendations, studies, according to which (often at a very early stage) pass 10-14 years and the death of the person concerned in the Middle with localized prostate cancer between the diagnosis. Therefore the benefit of a curative therapy for older and already otherwise diseased men should be low and do not outweigh the possible risks of this treatment. This is true for other studies for men with locally advanced tumor.
Expectant observation in a tumor recurrence after curative primary treatment
Rises of PSA after surgery or radiotherapy for prostate cancer again ("PSA relapse "), this can mean a tumor relapse (local recurrence of the tumor) or the growth of metastases. When a tumor recurrence as a cause and reasonable circumstances (see below), the wait-and-Watch is an option (with metastases as a cause see section after next).
Context for this opinion is that the course can be very long in this case, even without further treatment and caused the tumor in many patients not requiring treatment discomfort. Important for the decision on how to proceed are the patient's wish, after weighing the possible benefits and risks, the life expectancy of the patient, taking into account his age and other diseases, as well as the circumstances. Are considered to be low here after radical prostatectomy:
- Gleason score to 7 before surgery
- PSA rebound later than 2 years after surgery
- PSA doubling time more than 10 months (see also PSA testing )
- No involvement of seminal vesicles or lymph nodes
For some patients, it may therefore be useful to treat the tumor recurrence and later to be seen first of all. However, as early as possible local therapy cheap (irradiation after surgery or surgery after radiation therapy) for other patients.
Expectant observation in lymph node involvement
If in the determination of the disease state an MRI or CT used to examine the pelvic lymph nodes and here results are positive, the lymph nodes are very likely to infect (N1) and the tumor metastasizes it. These patients can be offered an immediate or delayed hormonal therapy and wait-watching instead of exposed to risks lymphadenectomy (lymph node dissection). These options apply to patients with histologically (histological) secured lymph node metastases.
Expectant observation in metastatic prostate cancer
Are metastases in local lymph nodes (N1, see above) or in other parts of the body (M1) is present, is usually performed hormone therapy. As long as no tumor-related symptoms are present, but also the expectant observation may come into question. In this case, you start hormone therapy only at the onset of symptoms. The wait-and-Watch is also in patients with androgen-independent or hormone (hormone-insensitive) prostate cancer possible (explanations see Progressive prostate cancer hormone therapy ).
Controls and timing of intervention
As with active surveillance (engl. active surveillance), so regular check-ups will take place (English watchful waiting) even when expectant observation. However, it is not necessary usually, even the PSA level and the tumor (by biopsies to monitor). It is important to recognize complaints by the tumor or possible metastases (eg urinating) as early as possible. Because their occurrence determines the timing for further therapy in expectant observation. This is then in a targeted possible treatment of these ailments. Of course, the intervention can be carried out at the request of the patient earlier.
Summary
The wait-watching can come into consideration at a localized (T1-2) or locally advanced (T3-4) prostate cancer, depending on desire, age and any comorbidities of the patient and the risk for the progression of this cancer, particularly in patients with a life expectancy of less than 10 years. Even with a tumor recurrence after curative (healing), initial treatment can wait, just as with lymph node metastases in local (N1) or elsewhere in the body (M1), as long as no tumor-related symptoms are present. Finally, the decision may only be taken individually when all relevant results are available and the person concerned is informed of all treatment options.
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