Neudiagnostiziertes Prostatakarzinom – Aktive Überwachung, Watchful Waiting, Standardtherapie oder alternative Medizin?

Eine aktive Überwachung setzt voraus, dass der Patient operabel ist, dass sein Gesundheitsstatus eine Lebenserwartung von mindestens 10 Jahren erwarten lässt und ein low–risk–Prostatakarzinom vorliegt: PSA < 10 ng/ml, Gleason Score ≤ 6 und Stadium T1–T2a. In der einzigen großen Studie von Klotz (N = 453, Nachbeobachtung median 7,2 Jahre) hatten 35  % der Patienten eine Progression und 99  % überlebten karzinomspezifisch. Watchful Waiting kommt nur beim inoperablen Patienten mit kurzer Lebenserwartung in Betracht, der bei einer symptomatischen Progression palliativ behandelt wird. Eine Standardtherapie kann anhand des Tumorstadiums gemäß der EAU–Leitlinie formuliert werden: T1a: keine Hormontherapie; T1b–T2b: RP bei einer Lebenserwartung > 10 Jahre, Antiandrogene werden nicht empfohlen, keine neoadjuvante Hormontherapie vor RP und neoadjuvante Hormontherapie (3 Jahre) + Radiotherapie bei schlecht differenziertem Pk; T3–T4: Radiotherapie > 70 Gy + Hormontherapie, sowie Hormontherapie bei Symptomen des lokal fortgeschrittenen Prostatakarzinoms und PSA > 25 ng/ml; auch im Stadium N+ M0 Hormontherapie. Eine alternative Therapie spielt studiengestützt in der Sekundärprophylaxe eine Rolle: Statine, Soja, vor allem Granatapfel und bestimmte Diäten können die PSA–Verdopplungszeit verlängern.

Active Surveillance is only indicated in low risk prostate cancer and a life expectancy of more than 10 years. After periodic reclassification the largest study of Klotz with 453 men observed 7,2 years (median) 35 % required active treatment, but the cancer specific survival was 99 %. Watchful waiting is applied in men with a short life expectancy due to high comorbidity or old age. Palliative therapy is provided if tumor symptoms start. Standard therapy is formulated in the EAU–guidelines. In stage T1a: no hormone therapy; T1b–T2b: radical prostatectomy when the life expectancy is longer than 10 years. T3–T4: Irradiation + hormone therapy; symptomatic cancers should be treated by androgen deprivation. Alternative therapy has been proven to be efficient for secondary prevention, i.e. statins, soy, and particularly pomegranate. Finally, certain diets may be used as complementary means.

Key words

Prostate cancer - active surveillance - watchful waiting - EAU guide lines - standard therapy - complementary and alternative medicine

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