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Urologie Scan 2015; 02(02): 125-141
DOI: 10.1055/s-0034-1392266
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© Georg Thieme Verlag KG Stuttgart · New York

Das Niedrig-Risiko-Prostatakarzinom – Strategien zur Reduktion von Überdiagnose und Übertherapie

Marianne Schmid
,
Andreas Becker
,
Katharina Boehm
,
Felix K.-H. Chun
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Publication History

Publication Date:
12 June 2015 (online)

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Zusammenfassung

Das Prostatakarzinom (PCa) ist die häufigste Krebserkrankung des Mannes in Deutschland. Im Gegensatz zu einer jährlich steigenden Neuerkrankungsrate ist die PCa-spezifische Sterberate konstant bzw. leicht rückläufig und beträgt aktuell etwa 3 – 4 %. Diese Entwicklungen sind unter anderem auf die seit Ende der 80er-Jahre im Rahmen der Früherkennung durchgeführte Blutwertbestimmung des prostataspezifischen Antigens (PSA) und verbesserte bildgebende Verfahren bzw. Biopsietechniken zurückzuführen. Tatsächlich wird heute die Mehrzahl der Patienten mit PCa in frühen, organbegrenzten und somit kurativen Stadien entdeckt. Zu diesen gehören auch die sogenannten „klinisch nicht signifikanten“ Karzinome (Niedrig-Risiko-Karzinome), die aufgrund ihrer wenig aggressiven Tumorbiologie einen langsamen klinischen Verlauf aufweisen. Daher leiden wenige der davon betroffenen Patienten im Verlauf der Erkrankung unter krebsspezifischen Beschwerden bzw. versterben ursächlich am PCa. Im Gegensatz dazu ist jede aktive Therapie (z. B. Operation oder Bestrahlung) mit spezifischen Risiken (z. B. Inkontinenz, Impotenz, Strahlenzystitis bzw. -proktitis) behaftet, sodass eine sorgfältige Risiko-Nutzen-Abwägung erfolgen muss. Die Gründe für die breite Indikation zu einer aktiven Therapie liegen vor allem in den mangelnden Kenntnissen der Tumorbiologie und der Angst ein Hoch-Risiko-Karzinom „zu verpassen“. Aktuell gibt es jedoch für das frühe, Niedrig-Risiko-PCa keine Evidenzgrad-1-Empfehlung hinsichtlich einer bestimmten Therapie. Das Therapiekonzept der so-genannten aktiven Überwachung (active surveillance [AS]) hat aktuell ein äquivalentes Tumorüberleben der Niedrig-Risiko-PCa-Patienten gezeigt. Dieses Konzept basiert auf seriellen klinischen Untersuchungen, die es erlauben, den Patienten über einen Zeitraum zu beobachten, um bei Veränderung des PCas, z. B. PSA-Anstieg oder Gleason-Score-Progress in den Kontrollbiopsien, eine aktive Therapie rechtzeitig einzuleiten. Dadurch sollen den Patienten während des Überwachungszeitraums potenzielle Nebenwirkungen einer aktiven Therapie erspart und die Rate der Übertherapie minimiert werden. Diese AS-Therapie-Strategie bietet neben der individuellen auch auf gesellschaftlicher und gesundheits-ökonomischer Ebene Vorteile.

 

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