Prostate Cancer Treatments in Germany

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In Germany, prostate cancer is treated in large multidisciplinary university hospitals with urology and oncology departments, as well as specialized centers of prostate cancer treatment and radiation therapy. The availability of robotic surgical systems, HIFU equipment, devices for three-dimensional conformal radiation therapy, drugs for androgen blockade and symptomatic therapy and other innovative resources allows specialists to choose exactly the right therapeutic regimen that will be most effective for a particular patient. The latest technique that has been successfully used in the treatment of metastatic prostate cancer is Lutetium-177 therapy. Lu-177 PSMA is unique among other cancer treatments because it targets prostate cancer loci regardless of their location in the body (including bone metastases). Immunotherapy and dendritic cell vaccines are novel approaches that have proven their efficacy in patients with advanced cancer.

Content

1. Therapy goals
2. Treatment of localized forms of prostate cancer
3. Treatment of locally advanced prostate cancer
4. Treatment of metastatic prostate cancer
5. Cost of the prostate cancer treatment abroad
6. Prostate cancer treatment in Germany with the Booking Health

Therapy goals

The treatment program in Germany is developed for each person individually, taking into account its age, stage of the disease, concomitant diseases, and general health. Typically, therapeutic interventions involving various medical resources have the following objectives:

1. Complete removal of the tumor or restriction of its growth
2. Prevention of tumor invasion into neighboring organs (urethra, bladder, intestines) and lymph nodes.
3. Prevention of metastasis throughout the body
4.  Removal of distant metastases or limiting their growth
5. Preservation of physiological urination, sexual function, etc.

German doctors use criteria such as life expectancy, remission, and life quality to assess the effectiveness of therapy in patients with this diagnosis. Quality of life is assessed using questionnaires developed based on the recommendations of the European Organization for Research and Treatment of Cancer.

It should be understood that not all patients are eligible for radical surgery or innovative Lutetium-177 therapy. The goals and treatment tactics are selected individually, since, for one person, Lu-177 treatment may not be effective for another, and that person will benefit from conventional radiation therapy.

Treatment of localized prostate cancer

According to the international classification of oncological diseases TNM, localized prostate tumors correspond to stages T1 and T2. This means that the growth is inside the prostate and does not penetrate its capsule. At this stage, the patient can be completely cured. To this end, doctors most often use radical prostatectomy to treat prostate cancer.

Radical prostatectomy is the complete removal of the prostate gland with its capsule and surrounding connective tissue. The prostate can be removed transurethrally, laparoscopically, or with the da Vinci surgical system. In some cases, an open removal can be performed. Open surgery is more traumatic than endoscopic surgery but provides the surgeon with better access to the tumor. Today, prostatectomy using the da Vinci surgical system is considered the gold standard. This preserves the nerves and blood vessels of the penis and minimizes the risk of postoperative erectile dysfunction and urinary incontinence. Prostatectomy with the da Vinci Surgical System is a good option for patients with localized prostate cancer with good expected long-term survival. Possible limitations in treating prostate cancer using the da Vinci surgical system are previous pelvic surgery and morbid obesity.

High-intensity focused ultrasound (HIFU) ablation is another method of removing the prostate. The gland is destroyed by a local increase in temperature using focused ultrasound. The prostate tissue is coagulated and destroyed, while the surrounding healthy tissue remains intact. The HIFU technique can also be used to treat local recurrence of prostate carcinoma after radical treatment. If relapse occurs after the initial HIFU ablation, a second procedure and surgery for prostate cancer or radiation therapy may be performed. Other options for minimally invasive treatment of early-stage prostate cancer include the VTP TOOKAD® and the NanoKnife® procedure, cryoablation.

Radiation therapy is mainly given to men with contraindications for surgery for prostate cancer. This includes local radiation therapy – brachytherapy (for example, implantation of radioactive gold seeds) and external beam radiation therapy. Brachytherapy for prostate cancer includes high dose rate (HDR) brachytherapy and low dose rate (LDR) brachytherapy. HDR for prostate cancer involves the temporary placement of radioactive sources inside the prostate.

These sources deliver a high dose of radiation for a few minutes and then are removed. LDR in prostate cancer involves the placement of radioactive "seeds" inside the prostate. These "seeds" emit radiation slowly, over several months, and do not need to be removed after the completion of radiation therapy for prostate cancer.

In addition, in elderly patients with severe comorbidities and short life expectancy, active treatment may be replaced by active surveillance. Such tactics for prostate cancer are possible due to the slow progression of localized tumors without clinical manifestations and threat to life. In this case, the potential risks of surgery or radiation therapy for prostate cancer are excluded.

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Treatment of locally advanced prostate cancer

Locally advanced prostate cancer affects the capsule of the gland (stage T3), affects adjacent organs (stage T4), or metastasizes to regional lymph nodes. At this stage, radiation therapy is preferred over other treatment options.

Radiation therapy for prostate cancer at this stage includes 3D conformal radiation therapy. This is a type of external radiation therapy in which the dose of ionizing radiation is determined individually, depending on the location of the tumor and its positional relationship with neighboring organs. Specialized German clinics also offer intensity-modulated radiation therapy (IMRT). This is a type of radiation therapy that additionally considers the shape and volume of the tumor. The choice of the type of radiation therapy primarily depends on the technical capabilities of the medical facility, since not all hospitals have equipment for intensity-modulated or three-dimensional conformal radiation therapy. To further reduce the risk of complications from radiotherapy, German doctors use rectal spacers to create a barrier between the irradiated prostate and neighboring healthy organs.

The combination of radiation therapy with the prescription of hormonal drugs increases the effectiveness of therapeutic measures. As hormone therapy, doctors use drugs that block the growth and spread of carcinoma under the influence of testosterone. Such drugs include analogs of the luteinizing releasing hormone, steroid and "pure" antiandrogens, estrogens.

In men with castration-resistant (i.e., antiandrogen-resistant) forms of prostate carcinoma, chemotherapy for prostate cancer may be used. Typically, chemotherapy drugs are given every three weeks in combination with daily glucocorticoids.

Prostatectomy at this stage of the disease is ineffective since radical surgical intervention to remove the entire mass of the tumor and metastases is most often impossible. However, many studies have demonstrated the benefits of prostatectomy combined with complete androgen blockade using modern hormonal drugs.

Treatment of metastatic prostate cancer

Metastatic prostate cancer can correspond to any T-stage in the presence of metastases in the lymph nodes of the pelvis or distant organs. Prostate tumors most often metastasize to the bones of the skeleton, lungs, and liver. In the case of metastatic tumors, the most effective treatment methods are high-tech radionuclide therapy and androgen blockade.

Bilateral orchiectomy and chemical castration are used to block the stimulating effect of androgens (testosterone) on the cells of the primary tumor and its metastases. In clinical practice, various mechanisms of androgen blockade are used, from removing the testes (the main source of androgens) to blocking tissue androgen receptors and increasing the level of antiandrogenic substances (estrogens).

Radionuclide therapy, that is,  Lutetium-177 therapy and Actinium-225 PSMA therapy, is currently the most modern and effective way to help men with metastases in the bones, liver, and lungs. Therapeutic radionuclides (Lu-177 PSMA and Actinium-225 PSMA) recognize cancer cells and selectively accumulate in them, thereby killing cancer with radiation.

In this case, normal cells and tissues that do not have characteristic receptors are not exposed to radiation. Therapy with Lutetium-177 and Actinium-225 can only be carried out in a few medical institutions in Europe. They require complex technological production of radionuclide preparations (for example, a drug containing Lu-177 PSMA) and strict radiation protection measures.

Although Lu-177 is recommended specifically for patients with metastatic cancer, it has a relatively wide range of indications. The introduction of Lu-177 PSMA shows good results in tumors that are resistant to hormonal drugs and chemotherapy. Lu-177 can be treated even in cases where the primary tumor cannot be surgically removed. Sometimes Lu-177 PSMA is considered life-saving therapy when no other treatment options are effective.

In addition to the treatment with Lutetium-177, PSMA therapy with Actinium-225 and radionuclide treatment with Radium-223 are also carried out in men with bone metastases of prostate cancer. The separate article is devoted to the comparison of the effectiveness of various radionuclides for the treatment of metastatic prostate cancer.

Men with metastatic hormone-resistant tumors can also receive immunotherapy. This treatment works even when chemotherapy, radiotherapy and hormone therapy are not effective anymore. In Germany, 4 types of immunotherapy are used: dendritic cell vaccines (Sipuleucel-T), monoclonal antibody preparations, immune response checkpoint inhibitors (CTLA-4, PD-1/PD-L1) and CAR T-cell therapy.

Symptomatic therapy is aimed at improving the quality of life. This includes painkillers, drugs to correct anemia, restore weight reduced due to illness, etc. For men diagnosed with a metastatic tumor, bisphosphonates are additionally prescribed. Bisphosphonates stop the destruction of bone tissue, reduces pain, and, to some extent, has an antitumor effect (reduces the blood supply to metastases). German clinics offer modern drugs prescribed every four weeks and have an extremely low risk of side effects.

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Cost of the prostate cancer treatment abroad

In most cases, prostate cancer therapy includes several treatment options. These can be operations in combination with radiation therapy, Lu-177 treatment with symptomatic therapy, etc. The development of the most effective treatment regimen is an undeniable advantage of undergoing prostate cancer therapy in German hospitals. The prices for the most demanded advanced treatments and various methods of radiation therapy are as follows:

Prostate cancer treatment options	Average prices
Da Vinci prostatectomy for prostate cancer treatment	20,440 EUR
Treatment of prostate cancer with high-intensity focused ultrasound (HIFU)	22,600 EUR
Transurethral electroresection of the prostate for prostate cancer	11,500 EUR
Lu-177 PSMA therapy for the treatment of prostate cancer	by request
Treating prostate cancer with conventional radiation therapy	22,480 EUR
Interstitial radiation therapy (brachytherapy) for prostate cancer treatment	18,110 EUR
Intensity-modulated radiation therapy (IMRT) for the treatment of prostate cancer	28,300 EUR

In addition to the method of treating prostate cancer, the cost of a medical program for treating prostate cancer depends on the level of the hospital (it must offer all the necessary technical and medical resources) and the position of the attending physician (for example, treatment is paid separately by the head of the department).

The list of the leading specialized clinics for prostate cancer treatment in Germany includes:

1. University Hospital of Ludwig Maximilian University of Munich, Department of Adult and Pediatric Urology headed by Prof. Dr. med. Christian G. Stief
2. Helios Hospital Berlin-Buch, Department of Urology headed by Prof. Dr. med. Mark Schrader
3. HELIOS Klinik Krefeld, Department of Adult and Pediatric Urology headed by Prof. Dr. med. Martin Friedrich
4. University Hospital Ulm, Department of Adult and Pediatric Urology headed by Prof. Dr. med. Christian Bolenz
5. Urology Hospital Munich-Planegg Munich, Department of Adult and Pediatric Urology headed by Prof. Dr. med. Martin Kriegmair and Dr. med. Ralph Oberneder
6. University Hospital Frankfurt-am-Main, Department of Urology headed by Prof. Dr. med. Felix Kyoung-Hwan Chun

The approximate costs of modern medical and related services in leading specialized hospitals are as follows:

Prostate cancer treatment in Germany with the Booking Health

Foreign patients planning to undergo diagnosis and treatment of prostate cancer in Germany should take into account the peculiarities of receiving medical services abroad. Choosing a specialized clinic from several dozen leading medical institutions specializing in urological oncology is also important. If a patient is prescribed Lutetium-177 therapy, it is also necessary to clarify the production time of Lu-177 PSMA and the cost of Lutetium treatment.

It will be much easier for such patients to assign responsibility for both medical and organizational issues to Booking Health.

Booking Health employees can help patients and their relatives with the following issues:

• Selection of a suitable clinic based on the annual qualification profile
• Direct communication with your doctor
• Preliminary preparation of the medical program without repeating previous examinations, answers to questions about the program
• Providing a favorable cost of treatment in Germany, including a favorable cost of Lutetium treatment, without overpricing and additional rates for foreign patients (savings up to 50%)
• Booking an appointment with a doctor on the desired date
• Monitoring a medical program at all its stages
• Assistance in purchasing and shipping medicines, including Lu-177 PSMA for Lutetium-177 therapy
• Contact with the clinic after the end of the program
• Account control and return of unspent funds
• Organization of additional examinations
• TOP-class service: hotel booking, air tickets, transfer

Please leave a request on the Booking Health website, and on the same day a medical consultant or patient leader will contact you and answer all your questions. You will find comprehensive information on prostate cancer treatments on the Booking Health website.

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Choose treatment abroad, and you will get the best results surely!

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See the interview for more information:

RADIONUCLIDE TREATMENT OF PROSTATE CANCER IN GERMANY – interview with Prof. Dr. med. Stefan Dresel

Authors:

The article was edited by medical experts, board-certified doctors Dr. Nadezhda Ivanisova, Alexandra Solovey. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!

 

Sources:

American Cancer Society

Healthline

Cancer Research Institute

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