The most common cancer in men. How does his treatment in Poland look like?

“Urology is still underestimated in the oncological field, and we are still not treated in this country as doctors to whom a patient should go without a referral”. With prof. Tomasz Drewa, we talk about the treatment of prostate cancer in Poland.

1. Approx. 70 percent prostate cancer patients are over 65 years of age. Increasingly, the disease affects men under 50 years of age
2. In younger patients, prostate cancer has a more aggressive course and a worse prognosis
3. Three treatment options for prostate cancer: active observation, surgery to remove the prostate (radical prostatectomy), radical radiotherapy (irradiation of the prostate with ionizing radiation)
4. Treatment of prostate cancer in Poland is very different from the standards in EU countries: no refunds for modern endoscopic treatment, the National Health Fund does not promote modern methods of treatment, based on surgical methods used in the last century
5. Do you want to live longer? Make a simple test and find out how!
6. You can find more such stories on the Onet homepage.

Professor, for several years now, the increase in mortality from prostate cancer in Poland has remained at a constant level, in EU countries the number of deaths has been decreasing – why?

Prof. dr hab. n.med. Tomasz Drewa: Indeed, mathematical models predict a significant increase in mortality from prostate cancer in Poland. In 2030, we can expect 6 deaths per year. In 550, there were 2014 deaths due to prostate cancer. I think we can talk about several reasons. Undoubtedly, it is influenced by the aging of the society, which is due to the progress in medicine. The first cause that we could most easily eliminate is the early diagnosis of prostate cancer, i.e. the ability to diagnose prostate cancer at the stage when it is cured.

Unfortunately, there is no awareness campaign to inform men about the need to see a urologist regularly, just like we visit a dentist. The second reason that can be easily eliminated is the administrative barrier, i.e. the requirement to obtain a referral to a urology clinic from a GP. Please note that we do not need a referral to an oncologist, and in fact urologists as a specialty largely deal with oncological activities.

1. What does urology do? When is it worth going to a urologist?

Five cancers of the genitourinary system in men account for about 32 percent. all male cancers: including prostate cancer, which is now the most common cancer in men, bladder cancer, kidney cancer, penile cancer, and testicular cancer. A urologist treats every third man with cancer in Poland! We also treat bladder and kidney cancer in women. It is believed that, depending on the profile of the urology department, cancer patients may be 50 to 80 percent.

Is there any chance for a change in regulations in the near future that would speed up diagnostics?

I don’t know… – urology is still underestimated in the oncological field. I will say more, especially when it comes to the valuation of surgical oncology procedures. Despite many interventions of the PTU Management Board, as well as personal interventions by the President of PTU, prof. Piotr Chłosta, national consultant to Prof. Artur Antoniewicz has not changed in this regard for years. Valuation of oncological operations leads to the generation of debts in hospitals.

Prostate cancer is considered to be cancer of old age – the statistical patient is senior?

About 70 percent. cases are recorded from the age of 65 and up. However, more and more prostate cancer affects men under the age of 50, which is to some extent related to lifestyle, mainly a high-fat, high-sugar diet. Unfortunately, in younger patients, prostate cancer has a more aggressive course and a worse prognosis.

1. Prostate – what should worry you?

Are overweight and obesity risk factors?

We know obesity is an established risk factor for many cancers, including kidney cancer, but in prostate cancer the relationship is not so obvious. It seems that what matters is what we eat, a high-energy “Western style” diet containing large amounts of sweets, sweetened drinks, “fast food”. People who eat this way may be obese, but they don’t have to.

If a man is diagnosed with prostate cancer, how long does he have?

You are asking, how long can you live?

Yes – many sick people see the funeral procession through their eyes of imagination, and after all, prostate cancer is not a sentence …

Absolutely not – in Poland about 85-90 percent. cases of prostate cancer are detected locally. Some patients with metastatic disease are curable and do not die of prostate cancer. What’s more, even if we find a relapse in the form of late biochemical recurrence or metastases, we can continue to treat them and they have a chance of relatively long survival. It can be as long as 10-15 years after the operation that started treatment.

How many patients have prostate cancer that is clinically insignificant?

Hard to say. Indeed, some low-grade cancers will never die. Research conducted at the end of the last century showed that 90 percent. 90-year-olds have prostate cancer. Only that we do not know when the neoplastic disease started to develop, and the course of prostate cancer is slow and metastasizes relatively late. Additionally, we do not have foolproof tools that can assure us that the cancer in question will be clinically insignificant.

At the moment, it is believed that if the tumor is very small, PSA is low, the degree of cancer is 6 on the Gleason scale (3 + 3 = 6), and tumor cells in sections are below 10%, there is a chance that that it would be clinically insignificant cancer. In such patients, active observation is sometimes attempted in order to possibly implement treatment if the parameters of the neoplastic disease worsen. On the other hand, although it is believed that Gleason grade 6 cancers should not metastasize, we have many patients who underwent surgery and later developed PSA recurrence and metastases, despite a histological diagnosis indicating grade 3 according to Gleason.

Let us move on to the methods of treatment – what are offered to patients with early stage prostate cancer?

We currently have three treatment options approved as standard by Urology Societies around the world, including PTU. The first is the so-called active observation, which I already talked about. In the case of more serious parameters of the neoplastic disease, there are: prostate removal surgery (radical prostatectomy) or radical radiotherapy, i.e. irradiation of the prostate with ionizing rays in various forms: teleradiotherapy, brachytherapy and their combinations.

However, looking at the treatment of other cancers, especially breast cancer, which is very similar to prostate cancer, it seems that surgery should be the basis for starting treatment and obtaining a proper diagnosis. First of all, because only the excision of the entire prostate gland, and not the prostate biopsy, gives us the final, correct histological result of the disease.

Is it common that the results of a prostate biopsy are underestimated?

Approximately every fifth patient after surgery turns out to have a more serious disease than in the results of the collected biopsies. Moreover, the migration of patients takes place in both directions – in about 10 percent. in patients who had a serious biopsy result after prostate removal, the diagnosis is corrected “in favor” of the patient. Therefore, we do not have to include such intensive treatment or such intensive diagnostics in postoperative management. I think this is one of the most important reasons why radical prostatectomy should be the first step in treatment.

If there are so many benefits in favor of surgery, why is radical radiotherapy treated as an alternative?

I think the main problem is insufficient communication between radiotherapists, oncologists and urologists. The debate about which method is better has been going on for years. Radiotherapists oncologists believe that in most cases patients should receive radiation, but we do not.

What is the treatment of advanced prostate cancer?

This treatment has also changed recently. Until recently, patients in the advanced stage did not undergo surgery. However, research in recent years has shown that removing the primary focus of the disease improves survival. Therefore, now, as far as it is possible, regardless of the existence of metastatic neoplastic foci, we are striving to remove the prostate.

Worldwide clinical trials conducted also in our clinic (Department of General and Oncological Urology at the Dr. A. Jurasz University Hospital no. the second improves oncological results, i.e. prolongs life.

What awaits the patient after the surgery?

We fight metastases by implementing systemic treatment, chemotherapy, hormone therapy, irradiating individual metastases, and sometimes we remove metastatic lymph nodes.

There is a lot of talk about complications after surgery, mainly incontinence disorders – how many men face an embarrassing problem?

Transient incontinence disorders occur in virtually all patients. Sometimes they are very short, up to two / three weeks, and sometimes even up to six months. In fact, the assessment of urinary continence after prostate removal takes place throughout the year after the procedure, and if it is unsatisfactory, the patient undergoes rehabilitation in the form of pelvic day muscles exercises. Unfortunately, some patients suffer from damage to the sphincter apparatus, which requires the implantation of an artificial urethral sphincter, which is fortunately reimbursed in our health care system.

1. Kegel muscles in men – how to exercise them?

Another complication men fear is erectile dysfunction – how often does it happen?

It is estimated that they concern half of the patients who had intercourse before the surgery. Fortunately, medicine has made significant progress in this case as well. We use drugs that improve sexual function in the form of tablets, injections, gels, although they are not available in Poland. Please don’t even ask me why… Polish men are forced to go to Germany and the Czech Republic to get them. It’s sad and embarrassing …

What are the risk factors for recurrence?

The most important factor is the degree of malignancy determined on the Gleason scale, i.e. the histological malignancy of the cancer described by the pathologist. That is why the correct result is so important, which we get only after removal of the prostate gland, usually with lymph nodes. Neither the PSA itself, nor the size of the prostate, nor the changes described in preoperative MRI are as important as the assessment of the entire prostate by a pathologist.

The most important factor of recurrence is when a patient has cancer in the prostate with Gleason 4 or 5. This gives rise to a risk of distant metastases, and provides doctors with information on how to perform postoperative follow-up. On the other hand, the factor of local recurrence is leaving the tumor cells in place after prostate excision, i.e. leaving the so-called “Positive margin”. The positive margin is influenced by various factors – one of the most important is the quality of the operation performed by the surgeon.

It would certainly be useful if we could finally introduce in Poland the evaluation of not only urological but also surgical operations, which is what many oncological surgeons say. Leaving a positive margin is also determined by the size of the prostate and the size of the cancer in the prostate, as well as the performance of surgery to conserve the nerve bundles in order to maintain an erection, which increases the risk of leaving cancer cells in the place where the prostate was.

Do many patients insist on sparing surgery?

Most patients think first of all about being freed from cancer, but there is a group of men for whom maintaining the ability to function in the sexual sphere is very important.

Does the removal of neurovascular bundles forever eliminate the chance of intercourse?

Not necessarily – the location of the nerves responsible for erection is not the same in all patients. It happens that one bundle is removed and the other is left, or the fibers run just under the prostate and sexual activity returns. However, if the operation is performed with a wide margin, it is necessary to install artificial penile prostheses, which the National Health Fund does not refund …

How much does the treatment of prostate cancer in Poland differ from the standards in the EU countries?

Unfortunately, very much. First of all, we have no refunds for modern endoscopic treatment, i.e. treatment with the assistance of a surgical robot. I will say more, there are not even rudimentary solutions that would facilitate this, i.e. the possibility of additional payments for this type of procedures by the patient.

1. Endoscopy – types and course

Secondly, the National Health Fund absolutely does not promote modern methods of treatment, all the time relying on surgical methods that were used in the last century. Laparoscopic surgery, using expensive equipment, is priced in the same way as classic surgery. It is just over 10 thousand. PLN – maybe it will illustrate: the cost of the operating room is about 1,5-2 thousand. PLN, pathologist for the assessment of preparations, which are sometimes a lot, is 1,5-3 thousand. PLN, a hospital day costs about PLN 500-700, the anesthesiologist calculates such anesthesia for about PLN 1,5 thousand. zlotys, plus tests for the procedure and tools and if the patient eats lunch, he has no salary for the doctor.

Sorry for the sarcasm, but unfortunately this is the economic reality that every head of the urology ward and director of a hospital that has such a ward must struggle with. The laparoscopic radical prostatectomy procedure was assessed disastrously by the National Health Fund – for comparison, in Germany it is about 40. PLN, in Switzerland about 90 thousand. zlotys, but these are standards that we do not have a chance to dream about yet.

Besides, not only radical prostatectomy is greatly underestimated, the same applies to other urological procedures in oncology; nephrectomy (excision of a kidney with cancer) or radical cystectomy (removal of the bladder). Underestimating oncological procedures in urology is a shocking topic that has not been touched on for many years.

Does this mean that there is a gap between us and the EU countries?

Yes, from the data of a national consultant, about 70-80 percent. urological wards in Poland, which, after all, deal with oncology and treat every third Polish man, bring losses. And it’s not because urologists don’t want to work or they work badly – it’s the economy that doesn’t allow us to treat the sick with the tools available in the European Union countries.

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