The revised S3 guideline on prostate cancer, published by the Oncology Guideline Program and funded by German Cancer Aid, brings groundbreaking changes for early detection, diagnosis and treatment. With around 74,900 new cases in 2022, prostate cancer is the most common cancer in men in Germany, occurring mainly at an older age. The new recommendations focus on risk-adapted early detection, a greater role for MRI and the avoidance of overtreatment of low-risk tumors. Particularly striking: palpation (digital rectal examination, DRU) is no longer recommended for early detection.

Early detection is undergoing a fundamental reorientation. Instead of the annual DRU, which was previously covered by health insurance companies from the age of 45, the guideline recommends PSA-based screening, in which the prostate-specific antigen (PSA) value in the blood is determined. “Studies show that the palpation test is clearly inferior to the PSA test. It leads to both many false-negative and many false-positive findings, the further clarification of which is associated with risks,” explains Professor Marc-Oliver Grimm, coordinator of the guideline group from Jena University Hospital. After consulting a doctor, men aged 45 and over should be offered PSA screening. If the PSA value is very low, the next check-up is only necessary after five years, otherwise every two years. If the confirmed value exceeds 3 ng/ml, further clarification follows, in which the DRU can be used in addition to the individual risk assessment. “The new PSA-based strategy is an example of evidence-based, risk-adapted early detection,” emphasizes Grimm, who hopes that the Federal Joint Committee will adapt the statutory early detection of cancer accordingly.

Magnetic resonance imaging (MRI) of the prostate is becoming increasingly important in diagnostics. It is now clearly used according to risk and diagnostic consequence. A key innovation: in the case of inconspicuous MRI findings (PI-RADS 1 and 2), which indicate a very low risk of cancer, a biopsy should not be performed in order to avoid unnecessary interventions. The guideline also contains updated recommendations on image-guided biopsies, human genetic counseling in cases with a family history and modern imaging such as PSMA-PET/CT for staging.

The guideline sets new therapeutic standards, particularly for low-risk tumors. Only active surveillance is recommended here, instead of surgery or radiotherapy as in the past. This strategy is also becoming increasingly relevant for low-risk intermediate tumors. “Treatments for prostate cancer are often associated with side effects and restrictions in quality of life,” explains Grimm. “With active monitoring, we avoid overtreatment and at the same time keep an eye on the patient so that we can act as soon as necessary.” New treatment options for metastatic tumors have been included in the guideline.

The revised guideline marks a paradigm shift towards more precise, patient-oriented care. It promises to improve diagnostics, reduce unnecessary interventions and protect the quality of life of those affected, while at the same time laying the foundation for future adjustments to statutory early detection.

Original Paper:

Oncology guideline program: Prostate carcinoma

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