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Das Prostatakarzinom-Screening – aktueller Überblick

Prostate cancer screening—current overview

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Zusammenfassung

Hintergrund

Der Mehrwert des Prostatakrebsscreenings wird kontrovers diskutiert – vor allem im Hinblick auf die geringe Spezifität der Testung auf prostataspezifisches Antigen (PSA).

Methoden

In dieser nichtsystematischen Übersicht präsentieren wir einen aktuellen Überblick über die Evidenz zum Prostatakrebs-Screening mit Fokus auf der Rolle der Magnetresonanztomographie (MRT) der Prostata.

Ergebnisse

Große randomisierte kontrollierte Studien haben gezeigt, dass ein PSA-basiertes Screening die krebsspezifische Sterblichkeit signifikant senkt. Das Problem bei der Entwicklung und Einführung von Prostatakrebs-Screening-Strategien ist aber die daraus resultierende Überdiagnose und in der Folge die Überbehandlung indolenter Karzinome. So ist das opportunistische Screening durch ein ungünstiges Nutzen-Schaden-Verhältnis gekennzeichnet und sollte nicht empfohlen werden. Das deutsche „Gesetzliche Früherkennungsprogramm“ für Prostatakrebs, das aus einer digitalen rektalen Untersuchung (DRU) als eigenständigem Screening-Test besteht, ist nicht evidenzbasiert und weder spezifisch noch sensitiv genug. Die Europäische Kommission hat nun die Mitgliedstaaten dazu aufgerufen, bevölkerungsbezogene, organisierte und risikoangepasste PSA-basierte Screeningstrategien unter Integration der MRT-Bildgebung zu entwickeln, wie sie auch in Deutschland in der laufenden deutschen PROBASE-Studie getestet werden. Die Feinjustierung des diagnostischen Weges nach der PSA-Testung scheint der Schlüsselfaktor zu sein, um den positiven wie auch negativen Vorhersagewert zu verbessern und damit das Prostatakrebs-Screening treffsicherer zu machen. Die Aufnahme der Prostata-MRT in Screeningstrategien führt zu einer genaueren Diagnose von klinisch bedeutsamem Prostatakrebs, während weniger Karzinome mit niedrigem Risiko entdeckt werden. In Zukunft könnten molekulare Biomarker im Blut oder Urin das PSA bei der Prostatakrebsfrühdetektion ergänzen oder sogar ersetzen und das Screening weiter personalisieren. Die aktive Überwachung als Alternative zur sofortigen aktiven Therapie der demografisch zunehmenden Prostatakrebsdiagnosen kann potenziell das Nutzen-Schadensverhältnis eines organisierten Screenings weiter verbessern.

Schlussfolgerung

Die Früherkennung des Prostatakarzinoms sollte organisiert auf Bevölkerungsebene in personalisierten und evidenzbasierten Screeningstrategien gestaltet werden. Die multiparametrische MRT der Prostata kann hier eine wichtige Rolle einnehmen.

Abstract

Background

The harm-to-benefit ratio of prostate cancer (PCa) screening remains controversial mainly due to the unfavorable test characteristics of prostate-specific antigen (PSA) as a screening test.

Methods

In this nonsystematic review, we present a current overview of the body of evidence on prostate cancer screening with a focus on the role of magnetic resonance imaging (MRI) of the prostate.

Results

Evidence generated in large randomized controlled trials showed that PSA-based screening significantly decreases cancer-specific mortality. The main obstacle in developing and implementing PCa screening strategies is the resulting overdiagnosis and as a consequence overtreatment of indolent cancers. Opportunistic screening is characterized by an adverse benefit-to-harm ratio and should, therefore, not be recommended. The German Statutory Early Detection Program for prostate cancer, which consists of a digital rectal examination (DRE) as a stand-alone screening test, is not evidence-based, neither specific nor sensitive enough and results in unnecessary diagnostics. The European Commission recently urged member states to develop population-based and organized risk-adapted PSA-based screening programs, which are currently tested in the ongoing German PROBASE trial. Finetuning of the diagnostic pathway following PSA-testing seems key to improve its positive and negative predictive value and thereby making PCa screening more accurate. Incorporation of prostatic MRI into screening strategies leads to more accurate diagnosis of clinically significant prostate cancer, while diagnosis of indolent cancers is reduced. In the future, molecular liquid-based biomarkers have the potential to complement or even replace PSA in PCa screening and further personalize screening strategies. Active surveillance as an alternative to immediate radical therapy of demographically increasing PCa diagnoses can potentially further improve the benefit-to-harm ratio of organized screening.

Conclusion

Early detection of PCa should be organized on a population level into personalized and evidence-based screening strategies. Multiparametric MRI of the prostate may play a key role in this setting.

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Authors and Affiliations

  1. Division of Personalized Early Detection of Prostate Cancer, German Cancer Research Center (DKFZ), Heidelberg, Deutschland

    Maxime De Vrieze, Rouvier Al-Monajjed MD & Peter Albers

  2. Department of Urology, University Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Deutschland

    Anne Hübner, Rouvier Al-Monajjed MD, Peter Albers & Jan Philipp Radtke

  3. Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Deutschland

    Jan Philipp Radtke

  4. University Dusseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, 40225, Düsseldorf, Deutschland

    Lars Schimmöller & Matthias Boschheidgen

  5. Department of Urology, University Hospital Düsseldorf, Department of Diagnostic, Interventional Radiology and Nuclear Medicine, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Deutschland

    Lars Schimmöller

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  1. Maxime De Vrieze
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  2. Anne Hübner
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  3. Rouvier Al-Monajjed MD
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  4. Peter Albers
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  5. Jan Philipp Radtke
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  6. Lars Schimmöller
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  7. Matthias Boschheidgen
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Corresponding author

Correspondence to Rouvier Al-Monajjed MD.

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Interessenkonflikt

M. De Vrieze, A. Hübner, R. Al-Monajjed, P. Albers, J.P. Radtke, L. Schimmöller und M. Boschheidgen geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Hinweis des Verlags

Der Verlag bleibt in Hinblick auf geografische Zuordnungen und Gebietsbezeichnungen in veröffentlichten Karten und Institutsadressen neutral.

Der Originalbeitrag wurde überarbeitet:

In diesem Artikel fehlten zunächst die Adressdaten für die Autoren Maxime De Vrieze1, Anne Hübner2, Rouvier Al-Monajjed1,2, Peter Albers1,2, Jan Philipp Radtke2,3, Lars Schimmöller4,5, Matthias Boschheidgen4.

Die Zugehörigkeit ist wie folgt: 1 Division of Personalized Early Detection of Prostate Cancer, German Cancer Research Center (DKFZ), Heidelberg 2 University Dusseldorf, Medical Faculty, Department of Urology, D-40225 Dusseldorf, Germany 3 Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg 4 University Dusseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, D-40225 Dusseldorf, Germany 5 Department of Diagnostic, Interventional Radiology and Nuclear Medicine, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Germany

Der Originalbeitrag wurde korrigiert.

Die Autoren Maxime De Vrieze und Anne Hübner teilen sich die Erstautorenschaft.

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De Vrieze, M., Hübner, A., Al-Monajjed, R. et al. Das Prostatakarzinom-Screening – aktueller Überblick. Radiologie 64, 479–487 (2024). https://doi.org/10.1007/s00117-024-01312-1

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