ENIn Germany, prostate cancer that has spread or come back is treated in steps, not by one operation, and the first step is almost always better imaging. Advanced prostate cancer treatment in Germany usually follows a rising PSA after surgery or radiotherapy, spread through the capsule or a late diagnosis.
Below: what “advanced” means and how it is treated. Prices and stage 4 have their own pages; the disease in general is covered under prostate cancer treatment in Germany.
What “advanced” actually means
“Advanced” covers four situations treated differently, so advanced prostate cancer treatment in Germany starts by naming the right one. Locally advanced: grown through the capsule or into the seminal vesicles, without distant metastases. Recurrence: a PSA rising after surgery or radiotherapy, with no visible tumour. Metastatic hormone-sensitive: spread, but still responsive to testosterone removal (see stage 4 prostate cancer). Castration-resistant: progressing despite suppressed testosterone.
This decides everything. A locally advanced tumour can still be treated with intent to cure: radiotherapy plus hormone therapy, or surgery within combined treatment. Recurrence after surgery usually means salvage radiotherapy; after radiotherapy, another local treatment is discussed. Metastatic disease is treated long-term but not curatively; castration resistance makes drugs the mainstay.
Treatment is discussed by a tumour board, a weekly meeting of several specialties. In centres certified by the German Cancer Society it includes urologists, radiation and medical oncologists, pathologists, radiologists and nuclear medicine physicians. Essen University Hospital has one, headed by Prof. Boris Hadaschik, director of the urology clinic; Tübingen has another, where Prof. Igor Tsaur is medical director of the university urology clinic.
Imaging before decisions: PSMA-PET
PSMA-PET shows where prostate cancer cells sit, including deposits that CT and bone scans miss: a weakly radioactive tracer binds to PSMA, a protein on these cells. The German S3 guideline on prostate cancer states that it detects metastases more accurately than CT with a bone scan.
The guideline requires PSMA-PET before treatment if spread is a risk, and for a rising PSA when the result would affect treatment. It often finds more than standard imaging, with fewer equivocal findings, so stage and plan can shift either way. Such scans are read by nuclear medicine physicians like Prof. Christoph Rischpler, medical director of nuclear medicine at Klinikum Stuttgart.
Scans brought on disc are reviewed at the tumour board and repeated if they cannot answer the current question, for instance if they predate the PSA rise. A local pathologist re-examines the tissue slides, which sometimes changes the findings, such as the Gleason grade. More under prostate cancer diagnostics.
Drug treatment: hormone therapy and what comes with it
The backbone of drug treatment is androgen deprivation therapy, which switches off the testosterone driving the tumour, usually with a depot injection, less often tablets or removal of the testicles. It starts soon after a metastatic diagnosis, continues at the castration-resistant stage and accompanies radiotherapy of locally advanced tumours. For a rising PSA alone, the guideline does not consider it standard.
Newer hormonal drugs (abiraterone, enzalutamide, apalutamide, darolutamide) are often added; the EU approves them for metastatic hormone-sensitive disease and the castration-resistant stage. Docetaxel is added in selected cases (see prostate cancer chemotherapy). PARP inhibitors serve mainly castration-resistant disease, some regimens only with BRCA1 or BRCA2 mutations, so men with metastases are offered genetic testing. The tumour board, not the stage alone, proposes the combination.
Removing testosterone causes hot flushes, fatigue and loss of bone and muscle, and affects mood, libido and erections. German departments counter this with calcium and vitamin D, bone-strengthening drugs for osteoporosis after a dental check, and exercise therapy, which the S3 guideline recommends for all men on hormone therapy. Between appointments, outpatients of certified centres should have a dedicated contact for psychological and social questions.
Local and targeted treatment: radiotherapy and radioligand therapy
Radiotherapy remains the main local treatment for both recurrence and locally advanced tumours. After prostate removal, salvage radiotherapy to the prostate bed starts as early as possible, with hormone therapy if features are unfavourable; locally advanced tumours are irradiated with long-term hormone therapy. Treatment is outpatient: usually five sessions a week for several weeks, a few minutes each.
Radioligand therapy with lutetium-177 PSMA (Pluvicto) homes in on the protein seen on the PET scan and irradiates tumour cells from inside. In the EU it is approved for progressive PSMA-positive metastatic castration-resistant prostate cancer after a newer hormonal drug and taxane chemotherapy. After the injection in a nuclear medicine department, the patient stays about 2–4 days in a radiation-protection area.
Single metastases can be targeted with precise radiotherapy; the S3 guideline allows this to delay hormone therapy or progression but says the evidence is insufficient. None of these methods is a guarantee; the aim is lasting control of the disease and its symptoms. Pain-directed radiotherapy and palliative care are part of proper treatment, not a last resort.
Frequently asked questions
Can advanced prostate cancer be cured?
It depends on the situation. Locally advanced tumours and some recurrences are treated with intent to cure, not always successfully and with lower chances than cancer confined to the gland. With metastases, prostate cancer is usually incurable, but in many men its progression can be slowed for a long time.
What happens if the PSA rises again after surgery?
First the rise is confirmed and its speed assessed, together with how aggressive the tumour was. A PSMA-PET scan follows if its result would change treatment. Without distant deposits, salvage radiotherapy to the prostate bed is usual, plus hormone therapy if features are unfavourable. With a slow rise and a less aggressive tumour, monitoring is an option.
What does castration-resistant prostate cancer mean?
It is the stage at which the disease progresses despite castration-level testosterone: the PSA keeps rising or new deposits appear. Hormone therapy continues and the next step is added: another drug, chemotherapy, a PARP inhibitor or radioligand therapy. This stage cannot be cured, but several options remain.
How AlenMed arranges treatment
First, the PSA history, histology and imaging are collected and translated, and the case goes to a uro-oncological department whose profile matches the situation. An interpreter attends appointments. AlenMed’s network: 86 partner clinics in 38 cities, 345 doctors and an office in Munich.
Then come the clinic’s written cost estimate (Kostenvoranschlag), the visa invitation, transfer and accommodation. Before travelling, check how treatment can continue at home, including injections, tablets and PSA tests; the discharge letter is translated. For figures, see cost of prostate cancer treatment.
This material is for information and is not an offer; a doctor decides on treatment at a face-to-face appointment.
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