Dr. Metodi Tahchiev is a urologist from the USBALO urology clinic in Sofia, known as the “cancer hospital”. His scientific interests are in the field of treatment of oncological diseases of the urogenital system, modern and innovative treatment of uroinfections, urolithiasis, BPH, urinary incontinence in both sexes, cystitis, as well as minimally invasive surgery in urology. He has over 33 scientific publications and participation in 3 monographs in the field of oncourology. -Dr. Tahchiev, what are the most common guiding symptoms for patients to watch for in order to detect prostate cancer early? Prostate cancer in Bulgaria is the third most common after lung and skin cancer in men. It has been scientifically proven that the first cancer cells can appear at the age of about 25-30 years. Over a period of about 10 years, a microscopic nodule is formed. Undiagnosed and left untreated for another 10-15 years, a macroscopic nodule forms. The presence of such a node determines the possibility of making a diagnosis through imaging studies such as nuclear magnetic resonance and physical examination with a rectal examination by a specialist urologist. Characteristic of this type of cancer is that it progresses slowly and metastasizes at a later stage of its evolution. Many of the patients die with it, not from it. According to the National Cancer Registry, the peak prevalence of prostate cancer is in the age group between 69-74 years. Many patients with prostate cancer do not have characteristic complaints such as benign prostatic hyperplasia (BPH) – a thin stream, intermittent stream, getting up several times at night to urinate, a feeling of not emptying the bladder. That is why it is of particular importance to carry out preventive examinations after the age of 50 with a urologist at least once a year. For men with fathers or grandfathers with this disease, it is recommended that these examinations take place after the age of 40-45 due to the increased risk of developing this oncological nox. – What are the new methods for earlier diagnosis? What is your opinion about fusion biopsy under ultrasound or MRI guidance? For the diagnosis of prostate cancer, the study of the tumor marker PSA (prostate-specific antigen) plays a major role, which can largely lead us to the diagnosis of “prostate cancer”. It is important to note that not every rise in PSA above normal warrants a prostate biopsy. According to recent guidelines, PSA density should be used. In other words, the tumor marker PSA shows what volume of prostate tissue it is made of. If a prostate gland is too enlarged, it is normal to have elevated PSA values, but if it is small, with an increase in PSA values, a prostate transrectal biopsy should be resorted to. As the limit of PSA density is considered 0.15. When the ratio of PSA to prostate volume is below 0.15, the risk of an oncological diagnosis is very low. As with any socially significant disease,as with prostate carcinoma, methods of diagnosis and treatment are constantly being improved. One such method is the multiparametric MRI and subsequent fusion biopsy. By its very nature, this is a very good diagnostic method that is about to establish itself as the “gold standard” for diagnosing prostate cancer. In it, the images obtained from the MRI are superimposed on the ultrasound image during the prostate biopsy. Thus, it is possible for very small lesions to be caught at a very early stage. – What is the success rate of robotic and laparoscopic minimally invasive surgical methods used to treat prostate cancer? Prostate cancer treatment methods are determined both by the stage at which the diagnosis is made and by the patient’s personal preference. Treatment options are related to the biology of the tumor. This is a tumor that is affected by the male hormone testosterone. It has been proven that eunuchs never develop prostate cancer. This is precisely why medicinal endocrine treatment induces chemical castration of patients. Unfortunately, it can only be effective for about 2 years, as a hormone-resistant prostate tumor develops after that. This necessitates the addition of radiotherapy as an additional treatment. With the diagnosis, it is important to stage the disease, as this determines the type of treatment. If the disease is localized in the prostate, without involvement of its capsule, long-term treatment options are surgical treatment (radical prostatectomy) or radiation therapy in the form of brachytherapy. Both types of treatment have their place, and the urologist must discuss with the patient the pros and cons of both. It is of particular importance to me as a specialist to give my patients the opportunity to make an informed choice. It is important to know that when there is an option for surgical treatment, it is good to use it, because once “closed” this door cannot be opened. In other words, once the patient has chosen radiotherapy or hormone therapy, it is very difficult to carry out surgical treatment. There are three options for surgical treatment. Open surgery to remove the prostate, laparoscopic surgery and robotic surgery. The oncological effect and outcome in all three is the same. The positive effect of the second two is the absence of an incision, less blood loss, atraumaticity of the surrounding tissues and very quick recovery. Which operative method the patient will choose depends on the capabilities of the oncology center, the availability of trained specialists and equipment. – What is prevention and follow-up for already formed tumors of the prostate gland? As I mentioned at the beginning, prostate cancer is a process that develops over decades until the patient gets a clinical manifestation. As with any disease, there is much the patient can do to prevent or delay a disease. Prostate cancer is no exception. The Japanese are the nationin which the incidence rate of prostate cancer is very low. Their main diet is seafood, which may be the reason for this fact. When Japanese people migrated to the US, starting to live according to the food style there, the risk equalized that of the native people, and this has been proven. I leave the conclusion to you. Very often I like to reassure my patients with Elliot Joslin’s aphorism: “Genes load the gun, but lifestyle pulls the trigger.” – Are there cases of prostate cancer that do not require treatment, but only active monitoring? If yes, what does it mean? Since 2016, the concept of watch and waiting has entered the medical literature, in other words, you observe and wait. This strategy has its place in a certain group of patients, namely those at low risk – patients with a low Gleason score, low PSA, small lesions in the prostate. Follow-up consists of monitoring PSA every 3 months, conducting periodic MRIs to monitor the size of the nodules. Unfortunately, in Bulgaria this strategy is not yet widespread, on the one hand, from the colleagues for whom, regardless of the risk, it is better to start treatment, on the other hand, from the point of view of the patients, in whom the psychological moment exists – if you have cancer, it must be treated. The moment is very important to establish this strategy, which is widely advocated in developed countries: to have a dialogue between the patient and the attending physician and to be able to make this decision together, especially since in the era of fusion biopsy, patients with low risk will be discovered more and more. – What are the innovations in radiotherapy? Radiation therapy is a wonderful modality in the treatment of prostate carcinoma, but only as long as the indications for both brachytherapy and percutaneous radiation are followed. The continuous development of technologies also leads to the development of radiation treatment of prostate tumors, especially brachytherapy. But in order for the patient to benefit from the positives of this treatment, I repeat, the indications for it must be observed. In addition, in advanced carcinomas affecting the bones, patients can be offered treatment with radiotherapeutics such as Lutetium and Radium 223. The interesting thing about them is that they accumulate in the tumor cells and give off radiation that kills the cancer cells. Unfortunately, in Bulgaria, these medications are still not reimbursed by the NHIF, and patients have to pay for them themselves, as the amounts are prohibitive for most of them. – Are anabolic supplements a risk for prostate cancer? Unfortunately, the era of anabolic steroids has not yet set in among fitness trainers. Steroids do a lot of damage to the body. We cannot prove a direct link with prostate cancer, but it is definitely indirect and is expressed by the rise to high levels of testosterone, which is a major predictor of prostate cancer. As I mentioned, prostate cancer does not occur in eunuchs. Therefore, it is very important that whatever supplements are taken,to consult at least with the personal physician.