There are different types of treatments for patients with prostate cancer. Treatments for prostate cancer are generally used one at a time, although in some cases they may be combined. Depending on the staging and patient’s profile, the choice of treatment for prostate cancer may include:
Since prostate cancer often grows very slowly, some men, especially those who are older or have other serious health issues, who have prostate cancer might never need treatment. Instead, doctors may recommend observation or active surveillance.
Observation, or sometimes called ‘watchful waiting’ is used to describe a less intensive type of follow-up that may mean fewer tests. Before deciding if a treatment is needed will rely more on changes in a patient’s symptoms. This way of treatment is often meant to control symptoms of the cancer but not to cure it.
Active surveillance is used to monitor the cancer closely. This will usually include a doctor visit with a prostate-specific antigen (PSA) blood test every six months, and a digital rectal exam (DRE) once a year. Prostate biopsies and imaging tests may be done every one to three years too. Depending on the test results and changes, if any, the doctor will recommend the treatment options to try and cure the cancer.
Surgery is a common treatment choice to curing prostate cancer. Patients in good health whose tumour has not spread outside the prostate gland may be treated with surgery to remove the tumour.
The main type of surgery for prostate cancer is radical prostatectomy. In this surgical procedure, the surgeon removes the entire prostate gland and some of the surrounding tissue, including the seminal vesicles. Removal of nearby lymph nodes may be done at the same time.
The main type of radical prostatectomy includes:
Robot-assisted laparoscopic radical prostatectomy: In this approach, also known as robotic prostatectomy, the laparoscopic surgery is done using a robotic system. Several small cuts are made in the wall of the patient’s abdomen. The surgeon inserts an instrument with a camera through one of the openings using robotic arms. The camera gives the surgeon a three-dimensional view of the prostate and the surrounding structures.
Radiation therapy is the use of high-energy rays to destroy cancer cells. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time.
Depending on the stage of the prostate cancer and other factors, radiation therapy may be used in the following situations:
The different types of radiation therapy used are:
Another method of external-beam radiation therapy used to treat prostate cancer is called hypo fractionated radiation therapy. This is when a patient receives a higher daily dose of radiation therapy given over a shorter period, instead of lower doses given over a longer period. Extreme hypo fraction radiation therapy is when the entire treatment is delivered in five or fewer treatments. This is also called stereotactic body radiation therapy (SBRT) or stereotactic ablative radiation therapy (SABR).
Stereotactic body radiation therapy (SBRT): In SBRT technique, doctors uses advanced image guided techniques to deliver large doses of radiation to a precise area of the prostate. Due to the large doses of radiation in each dose, the entire course of treatment is given over just a few days.
Hormone therapy is a cancer treatment that removes hormones or blocks their action to stop cancer cells from growing. Because prostate cancer growth is driven by male sex hormones called androgens, lowering levels of these hormones can help slow the growth of the cancer. The most common androgen is testosterone. Hormonal therapy is used to lower testosterone levels in the body, either by surgically removing the testicles, known as surgical castration, or by taking drugs that turn off the function of the testicles, called medical castration. Which hormonal therapy is used is less important than the main goal of lowering testosterone levels. This treatment can be referred to with other names, including androgen-deprivation therapy (ADT).
Hormone therapy alone does not cure prostate cancer. Hormone therapy may be used in cases where:
The several types of hormone therapy can be used to treat prostate cancer are:
Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.
This vaccine is made specifically for each man and is used to treat advanced prostate cancer that is no longer responding to hormone therapy. To create the vaccine, white blood cells (cells of the immune system) are removed from the patient’s blood over a few hours while they are hooked up to a special machine. The cells are then sent to a lab, where they are mixed with a protein from prostate cancer cells called prostatic acid phosphatase (PAP). The white blood cells are then sent back to the doctor’s office or hospital, where they are given back to the patient by infusion into a vein (IV). This process is repeated two more times, two weeks apart, so that the patient gets three doses of cells. The cells help the patient’s other immune system cells attack the prostate cancer.
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and may reach cancer cells throughout the body. This is also commonly termed as systemic chemotherapy.
Chemotherapy is used if the prostate cancer has spread outside the prostate gland, and when hormone therapy is not working. Chemotherapy is however not a standard treatment for early prostate cancer.
For prostate cancer, chemotherapy drugs are typically used one at a time. Some of the common chemotherapy drugs used to treat prostate cancer include:
These drugs are typically given intravenously (IV) over a certain period of time. Often, a slightly larger and sturdier IV is required in the vein system to administer chemotherapy. They are known as central venous catheters (CVCs), central venous access devices (CVADs), or central lines. They are used to put medicines, blood products, nutrients, or fluids right into the patient’s blood. They can also be used to take out blood for testing.
Chemotherapy is given in cycles, with each period of treatment followed by a rest period to give the patient time to recover from the effects of the drugs. Cycles are most often two or three weeks long, and the schedule varies depending on the drugs used for the treatment.
Lutetium-177 PSMA therapy, also called Prostate-Specific Membrane Antigen Therapy, is a targeted treatment for men experiencing advanced prostate cancer with metastatic or treatment-resistant prostate tumors.
Lutetium-177 PSMA therapy allows for very specific and targeted radiation on prostate cancer cells, which is usually radiosensitive. The therapy aims to shrink the tumour and stabilise the disease. Patients whose bodies have not been responsive to other therapies or treatments may be referred to undergo this therapy.
The Lutetium-177 PSMA therapy combines therapy with diagnostics. The approach is referred to as ‘theranostic’. Most types of prostate cancers express high levels of PSMA. Rarely, about five to ten percent of prostate cancers do not create PSMA. Prior to starting Lutetium-177 PSMA therapy, a diagnostic scan will be performed to ensure that the therapy’s radiation will target the right areas during treatment.
PSMA is a type of protein expressed on the membrane of prostate cells, that is believed to have numerous cellular functions. Although the epithelium of the prostate naturally creates very low levels of PSMA, cancerous prostate tumours prostate extremely high levels (often 1,000 times higher than a normal prostate cell). If prostate cancer has spread to other areas of the body, the PSMA will be detectable in those areas. Lutetium is a radiation-based treatment that utilises a molecule to attach itself to the PSMA receptors located on the cancer cells. Lutetium-177 emits beta radiation that effectively damages cancer cells and, over time, destroys them. By targeting the molecules of PSMA, the radiation-focused treatment by Lutetium becomes very precise as the Lutetium molecule binds with the PSMA. The act of targeting the cancer cells is also often referred to as, ‘Peptide Receptor Radionuclide Therapy (PRRT).
Surgery, like all cancer treatments, has benefits, risks, and side effects. After surgery, it is common to have some pain from the surgery’s effect on the body. The major possible side effects of radical prostatectomy are urinary incontinence (unable to control urine) and erectile dysfunction (impotence or problems getting/keeping erections).
Radiation therapy may cause side effects during treatment, including:
Most of these side effects usually go away after treatment.
The possible side effects of hormone therapy may include:
The common side effects from immunotherapy can include:
The side effects of chemotherapy commonly include the following:
The most common side effect is dry mouth and dry eyes. Occasionally, some patients may experience nausea or vomiting. Mild lethargy is also a side effect. Most of these side effects are transient and usually resolve after a few days. In patients with very extensive bone disease, marrow suppression is also a potential side effect due to collateral damage from the radiation on adjacent bone marrow.
Prostate cancer tends to grow slowly over many years. Most men with early prostate cancer do not have changes that they notice. Signs of prostate cancer most often show up later, as the cancer grows. Some signs of prostate cancer are trouble peeing, blood in the urine, trouble getting an erection, and pain in the back, hips, ribs, or other bones. If signs are pointing to prostate cancer, tests will be done.
If you suspect that you or your loved one have Prostate Cancer, it is advisable to get the support you need. Early detection and diagnosis of Prostate Cancer is key to treating the disease.
Regardless of what stage your Prostate Cancer may be, you should schedule an appointment to see an oncologist specialising in Prostate Cancer as soon as possible. With the speed of developments in Prostate Cancer diagnosis and treatment, novel emerging treatment options could be explored by your medical oncologist.
Our cancer specialists at OncoCare specialise in treating late stage and advanced stages of Prostate Cancer, as well as earlier stages of the disease.
MBBS (Delhi) – American Board Certified (Int Med) – American Board Certified (Hematology) –
American Board Certified (Med Oncology)
Before joining OncoCare Cancer Centre at Mount Elizabeth Hospital, Singapore, Dr Akhil Chopra was a Senior Consultant in Medical Oncology at Johns Hopkins Singapore, Tan Tock Seng Hospital and Adjunct Associate Professor at Lee Kong Chian School of Medicine.
Dr Chopra has experience treating multiple cancer types including breast cancer, lung cancer, cancers of stomach, colon, rectum, liver, prostate, kidney, testicular and bladder, gynaecological cancers such as ovarian and uterine/cervical cancers; as well as Stomach Cancers and chronic leukaemia’s/multiple myeloma. Besides his clinical and research work, he has been involved in teaching medical students from the Lee Kong Chian School of Medicine as well as medical residents and students from Johns Hopkins University, Baltimore in USA.
Cancer Specialities: breast cancer, lung cancer, cancers of stomach, colon, rectum, liver, prostate, kidney, testicular and bladder, gynaecological cancers such as ovarian and uterine/cervical cancers
MBBS (Singapore) – M.Med (Singapore) – MRCP (United Kingdom) – FAMS (Medical Oncology)
Dr Tay Miah Hiang, Senior Consultant Medical Oncologist at OncoCare Cancer Centre, was previously consultant at the National Cancer Centre Singapore’s Department of Medical Oncology, and Chairperson of Patient Education & Patient Survivorship programmes. Dr Tay also served on the board of Singapore Children’s Cancer Foundation from 2006 till 2015, and was Chairperson of this foundation from 2011 to 2013, and now serving as advisor. He is an elected member of Singapore Medical Council (SMC) since 2017 till date.
Dr Tay is passionate in contributing to Continuous Medical Education in the region, giving lectures in cancer management to cancer specialists, general practitioners, medical students and patients. He has won numerous awards for his service excellence and humanity contribution to disaster inflicted regions as such as post-Afghanistan war and Sri Lanka after Tsunami.
He has been actively involved in clinical and translational research for many years, in genitourinary (testicular, kidney, bladder, prostate), lung and other cancers. His research work is well published in hormone-refractory prostate cancer involved chemotherapy agents such as docetaxel and carboplatin. Acknowledged as a senior cancer specialist and an authority in prostate cancer in Singapore, he had also published on the use of ketoconazole and as part of a multi-centre clinical trial, the use of abiraterone acetate in metastatic castration-resistant prostate cancer progressing after chemotherapy.
As a pioneer in kidney cancer oncology, he had used sunitinib (Sutent), refametinib in kidney cancer patients when the drugs were coming into clinical practice in Singapore. Recognised as an authority in prostate cancer in Singapore, he had helped developed guidelines for the treatment of prostate cancer in Singapore in 2013 and the management of kidney cancer in Asia at the Asian Oncology Summit 2012.
His significant research work has been published in both local and international journals including Urology, Cancer, and Annals of Oncology. He also wrote chapters in several internationally recognised cancer specialty books such as Comprehensive Textbook of Genitourinary Oncology (3rd Edition), American Cancer Society’s Complete Guide to Prostate Cancer 2006, and Textbook on Urologic Oncology 2004.
Dr Tay is lauded for his experience in treating prostate, kidney, testicular and the bladder, gynaecological cancers such as ovarian and uterine/cervical cancers, gastrointestinal & hepatobiliary cancers, lung cancer, brain tumour. He does not see patients with lymphoma, leukemia and breast cancer.
Definition of Prostate Cancer
Prostate cancer is cancer that occurs in the prostate. The prostate is a small walnut-shaped gland in males that produces the seminal fluid that nourishes and transports sperm.
Prostate cancer is one of the most common types of cancer in men. Many prostate cancers grow slowly and are confined to the prostate gland, where they may not cause serious harm. However, while some types of prostate cancer grow slowly and may need minimal or even no treatment, other types are aggressive and can spread quickly. Prostate cancer that is detected early — when it is still confined to the prostate gland — has the best chance for successful treatment.
Prostate cancer is the second most common occurring cancer in men and the fourth most common cancer worldwide. More than 47, 500 men are diagnosed with prostate cancer every year, translating to 129 men daily. 1 in every 8 men will be diagnosed with prostate cancer in their lifetime.
In Singapore, prostate cancer is the third most common cancer amongst men and every day, two men are diagnosed with prostate cancer.
The most common symptoms of Prostate Cancer are:
If cancer has spread outside of the prostate gland, symptoms may include:
Change in bowel habits
Screening for prostate cancer is done to find evidence of cancer in otherwise healthy adults. The tests that are commonly used to screen for prostate cancer includes:
Prostate biopsy: For some men, getting a prostate biopsy might be the best option, especially if the initial PSA level is high. A biopsy is a procedure in which small samples of the prostate are removed and then looked at under a microscope. This test is the only way to know for sure if a man has prostate cancer. If prostate cancer is found on a biopsy, this test can also help tell how likely it is that the cancer will grow and spread quickly.
The examination may include a digital rectal exam (DRE), during which the doctor inserts a gloved, lubricated finger into your rectum to feel for any bumps or hard areas on the prostate that might be cancer. If the patient does have cancer, the DRE can sometimes help tell if it is only on one side of the prostate, on both sides, or if it is likely to have spread beyond the prostate to nearby tissues. The doctor may also examine other areas of the patient’s body.
PSA in the blood is measured in units called nanograms per milliliter (ng/mL). The chance of having prostate cancer goes up as the PSA level goes up. However, there is no set cutoff point that can confirm if a man does or does not have prostate cancer. Many doctors use a PSA cutoff point of 4 ng/mL or higher when deciding if a man may need further testing.
A biopsy is a procedure in which small samples of the prostate are removed and then looked at with a microscope. A core needle biopsy is the main method used to diagnose prostate cancer and is usually done by a Urologist.
During the biopsy, the doctor usually looks at the prostate with an imaging test such as transrectal ultrasound (TRUS) or MRI, or both. The doctor quickly inserts a thin, hollow needle into the prostate. This is done either through the wall of the rectum (a transrectal biopsy) or through the skin between the scrotum and anus (a transperineal biopsy). When the needle is pulled out, it removes a small cylinder (core) of prostate tissue and is repeated several times. Most often the doctor will take about twelve core samples from different parts of the prostate.
For this test, the patient is injected with a small amount of low-level radioactive material, which settles in damaged areas of bone throughout the body. A special camera detects the radioactivity and creates a picture of your skeleton. A bone scan may suggest cancer in the bone, but to make an accurate diagnosis, other tests such as plain x-rays, CT or MRI scans, or even a bone biopsy might be needed.
The following factors may increase a man’s risk of Prostate Cancer:
The type of prostate cancer talks about the type of cell the cancer started in. Knowing this helps the doctor decide which treatment the patient will need. They use the information about the patient’s prostate cancer type along with:
Another way doctors may describe the cancer is as localised, locally advanced, or advanced.
There are different types of prostate cancer.
Staging is a way of describing where the cancer is located, or if it has spread and whether it is affecting other parts of the body. The tests and scans used to diagnose the patient’s cancer will give some information about:
One tool that doctors use to describe the stage is the TNM system. Results from diagnostic tests and scans are used to answer these questions:
The results are combined to determine the stage of cancer of each patient and to plan the best treatment.
Stage 1 Prostate Cancer
Cancer in this early stage is usually slow growing. The tumour cannot be felt and involves one-half of one side of the prostate, or even less. The PSA level in this stage is low, and the cancer cells look like healthy cells.
Stage 2 Prostate Cancer
Stage 2: The tumour is found only in the prostate. The PSA levels are medium or low. Stage ll prostate cancer is small but may have an increasing risk of growing and spreading.
Stage 2A: The tumour cannot be felt and involves one-half of one side of the prostate, or even less. The PSA levels are medium, and the cancer cells are well differentiated. This stage also includes larger tumours found only in the prostate.
Stage 2B: The cancer has not yet spread outside the prostate. It may be felt by digital rectal exam or seen with imaging such as transrectal ultrasound. The PSA level is medium. The cancer cells are moderately differentiated.
Stage 2C: The tumour is found only inside the prostate, and it may be large enough to be felt during DRE. The PSA level is medium. The cancer cells may be moderately or poorly differentiated.
Stage 3 Prostate Cancer
Stage 3: The PSA levels are high, the tumor is growing, or the cancer is high grade. These all indicate a locally advanced cancer that is likely to grow and spread.
Stage 3A: The cancer has spread beyond the outer layer of the prostate into nearby tissues. It may also have spread to the seminal vesicles. The PSA level is high.
Stage 3B: The tumour has grown outside of the prostate gland and may have invaded nearby structures, such as the bladder or rectum.
Stage 3C: The cancer cells across the tumour are poorly differentiated, meaning they look very different from healthy cells.
Stage 4 Prostate Cancer
Stage 4: The cancer has spread beyond the prostate.
Stage 4A: The cancer has spread to the regional lymph nodes.
Stage 4B: The cancer has spread to distant lymph nodes, other parts of the body, or to the bones.
How prostate cancer can spread to the bones, the symptoms of this spread and possible avenues of treatment.
Interview done by CNA938 – Listen to Dr Akhil Chopra, Senior Consultant Medical Oncologist, OncoCare Cancer Centre: