Prostate Cancer Diagnosis & Treatment in Singapore
What are Prostate Cancer Treatments in Singapore?
Presenting treatments for both localised cancer and metastatic kidney cancer
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:
- Open radical prostatectomy: In this open operation, an incision or cut is made in the retropubic area (lower abdomen) or the perineum (the area between the anus and scrotum). Surgery is performed through the incision. If there are any reasonable chances that the cancer may have spread to nearby lymph nodes (based on a patient’s PSA level, prostate biopsy results and other factors), the surgeon may also remove some of these affected lymph nodes (known as a pelvic lymph node dissection). These nodes will be sent to the lab to check for cancer cells.
- Radical laparoscopic prostatectomy: Several small incisions or cuts are made in the wall of the abdomen. A laparoscope (a thin, tube-like instrument with a light and lens for viewing) is inserted through one opening to guide the surgery, while surgical instruments are inserted through the other openings to remove the prostate.
- 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.
- Transurethral resection of the prostate (TURP): This operation is more often used to treat men with non-cancerous enlargement of the prostate called benign prostatic hyperplasia (BPH). It is also sometimes used in men with advanced prostate cancer to help relieve symptoms such as urinary blockage, however, it is not used to treat or cure the cancer. In this procedure, the surgeon inserts a narrow tube with a cutting device called a cystoscope into the urethra and then into the prostate to remove prostate tissue.
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:
- As the first treatment for cancer that is still just in the prostate gland and is low grade. The cure rates for men in these types of cancers are similar in men treated with radical prostatectomy.
- As part of the first treatment for cancers that have grown outside the prostate gland and in nearby tissues. The radiation therapy is done together with hormone therapy.
- Radiation therapy is used if the cancer is not removed completely or recurs (come back) around the prostate after surgery.
- If the cancer is advanced, radiation therapy is used to help keep the cancer under control and help keep prevent or relieve symptoms.
The different types of radiation therapy used are:
- External-beam radiation therapy: This is the most common type of radiation therapy treatment. Beams of radiation are focused on the prostate gland from a machine outside the body. This type of radiation can be used to try to cure earlier stage cancers, or to help relieve symptoms such as bone pain if the cancer has spread to a specific area of bone.
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).
- Brachytherapy: Brachytherapy, or internal radiation therapy, is the insertion of radioactive sources directly into the prostate. These sources, called seeds, gives off radiation just around the area where they are inserted and may be left for a short time (high-dose rate) or for a longer time (low-dose rate). Low dose rate seeds are left in the prostate permanently and work for up to one year after they are inserted. High-dose-rate brachytherapy is usually left in the body for less than 30 minutes, but it may need to be given more than once. Brachytherapy may be used with other treatments, such as external-beam radiation therapy and/or hormonal therapy.
- Three-dimensional conformal radiation therapy (3D-CRT): 3D-CRT is a radiation therapy that uses computers to precisely map the location of a patient’s prostate. Radiation beams will then be shaped and aimed at the prostate from several directions. This helps to make it less likely damage the surrounding normal tissues and organs.
- Intensity modulated radiation therapy (IMRT): IMRT is an advanced form of 3D-CRT therapy which is also the most common type of external beam radiation therapy for patients with prostate cancer. IMRT uses CT scans to form a 3D picture of the prostate before treatment. A computer uses this information about the size, shape, and location of the prostate cancer to determine how much radiation is needed to destroy it. With IMRT, high doses of radiation can be directed at the prostate without increasing the risk of damaging nearby organs.
- Proton therapy: Proton therapy, also called proton beam therapy, is a type of external-beam radiation therapy that uses protons rather than x-rays. At high energy, protons can destroy cancer cells. Unlike x-rays, which release energy both before and after they hit their target, protons cause little damage to tissue they pass through and release their energy only after traveling a certain distance. This means that proton beam radiation may deliver more radiation to the prostate while doing less damage to nearby normal tissues. Proton beam radiation can be aimed with techniques like 3D-CRT and IMRT.
- 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 cancer has spread too far to be cured by surgery or radiation
- If the cancer remains or recurs after treatment with surgery or radiation therapy
- Along with radiation therapy as an initial treatment, or if a patient is at a higher risk of the cancer recurring back after treatment, and/or growth of the cancer outside the prostate
- Before radiation to try to shrink the cancer to make the treatment more effective
The several types of hormone therapy can be used to treat prostate cancer are:
- Orchiectomy (surgical castration): Even though this is a type of surgery, its main effect is as a form of hormone therapy. In this operation, the surgeon removes the testicles, where most of the androgens (such as testosterone and DHT) are made. This causes most prostate cancers to stop growing or shrink for a time.
- LHRH Agonists: Luteinizing hormone-releasing hormone (LHRH) agonists, also called LHRH analogs or GnRH agonists, are drugs that lower the amount of testosterone made by the testicles. Treatment with these drugs is sometimes called medical castrationbecause they lower androgen levels just as well as orchiectomy. With these drugs, the testicles stay in place, however they will shrink over time. LHRH agonists are injected or placed as small implants under the skin. Depending on the drug used, they are given anywhere from once a month up to once every six months.
- LHRH Antagonists: This drug, also called a gonadotropin-releasing hormone (GnRH) antagonist, stops the testicles from producing testosterone like LHRH agonists. However, they reduce testosterone levels more quickly and do not cause the flare associated with LHRH agonists.Treatment with these drugs can also be considered a form of medical castration.
- Androgen receptor inhibitors: For most prostate cancer cells to grow, androgens must attach to a protein in the prostate cancer cell called an androgen receptor. Anti-androgens are drugs that also connect to these receptors, keeping the androgens from causing tumor growth. Anti-androgens are also sometimes called androgen receptor antagonists. These drugs are taken daily as pills but are not usually used on its own to treat the cancer. New generation of androgen receptor inhibitors that are more potent and efficacious are now available such as Enzalutamide, Apalutamide and Darolutamide.
- Novel hormonal agents such as Abiraterone Acetate which interrupts androgen production at testes, adrenal gland and cancer cell itself.
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.
- Sipuleucel-T (Provenge): For some patients with castration-resistant metastatic prostate cancer who have no or very few cancer symptoms and generally have not had chemotherapy, vaccine therapy with Sipuleucel-T (Provenge) may be an option. Unlike traditional vaccines that helps boost the body’s immune system to help prevent infections, Sipuleucel-T (Provenge) boosts the immune system to help the body attack prostate cancer cells.
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.
- PD-1 inhibitor: Another form of immunotherapy treatment is PD-1 inhibitor. Pembrolizumab (Keytruda) is a drug that targets PD-1, a checkpoint protein on immune system cells called T cells,that normally helps keep these cells from attacking normal cells in the body. By blocking PD-1, this drug boosts the immune response against prostate cancer cells. It has shown promising results in some men with prostate cancer and continues to be studied. This drug is given as an intravenous (IV) infusion every two or three weeks.
- PARP Inhibitor: Studies have shown that 20%–30% of men with metastatic prostate cancer have genetic alterations that impair cells’ DNA repair mechanisms. These mutations or alterations can be detected with genomic characterization of tumor and normal cells of the patient. 2 drugs- Olaparib and Rucaparib have been approved by the FDA for treatment of advanced metastatic castration resistant prostate cancer that have certain genetic alterations (BRCA 1 and 2, ATM and other DNA repair pathway genes)
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:
- Docetaxel (Taxotere)
- Cabazitaxel (Jevtana)
- Mitoxantrone (Novantrone)
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).
Are there any Side Effects of Prostate Cancer Treatment?
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).
- Urinary incontinence: In urinary incontinence, the patient may not be able to control their urine or may have leakage and dribbling. Being incontinent can affect the patient physically, emotionally, and socially too. After surgery for prostate cancer, normal bladder control usually returns within several weeks or months. This recovery usually occurs slowly over time.
- Erectile dysfunction (impotence): This refers to the inability to have an erection of the penis adequate for sexual intercourse. The ability to have an erection after surgery depends on the patient’s age, the ability to get an erection before the operation, and whether the nerves were cut. All men can expect some decrease in the ability to have an erection, but the younger the patients are, the more likely it is that they will keep this ability. The ability to have erections after surgery may take from a few months to up to two years. Medications or other treatments such as penile rehabilitation may be used to help regain potency.
Radiation therapy may cause side effects during treatment, including:
- Increased urinary urge or frequency
- Erectile dysfunction (impotence)
- Problems with bowel function, including diarrhea, rectal discomfort, or rectal bleeding
- Lymphedema (swelling or pain in the legs or genital area)
Most of these side effects usually go away after treatment.
The possible side effects of hormone therapy may include:
- Reduced or absent sexual desire
- Erectile dysfunction (impotence)
- Shrinkage of testicles and penis
- Hot flashes, which may get better or go away with time
- Breast tenderness and growth of breast tissue (gynecomastia)
- Osteoporosis (bone thinning), which can lead to broken bones
- Anaemia (low red blood cell counts)
- Decreased mental sharpness
- Loss of muscle mass
- Weight gain
- Increased cholesterol levels
The common side effects from immunotherapy can include:
- Back and joint pains
- Skin rash
- Decreased appetite
The side effects of chemotherapy commonly include the following:
- Nausea and vomiting
- Loss of appetite
- Hair loss
- Skin and nail changes
- Numbness and tingling
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.
What do I need to do if I have Prostate Cancer?
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.
Who are the Kidney Cancer Specialists in Singapore?
Senior Consultant, Medical Oncologist
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 Sarcomas 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.
- Graduated from Delhi in 2001
- American Board Certified, Internal Medicine
- American Board Certified, Medical Oncology
- American Board Certified, Hematology
- Fellowship Training at Hahnemann University Hospital/Drexel University College of Medicine in Philadelphia, 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.
- Graduated from the National University of Singapore in 1992.
- Obtained Master of Medicine (Internal Medicine) and Membership of the Royal College of Physicians (United Kingdom) in 1999.
- Awarded the Ministry of Health Manpower Development Programme (HMDP) Scholarship to train at Dana Farber Cancer Institute, (Teaching Affiliates of Harvard Medical School), Boston USA 2003.
- Completed the Cancer Medicine and Hematology course at Harvard Medical School, Boston, MA, USA 2003.
- He was the Chairperson of Cancer Education for National Cancer Centre and Dr Tay was also previously the Chairperson and management committee member of Children’s Cancer Foundation. He is an elected member of Singapore Medical Council since 2017.
- In clinical patient care, he was awarded for his professional and genuine care with National Excellent Service Gold Award (EXSA*) in 2006 and Star Award in 2007.
- He has been actively involved in clinical and translational research for many years, in prostate, kidney, lung and other cancers. These have involved international trials of chemotherapy drugs currently in active use and newer targeted therapy. He was principal investigator for more than 10 clinical trials for cancer drug development.
- Research work by Dr Tay has been published in both local and international journals including Urology, Cancer, Annals of Oncology. He also wrote chapters in several international 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.
- With respect to public service, Dr Tay has given talks both locally and overseas. These include the 13th and 15th Malaysian Urological Symposium on management of prostate cancer and renal cell cancer and Urological Conferences held in Singapore in 2004-2007
- With teaching appointments as Clinical Teacher, Faculty of Medicine, National University of Singapore and had been one of the lecturer for the First Singapore Medical Oncology Review Course (2007) involving surgeons, medical oncologists, radiation oncologists and physicians.
- Accredited for Palliative Medicine.
- Clinical interest in lung cancer, cancers of stomach, colon, rectum, liver, prostate, kidney, testicular and the bladder, gynaecological cancers such as ovarian and uterine/cervical cancers, and brain tumour.
- (*) National Excellent Service Award (EXSA) is a national award managed by SPRING Singapore and nine industry lead associations in Singapore. This award recognises the best of the best individuals who have delivered outstanding service in their respective industries. It seeks to develop models for service staff to emulate, create service champions and enhance professionalism in service delivery.
What is Prostate 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.
What are the Signs and Symptoms of Prostate Cancer?
The most common symptoms of Prostate Cancer are:
- Frequent urination
- Weak or interrupted urine flow or the need to strain to empty the bladder
- The urge to urinate frequently at night
- Blood in the urine
- New onset of erectile dysfunction
- Pain or burning during urination, which is much less common
- Discomfort or pain when sitting, caused by an enlarged prostate
If cancer has spread outside of the prostate gland, symptoms may include:
- Pain in the back, hips, thighs, shoulders, or other bones
- Swelling or fluid build-up in the legs or feet
- Unexplained weight loss
- Change in bowel habits
Screening for Prostate Cancer
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:
- Digital rectal examination (DRE):A DRE is a test in which the doctor inserts a gloved, lubricated finger into the rectum and feels the surface of the prostate through the bowel wall for any irregularities. This exam can be uncomfortable (especially for men who have hemorrhoids) but is usually not painful and only takes a short time.
- PSA blood test:This test is useful for detecting early-stage prostate cancer, especially in those with many risk factors, which helps some get the treatment they need before the cancer grows and spreads. Prostate-specific antigen (PSA) is a protein made by cells in the prostate gland (both normal cells and cancer cells). PSA is mostly found in semen, but a small amount is also found in blood.
- Imaging test of the prostate gland: This screening such as MRI or transrectal ultrasound (TRUS) may be another option to help the patient and doctor detect prostate cancer.
- 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.
How Prostate Cancer is Diagnosed
Tests to diagnose Prostate Cancer include:
- Physical examination: If the patient is suspected to have prostate cancer, he or she the doctor will ask about any symptoms the patient may be having, such as any urinary or sexual problems, and how long he have had them. The patient may also be asked about possible risk factors, including the family history.
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.
- Prostate-Specific Antigen (PSA) Blood Test: The PSA blood test is used mainly to screen for prostate cancer in men without symptoms. It is also one of the first tests done in men who have symptoms that might be caused by prostate cancer.
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.
- Imaging tests for prostate cancer: Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. One or more imaging tests might be used to look for cancer in the prostate, to help the doctor see the prostate during certain procedures (such as a prostate biopsy or certain types of prostate cancer treatment) or to look for spread of prostate cancer to other parts of the body. The imaging tests used most often to look for prostate cancer spread include:
- Transrectal ultrasound (TRUS): For this test, a small probe about the width of a finger is lubricated and placed in the patient’s rectum. The probe gives off sound waves that enter the prostate and create echoes. The probe picks up the echoes, and a computer turns them into a black and white image of the prostate.
- Magnetic resonance imaging (MRI): MRI scans create detailed images of soft tissues in the body using radio waves and strong magnets. MRI scans can give doctors a very clear picture of the prostate and nearby areas. A contrast material called gadolinium may be injected into a vein before the scan to better see details.
- Prostate Biopsy: If the results of a PSA blood test, DRE, or other tests suggest that the patient might have prostate cancer, he will most likely need a prostate biopsy.
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.
- Bone scan: If prostate cancer spreads to distant parts of the body, it often goes to the bones first. A bone scan can help show if cancer has reached the bones.
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.
- Positron emission tomography (PET) scan: A PET scan is similar to a bone scan, in where a slightly radioactive substance (known as a tracer) is injected into the blood, which can then be detected with a special camera.
- Computed tomography (CT) scan: A CT scan uses x-ray to make detailed cross-sectional images of the patient’s body. This test may help detect prostate cancer that has spread into nearby lymph nodes. If the patient’s prostate cancer recurs after treatment, the CT scan may often tell if it is growing into other organs or structures in the pelvis.
- Lymph node biopsy: In a lymph node biopsy, also known as lymph node dissection or lymphadenectomy, one or more lymph nodes are removed to see if they have cancer cells. This is not done often for prostate cancer; however it may be used to detect if the cancer has spread from the prostate to nearby lymph nodes.
What are the Causes and Risk Factors of Prostate Cancer?
The following factors may increase a man’s risk of Prostate Cancer:
- Age: The risk of prostate cancer increases with age, especially in men over the age of 50. Around 60% of prostate cancers are diagnosed in people who are 65 or older. Older adults who are diagnosed with prostate cancer can face unique challenges, specifically regarding cancer treatment.
- Family history: Prostate cancer that runs in a family, called familial prostate cancer, makes up about 20% of all prostate cancers. This type of prostate cancer develops because of a combination of shared genes and shared environmental or lifestyle factors.
What are the Types 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:
- how abnormal the cancer cells look under the microscope (the grade)
- the size of the cancer and whether it has spread (the stage)
Another way doctors may describe the cancer is as localised, locally advanced, or advanced.
There are different types of prostate cancer.
- Acinar adenocarcinoma: This is the most common type of prostate cancer, with nearly most men having this type. This cancer develops in the gland cells that line the prostate gland.
- Ductal adenocarcinoma: This cancer begins in the cells that line the duct (tubes) of the prostate gland. It tends to grow and spread more quickly than acinar adenocarcinoma.
- Transitional cell (or urothelial) cancer: Transitional cell cancer of the prostate starts in the cells that line the tube carrying urine to the outside of the body (the urethra). This type of cancer usually starts in the bladder and spreads into the prostate. However rarely it can start in the prostate and may spread into the bladder entrance and nearby tissues.
- Squamous cell cancer: These cancers develop from flat cells that cover the prostate. They tend to grow and spread more quickly than adenocarcinoma of the prostate.
- Small cell prostate cancer: Small cell prostate cancer is a rare type of prostate cancer. Around 1 in every 100 prostate cancers (1%) are small cell prostate cancer. They can also be classed as a type of neuroendocrine cancer. Small cell prostate cancers are very different from the most common type of prostate cancer. They grow more quickly than other types. Most men have a cancer that has spread to other parts of the body such as the bones at diagnosis (advanced cancer).
- Other rare cancers: Other rare cancers may develop in the prostate such as sarcoma. Soft tissue sarcomas are cancers that develop in the connective and supporting tissues of the body. These include tissues such as the muscle, nerves, fat, fibrous tissue, and blood vessels.
What are the Stages 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:
- the type of cell the cancer started in and where it began
- how abnormal the cells look under the microscope (the grade)
- the size of the cancer and whether it has spread (the stage)
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:
- Tumour (T): How large is the primary tumour? Where is it located?
- Node (N): Has the tumour spread into the lymph nodes? If yes, where and how many?
- Metastasis (M): Has the cancer spread to other parts of the body? If yes, where and how much?
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.
More about Prostate Cancer
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: