Prostate Cancer

Prostate Cancer is a formation of malignant cancer cells in the tissues of the prostate. It is 5th most common type of cancer in males in Singapore which recently has gone up the ranks to 3rd position.

There are 3 recent changes related to cancer of the prostate

  1. Prostatic cancer is the 5th most common type of cancer in males in Singapore, which now has recently gone up to 3rd position. It has increased recently due to the aging population, improved health awareness, and use of serum Prostatic Specific Antigen (PSA).

  2. Due to the advanced cancer of the prostate due to the use of PSA, the detection of early prostate cancer has increased through improved biopsy and histology evaluation.

  3. Since the management in surgery and hormonal treatment has advanced significantly, the outcome of cancer treatment has improved resulting in patient living longer.

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Symptoms and signs of Prostate Cancer (CAP)

Generally early CAP might not have any symptoms or sign. Nevertheless, thy might give rise to symptoms as follow:

  • blood in the urine

  • renal failure (due to blockage by the involvement of CAP to the ureters)

  • presented late with the complaint of bone pain and pathological fracture (due cancer spread to bone)

Hence, further check with a qualified urologist will help to confirm your condition. Nowadays, 80% of prostate cancers are usually clinically diagnosed by:

  1. Doing blood test called serum prostatic specific antigen either during the executive screening program (if the patient is asymptomatic) or during the consultation of a complaint related to bladder outlet obstructions. If a raised PSA of more than 4, it usually needs further evaluation or biopsy.

  2. Digital rectal examination (DRE). The patients usually see the urologists for complaint of lower urinary tract symptoms and through digital rectal examination, a prostatic nodule is detected, and the patients are usually advised for trans-rectal ultrasound and biopsy.

  3. Detecting the cancer after Transurethral Resection of The Prostate (TURP), where the specimen shows the cancer histology​

Treatment of Prostate Cancer (CAP)

The treatment of patients with CAP will depend on the:

  1. Fitness and Age of patient

  • Over the age of 70 and he is not considered fit for surgery, then the patient will opt for radiotherapy or other treatment.

  • Fit and below the age of 70, and the cancer is early in the stages of A to C, surgery or radiotherapy options can be offered to the patient

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   2. Staging of CAP

Depends on the stage of cancer, then urologist will recommend the best treatment for patient

 

   3. Patient’s decision

 

Surgery

There are two types of surgical treatment for CAP:

  • Radical prostatectomy, or

  • Transurethral Resection of The Prostate (TURP with or without bilateral orchidectomy

 

Radical prostatectomy is one of the main modalities of treatment, it is mainly for curative treatment especially when:

  • The cancer is high grade with low PSA (<10ng/dl)

  • The patient is relatively young (<70 years) and the cancer is in its early stage

 

The 2 types of radical prostatectomy are:

The potential complications of surgery are bleeding from uncontrolled vein bleeding and injury to the surrounding organs. The potential after-surgery complications are those of incontinence and impotence.

Transurethral Resection of The Prostate (TURP) is usually done when the CAP is causing bladder outlet obstruction and when radical curative surgery cannot be performed on the patient due to old age, or if the patient is not fit for surgery, or if the tumour has spread far beyond the prostate.

Radiotherapy

Radiotherapy is the treatment for patients who refuse surgery and it is also indicated for a patient when he is not fit for surgery, especially when the cancer is locally advanced (with bladder neck and lymph nodes involvement) and causing symptoms e.g. bleeding.

The complications of radiotherapy are those related to the acute symptoms immediately after the radiation:

  • peri-anal irritation

  • mucus secretion, etc;

The long-term complications in the pelvic organ like bleeding due to neo-vascular formation etc. The efficiency of radiotherapy (DXT) is good as up to 85% of the cancer can be controlled within 5 years, but there are controversial reports beyond this.

Hormonal treatment

Hormonal therapy is indicated commonly in patients with advanced cancer of prostate, especially when there is bone or lymph nodes’ involvement. It is also being used after surgery and radiotherapy, when there is an increase in PSA.

There are 2 types of hormonal treatments:

  • Medical hormonal therapy by medication (total androgen therapy or mono-therapy)

    • It is given either through the oral route or injection

    • Total androgen therapy is to deplete the androgen secretion by stimulating it excessively by Luteinising Hormone Releasing Hormone analogue. In the beginning phase, there may be a surge in testosterone and that is why there is a need to give an androgen-suppressor at the same time, to reduce the side-effects.

    • The mono-therapy will only suppress the testosterone from the testes.

The total androgen blockage is an effective mode of treatment. But there are side effects when hormonal therapy is used and these include andropause symptoms like malaise, hot flush, etc. Some types of medication like flutamide and casodex may also cause liver problems.

  • Surgical hormonal therapy

 

Chemotherapy

This is the ‘last resort’ form of therapy when the CAP is hormonal refractory or when the spread does not respond to other forms of therapy, especially hormonal treatment.

There are a lot of side effects for chemotherapy and it will not be used unless it is really indicated. Chemotherapy will be given by the oncologists and usually it is the treatment of choice for advanced CAP.

Prostatic disease is the most problem encountered in Singapore males in the age group of more than 50 years old. It can be treated properly if diagnosed early, to avoid unnecessary side effects and outcome.

Screening by serum PSA

There is no literature to suggest screening by serum PSA is useful to pick up cancer of the prostate. Nevertheless, patients who are more than 45-year-old and with family history of cancer of the prostate gland (first degree relative e.g. father, uncle and brothers) recommend to do yearly testing by serum PSA which is able to detect curable cancer. As for the rest, 2-3 yearly check of PSA is adequate.

The normal level of PSA is less than 4ng/dl and it will increase in patient with

  • benign enlargement of prostate gland

  • prostatic cancer

  • prostatic infection

  • manipulation of the prostate by instrumentation e.g. after sex or massage of the prostate or catherization

When one has abnormal PSA, this blood test should be repeated with 2 weeks of antibiotics. Meanwhile digital rectal examination (DRE) of the prostate will be done to detect any prostatic nodule. Transrectal ultrasound (TRUS) and biopsy will be performed on the patient if

  • Persistently high PSA (>4ng/dl) despite antibiotic

  • DRE detected nodule regardless of PSA level

If the TRUS and biopsy showed no cancer, but the repeated PSA is still high, the serum PSA should be repeated and follow the trend of the PSA. If there is still increasing trend, then a repeated biopsy should be done. Sometimes transrectal ultrasound and biopsy of the peri-urethral area of the prostate gland may be necessary just to exclude the central origin of the prostatic cancer.

Disclaimer: This is not a guide to self-diagnose. We encourage to seek urologist advice further.

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