Prostate Cancer Treatment

What is prostate cancer?

The prostate is a small male reproductive gland located under the bladder. It surrounds part of the urethra which allows the flow of urine from the bladder to the penis. The cells that make up the outermost part of the prostate can become damaged and begin to grow inappropriately which gives rise to prostate cancer. Prostate cancer is the third most common cancer of men in Singapore¹ and is typically treated by a medical oncologist.

What are the symptoms of prostate cancer?

The symptoms of prostate cancer vary from person to person. However, if you do have prostate cancer, it is common to have symptoms that include trouble with urination, such as having to use the bathroom to urinate more often than usual, an increased sense of needing to urinate but with a decreased flow of urine when urinating, and sometimes there is no urine when you are ready to urinate.

You may experience pain or burning during urination and there may be blood in the urine. There may also be blood in the semen and pain during ejaculation. ²

What are the causes of and risk factors for prostate cancer?

There is no universal cause of prostate cancer. However, it is associated with increased age. There are a number of risk factors for prostate cancer including:

· Age over 50. More than 80% of prostate cancers are diagnosed in men who are 65 or older.
· A lifestyle with less physical activity and a less healthy diet.³
· Inherited factors that contribute to prostate cancer are predicted to account for 40%-50% of cases. ⁴
· Hereditary prostate cancer, meaning the cancer that is directly caused by inherited mutated genes, is rare and accounts for about 5% of cases.⁵ ⁶
· If a man has a first-degree relative, meaning a father, brother, or son, with prostate cancer, his risk of developing prostate cancer is two to three times higher than average.⁷

Did you know?

A recent study in Singapore examined the possibility of lowering the dose of a chemotherapy used to treat a severe form of prostate cancer, while maintaining the benefits. The conclusion was that it is possible to lower the dose, which should make the patient experience more comfortable in the near future.⁸

What are the possible complications of prostate cancer?

Complications of prostate cancer include back pain eventually leading to paralysis (inability to move). There may be weight loss and loss of appetite, tiredness, and difficulty concentrating, bone pain, and lower extremity (leg and foot) pain and swelling⁹.

In addition, inability to have sex (impotence) due to nerve damage to the penis may result from the tumour or from complications from surgery. Urinary incontinence (loss of bladder control) is also a possible complication from surgery.⁹

Your medical oncologist will discuss with you these complications and your options, which may include not having surgery, before any decision is made.

When should I see a specialist for prostate cancer?

The Singapore Cancer Society recommends that you should see a specialist for prostate cancer screening if you are a man, above 50 years of age and have a family history of prostate cancer diagnosed below 60 years of age. If you experience any of the symptoms of prostate cancer described above you should seek specialist medical advice.

How should I prepare for my appointment?

Before you visit your medical oncologist, prepare any questions you may have and be ready to discuss your symptoms in detail. Your medical oncologist will also need you to establish a timeline, so reflect on how and when your symptoms started.

How do specialists screen for and diagnose prostate cancer?

The prostate cancer screening and diagnostic test consists of both a prostate specific antigen (PSA) blood test and a digital rectal examination (DRE). The prostate specific antigen is a protein that is made by the prostate gland. It is used as a marker for early detection of prostate cancer (screening), as well as a marker of treatment response and disease recurrence in patients with active disease. ¹⁰

The digital rectal exam consists your medical oncologist examining your prostate by inserting a lubricated, gloved finger into your rectum, and feeling the prostate through the rectal wall for lumps or abnormal areas.

If the prostate specific antigen and digital rectal exam tests are positive, then an ultrasound biopsy conducted under local anesthetic will be administered and a specialist will confirm or reject the cancer diagnosis. Upon diagnosis a further CT scan or MRI of the pelvis may be administered. This is a detailed scan of the pelvis that helps to determine the size and spread of the cancer and helps inform your treatment.¹⁰

What treatments are available for prostate cancer?

The decision on the choice of treatment depends on your prostate cancer profile which your medical oncologist will discuss with you. Your specialist will guide you as to the relative risks and benefits of each treatment option. Standard recommended treatment options include active surveillance, surgery, radiation therapy, hormonal therapy, and chemotherapy.¹

The most advanced but least well tested, and therefore risky, experimental treatments are only available under clinical trial and include high-intensity focused ultrasound, and immunotherapy. Your medical oncologist will advise you if a clinical trial is right for you.

References:

[1] Sim HG, Lim KH, Tay MH, Chong KT, Chiong E. Guidelines on management of prostate cancer. Ann Acad Med Singapore. 2013 Apr;42(4):190-9. Review. PubMed PMID: 23677214.

[2] Hermanns T., Kuk C., Zlotta A.R. (2015) Clinical Presentation, Diagnosis and Staging. In: Nargund V., Raghavan D., Sandler H. (eds) Urological Oncology. Springer, London https://doi.org/10.1007/978-0-85729-482-1_40

[3] Mucci L.A., Wilson K.M., Giovannucci E.L. (2017) Epidemiology of Prostate Cancer. In: Loda M., Mucci L., Mittelstadt M., Van Hemelrijck M., Cotter M. (eds) Pathology and Epidemiology of Cancer. Springer, Cham https://doi.org/10.1007/978-3-319-35153-7_9

[4] Giri VN, Beebe-Dimmer JL. Familial prostate cancer. Semin Oncol. 2016 Oct;43(5):560-565. doi: 10.1053/j.seminoncol.2016.08.001. Epub 2016 Aug 18. PubMed PMID: 27899188.

[5] Cavanagh H, Rogers KM. The role of BRCA1 and BRCA2 mutations in prostate, pancreatic and stomach cancers. Hered Cancer Clin Pract. 2015 Aug 1;13(1):16. doi: 10.1186/s13053-015-0038-x. eCollection 2015. PubMed PMID: 26236408

[6] Raymond VM, Mukherjee B, Wang F, Huang SC, Stoffel EM, Kastrinos F, Syngal S, Cooney KA, Gruber SB. Elevated risk of prostate cancer among men with Lynch syndrome. J Clin Oncol. 2013 May 10;31(14):1713-8. doi: 10.1200/JCO.2012.44.1238. Epub 2013 Mar 25. PubMed PMID: 23530095

[7] Albright F, Stephenson RA, Agarwal N, Teerlink CC, Lowrance WT, Farnham JM, Albright LA. Prostate cancer risk prediction based on complete prostate cancer family history. Prostate. 2015 Mar 1;75(4):390-8. doi: 10.1002/pros.22925. Epub 2014 Nov 18. PubMed PMID: 25408531

[8] Ang JW, Tan MH, Tay MH, Toh CK, Ng QS, Kanesvaran R. Outcomes of Dose-Attenuated … in Asian Patients with Castrate-Resistant Prostate Cancer. Ann Acad Med Singapore. 2017 May;46(5):195-201. PubMed PMID: 28600580.

[9] Simoneau AR. Treatment- and disease-related complications of prostate cancer. Rev Urol. 2006;8 Suppl 2:S56-67. PubMed PMID: 17021643

[10] Hoffman, Richard M. “REFERENCES.” Screening for prostate cancer, Wolters Kluwer, 14 Sept. 2017, www.uptodate.com/contents/screening-for-prostate-cancer.