Prostate Cancer

Prostate Cancer is the 3rd most common cancer in men in Singapore.

It is also the commonest cancer in men in the US (not including skin cancers).

We should all be aware of it and know what we need to do about it.

Where and what exactly is the prostate?

A picture tells a thousand words.

Diagram showing the location of the Prostate Gland

The prostate is a gland sitting just below the bladder. It is the junction which the tubes from the bladder carrying urine and the tubes from the testis carrying sperm meet.

The prostate is responsible for producing a nutritious liquid for sperm. The sperm from the testis mixes with this liquid and comes out through the penis as semen.

How do you know when you have Prostate Cancer?

This is a tough one. Prostate Cancer does not show any symptoms until it is very late.

Common symptoms are:

1. Problems passing urine (This is much more commonly caused by a non-cancer enlargement of the Prostate BPH).

2. Back Pain

3. Blood in the urine

This why screening is so important. But here is the catch: there is no foolproof method to screen for Prostate Cancer.

The 2 most common methods is use right now are:

1. PSA test – This tests for a particular protein in your blood called the Prostate Specific Antigen. People with prostate cancer may have more of this protein in their blood.

When the PSA level is 1 ng/ml, the risk of you having Prostate Cancer is 1%.
When the PSA rises to 10 ng/ml, the risk of you having Prostate Cancer is 10%.

This also means that no matter how low your PSA level is, there is always a chance you can have cancer.

The PSA level is also affected by medicines to treat enlarged prostate (BPH) such as Finasteride and Dutasteride. These medicines can lower the PSA level by as much as 50%. In other words, if you are taking these medicines and your PSA is 2 ng/ml, it is actually 4 ng/ml. So it is really important to let your Doctor know if you are on these medicines. Aside from being used to treat BPH, Finasteride is commonly taken by men to treat male-pattern balding.

The other number some Doctors look at is the PSA Velocity. That means how quickly the PSA is rising. You basically get at least 3 PSA tests in the span of 18 to 24 months.

If the starting PSA is < 2.5 ng/ml and the PSA is rising by more than 0.35 ng/ml/year, it is suggestive of Prostate Cancer.

If the starting PSA is 4 to 10 ng/ml and the PSA is rising by more than 0.75 ng/ml/year, it is suggestive of Prostate Cancer.

2. DRE (Digital Rectal Examination) test – This involves a doctor putting a gloved finger into the anus to feel for the prostate. If the prostate feels hard or had lumps, this could indicate cancer.

As you can imagine this test is not very comfortable. Also, it is not very accurate. If the cancer lump is small or deep, the doctor will not be able to feel it. In fact, some studies literally says that this test is useless. It is however still very commonly used today in conjunction with the PSA for the screening of Prostate Cancer.

At what age must I start to screen for Prostate Cancer?

This is again controversial, just like the tests.

As a general rule, men should start screening for Prostate Cancer at the age of 50. Or at the age of 40 if he has multiple 1st degree relatives with Prostate Cancer.

How often should I screen for Prostate Cancer?

This is also controversial. Every guideline seems to suggest something different.

As a very general rule, if the PSA is low, screen every 2 years. If the PSA is high, screen every year.

The controversy lies in what is considered ‘high’ (>2.5 ng/ml in one guideline and >1.0 ng/ml in another) and what is considered ‘low’ (< 2.5 ng/ml in one guideline and < 0.7 ng/ml in another).

What happens when the screening test is positive for Prostate Cancer?

If your PSA is high enough or the doctor feels a lump on the DRE, the next usual step is getting a biopsy of the Prostate.

This is done via the rectum. An ultrasound probe is used to locate the Prostate Gland then a needle is injected through the rectum to get pieces of the gland out for testing.

Some doctors might opt to do an MRI of the prostate gland before getting the biopsy. This is a painless procedure. You just lie on a bed and the machine scans the prostate.

What causes Prostate Cancer?

Genetics play a big role. People with Sub-Saharan ancestry are at greater risk.

Asian people are at lower risk.

Obesity and fay intake play an important role in Prostate Cancer. Click here for a more detailed discussion.

I have just been diagnosed with Prostate Cancer. Am I going to die?

Whoa. Take it easy. Although Prostate Cancer is the 3rd most common cancer diagnosed in Singaporean Men, it is only the 5th most common cause of cancer death.

Most Prostate Cancers are very slow growing so what happens more often than not is people die with Prostate Cancer and not of Prostate Cancer.

With modern surgical and medical treatments theses days, most people no longer die of Prostate Cancer.

Of course, a lot depends on various factors like how aggressive the cancer is, how large the cancer is, whether or not it has spread etc etc

What are the treatment options?

The treatment options of Prostate Cancer are many.

Some experts even think we should not treat Prostate Cancer but just observe it to see if it grows aggressively. This is because a large number of Prostate Cancers are very slow growing cancers. Treatment can result in more side effects and harm the patient even more than just leaving the cancer alone. A large study also showed that patients whose Prostate Cancers were just observed did not have a shorter lifespan compared to people who had treatment for their Prostate Cancer.

Surgery is also very commonly done for Prostate Cancer. Now most of such surgeries are done with a robot. So there is no longer a need to cut a big incision in the patient. Only several small holes are required for the instruments. Healing is therefore much quicker and patients spend less time in hospital. Surgical techniques are have also improved. Surgeons have identified the nerves on either side of the Prostate that are important for Erection. They can therefore avoid cutting these nerves (unless these nerves are also involved in the cancer). This greatly improves the patient’s chance of getting his erection back.

Aside from problem with erection, the other common complication after Prostate Surgery is urinary incontinence. This means the patient cannot control his urine.

There have also been great advances in various radiotherapy and chemotherapy medicines to treat Prostate Cancer.

What to do now?

If you are, or know someone who is above the age of 50, encourage him to talk to a Doctor about getting screened for Prostate Cancer.

If you are, or know someone who is 40 years old and whose father has Prostate Cancer, encourage him to talk to a Doctor about getting screened for Prostate Cancer.