Prostate Cancer – The Right Way to Fight
Ranked as the most common cancer for men above 60 years old and second most common for all men in Singapore, prostate cancer affects more than 1,000 new patients every year. Although the public is generally aware of the condition, a number of misconceptions and biases exist, making early diagnosis a challenge. For instance, it is commonly believed that prostate cancer is an old man’s disease. While it is true that age is a risk factor, there are cases of prostate cancer involving men in their 40s and 50s. Holding such belief results in delayed diagnosis and less effective treatment.
In this 8-minute long article, we will cover the important facts of prostate cancer, including its causes, symptoms, treatment, prevention (hint, diet has a role to play), and screening tests. Male readers can walk away with a good grasp of their risk profile, how to identify symptoms and when to get screened, even if no symptoms are present. Female readers who are equipped with necessary knowledge of this cancer can help their spouses and male family members overcome the mental complacency and bias to get screened and diagnosed earlier.
What is prostate cancer?
The prostate is a male productive gland located below the bladder and in front of the rectum. It is responsible for the production and secretion of substances that make up semen. Prostate cancer is cancer that develops from the prostate tissue. When the cells making up prostate tissues undergo a genetic mutation that makes them lose control over multiplication, malignant tumour forms and prostate cancer occurs as a result.
One common mutation causing prostate cancer has been identified in the P53 gene. This gene encodes for a protein that acts as a checkmark for cellular multiplication. In other words, cells need to get approval from this protein to be able to divide. Healthy cells are given the green light to multiply while damaged cells are signalled to perish. Because of the mutation, this careful control process becomes imperfect. Damaged cells are allowed to replicate, giving rise to the risk of prostate cancer and other types of cancer.
Once developed, prostate cancer can spread to the lymph nodes and the bones such as the spine, hips and ribs. This is known as metastatic or advanced prostate cancer.
Causes and risk factors of prostate cancer
Similar to other types of cancer, the exact causes of prostate cancer remain unknown. However, scientists have identified a number of risk factors, including:
Age – The risk of developing prostate cancer increases substantially with age. In Singapore, 9 in 10 cases of prostate cancer occur in men aged 60 years and above.
Family history – Those with fathers, brothers, or uncles who have/had prostate cancer are more likely to develop it by about 70%.
Obesity – This is a well-documented risk factor of prostate cancer. However, the underlying mechanism is still unclear.
Genetic mutations – Individuals with certain genetic mutations (e.g., P53) have a higher risk of several cancer types, including prostate cancer.
Other factors – Outside Singapore, ethnicity and geography have been associated with the development of prostate cancer. Japan is known to log a lower incidence of prostate cancer.
The signs and symptoms of prostate cancer
The early stages of prostate cancer often show no warning signs. In the advanced stages, the signs and symptoms of prostate cancer mainly affect the genitourinary tract and are not specific. A number of benign urinary conditions mimic the same symptoms of prostate cancer, including urinary tract infection, urinary stones or benign prostate hyperplasia (BPH). Thus, the only way to catch prostate cancer early is to notice the symptoms and have them checked as soon as possible by a professional to find out the cause.
Below we will look at the most common symptoms.
The prostate gland is located below the bladder and surrounded by the urethra, i.e., the tube to pass urine from the bladder to outside the body. Urinary symptoms arise when the enlarged prostate gland presses on the two surrounding organs. Symptoms may include:
- Frequent urination
- The urgency to pass urine
- Slower stream of urine
- Blood in urine
These signs and symptoms are the first indications that something is wrong but not necessarily prostate cancer. These might well be a case of urinary tract infection (UTI) or benign prostate hyperplasia (BPH), which share the same symptoms. A good way to differentiate UTIs from other serious conditions is by looking for other signs that point to an infection. These include chills and fever. BPH is diagnosed in similar steps with prostate cancer (more about that in the Diagnosis section).
In all cases, there is no need to panic at this stage. The most important thing is to visit your doctor immediately to obtain a diagnosis.
Erectile dysfunction (ED) describes the inability to get or maintain an erection for sexual intercourse. ED is often associated with advanced cases of prostate cancer.
However, some reports confirmed that a number of patients with prostate cancer first presented to the doctor’s office to complain about their ED, which later revealed their cancer.
It is uncommon to experience pain with prostate cancer. More often, this indicates that the cancer has spread to other parts of the body (i.e., metastasis). This occurs after the tumour penetrates the basal membrane of the tissue it grew in, and then travels to nearby or distant tissues/organs. As a result, these patients may develop pain in their chest, abdomen, or back. Some patients skip directly to this sign without even developing genitourinary symptoms.
How to diagnose prostate cancer
To diagnose prostate cancer, your doctor will follow a step-by-step approach.
First, he/she will discuss the symptoms you are experiencing and take your medical history and family history in relation to prostate cancer and BPH.
Then, your doctor may ask your permission to perform a digital rectal examination (DRE), which involves touching the prostate by placing a finger inside the rectal canal. Accepting or declining the performance of this manoeuvre remains a personal choice.
During the DRE, your doctor will search for malignant features of the examined lump. These include:
- Irregular borders
- Attachment to other tissues
- The consistency of the lump (e.g., solid, rubbery)
If signs of malignancy are present, it is time for complementary tests, which involve blood tests and imaging techniques.
One of the most famous tests for prostate cancer is prostate-specific antigen or PSA. The elevation of this protein indicates that there is something wrong with the prostate, which may or may not be prostate cancer. Other conditions where high levels of PSA can be seen include BPH and inflammation of the prostate (prostatitis). As such, an important part of prostate cancer diagnosis involves ruling out other causes that lead to elevated PSA, using other clinical evidence.
The gold standard procedure to diagnose this cancer is a prostate biopsy, which is also the most invasive test. Your doctor will only order the biopsy if there is solid evidence from the DRE and PSA that a malignant process is occurring in the prostate. Tissue samples from the biopsy are then sent to the lab for analysis. Results sometimes include the reporting of Gleason score, which helps doctors stage the cancer, predict its behaviours and recommend treatment options.
Imaging tests that may be ordered include a bone scan and CT scan, PET scan or MRIs. These help with evaluating if prostate cancer has spread to surrounding areas and the bone – a common metastasis site, or if cancer is likely to spread, if it has not done so. A specific type of scan called PSMA (prostate-specific membrane antigen) PET (positron emission tomography) scan was introduced recently to detect signs of prostate cancer spreading to surrounding lymph nodes. Newly diagnosed patients who are concerned about the risk of metastasis should check with their doctors if a PSMA PET scan is relevant to them.
The staging of prostate cancer
The staging of prostate cancer is commonly done using the TNM model (T for tumour, N for lymph nodes, and M for metastasis) and references of PSA level and Gleason score.
Prostate cancer stage helps doctors in selecting treatment plans. Prostate cancer stages include:
- Stage 1 prostate cancer: this is the earliest stage where cancer cells may still look like healthy cells and PSA levels are not elevated. This stage is also characterised by:
- Cancer located on a single side of the prostate
- Slow growth of the cancer
- No lymph node involvement or metastasis
- Tumour is uncommonly felt during a DRE
- Stage 2 prostate cancer: this stage is characterised by low to medium PSA levels and an increasing risk of the tumour growing. There are 3 sub-stages 2A, 2B, 2C, depending on the tumour size and the characteristic of the cancer cells.
- Stage 3 prostate cancer describes a locally advanced cancer with high levels of PSA and spreading of cancer to nearby organs such as the rectum or bladder. Doctors further divide stage 3 into Stage 3A, 3B and 3C depending on the level cancer has spread.
- Stage 4 prostate cancer refers to the spreading of cancer to lymph nodes or other parts of the body. Stage 4A describes metastasis to nearly lymph nodes and organs and Stage 4B indicates cancer has spread to distant parts of the body, such as the bones. 5-year survival rate of stage 4 prostate cancer can be lower than 30%.
Treatment of prostate cancer
After conducting an array of blood and imaging tests, your doctor will work with other specialists to determine the best approach for your case. Tailored medical therapy is by far the best way of prostate cancer treatment, due to the heterogeneous nature of the disease. Prostate cancer is highly treatable. 5-year survival rate for localised cancer with low Gleason grades can be as high as 95%.
The type of treatment recommended often depends on staging, how aggressive the cancer is expected to be, and the patient’s profile (e.g., age, existing conditions, treatment preferences)
There are mainly 5 therapies to treat and manage prostate cancer, each with its unique indications and contraindications. Make sure you discuss the treatment strategy with the principal doctor to understand how to make it work best for you.
- Active surveillance: suitable for patients with early stage and low risk prostate cancer. Instead of receiving curative treatment, the patients will be monitored with regular blood tests and biopsies.
- Surgery: to remove the prostate gland, and in some cases the surrounding lymph nodes. Known as radical prostatectomy, it is recommended for healthy patients who have localised prostate cancer and can withstand a surgery. There are 2 ways to perform the surgery – open radical prostatectomy and more commonly nowadays, robot-assisted radical prostatectomy. Surgery involves certain risks such as bleeding, infection (UTI), urinary leakage, urinary incontinence, erectile dysfunction. In most cases, these side effects can be mitigated with medical intervention and exercises within a few months after the surgery. Patients may also require other treatment following the surgery to ensure elimination of cancer.
- Radiation therapy: this therapy uses high energy x-ray beams to kill cancer cells in the prostate. Though relatively accurate, radiation therapy can damage nearby healthy cells such as those in the bladder, rectum or urethra. Patients should report any discomfort or side effects to the doctor immediately for necessary adjustment to the doses or treatment frequency.
- Hormonal therapy: The objective of hormonal therapy is to halt the production of testosterone – the male hormone that prostate cancer needs to grow. It may be prescribed together with other therapies, as hormonal therapy can slow down or stop the growth of cancer but do not get rid of existing cancer cells. This can be done with a surgery to remove the testicles or by injection. Side effects may include erectile dysfunction, loss of sex drive, weight gain, osteoporosis, etc.
- Chemotherapy: this is a less common choice in treating prostate cancer and often recommended if patients do not respond to the above treatments. It might also be employed for palliative purposes to relieve pain and discomfort in advanced cases.
- Radionuclide therapy: this nuclear medicine therapy aims to target a specific protein associated with prostate cancer cells called PSMA (prostate specific membrane antigen), thereby eliminating cancer cells. Due to the targeted approach, normal cells are minimally affected. However, side effects may still be experienced, including nausea, vomiting, fatigue, dry mouth, etc, typically for a week after the treatment. Currently, it is offered to patients with advanced prostate cancer who do not tolerate or respond well to other conventional therapies.
Once you receive the treatment, it is time for another important part – medical surveillance. The purpose of this step is to observe and assess the effectiveness of the prescribed treatment. If you respond positively to therapy, your doctor may recommend continuing with the same protocol. Otherwise, you may be advised to take a new medication or try another modality of prostate cancer treatment. Compliance with follow-up and surveillance from patients is crucial to ensure effective and lasting treatment outcomes. It is estimated that 20-30% of prostate cancer patients will experience a relapse 5 years or more after initial therapy.
Prevention of prostate cancer
There are many factors that you cannot control about prostate cancer including genetics, family history, and sporadic mutations. Since they are unmodifiable risk factors, worrying about these factors does not help. Instead, you should focus on the things you can improve in your life.
Recent large research finds that every extra 10 centimetres of a man’s waistline increases his risk of dying from prostate cancer by 7%. Adopting a healthy lifestyle is highly recommended to not only reduce your risk of prostate cancer but will also prevent other chronic illnesses. In the following section, we will cover some of the ways to prevent prostate cancer including reducing your midsection.
1. Make dietary changes
Controlling your calorie intake and maintaining a healthy weight is one of the key ways to prevent prostate cancer. Specifically, lower your intake of fat from red meat and dairy products and avoid trans-fatty acids. Including leafy green veggies, such as kale and broccoli and fatty fish in your diet is another way to lower your risk of prostate cancer. According to studies, omega-3 fatty acids can protect the cells from oxidative stress; therefore, they lower the risk of genetic mutations.
2. Stop destructive lifestyle habits
Many studies have linked smoking, drinking alcohol and sedentary lifestyle with higher risk of prostate cancer. However, as we all know, quitting unhealthy lifestyle habits can be highly challenging. To successfully adopt a healthy lifestyle, first, you must acknowledge the damage of these habits to yourself and loved ones. Then, enlist professional help and family members to keep you accountable and committed. The rest is to keep going with the new habit, one day at a time.
3. Control chronic illnesses
If you suffer from concurrent medical conditions, such as diabetes mellitus, high blood pressure, chronic stress, or depression, make sure to address these issues. They can make it harder for you to improve your lifestyle, which as we discussed above, will definitely lower your risk of prostate cancer. Moreover, those who already have prostate cancer can benefit dramatically from controlling these illnesses, during and after treatment.
4. Don’t over-rely on mega-vitamins and supplements
While megavitamins and supplements are unlikely to harm you directly, you may find yourself relying too much on their alleged effect. Instead of eating healthy and exercising regularly, you may just take a few pills of these supplements, believing that they will make you healthy.
In addition, some studies point to a linkage between intake of calcium and an increased risk of prostate cancer. Similarly, some herbal supplements may have unwanted effects. Speak with your primary care doctor and nutritionist about this topic.
5. Consult an oncologist on screening
One in four cases of prostate cancer in Singapore is diagnosed at an advanced stage, resulting in more costly and less effective treatment, and poorer outcomes. Early diagnosis is challenging, as we discussed above, due to the lack of symptoms in the early stage of the disease, and the fact that other conditions share the same symptoms of prostate cancer.
Screening therefore is the solution to early detection. This often involves a simple PSA test at first, and additional steps depending on PSA test results. In general, men above 50 years old with a family history of prostate cancer or other risk factors should take the screening test. However, it needs to be done in consultation with an oncologist to achieve reliable results. PSA tests might not be suitable for everyone, as it may result in false positives and over-treatment. Make sure you speak with your doctor about the benefits and risks of screening for prostate cancer before proceeding.
To find out more about how to make the most of prostate cancer screening, check out our article on cancer screening here.
Prostate cancer is one of the most common types of cancer in men. Though highly treatable, the delayed diagnosis of prostate cancer and mistaking it for other benign conditions (e.g., BPH, UTIs) contribute to the unfavourable prognosis of this condition.
For those with urinary symptoms, knowing the signs and overcoming complacency and embarrassment to seek treatment early might significantly change the course of prostate cancer and your prognosis. For other individuals without symptoms, screening tests offer the ability to detect the disease early. Make sure you understand your individual risks and the pros and cons of prostate cancer screening before you take the test. And if you do not need a visit to the doctor, keeping your waistline in check could be one of the best ways to prevent prostate cancer as well as many other diseases.