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The Ultimate Guide to Prostate Cancer in Singapore (2021)

PLACEHOLDER
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Human

July 5th, 2019· 5 min read

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Did you know that Prostate Cancer is the third leading cause of cancer in Singaporean males?

According to statistics from the National Cancer Center Singapore (NCCS), prostate cancer accounts for 14% of cancer cases in males from 2013-2017. [1] It only ranks behind colon-rectum cancer (16.8%) and lung cancer (14.5%). [1]

Dr Ronny Tan is a board-certified Singaporean urologist. He will share his advice on how to deal with prostate cancer. Read on to find out about how you can cope with its symptoms as well as the treatment’s side effects.

What is prostate cancer?

The prostate is a walnut-sized gland in males responsible for the production of seminal fluid which nourishes and transports sperms. It is located just below the bladder and in front of the rectum.

Prostate cancer is a disease where a malignant tumour is formed in the prostate tissue due to an uncontrollable divide of cancer cells. Sometimes, the cancer can spread to other parts of the body such as the lungs through the lymphatic system [2].

What are the types of prostate cancer?

There are various types of prostate cancers, depending on where the cancer started. This can help your doctor come up with an effective treatment plan to treat the cancer, together with information on the size of the cancer, whether it has spread, and how abnormal the cancer cells are.

The different types of prostate cancer are: [3]

  • Acinar adenocarcinoma: The most common form of prostate cancer, the cancer originates and develops in gland cells lining the prostate gland.
  • Ductal adenocarcinoma: This cancer originates in cells lining the ducts (or tubes) of the prostate gland. This cancer usually grows and spreads quickly.
  • Transitional cell/Urothelial cancer: This cancer originates in cells lining the urethra tube, responsible for the transport of urine out of the body. This cancer usually starts in the bladder before moving to the prostate, but can also start from the prostate before moving to the bladder.
  • Squamous cell cancer: This cancer develops from cells covering the prostate, and tends to grow quicker and bigger than adenocarcinomas.
  • Small cell cancer: This cancer is an extremely rare type of neuroendocrine cancer occurring in less than 1% of the population and typically has cells that are very small in size in the prostate glands. [4]

What are the Signs and Symptoms of Prostate Cancer?

illustration on the signs and symptoms of prostate cancer

Most of the time, symptoms do not show itself in the early stages of prostate cancer. However, you should seek medical advice from your doctor if you experience any of the following signs: [5]

  • Lower limbs feeling weak or swollen
  • Lumps on your prostate gland
  • Difficulty urinating or decreased force of urine
  • Waking up to urinate at night (Nocturia)
  • Interrupted urination
  • Pain during ejaculation
  • Bone pain, which is a sign of bone metastasis, and advanced prostate cancer [6]

All men are at risk of prostate cancer, with the most common risk factors being age, diet and genetic disposition.

Will prostate cancer improve with early diagnosis?

Certain symptoms, such as urinary problems and pain during ejaculation are observed in both prostate cancer and other conditions.

Some of the conditions that also cause these symptoms include:

It is important to have these checked out, as early detection will lead to better management of your condition. It is recommended that you go for screening if you are male, above 50 years of age and have a family history of prostate cancer diagnosed before 60 years old. [8]

There is no standardised test for the detection of prostate cancer. However, here are the possible tests that your doctor may run to help him diagnose your condition. [5] [7]

1. Digital Rectal Examination

illustration of a digital rectal examination

The first step when your doctor wants to diagnose prostate cancer is to conduct a digital rectal examination. This process is done by inserting a lubricated gloved finger into the rectum. Your doctor will feel for any lumps or abnormal growths on the prostate.

2. Prostate-Specific Antigen (PSA) Screening

illustration of psa test

PSA screening is one of the most common tools used by doctors to screen for prostate cancer. PSA is a substance that is produced by the prostate gland. Going for a PSA test will allow your doctor to determine if the PSA levels in your blood are elevated, which could be a sign of prostate cancer.

Although experts have previously determined that the normal PSA level is to be less than 4 ng/mL, increased PSA levels do not usually mean that someone has prostate cancer. Elevated PSA levels could be due to a number of other factors such as consumption of certain medications to treat benign prostate hyperplasia, or if someone has a urinary tract infection. [9]

Typically, your doctor would monitor your PSA levels at regular intervals if it is considered high. Imaging tests such as transrectal ultrasounds or X-rays may be done if your PSA levels continue to rise. If prostate cancer is suspected, a prostate biopsy may be carried out. [9]

Also read: What are the prostate tests available in Singapore?

3. Transrectal or Transperineal Ultrasound-Guided Biopsy

illustration of transrectal / transperineals ultrasoundguided biopsy

During this procedure, your doctor will insert an ultrasound probe into your rectum. This probe will be about the size of a finger. Your doctor will examine your prostate’s condition, by taking a series of images and measurements, as well as calculating the volume of your prostate. [10]

Doctors will also remove tissue samples from your prostate by using a thin needle. It will then be taken to the pathologist to be examined. [11]

4. MRI Scan of Prostate

doctor showing asian patient mri scan of pelvis

A Magnetic Resonance Imaging (MRI) scan of your pelvis can also help your doctor to diagnose prostate cancer. It helps to determine the extent of the cancer's growth in the prostate gland and lymph nodes. [12]

Related: The Ultimate Guide to Health Screening in Singapore (2021)

5. Bone Scan

A bone scan helps to detect the spread of cancer from the prostate to the bone, the most common place that the cancer will metastasise to. A small amount of radioactive dye is injected and a scan will be taken 2-3 hours after to see where the dye has been collected, which is used to see if the cancer has spread to the bone. [13]

What are the Treatment options for Prostate Cancer?

The growth rate of prostate cancer varies among men. For some, their prostate cancer develops slowly and they may not face any signs or symptoms. In others, prostate cancer may develop quickly and result in pain, severe complications or death.

You should discuss your choices together with your doctor, who will be able to advise you on the best treatment to undergo, based on your age, fitness and cancer progression. [7]

Treatment methods include:

1. Active Surveillance vs Watchful Waiting

**asian elderly men under care of doctor and wife
**

These two methods are usually used for older men who are asymptomatic or have other symptoms, or men whose prostate cancer was discovered during screening. [7]

a) Active Surveillance

Active surveillance refers to the close monitoring of a patient’s conditions without giving treatment until there are changes to the test results. [7] In active surveillance, tests such as digital rectal exam, PSA screening and transrectal ultrasound-guided biopsy, are typically given to help to check if the cancer is growing.

Instead of going through with treatment immediately, you will be kept under close supervision to monitor your condition.

b) Watchful Waiting

Watchful waiting refers to the mere close monitoring of a patient’s condition without giving treatment until symptoms start to appear. Treatment will then be given to relieve the symptoms and improve your quality of life. [7]

Most of the time, watchful waiting involves less-intensive follow-up tests than active surveillance.

Related: When should I start getting screened for prostate cancer?

2. Surgery

**illustration of radical prostatectomy on enlarged prostate with malignant tumors
**

Surgery can be either open or robot-assisted radical prostatectomy (RP). The prostate, together with the seminal vesicles, will be removed. Sometimes, the pelvic lymph nodes may be removed together. [7]

Surgery can also be used to treat men with locally advanced prostate cancer. They may also have to go through radiotherapy after the surgery. The reason for this is due to the multi-modality treatment regime.

3. Radiotherapy

man receiving radiotherapy

Radiotherapy helps to treat prostate cancer through the use of high-energy beams. These beams help to eliminate as well as prevent the growth of cancer cells. There are three choices:

  • External beam radiotherapy (EBRT)

Radiation is used to treat areas affected by cancer, and may include Three-Dimensional Conformal Radiation Therapy (3D-CRT). A 3D-CRT will spot the tumour and shape the radiation, targeting the tumour from different directions. This technique does not damage the surrounding healthy tissue as much as other treatments.

  • Stereotactic Body Radiation Therapy (SBRT)

SBRT uses highly focused beams to eliminate cancer cells in the prostate, which cuts the treatment sessions from 45 days to about 5 days. [14]

  • Brachytherapy

An implant will be surgically placed to give off radiation to the prostate. The implants can either be temporary or permanent.

You should take note that the form of radiotherapy you choose depends on the type and stage of cancer you have.

4. Hormone (Androgen Deprivation) Therapy

illustration on the forms of hormone therapy

Hormone therapy helps to prevent the development of androgen, the male sex hormone [15]. When the level of androgen is low, the growth of the prostate cancer cells will slow down.

This method is frequently used to treat:

  • Prostate cancer which has spread to other areas
  • High-risk or locally advanced prostate cancer

By undergoing hormonal therapy, it can help to slow down or stop the growth of your prostate cancer. It can also help to prevent the cancer from spreading.

The forms of hormonal therapy include:

  • Drug prescription to prevent the release of male hormones
  • Surgical removal of the testes
  • Use of other hormones such as anti-androgens to stop testosterone from reaching your cancer cells [15]

5. Chemotherapy

illustration on chemotherapy and its side effects

Chemotherapy is the approach of using drugs to stop the growth of cancer cells and prevent them from spreading. This is usually given to patients in advanced stages of cancer when they are no longer responsive to hormonal treatment. [13]


Also read:

The Ultimate Guide to Fighting Cancer in Singapore (2021)

How does chemotherapy affect the desire for sexual activity?


Long-term side effects of prostate cancer treatment

When considering a treatment for prostate cancer, you should take note of the risks that come with it. The treatments for prostate cancer can incur long-term side effects. Often, they lead to conditions such as stress urinary incontinence (SUI) and erectile dysfunction (ED). While both these conditions can affect your self-esteem and quality of life, an ED can affect both you and your partner. [16]

The Prostate Cancer Outcomes Study (PCOS) also revealed the following findings of erectile dysfunction: [17]

  • 60% of men experienced self-reported erectile dysfunction 18 months after RP
  • At a 5-year follow-up, only 28% of men reported to have erections firm enough for sexual intercourse

Erectile function typically returns to 40-50% of men after the first year of treatment [18].

SUI, on the other hand, tends to be less common. Most men are able to regain their continence after a period of rehabilitation with pelvic floor exercises, commonly known as Kegel exercises.

Why does SUI occur in men with Prostate Cancer?

illustration of stress urinary incontinence

SUI is when your sphincter muscles open briefly due to sudden pressure on the bladder and urethra, causing urine to leak out. If you’re suffering from mild SUI, your urine could leak from activities such as laughing, sneezing or coughing. However, if you’re suffering from severe SUI, your urine could leak from basic activities like standing up or walking.

Also read: [Are you Leaking? We Examine 5 Ways to Deal with Urinary Incontinence.

](https://www.human.com.sg/5-ways-to-deal-with-urinary-incontinence)

Urinary continence is maintained by two sphincters, mainly the internal and external sphincter. The internal sphincter is located at the bladder neck, where the urinary bladder meets the prostate. The external sphincter is found at the pelvic floor.

Your internal sphincter will likely be removed together with your prostate during your surgery, leaving only your external sphincter and pelvic floor muscles to maintain your urinary continence.

Your body may not be used to solely relying on the external sphincter and pelvic floor muscles to keep the bladder neck shut which weakens your ability to stay dry. In short, losing the internal sphincter is the reason why most men experience SUI in the initial weeks after prostate cancer surgery. [19]

Kegel Exercises Pre and Post Prostate Removal

Kegel Exercise

Kegel exercises are said to strengthen the pelvic floor muscles, which support the bladder and bowel functions, as well as improve your sexual functions. [20] If you are planning to undergo a prostate surgery, you will most likely be advised to start on Kegel exercises before surgery.

After your urine tube has been removed, you should also continue to carry out the exercise regime for at least a week after the surgery. [19]

What are the surgical options for persistent SUI after prostate cancer treatment?

comparison of a sling procedure and artificial urinary sphincter
Source: Urethral Sling Illustration, Artificial Urinary Sphincter Illustration

If SUI still persists despite your efforts to strengthen your pelvic floor muscles, you may want to consider surgery.

Surgical options available to treat persistent SUI include: [21], [22]

  • Urethral Sling Procedure
  • Artificial Urinary Sphincter

Urethral Sling Procedure

During this procedure, a mesh-like surgical tape is placed around the urethra bulb to compress the urethra slightly and move it into a new position. [23] This procedure is best suited for men who have mild to moderate urinary incontinence (wetting one to three pads per day or less).

Artificial Urinary Sphincter

An artificial urinary sphincter (AUS) is a device made of silicone rubber and has an inflatable cuff that cuts around the urethra close to the point where it joins the bladder. [24]

The AUS functions based on three main components: [25]

  • Urethral cuff that wraps around the urethra to control the flow of the urine
  • Scrotal pump to move fluid in and out of the urethral cuff
  • Pressure-regulation balloon to regulate the pressure of the urethral cuff

To urinate with an AUS, you have to squeeze the pump located in your scrotum to move the fluids into the balloon. The balloon then deflates the cuff and allows the urethra to open, closing automatically after about 3 minutes.

Why does erectile dysfunction occur after prostate cancer treatment?

comparison of a flaccid and erect penis

Three aspects are usually focused on when it comes to treating prostate cancer:

  • Cancer Control
  • Urinary Continence
  • Erectile Function

Erectile dysfunction is when a male is having difficulty getting or keeping an erection firm enough for sexual intercourse. [26]

closeup on neurovascular bundle

If you have problems with having an erection, it is most likely due to the effects of the treatment on your neurovascular bundle.

This bundle is a combination of nerves, arteries, and veins in the human body. They send out impulses in a man, triggering an erection. During an erection, the amount of blood sent to the penis will also determine its length and girth. [27]

During a non-nerve sparing surgery, your nerves may also be cut when the cancer is being removed. This may lead to losing your ability to have an erection. Even in the best of hands, temporary nerve damage may occur. As a result, this can cause temporary erectile dysfunction or a weaker erection.

What does the recovery of Erectile function depend on?

Some factors that may affect your recovery of erectile function include: [28]

  • Your erectile function pre-treatment
  • Degree of nerve sparing
  • Extent of neuropraxia (mild form of traumatic peripheral nerve injury)
  • Type of treatment given to treat the cancer
  • Existing medical conditions such as high blood pressure or diabetes
  • Lifestyle choices such as drinking or smoking
  • Age

In most cases, studies have shown that it takes about 2 years for most men to regain their erectile function. [18]

However, it does feel like a very long time and if your relationship is strained over this, please visit your doctor who will be able to help you.

How does Penile Rehabilitation help me with Prostate Cancer?

Usually, after prostate cancer treatments, erectile dysfunction is one of the long-term risks that affects nearly all men. Penile rehabilitation helps to minimise the negative impacts on a man’s sexual functions and help speed up the recovery. [29] Penile rehabilitation is in no way a treatment for erectile dysfunction and penile rehabilitation may only restore whatever erectile function you had.

The treatments for penile rehabilitation are usually:

1. Erectile Dysfunction pills (Oral medication)

types and benefits of PDE5 inhibitors

Erectile dysfunction pills that men can take to help with their condition include Sildenafil (Viagra), Vardenafil (Levitra) and Tadalafil (Cialis). It works by inhibiting the phosphodiesterase 5 (PDE5), and increasing the cyclic guanosine monophosphate (cGMP) supply and improving the blood flow to the penis, allowing an erection to occur. [30]

2. Prostaglandin E1 Therapy (Injection Therapy)

illustration of intracavernosal injection Source: http://menshealthinstitute.ca/for-patients/about-intracavernosal-injections/

Also known as Alprostadil, it is a potent vasodilator which widens arteries and allows them to carry more blood. Although effective in producing erections, it is directly injected into the corpora cavernosa of the penis or using a medicated urethral system for erection (MUSE) to insert the drug into the urethra. [30]

3. Vacuum Erectile Device (VED)

illustration of vacuum erection device
Source

The VED is a device made out of plastic and fitted over the penis. The VED causes an erection by creating a negative pressure around the penis. This helps to draw both the venous and arterial blood into the tissue of the penis. A constriction ring is placed around the base of the penis to maintain erection, which can be left in place for up to 30 minutes. The tube is then removed. [31]

4. Low-Intensity Extracorporeal Shockwave Therapy (LiESWT)

closeup on extracorporeal shockwave device

During this procedure, the corpus cavernosum will have shockwaves applied to it. This causes mechanical stress and microtrauma which then creates a chain of biological reactions. This allows blood vessels to form in the erectile tissue, and allows an erection to occur.

5. Penile Vibratory Stimulator (PVS)

illustration on how penile vibratory simulation works on penile shaft

The newest kid on the block would be PVS.

First used in men with spinal cord injuries to help them with having erections and ejaculations, PVS works by arousing the nerves along the penile shaft. In doing so, this can help to cause an erection.

Also Read: The Ultimate Guide to Fighting Cancer in Singapore (2020)

Penile rehabilitation aims to help improve the oxygen flow to the cavernosal bodies and help to preserve your endothelial structure and function, which can prevent smooth muscle structural changes.

Just like our muscles shrinking without exercise, the penis will also shrink in size with infrequent erections after treatment for prostate cancer. In some cases, it may even result in penile curvatures, further decreasing the functionality of a penis. [32] Therefore, experts would recommend the continuation of regular erections during penile rehabilitation as well.

Summary

All in all, we hope that our article has given you a better understanding of prostate cancer, its available treatments and its long term side effects.

Prostate cancer, being one of the leading causes of cancer in Singapore, should not be taken lightly. There are many treatments to choose from to battle your cancer.

Ultimately, there is no best treatment so we would recommend that you speak to your doctor who is able to advise you according to your condition.


Dr Ronny Tan is a Consultant Urologist and Andrologist who is practicing at Advanced Urology. Dr Tan is also a Fellow of the Academy of Medicine, Singapore. He has received his fellowship training in the USA in his area of specialty as well as an SMSNA (Sexual Medicine Society of North America)-accredited clinical fellowship in Tulane University, New Orleans.

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This article was written by Human and published on Wednesday, 25 January 2017. Human medically reviewed the article on Wednesday, 25 January 2017. The last update was made on Friday, 18 September 2020.

Disclaimer: Opinions belong to the author and not to the platform.

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