A Guide To Prostate Cancer: What Are The Available Treatment Options?

Medically reviewed by Dr Johann Tang, Senior Consultant Radiation Oncologist

PART 1 – INTRODUCTION

Prostate cancer is one of the most commonly diagnosed cancers among males. Naturally, those with prostate cancer or have loved ones afflicted with this disease may wish to learn more about the condition, symptoms, and treatments available in Singapore.

1.1. What Is The Prostate Gland And What Is It For?

The prostate gland is a small, walnut-sized organ located below the bladder and in front of the rectum. It forms a crucial part of the male reproductive system, contributing to the complex process of reproduction. Although its size may be modest, its functions are anything but.

This tiny organ is responsible for the production of semen, the milky fluid that transports sperm from the testicles through the penis during ejaculation. It also plays an essential role in regulating the flow of urine, as the prostate surrounds part of the urethra, which is the tube that carries urine out of the bladder and through the penis.

1.2. How Does The Prostate Change As We Age?

As we age, hormonal changes can cause the prostate tissue to grow. This enlargement may result in the squeezing of the urethra, causing symptoms such as frequent urination, weak urine flow, incomplete emptying of the bladder, and a constant urge to urinate. Some men in their 30s and 40s may begin to experience these urinary symptoms. Meanwhile, others may not notice them until much later in life.

Another age-related change that can affect the prostate is the increased risk of developing prostate cancer. Prostate cancer is more commonly diagnosed in older men, with the risk rising significantly after age 50.

It is vital to note that not all age-related changes in the prostate result in health problems. It is possible for men to experience these alterations without significant impacts on their daily lives. Nevertheless, we recommend monitoring and addressing any abnormalities or concerning symptoms through regular health screenings. If further issues arise, consult an oncology doctor.

Learn More: 3 Prostate Cancer Risk Factors You Should Be Aware Of

1.3. What Are The Symptoms Of Prostate Cancer?

Prostate cancer cells usually grow slowly compared to other forms of cancer. These cell changes may take up to 30 years before a tumour gets sufficiently large to cause symptoms. Eventually, the cells start spreading (metastasize). By the time symptoms surface, the cancer may already be advanced. As a result, few men above the age of 50 display symptoms of prostate cancer.

However, some precancerous or cancer cells may already be present. Therefore, it is vital to understand and spot the symptoms of prostate cancer early so that patients can seek the appropriate cancer treatments promptly. Please refer to our infographic above to learn more about the symptoms of prostate cancer.

It is also vital to note that the symptoms listed above may be caused by benign prostate changes or other health problems. Those who remain unsure are advised to consult an oncology doctor.

PART 2 – A DETAILED LOOK AT COMMON PROSTATE CANCER TREATMENTS

2.1. How Is Prostate Cancer Diagnosed?

Early detection is crucial for effective prostate cancer treatment. As such, it is vital for those who suspect they have prostate cancer to undergo screening as soon as possible. From routine screenings to advanced diagnostic tests, there are numerous ways to detect and diagnose this disease accurately. Let us explore the various methods and procedures used by healthcare professionals.

1. Digital Rectal Exam

A digital rectal exam (DRE) is a standard procedure used for examining the prostate. During a DRE, which lasts about 10 to 15 seconds, a doctor will insert a gloved, lubricated finger into the patient’s rectum to inspect the prostate. By feeling the prostate, the doctor can assess its size and shape and check for any irregularities. If any abnormality is detected, they will recommend further tests.

2. PSA Blood Test

Our prostate gland produces a substance known as PSA (prostate-specific antigen), which normally secretes into ducts in the prostate. But it is normal for a tiny amount of PSA to be found in our bloodstream too. However, if an elevated PSA level is detected during the test, it may indicate the possibility of prostate infection, inflammation, enlargement, or cancer.

3. Ultrasound And MRI

A doctor may recommend using ultrasound or magnetic resonance imaging (MRI) to obtain more detailed images of the prostate gland for analysis. For the former, a small probe will be inserted into the patient’s rectum to create images of the prostate gland using sound waves. As for the latter, powerful magnets and radio waves are utilised to aid in evaluating the extent and location of any abnormalities within the prostate gland, assisting oncology doctors in the diagnosis and staging of prostate cancer.

4. Biopsy

If any of the earlier tests indicate the possibility of prostate cancer, the doctor will recommend patients undergo a prostate biopsy. The procedure is typically performed using ultrasound guidance, where a thin needle is inserted through the rectum or perineum to collect the tissue samples necessary for biopsy examination.

Samples are taken from several areas of the prostate gland to lower the risk of missing any areas of the gland that may contain cancer cells. Subsequently, a pathologist will examine the tissue samples to determine the presence and aggressiveness of cancer cells. If the test is positive, the pathologist will assign a Gleason score ranging from 2 to 10.

This number indicates how likely a tumour will spread. The lower the score, the less aggressive the tumour is and the less likely it will spread. Based on this information, along with the patient’s age, imaging findings, PSA levels, and general health, the oncology doctor can determine the most suitable prostate cancer treatment programme to administer.

2.2. Available Treatment Options For Prostate Cancer

External Beam Radiation Therapy (EBRT) involves delivering high-energy radiation beams to precisely target and eradicate cancer cells in the prostate gland from outside the body while minimising damage to the surrounding healthy tissue. This non-invasive treatment modality is the primary treatment method for prostate cancer, usually for early-stage cancer confined to the prostate.

This treatment usually lasts several weeks, with patients undergoing radiation therapy 5 days a week at an outpatient centre. The procedure is similar to getting an X-ray. The exception is that the radiation is stronger than those used for a normal X-ray. However, rest assured that the treatment is painless and only lasts for a few minutes.

As medical technology advances, newer forms of EBRT techniques have been developed to deliver higher doses of radiation to the tumour while reducing radiation exposure to the surrounding healthy tissues. Let us examine the common radiation therapy treatments patients can expect.

1. Stereotactic Body Radiation Therapy

Patients with early or intermediate-stage prostate cancer are generally recommended to seek Stereotactic Body Radiation Therapy, as it delivers highly focused radiation doses to the tumour with extreme precision over 5 days. The precise delivery of radiation is achieved using highly advanced image-guided techniques, which helps to minimise damage to healthy tissue, thus reducing the risks of side effects during and after treatment. Because large doses of radiation are delivered in each session, the entire treatment plan can be completed over 5 days while maintaining excellent tumour control rates.

2. Volumetric Modulated Arc Therapy And Image Guided Radiation Therapy

Intensity Modulated Radiation Therapy (IMRT), which uses a computer-driven machine that moves around the patient as it delivers radiation, used to be one of the most common types of External Beam Radiation Therapy for prostate cancer. However, thanks to the advancement in medical technology, this treatment has been phased out for more specialised techniques like Image Guided Radiation Therapy (IGRT) and Volumetric Modulated Arc Therapy (VMAT).

The former utilises a different approach, with built-in imaging scanners to allow oncology doctors to take pictures of the prostate. That ensures the radiation is accurately delivered to the intended target, reducing the impact on surrounding healthy tissues, improving treatment accuracy, and reducing the risks of side effects.

Meanwhile, the latter technique is a more advanced form of IMRT that enables precise radiation delivery using a rotating gantry. This treatment option is ideal for patients with irregular tumours or tumours growing close to vital organs, as the VMAT machine allows for continuous modulation of the radiation dose, allowing oncology doctors to adjust the intensity and shape of the beam to conform to the tumour’s shape. As a result, patients can expect shorter treatment times and improved dose distribution with VMAT. Patients must still undergo multiple sessions of treatment over 4 to 7 weeks, depending on the stage of their disease..

3. Proton Therapy

Source: National Cancer Center

Unlike conventional radiation therapy, which utilises X-rays, Proton Beam Therapy employs protons, which are charged particles, to precisely target cancer cells in the prostate gland. This treatment may be beneficial for younger patients or those with localised prostate cancer, as it offers a more precise and potentially curative approach to cancer management.

That is because protons cause minimal damage to tissues they pass through, and they only release their energy after travelling a specific distance, unlike x-rays, which release energy before and after they reach their target. Therefore, Proton Therapy can, in theory, deliver more radiation to the prostate while reducing damage to nearby healthy tissues, offering the potential to minimise the risks of side effects associated with radiation therapy. Treatment using Proton beam is similar to VMAT and is carried out over 4 to 7 weeks, depending on the stage of the cancer.

The Use of SpaceOAR Hydrogel for EBRT and Proton Therapy Treatment

Source: El Portal Cancer Center

Whether a patient decides to opt for SBRT, VMAT, or Proton Therapy, they are recommended to undergo a procedure to implant SpaceOAR Hydrogel to create space between the prostate gland and the rectum. This process involves the hydrogel being injected as a liquid through a needle inserted between the rectum and the prostate.

This helps to reduce the radiation dose received to the rectum during treatment, minimising bowel side effects for prostate cancer patients. The gel remains in place for up to 6 months before it is absorbed by the body.

Why EBRT Is Recommended For Prostate Cancer Patients

While surgery may be an effective means of treating prostate cancer, it carries risks of infection, bleeding, urinary incontinence, and impotency. As such, oncology doctors may recommend radiation or proton therapy as an alternative for prostate cancer patients.

2.2.2. Brachytherapy

Brachytherapy, using seed implantation or high dose rate brachytherapy, is a highly targeted radiation therapy technique involving the temporary placement of tiny radioactive seeds directly into the patient’s prostate gland. These seeds, each approximately the size of a grain of rice, will remain in the prostate gland for a few minutes, delivering a high dose of radiation to target and destroy cancer cells before being removed.

This treatment is generally used alone in men with early-stage prostate cancer that is relatively slow growing (low-grade) and unlikely to spread beyond the prostate. In cases where the patient has a higher risk of cancer growing outside the prostate, Brachytherapy may be combined with EBRT (given at a lower dose than if used by itself) or Hormone Therapy.

However, Brachytherapy can be limited by several factors. For example, this treatment is not recommended for advanced cases where the cancer cells have spread to the lymph nodes or distant areas of the body. Patients with transurethral resection of the prostate (TURP) or those with urinary problems are also advised not to undergo Brachytherapy, as the risk of urinary side effects may be higher.

Lastly, Brachytherapy might not be as effective for men with large prostate glands, as it might be impossible to place the seeds into the correct positions. A possible workaround for this issue requires the patient to undergo a few months of Hormone Therapy to shrink the prostate before Brachytherapy can be administered.

2.2.3. Hormone Therapy

Most prostate cancer cells rely on testosterone to develop. As such, an oncology doctor may recommend Hormone Therapy to prevent testosterone from being produced or reaching the prostate cancer cells.

Hormone Therapy can be recommended during various stages of prostate cancer. It is also commonly used in combination with radiation therapy to enhance the effectiveness of radiation treatment and control the growth and spread of cancer, lowering the chance of recurrence.

2.2.4. Surgery As An Alternative Treatment For Prostate Cancer

Although surgery carries risks, an oncology doctor may still recommend it as an alternative treatment for prostate cancer, depending on the patient’s condition, particularly in aggressive cases of prostate cancer where the cancer cells are localised. The aim is to remove the entire prostate gland, thus eliminating the cancer cells and preventing them from spreading. However, as we shared, there are possible side effects, like urinary incontinence or erectile dysfunction, to consider.

2.2.5. Why Radiation Therapy Is Still Necessary Post-Surgery

After surgery, patients are still expected to attend regular checkups with their oncology doctor. As part of the checkup, they must undergo blood tests to check their PSA level to determine whether the treatment is effective.

If the patient’s PSA level is rising or has positive margins (i.e. disease left behind post surgery), adjuvant radiation therapy is usually recommended to eliminate any remaining cancer cells and reduce the risk of recurrence.

PART 3 – LIVING WITH PROSTATE CANCER

Source: Optimist Daily

After receiving their diagnosis, it is understandable that many may feel overwhelmed by this news. However, with the proper knowledge and support, individuals can still manage their condition effectively and maintain a good quality of life. Let us provide some valuable insights on how patients can navigate the challenges of prostate cancer with confidence and make informed decisions about their well-being.

3.1. Misconceptions About Prostate Cancer

Even though medical professionals have spent decades identifying and researching various forms of prostate cancer, it remains one of the least talked about forms of cancer. As a result, there lingers several misconceptions about this disease. So allow us to clear the air and debunk the frequent myths we have come across so that patients have a better understanding of the subject.

Misconception #1: Prostate Cancer Only Affects Older Men.

While it is true that prostate cancer is more common in older men (those over age 40), it can affect individuals at any age. After all, age is not the only factor. Studies have shown that family history and high-fat diets can increase a person’s risk of developing prostate cancer. Therefore, it is crucial for men, regardless of age, to stay informed about prostate health and undergo regular screenings to detect potential issues early.

Misconception #2: Prostate Cancer Is Life-Threatening.

Prostate cancer is a severe disease, but most patients diagnosed with it do not die from the condition. In fact, studies have shown that the 5-year relative survival rate for most patients with local or regional prostate cancer is almost 100%. However, like other forms of cancer, early detection and treatment are pivotal. With advancements in medical technologies and prostate cancer treatments, many patients can continue living long and fulfilling lives.

Misconception #3: Elevated PSA Levels Mean Patients Have Prostate Cancer

While elevated PSA levels may be cause for concern, it does not necessarily mean cancer is present. The PSA could be produced in response to various problems in the prostate, including inflammation or infection (prostatitis) or enlargement of the prostate gland (Benign Prostatic Hyperplasia – BPH). Further diagnostic tests are required to confirm a prostate cancer diagnosis.

3.2. Prostate Cancer Prevention: How To Reduce Risk Of Recurrence

It is always encouraging and heartening for patients to learn that they are cancer-free after their prostate cancer treatment is complete. Understandably, many would like to continue living cancer-free. While it is possible for the disease to return, there are things individuals can change to potentially reduce the risks of recurrence. Most notably, their diet and lifestyle.

Tip #1: Eat Healthy

While oncology doctors have yet to completely understand the link between prostate cancer prevention and diet, studies suggest that a diet rich in fruits, vegetables, whole grains, and lean proteins can lower the risk of prostate cancer. Meanwhile, food to avoid include ingredients rich in saturated fat, red and processed meat, and sugar, as they may increase the risk of recurrence.

Tip #2: Increase Vitamin D Intake

Most people may not know that Vitamin D can help safeguard against prostate cancer and other conditions. Fortunately, there is always a readily available source of Vitamin D – the sun! Additionally, patients can consider Vitamin D-rich foods like cod liver oil, dried shitake mushrooms, and salmon or Vitamin D supplements. For the latter, we recommend speaking to an oncology doctor before taking the supplements.

Tip #3: Maintain A Healthy Weight

Obesity can be a factor in developing more aggressive prostate cancer. The best way to minimise this risk is to maintain a healthy weight by exercising, which can help reduce inflammation, improve immune function, and combat the negative health effects of a sedentary lifestyle. Besides engaging in regular physical activity, patients should adopt a well-balanced diet to achieve a healthy weight.

Tip #4: Increase The Frequency Of Ejaculations

Research has shown that men with a higher frequency of ejaculation (with or without a sexual partner) are less likely to develop prostate cancer. While these studies remain inconclusive and require further examination, some oncology doctors have theorised that ejaculation clears the body of toxins and other substances that could cause inflammation.

Tip #5: Cut Down On Smoking And Drinking

Smoking and excessive alcohol consumption have long been associated with an increased risk of developing various forms of cancer. So naturally, quitting smoking and moderating one’s alcohol intake can have a positive impact on overall health and potentially reduce the risk of developing prostate cancer.

Tip #6: Go For Regular Health Screenings

Despite being cancer-free, patients are still recommended to attend regular health screenings to enable early detection of recurrence and facilitate appropriate intervention if necessary. Remember, the prompt discovery of prostate cancer is crucial for the effective management of the disease.

3.3. FAQs About Prostate Cancer

We hope what we shared proves helpful for those seeking to understand and learn more about prostate cancer. Nevertheless, we understand that readers may have further questions about the disease that our comprehensive guide may not cover. So let us compile the common questions our radiation oncologist, Dr Johann Tang, receives from patients and his response to these queries.

Question #1: At What Age Should Individuals Start Screening For Prostate Cancer?

The age at which individuals should start screening for prostate cancer can vary depending on various factors, including personal and family medical history, as well as individual risk factors. We recommend having discussions about screening for prostate cancer around the age of 50 for most men.

Individuals with higher risk, such as those with a family history of prostate cancer, may wish to have these discussions even earlier, around age 45. In cases where there are multiple family members affected by prostate cancer or a strong family history, screening is recommended as early as age 40.

Question #2: How Do Individuals Know If They Have Prostate Cancer?

Prostate cancer often develops without noticeable signs in the early stages. Therefore, it is challenging to tell if an individual is afflicted. That is why regular screening is essential for early detection. With that said, individuals who notice the following symptoms should speak to an oncology doctor as soon as possible:

• Blood in the urine or semen
• Frequent urge to pass urine, especially at night
• Pain or burning sensation when passing urine
• Painful ejaculation
• Nagging pain in the back, hips, or pelvis
• Trouble passing urine
• Weak or interrupted urine stream

Question #3: How Serious Is Prostate Cancer?

Prostate cancer can vary in seriousness depending on several factors, such as the stage and grade of cancer, the overall health of the individual, and the presence of any other medical conditions. While prostate cancer is a severe disease, it is also vital to note that many cases that are diagnosed early have favourable outcomes. Therefore, we recommend that individuals attend regular health screenings to enable early detection.

Question #4: What Should Individuals Ask Their Doctors Upon A Confirmed Diagnosis?

Upon receiving a confirmed diagnosis, some patients may understandably be anxious and at a loss for what to do. However, it is crucial for individuals to actively engage with their oncology doctor and ask relevant questions to understand their condition and make informed decisions about treatment.

Here is a list of questions to help patients begin:

1. What are the chances that the cancer cells have spread beyond the prostate? If so, is the condition still treatable?
2. Should I get a second opinion or further tests before deciding on treatment?
3. What is the Gleason score or Grade Group of my cancer? What do these terms mean to me?
4. Should I monitor my condition first before deciding on treatment? Why or why not?
5. How will the cancer affect my daily life? Will it cause problems if I am not treated immediately?
6. What are the recommended treatment options based on my condition?

Question #5: What Are The Treatment Options Available?

There are various prostate cancer treatments available. However, the suitability of each method depends on several factors, such as the stage, grade, characteristics of the cancer, and the individual’s overall health and preferences. As such, any decision should be made in consultation with an oncology doctor. They will consider the details on a case-by-case basis and determine the most appropriate treatment plan for the individual.

PART 4 – CONCLUSION

Navigating a prostate cancer diagnosis can be a challenging journey. However, armed with what we shared about the disease and the available prostate cancer treatment options, individuals can now make a more informed decision about their care.

Nevertheless, patients should understand that each treatment option carries its benefits, potential side effects, and considerations. Therefore, it is crucial for them to work closely with an experienced and reliable oncology doctor who can provide them with the expertise and support required to make the best decisions for their situation.

With ethics and empathy as our guiding principles, we put patients first as we journey with them from diagnosis to treatment completion. As a radiation oncologist with over 20 years of experience, Dr Johann Tang remains current and on top of best practices and novel techniques, providing his patients with full assurance that they are receiving the most effective treatment available. Contact us today to learn more about our treatments and radiotherapy costs.