Prostate cancer is increasing in incidence. Prostate cancer is the No. 1 cancer in men in the USA and the 5th commonest cancer among men in Singapore.

Prostate Cancer

Prostate cancer is increasing in incidence. Prostate cancer is the No. 1 cancer among men in the USA and the 5th commonest cancer among men in Singapore.

As of 1 March 2008, according the latest statistics from Singapore Cancer Registry obtained by the Straits Times newspaper, Prostate Cancer is now the 3rd commonest cancer among men in Singapore. To read more, please click link or refer to the article in the Highlight section of this website.This is in keeping with its trend of rising incidence over the past decade.

Prostate cancer in its early stages does not cause any pain or symptoms. In the past most of these prostate cancers were detected at an advanced stage. However, with the advance in scientific and medical knowledge, the situation is reversed in the present days with most prostate cancer diagnosed early. This results in more effective treatment of the prostate cancer with better results. Patients with early prostate cancer and treated appropriately can expect 10 or more years of survival.

Diagnosis

The diagnosis of prostate cancer involves the following:

Digital Rectal Examination (DRE)

DRE is a physical examination where the doctor inserts a gloved finger into the back passage to examine for hard lumps on the prostate. It is quick and usually painless procedure.

Prostate Specific Antigen (PSA) Blood Test

PSA is a chemical produced by both normal and malignant prostate cells. A raised PSA blood test is a warning sign of possible prostate cancer.

Prostate Biopsy

If prostate cancer is suspected from an abnormal DRE and PSA, a prostate biopsy will be needed to confirm its presence or absence. Prostate biopsy is performed using a Trans-Rectal Ultrasound Scan (TRUS) to view the prostate and guide a needle into the prostate to obtain samples of prostate tissues. This is known as Trans-Rectal Ultrasound Scan (TRUS) guided prostate biopsy. The small strips of tissue obtained from the prostate biopsy are sent for examination by a pathologist experienced in analyzing these strips for prostate cancer.

The pathologist examination will determine if there is prostate cancer in the tissue samples. If there is prostate cancer, the pathologist will then assess how aggressive the prostate cancer is by looking at its appearance. The prostate cancer is then given a number known as Gleason score. The score ranges from 2 to 10. The higher the Gleason score, the more aggressive the prostate cancer.

Gleason Score

The next information required is the Staging of the prostate cancer.

What does staging of the prostate cancer means?

Staging refers to the extent of prostate cancer.

When the prostate cancer is localized, it means the prostate cancer remains confined within the prostate. If the prostate cancer has spread into the tissues surrounding the prostate, it is at a locally advanced stage. In advanced prostate cancer, it has spread to other parts of the body distant from the prostate. This is also known as prostate cancer metastasis. This is a simple understanding of the stages of prostate cancer.

There are more detailed staging systems. The one most commonly used is the TNM Staging system.

TNM Staging for prostate cancer

TNM Staging stands for Tumor, Node and Metastases Staging.

PROSTATE CANCER TNM STAGING

TX - Primary prostate cancer cannot be assessed in prostate
TO - No evidence of primary prostate cancer
TI - Prostate cancer not clinically apparent.
TI (a-c)
In T1c, the prostate cancer is detected by PSA. This represents the largest group of men with prostate cancer


T2   - Prostate cancer palpable/confined to prostate
T2a - Prostate cancer involves one prostate lobe

T2b - Prostate cancer involves both prostate lobes

T3    - Prostate cancer palpable and extends beyond prostate capsule
T3a  - Prostate cancer extends beyond prostate capsule, either on one side (unilaterally) or both sides  (bilaterally)
T3b  - Prostate cancer invades seminal vesicles

T4  - Prostate cancer is fixed or invades adjacent anatomy other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall

NX  - Regional lymph nodes cannot be assessed
NO  - No regional lymph node metastasis
NI  - Metastasis in regional lymph node or nodes

MX  - Presence of distant metastasis cannot be assessed
MO  - No distant metastasis
MI   - Distant metastasis
MI a - Metastasis to no regional lymph nodes
MI b - Metastasis to bone
MI c - Metastasis to other distant sites

Staging helps decide the most suitable treatment for the Prostate cancer.

TREATMENT OPTIONS for Prostate cancer

The various treatment options for prostate cancer are:

Radical Prostatectomy

Radical prostatectomy is the complete surgical removal of the prostate cancer together with the prostate. Ideally the prostate cancer should be confined to the prostate.

Radical Prostatectomy is done through an open wound at the lower abdomen. However, with advancement in telescopes and robotics, the present state-of-the-art treatment is Robotic Radical Prostatectomy.

Robotic Radical Prostatectomy

In Robotic Radical Prostatectomy, the prostate is removed using telescopes and instruments inserted through tiny keyholes in the body. These instruments are then manipulated using a robot by the surgeon.

The da Vinci Surgical System robot cannot be programmed nor can it make decisions on its own. The da Vinci Surgical System requires that every surgical maneuver or movement of the Robotic Radical Prostatectomy be performed with direct input from the surgeon at the console.

The da Vinci robot surgical system has been successfully used worldwide in thousands of Robotic Radical Prostatectomy prostate cancer procedures by surgeons certified to use the system. We are certified to use the da Vinci Surgical System.

Robotic Radical Prostatectomy with the da Vinci Surgical System robot is available at Mt. Elizabeth Hospital.

How does robotic radical prostatectomy improve prostate surgery?

The da Vinci Surgical System offers improved visualization, magnification and surgical precision over open radical prostatectomy surgery. The specially designed InSite™ Vision System offers magnification and a 3-D visualization of vital anatomy such as blood vessels and nerves. The mechanical arms provide precision and many degrees of freedom of wrist movement greater than that achieved by traditional laparoscopic instruments and even the human hand. They also act to reduce the fatigue associated with long procedures and eliminate tremor.

These advances should allow the surgeon to separate critical nerves, blood vessels and muscles from the prostate to improve the side effects of erectile dysfunction and incontinence while reducing blood loss and still completely removing the cancer. The smaller incisions may reduce post-operative pain, reduce scarring, shorten the hospital stay and lead to faster recovery and return to normal activity.

Benefits of Robotic Radical Prostatectomy

The benefit of Robotic radical Prostatectomy includes:

1. Better cancer clearance
2. Better preservation of vital structures such as nerves for erection
3. Less blood loss and transfusions
4. Less risk of infection
5. Less scarring
6. Less pain
7. Faster recovery
8. Shorter hospital stay
9. Quicker return to normal activities

As with any surgical procedure, these benefits cannot be guaranteed, as surgery is both patient and procedure specific.

Radiation Therapy

Radiation therapy uses high-energy rays to kill prostate cancer cells. It may optimally treat early stage cancer and help extend life in later stages.  However, as its rays also damage healthy cells nearby, its side effects may include impotence, urinary incontinence, tiredness, skin reaction, as well as frequent and painful urination.

Improvement in delivery systems involving the use of artificial intelligence and computer software has made possible more precise delivery of the radiation to the prostate, sparing the surrounding normal organs.

One such system is known as Intensity Modulated RadioTherapy or IMRT for short. IMRT is available in Mt. Elizabeth Hospital Cancer Centre. 

Watchful Waiting

This option is not recommended for young patients with early stage prostate cancer who have an excellent outcome with treatment.

"Expectant Therapy" is a watch-and-wait approach to monitoring prostate cancer involves regular DRE and PSA tests. This is a choice of patients who have other severe health conditions that may preclude more aggressive treatments including radiotherapy or have limited life expectancy.  Patients must be committed to regular check-ups.

Hormonal Therapy

This treatment is usually reserved for cancer that has spread beyond the confines of the prostate.

The object of treatment is to remove or ablate testosterone, which act to stimulate growth of the cancer. Depriving the prostate cancer cells of testosterone prevents further growth and causes the cancer to shrink.  

This can be achieved by:

• Orchiectomy or surgical castration to remove the testes, which produces 95% of the body’s testosterone. The removal of the testes is permanent, and its effects are irreversible.
• Drug therapy or medical castration is an alternative to surgery. It is equally effective. Luteinising Hormone-Releasing Hormone (LHRH) analogues and anti-androgen hormonal drug therapy act to suppress the release and action of testosterone on the cancer cells.  Possible side effects may include hot flushes, a decrease in sexual desire, and erectile dysfunction. Anti-androgen therapy causes less impotence, decrease in libido and hot flushes.

Chemotherapy

Chemotherapy involves the use of powerful and toxic drugs to attack cancer cells.  The drug circulates throughout the body in the bloodstream and may kill any rapidly growing cells, including healthy ones.  It provides an additional means to relieve the symptoms of advanced prostate cancer in some patients whose disease no longer responds to hormonal therapy.  Its possible side effects may include hair loss, nausea and vomiting.