The prostate is a walnut shape and size gland found in men and its main function is to produce the fluid in semen. It sits in front of the rectum and underneath the bladder. Prostate cancer develops when gland cells turn malignant and become a tumour. It tends to occur at age 50 and above, which is when men can opt to start screening for prostate cancer using a blood test known as PSA (prostate specific antigen).
It is important to recognise that high PSA may not be just due to cancer, but other causes like infection and benign enlargement of the prostate. However, further checks have to be done to exclude cancer as early diagnosis and treatment has a good chance of success. These checks involve further blood tests, prostate MRI scans and ultimately a biopsy of the prostate to confirm the presence of cancer.
The main curative treatment options for prostate cancer include:
Radical prostatectomy is a surgery done to remove the entire prostate gland. Increasingly, the robotic technique is used. Several small incisions are made with small instruments and a camera placed through them. The surgeon operates by looking at a monitor and controls the instruments with fine movements via the robot.
Radiation Therapy comes in two forms – external beam or internal (brachytherapy). External beam radiotherapy is non-invasive and involves using a machine to direct x-rays focused on the prostate that kill the cancer cells within. Each daily treatment takes a few minutes and most patients can continue their daily activities. Advances in radiotherapy have allowed external beam courses to be shortened from 8 weeks to 4 weeks in 20 treatments and most recently, 1.5 weeks in just 5 treatments.
Brachytherapy is the use of radioactive sources placed within the prostate via needles, under general anesthesia. In one form, tiny rice-grain-sized seeds placed permanently within the prostate release radiation slowly and kill the cancer. Another form involves temporarily implanting radioactive sources into the prostate that are removed after one or two days.
Active surveillance is used for small tumours with a low risk of growth and spread. The tumour will be monitored closely using the PSA blood test every few months, and periodic MRI scans of the prostate. The rationale is to postpone aggressive treatment and its side effects, and only have surgery or RT when the cancer begins to grow.
The most common side effects of prostatectomy are urinary incontinence and erectile dysfunction. The incontinence is usually temporary but there may still be occasional leakage in the long term for some patients. As for radiation therapy, there may be increased urinary and bowel frequency, mainly in the first six months after treatment, with subsequent recovery. While in the past having blood in the stool was a potential long term side effect post-radiation, this has become quite rare due to advances in targeting and delivery that minimize exposure of the rectum to high dose radiation. The placement of biodegradable hydrogel spacers in between the prostate and rectum prior to radiation is now available to further protect the rectum.
In early-stage cancers, both are equally effective when used alone. For more advanced or aggressive tumours, a combined approach may be required. Surgery might need to be followed by radiotherapy, while radiotherapy would need to be combined with hormonal therapy. These two approaches again afford equivalent cure rates.
A proportion of men with prostate cancer experience ‘treatment decision regret’. It has been found that those who were well informed of the pros and cons of the options and kept involved in decision-making experienced the least regret about their treatment choice. Therefore, men should have an in-depth discussion with both a urologist as well as a radiation oncologist to get a full picture, before making their decision.
The vast majority of prostate cancers that have spread can be well controlled by hormone therapy which reduces testosterone levels in men or blocks the action of testosterone. More aggressive stage IV cancers may benefit from the addition of chemotherapy as well. Newer targeted therapy against certain genetic mutations is an option for a small proportion of men with prostate cancer.
You may read this article on https://365cps.org.sg/resourcehub/prostate-cancer/
Prostate cancer is the uncontrolled growth of abnormal cells in the prostate. These abnormal cells divide and accumulate, forming a tumour. The tumour can then grow to invade other tissue, and can also spread to other parts of the body. It is the third most common cancer among Singaporean men. Many prostate cancers grow slowly and do not cause any symptoms. These usually do not cause serious harm. However, some prostate cancers can grow aggressively and spread quickly, and this may cause serious harm. Almost all prostate cancers develop from the gland cells – cells that make the prostate fluid that is in semen. This is known as adenocarcinoma. There are, however, other types of rarer cancers of the prostate. These types include:
The early stages of cancer often have no symptoms. However, growth of the cancer in the gland may cause these symptoms: These symptoms could also be caused by other conditions besides prostate cancer. Problems with urination can be caused by benign prostatic hyperplasia – a non-cancerous enlargement of the prostate. It is, however, still important to consult your doctor so that these causes may be treated appropriately. In later stages of prostate cancer, the following symptoms may be present:
Men over the age of 50 years should discuss with their doctor if the benefits and limitations of prostate cancer screening. Men with a brother or father with prostate cancer diagnosed before 65 years old have increased the risk of getting prostate cancer. Therefore, they should discuss with their doctor about starting screening at an earlier age. There are several tests for prostate cancer. A digital rectal examination (DRE) allows the doctor to detect any abnormalities in the prostate gland – whether it is the texture, shape or size. A transrectal ultrasound will also allow for the detection of abnormalities in the prostate gland. A blood sample can be taken to detect the prostate-specific antigen (PSA). This is a chemical that is naturally produced by the prostate gland. A high level of this antigen will alert the doctor to begin further investigations. Prostate cancer screening usually involves taking a blood sample for PSA, and may be combined with a DRE. Patients with a high PSA or abnormal DRE may require a prostate biopsy, which involves taking small amounts of tissue from the prostate gland for examination. It checks for the presence of cancer, and also how aggressive it is likely to be (grade). Once prostate cancer is diagnosed, other tests that help with finding out the stage of the include computerised tomography (CT) scans, magnetic resonance imaging (MRI), PSMA-PET scans and bone scans. Treatment options for prostate cancer depends on what the stage and grade of the cancer is, and also the age and general health of the individual. Active surveillance – some prostate cancers grow very slowly. This means it may take many years for any symptoms emerge, but men in good health should be followed up closely by their doctor to lookout for any sign the cancer is turning aggressive. Treatment is multidisciplinary, personalised and precise and there are a variety of treatment options available. These may include the following, and possibly in combination: Once the diagnosis is made the consultation with an oncologist is essential in order to understand which treatment options are the most suitable. It is advantageous to be seen by an oncologist with subspecialty interest in treating prostate cancer using both drug and radiation therapy for a holistic assessment. SpaceOAR Rectal Spacer Radiation Therapy is an effective curative treatment for Prostate Cancer. Technological advances like Intensity Modulated Radiotherapy (IMRT), Stereotactic Body Radiation Therapy (SBRT) and Proton Beam Therapy (PBT) have allowed high doses of radiation to be more focused on the prostate while avoiding the nearby healthy tissues. The rectum is located right next to the prostate, so it is inevitable that a very small part of it would still receive high doses of radiation. There is a small risk of bleeding from the back passage, months to years after radiotherapy, because of this. That is where SpaceOAR Rectal Spacer comes in, literally and figuratively, to make Prostate Radiotherapy even safer. What is SpaceOAR Rectal Spacer and how does it work? SpaceOAR Rectal Spacer Hydrogel is made from a soft gel-like synthetic material that consists of 90% water and is safe to use in the body. It is placed in between the rectum and the prostate, increasing the distance between the 2 organs by approximately 1 cm. The space created, essentially pushes the rectum away from the radiotherapy high dose region, vastly reducing high radiation dose to the rectum. The gel will have a fixed shape and size for 3 months, before liquifying and being naturally absorbed and excreted by the body within 6 months. Less exposure to high dose radiation means less risk of long-term side effects from radiation. This has been demonstrated in a clinical trial whereby patients receiving prostate radiotherapy with the SpaceOAR Rectal Spacer had significantly a 75% reduction in mild and above rectal bleeding compared to those who did not. Notably, there were no cases of moderate and above rectal bleeding in patients who had SpaceOAR Rectal Spacer (refer to Figure 3) The SpaceOAR Rectal Spacer Procedure It can be done as a minimally invasive office procedure / day case under local anaesthesia, and typically takes less than an hour. Guided by an ultrasound probe, sterile saline is injected to open up the space between the rectum and the prostate, followed by injection of the SpaceOAR Rectal Spacer gel into the space. What happens after the SpaceOAR Rectal Spacer placement? Hospital stay is not required and the patient can go home soon after the procedure. A sensation of fullness in the back passage may be felt for a day or two, but this is temporary. Return to normal activities can be expected soon after the procedure and there is virtually no downtime. The CT and and MRI scans for radiotherapy planning can then be done a week after the procedure. In Summary, SpaceOAR Rectal Hydrogel is clinically shown to minimise urinary, sexual and bowel side effects and protect quality of life for prostate cancer patients undergoing radiation therapy. In addition, it is also
Stereotactic Radiosurgery (SRS/SBRT), Head & Neck, Pediatric, Urologic, Gastrointestinal Cancers & Sarcoma Stereotactic Radiosurgery (SRS/SBRT), Brain and Spine, Breast and Prostate Cancers
Prostate
Cancer
Figure 1: Hydrogel Placement (Boston Scientific, 2022)
Figure 2: MRI of a patient with SpaceOAR Rectal Spacer Hydrogel (Mariados N et al., 2015)
Figure 3: Results from a clinical trial on the usage of SpaceOAR: Reduction in rectal bleeding (Mariados N et al., 2015)
Figure 4: Hydrogel Placement (Boston Scientific, 2022)
Meet Our Prostate Cancer Specialists
Dr. Jonathan Teh Yi Hui
Medical Director (CSR) & Senior Consultant Radiation Oncologist 
Dr. Daniel Tan Yat Harn
Director & Senior Consultant Radiation Oncologist
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