Q: Is the incidence of Prostate Cancer [PCa] rising?

Ans: Yes, the incidence is rising globally. We are certainly seeing more cases at UMMC. The greater awareness about prostate cancer makes more men go for diagnostic tests earlier. This picks up more cases which partly explains the increase in incidence.” 

Q: In your opinion, what is the contributing factor? 

Ans: Age is one of the most important factors. Life expectancy is longer now than before because of lifestyle changes, improved technology and advances in medicine. This is good news. But of course, the risk of developing prostate cancer rises with age. So, men need to be more vigilant about this increasing risk as they grow older. 

Q: What causes prostate cancer? 

Ans: Prostate cancer develops from mutations resulting in faulty genes in the cells. Mutations occur all the time in our cells and most are spontaneous. While our body can correct most of them, some mutations persist and may result in the cells turning into cancer. Age, lifestyle and environmental carcinogens are some of the factors that lead to the mutations and inability of our body to correct them well. In small number of cases, cancer develops due to faulty genes that are inherited. This may occur in up to 10% of men with prostate cancer. 

Q: At what stage are these cases being detected? 

Ans: Patients may present at early or advanced stages. In early stage, the cancer is still contained within the prostate gland. In advanced stage, it may grow outside the prostate gland into the capsules and nearby tissues or spread to lymph nodes or organs away from the prostate gland. In Asian countries including Malaysia, more cases are being detected at the advanced stage at the initial diagnosis. 

Q: Can you categorize these cases in terms of demographics? 

Ans: Globally, we see more prostate cancer occurring in older men, usually beyond the age of 60-65. The Malaysia National Cancer Registry

2012-2016 reported more cases in Chinese compared to Malay or Indian men. At UMMC, we do see more Chinese men with prostate cancer but this may be confounded by the hospital catchment area. 

Q: Is the late detection because PCa is often asymptomatic? 

Ans: This is a real challenge. At the early stage, almost all men will not have any symptoms from the prostate cancer. Many men present with urinary symptoms due to benign prostatic hyperplasia, more well known as BPH. This is a non-cancerous condition. It is an enlargement of prostate gland that occur when men age. So many men above the age of 60 may not know they have prostate cancer unless they go for a medical check-up. I advise men above the age of 50-60 with urinary symptoms and/or family history of cancer to discuss with their doctors for a PSA test. Those who have raised PSA on medical check-up should go for further testing. 

Q: What treatment options are available in Malaysia now? 

Ans: The main message that I wish to highlight to all men with prostate cancer is this – All standard treatments are available in Malaysia. The challenges include how to choose the most suitable treatment at different stages or phases of the disease and also gaining access to them since the costs of some treatments are high. 

For early prostate cancer, options are active surveillance, surgery and radiotherapy. The suitable treatment options would depend on the risk groups, predicted life expectancy and patients’ preference. We categorise men into low, intermediate and high-risk groups based on the local tumour extent, Gleason score and initial PSA level. Active surveillance is recommended for men with low-risk disease while surgery or radiotherapy are advisable for men with intermediate and high-risk groups with expected life expectancy of at least 10 years. Some men may also need hormonal therapy. 

For metastatic prostate cancer, we tend to use drug therapy. They can be categorised into hormonal therapy, chemotherapy, targeted therapy and radioisotope therapy. Outcomes have improved with the advent of novel drugs and their use in the earlier phase of the disease in combination with androgen deprivation therapy. 

Q: What about the incidence of relapse after treatment? 

Ans: Early prostate cancer treated with surgery or radiotherapy may relapse. This is usually detected based on rising level of PSA – we call this biochemical relapse. The risk of relapse will depend on the initial risk groups. Higher risk of relapse is expected for high-risk as compared to the intermediate-risk disease. All men will need continued follow-up after treatment to monitor for relapse so they can be managed adequately. 

Q: From your experience and observations, are PCa patients living longer? 

Ans: Yes, they do live longer now compared to several years ago – thanks to the more effective therapies. Increased awareness among men also contributes to the increasing survival as more men get tested earlier and complete the recommended treatment. For example, men with newly diagnosed metastatic prostate cancer had potential survival of about 3 years in the past. But now with better treatment, they can expect to survive for at least 5 years. One may say “That is only 2 extra years.” Well, we need to look at that in the right context. For a relatively young and healthy man who have 10-20 years to live, 2 years may be a small number. But for someone who potentially has only 3 years to live, that extra 2 years is certainly a significant number. In our practice at UMMC, we aim to not only prolong survival but we also hope to achieve a meaningful survival for our men. 

Q: What is your advice to anyone who has just found out he has prostate cancer? 

Ans: I have several! First of all, get the facts right. Know all you can about the disease. Get the correct information from credible sources – not everything that you find on the internet is correct. Secondly, meet the correct specialists – a urologist and an oncologist. Ask them questions about the disease and the treatment options including the pros and cons of each option. Thirdly, make your choice, start your treatment early and follow through the treatment until its completion. Fourthly, keep to the monitoring schedule after treatment. And finally, get appropriate support from family and friends. You may join a peer support group if one is available. For example, PCSM for men with prostate cancer.