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Posted by Vishal Chand (Republished by Forum Admin)
Is prostate cancer hereditary?
And generally which age group is more susceptible?
Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)
Dear Mr Chand, thanks for the question.
In general, the 3 major risk factors for prostate cancer include older age, race (African-American) and family history. Familial or hereditary prostate cancer represents 10% of all prostate cancers, where we see clustering of prostate cancer in certain families. By definition, to have familial prostate cancer there must be 3 generations affected, with 3 first degree relatives (direct relations) or 3 relatives under the age of 55 years. Having a family member with prostate cancer may increase one’s risk of having prostate cancer. If one relative is affected, there is 2 - 3 times risk over the average person. If two relatives are affected, there is a 5 times risk, and if 3 relatives are affected, there is an 11 times risk. In addition, familial breast cancer also confers a greater risk of prostate cancer in those families as they share the same gene (BRCA 1 gene). In general, for those with a significant family history of prostate cancer, we do advise them to seek physicians’ advice regarding risk and benefits, and do a blood PSA test after the age of 45 years. I hope this answer has helped you! Regards.
Posted by Ang EH (Republished by Forum Admin)
I did MRI over my prostate and the doctor found an area of suspicious and later over a conference with radiology, the opinion is that it is not likely to be suspicious.
I had no pain except that there are occasionally difficulty to start urinating but when there is urge, there is no issue urinating.
Often I feel there seems to be an urge but not very urgent, then likely there will be no urine.
Years ago, I have done biopsy over prostate and found ok.
I have taken avadag over several years say 3 to 4 years.
What do you recommend and the follow up? Thank you!
Posted by Michael K (Republished by Forum Admin)
My regular internal medicine doctor do not recommend PSA as he claimed is not reliable and accurate. Beside MRI and biopsy is there any simple check for prostrate cancer and how regularly should this check be conducted? Thank you.
Dear Mr Michael,
Thanks for the question. Your question has 2 parts. The first one is on role of PSA as a screening test. This is still a controversial area as PSA test can be elevated for many reasons apart from prostate cancer like benign prostate hyperplasia or prostate infections. Doing indiscriminate screening in patients without risk factors does lead to significant overtreatment and over diagnosis, with unnecessary additional risk and costs to patients. PSA test for screening should only be done after consultation with your physician.
For the second question, unfortunately there is no one such simple investigation for prostate cancer, and no recommended timeline or schedule for tests. Apart from blood tests (PSA) other tools used would include digital rectal examination (finger in anus to feel the prostate). However, it should be noted that a normal digital rectal examination does not exclude prostate cancer. MRI prostate has been discussed recently in literature as a possible tool in patients who have a raised PSA, however, it is a costly option. Pros and cons should be discussed with your physician.
I hope this answer has helped you! Regards.
Posted by Roy S (Republished by Forum Admin)
We would be grateful if you could shed some light on this:
Dear Mr Roy,
Thanks for the questions.
Posted by Mengdong (Republished by Forum Admin)
Dear Mr Mengdong thanks for the questions.
Posted by anthony (Republished by Forum Admin)
How long can a patient live after removed his 3 stage of prostate cancer?
Dear Mr Anthony, thanks for the question.
Stage 3 prostate cancer are generally what we define as locally advanced prostate cancer where there is extra capsular extension of the prostate cancer outside the prostate capsule or invasion to seminal vesicle (organ near the prostate). The treatment of these cancers is multi-modality, meaning, apart from the primary treatment of surgery or radiation, they may require other additional treatments like adjuvant radiation therapy or hormone therapy. The prediction of life expectancy for these patient will be based on PSA level before surgery, grade and stage of the cancer in the prostate, any positive surgical margins or lymph node present in pathology specimen and finally the PSA level after the procedure. With absence of those negative factors and normal PSA levels after surgery or radiation therapy, many patients can live well above 10 years. However, presence of those negative factors or PSA recurrence after treatment may reduce survival and as such further multi-modality treatment would be necessary. In those cases, survival would be best judged on an individual case by case basis after consulting the treating urologist.
Posted by soh (Republished by Forum Admin)
Is the PM safely out of the woods from prostate cancer? He may have survived till now but it's only been 2 years after surgery...too early a call? I hope he will not let his guard down so soon.
Dear Mr Soh,
Thanks for your question.
Posted by Harry (Republished by Forum Admin)
I am 69 years of age. Currently I have some difficulties in passing my urine but not so frequent. My general health is good. And I exercise regularly. I have no diabetes and my blood pressure is under control without medication.
My question is whether is it necessary for me to go for a check-up as I have never done such test before.
Dear Mr Harry,
Thank you for your question.
Difficulty passing urine occasionally in older men could be a symptom of benign prostate enlargement which is an age-related benign condition. If the symptoms do become bothersome, they may require some medical therapy. I would recommend you to seek consultation with an urologist to get it evaluated. During the consultation, your urologist will take your history to understand your background and symptoms better as well as do a physical examination check up to assess your prostate as well as other urinary related organs.
Posted by F Javier (Republished by Forum Admin)
I had surgery on May 2016, radiation on March 2017 and ADT on April 2017. Since then my PSA is undetectable but my testosterone is returning to normal. Some doctors have congratulate me. I have heard that testosterone feed the tumour. May you explain this? What advice can you give me? Another ADT?
Dear Mr Javier,
Your journey in prostate cancer has been a long one. From your question, I can surmise that you have had both surgery then radiation and are currently on androgen deprivation therapy (ADT). Patients on androgen deprivation therapy are monitored by checking both the blood PSA level and testosterone level. The PSA level is a marker of cancer recurrence and should be low and not rising. The testosterone level should be at castrate level (castrate means testosterone at very low level usually less than 50ng/dL or 1.7 nmol/L). You are right that testosterone does stimulate prostate cancer, as such the purpose of ADT is to keep its testosterone level castrate.
A rising testosterone level together with rising PSA level while on ADT is concerning and should require further investigation by your urologist as some advanced prostate cancer do develop resistance to ADT over time. While I understand that your PSA level is undetectable (which is very good), I would recommend you to discuss the rising testosterone level with your doctor.
Posted by Michelle (Republished by Forum Admin)
As my father side families have history of prostate cancer, I would like to ask some questions on it.
Dear Ms Michelle,
Thanks for your questions.
Prostate cancer arises from the
glandular and epithelial cells of the prostate gland, which is a walnut shaped
gland that lies below the bladder along the urine pipe. Its function is to aid
in production of semen. Common risk factors for development of prostate cancer
including advanced age (older patients have more prostate cancer, a study in
men over 80 years old showed that almost 80% did have some kind of prostate
cancer), racial groups (African- American) and family history. Other risk
factors include obesity and smoking with unhealthy high fat and high
Only 10% of all prostate cancer
are inherited. The rest are due to lifestyle habits or risk factors mentioned
above. Of the inherited or familial prostate cancers we generally have some
criteria to diagnose them. By definition, to have familial prostate cancer
there must be 3 generations affected, with 3 first degree relatives (direct
relations) or 3 relatives under the age of 55 years.
Having a family member with
prostate cancer may increase one’s risk of having prostate cancer. If one
relative is affected, there is 2 - 3 times risk over the average person. If two
relatives are affected, there is a 5 times risk, and if 3 relatives are
affected, there is an 11 times risk. In addition, familial breast cancer also
confers a greater risk of prostate cancer in those families as they share the
same gene (BRCA 1 gene).
In general, for those with a
significant family history of prostate cancer, we do advise them to seek
physicians’ advice regarding risk and benefits, and do a blood PSA test after
the age of 45 years.
The role of prevention of prostate
cancer with certain foods has been extensively studied. Some dietary factors
have been shown to increase the risk of prostate cancer with obese patients,
and those with high meat diets having higher risk of the disease. Many other
dietary factors have been studied to see if they reduced risk of prostate
cancer. Fruit and vegetables (no benefit), Beta-carotene (no benefit), lycopene
(rich in tomatoes – some mild benefit), vitamin D (no benefit) and selenium (no
benefit). As such, from a dietary perspective we would advise patients to have
a healthy balanced diet, and regular exercise to avoid obesity. Smoking is also
associated with most cancers including prostate cancer and I would recommend
all smokers to stop smoking.
There is no evidence that regular
sex will prevent prostate cancer.
I hope this answer has helped you!
Posted by AJ (Republished by Forum Admin)
Hi Dr Raj Vikesh Tiwari,
I am age 55. I recently did some checks in a hospital to determine if I have possible prostate cancer. I did digital rectal examination and is ok. I also had a CT scan which is fine but a PSA resulted 6 which I was told above limit. I was then ask to do a biopsy. As I understand, a PSA 6 does not necessary equate to prostate cancer and can be inflammation or prostate enlargement. I also understand that biopsy is not a sure result because sampling taken may not be where the cancer is. In addition, there are side effects and risks if biopsy. Would really appreciate if you can share with me your opinion what best should I do so that I don’t have to go through unnecessary over diagnosis causing too much mental stress and inconvenience.
Thanks in advance!
Dear Mr AJ,
Thank you for your question, the management of raised PSA is indeed a large topic which understandably causes much patient stress. Let me try to summarise the options for you.
As you rightly pointed out, PSA of 6 is consider high and does carry a 30% risk of prostate cancer. Other possibilities include benign prostate hyperplasia or prostate infections/inflammations. At this stage you do have several options. Choosing the right option for you will need consultation with your urologist and weigh the pros and cons. Of note, not all options may be available in every medical centre or suitable for you.
The recommended treatment based on guidelines would be trans rectal prostate biopsy, where a needle is inserted thru the rectum into the prostate to take several biopsy cores for testing under local anesthesia. This procedure does carry up to 5% risk of bleeding in urine, stool or semen, retention of urine, infections including those for need of hospitalization. As you pointed out, these biopsies do have a 25% of not picking up the correct zone of the tumour as they are random biopsies.
Another method of diagnosis that is becoming more popular recently is a multi-parametric MRI scan of the prostate followed by targeted prostate biopsy either via the trans rectal route or trans-perineal (skin under the scrotum) route. MRI scans of the prostate are non-invasive however relatively more costly. They do have excellent ability to identify areas of the prostate which are deemed suspicious for targeted biopsy. These biopsies may be done using trans-perineal route (under general anesthesia, only available in certain hospitals), where risk of infections and complications of biopsy are lower than trans rectal route. Being targeted the pick-up rate of the biopsies would be better. There have been a couple large clinical trials in the West comparing MRI and targeted biopsies with the conventional trans rectal biopsies and results have been promising showing that MRI and targeted biopsies have a higher pick up rate of clinically significant prostate cancers, with less unnecessary biopsies in those with clinically non- significant prostate cancer. I would like to say at this point that trans rectal biopsy of the prostate still remains the 1st line investigation for raised PSA, and at this point in Singapore the role of MRI and targeted biopsy is in patients who have already had one negative prostate biopsy. Should you be keen for MRI and targeted biopsies, you should discuss with your urologist.
Apart from going in for a biopsy, there are several options now available to better risk stratify patients with slightly elevated PSA between 4 - 10 (yours is 6). I could suggest 2 bloods tests. One is the free-total ratio PSA test which tests the sub-forms of PSA ad measures them in a ratio. If ratio >0.2 it suggest a benign process, if ratio <0.1 it suggests a malignant process. 0.1-0.2 is equivocal (could be either cancer or benign). The other blood test would be the prostate health index (PHI) which uses 3 blood tests the p2PSA, free PSA and total PSA in an equation to try and predict likelihood of prostate cancer. You should discuss these tests with your urologist if you are not keen for biopsy.
Lastly, if you are not keen for any of the above tests, then perhaps just repeating the PSA test after a few months to see if levels reduce or will normalise. This would be the least risky and costly option.
Posted by Mr Ahmad (Republished by Forum Admin)
Dear Mr Ahmad,
Posted by Laurence (Republished by Forum Admin)
Dear Dr Tiwari
In addition to the usual indicators of Total PSA, Free PSA and Free/Total PSA, further indicators, viz Prostate Health Index (phi) and p2PSA, have now been used to determine prostate health.
How should these indicators collectively be used to determine the course of action? There can be cases where a person’s PSA hover around 4-5 and free/Total PSA is indeterminate but phi is at the upper end of the moderate range. What would you advise such people?
How should these indicators be used to determine whether a person should go for MRI and prostate biopsy, given that phi, by itself, does not indicate whether a person has prostate cancer?
How often should a person undergo MRI and biopsy of the prostate?
Dear Mr Laurence,
Prostate health index (PHI) and Free/Total PSA ratio are adjunct tests used to help better decide if patients with borderline PSA (4-10) would be more or less likely to have a malignant vs benign process. They aim to help provide more information to patients for decision making to choose prostate biopsy. As you rightly pointed out, PHI and Free/Total PSA ratio are just guides for likelihood of malignant process rather than firm diagnostic tools for cancer. I see them a complementary investigations which if indicating a malignant process does help me counsel my patient more for biopsy or MRI rather than observation.
The current standard of care for patients with raised PSA who need a biopsy would be for trans rectal ultrasound guided prostate biopsy. This procedure is performed under local anesthesia as a day surgery procedure. It does carry 5% risk of bleeding, infections and urine retention. 25% of these patients also get inaccurate biopsies. There has been increasing interest and study in the role of multiparametric MRI of the prostate and targeted prostate biopsy as a first line diagnostic tool as compared to regular trans rectal biopsy. 2 large clinical trials done have shown that MRI and targeted biopsy does pick up clinically significant prostate cancers better and helps avoid unnecessary biopsy in clinically non-significant cancers. However, the issue with MRI and targeted biopsy is increased cost to patients and the possible need for a general anesthesia transperineal targeted biopsy. (However now some centres do perform targeted biopsy via transrectal route under local anesthesia). Should you be interested in MRI and targeted biopsy, you should consult your urologist as the facilities may differ from hospital to hospital.
There is no set limit on the number or MRI or biopsy to be performed, but we would generally wait 3 months after a prostate biopsy before doing an MRI as biopsy induced bleeding creates artefacts in the prostate tissue which affects our ability to read the scans accurately.
Posted by Ramesh V (Republished by Forum Admin)
What are the physical symptoms I need to lookout for potential prostate cancer? Growth, pain, skin discoloration etc.? Thank you.
With Best Wishes & Regards,
Dear Mr Ramesh, thanks for the question.
Most of the time prostate cancer has no symptoms. However, when symptoms do appear they be related to urinary tract such as fresh blood in urine, frequency and urgency or urination or difficulty passing urine. Blood in the semen may also occur. More advanced cases of prostate cancer may present with bone pain, weight loss and urine retention.
Posted by peri (Republished by Forum Admin)
I am having enlarged prostate since 2014 and urine flow is normal.
NUH has conducted biopsy and found no problem.
Uroflow also conducted there is also no problem.
But psa was 7 in jan2018 and now 9.77 in the blood test.
So they told one more biopsy and MRI scan can be done to by Feb2019 and asked me not to take medicine since April 17 as there is no problem in flow of urine.
What is your suggestion?
Dear Mr Peri thanks for the question.
I note you have had raised PSA tests and a previous negative prostate trans rectal biopsy. Your latest readings are 7 and then 9.77. 30% of all patients with elevated PSA from 4 - 10 actually have prostate cancer. The rest will have other causes like benign prostate enlargement and prostate infections.
As your urologists have rightly advised, you would benefit from a multi-parametric MRI of the prostate which is a detailed non-invasive test that studies the prostate gland for any cancerous or suspicious growth. These suspicious growths are then targeted and biopsied using fusion biopsies (either via transrectal or transperineal route). The accuracy of these targeted biopsies is high.
As you do not have any bothersome urinary symptoms and a normal flow, I do feel your doctors are correct in stopping your prostate medications.
Posted by Hanah (Republished by Forum Admin)
Recently my dad's prostate cancer had been diagnosed to stage 4.
I am truly affected by this news.
What can i do to help my dad in this difficult moment?
Could you give me some advice on his meal planning e.g. what kind of food for him to avoid and what suitable exercise for him to do?
Thank you for your question. I am sorry to hear that your dad was recently diagnosed with stage 4 prostate cancer. I hope my answer can help you and your family during this difficult period. As you are aware, treatment of patients like your dad are of palliative and not curative nature, which means the emphasis is patient’s quality of life and maintaining their ability to function comfortably and live with dignity. Cure of the cancer is not a treatment aim here. With improvements in medical care, the palliative treatments for this group of patients have become better. I would divide the care for your dad into the medical aspects, the general health and nutrition aspects and psychological aspects.
Medical care for patients with stage 4 prostate cancer would include hormone therapy (androgen deprivation therapy) which may involve medications or surgery to reduce their testosterone hormone level (testosterone is hormone that drives prostate cancer). It is important that patients take their hormone medications regularly as it has been to shown to help prolong their lifespan. Patients on hormone treatment are at increased risk of osteoporosis so it would be advisable for them to take regular calcium and vitamin D supplements. Other than hormone therapy there are several other treatments available for metastatic prostate cancer including chemotherapy (docetaxel) and second line hormone therapy (abiraterone). You should discuss with your urologist if these treatments are suitable for your dad.
General health and nutrition support is essential in these patients. I would recommend a healthy balanced diet with regular physical activity such as walks. Hormone therapy is known to cause decrease muscle mass and increased fat mass in patients as such balanced diet and physical activity will benefit these patients greatly. Examples of suitable exercise may be walks or swimming. Strenuous activities may not be suitable especially for patients with bone metastasis. Psychological health is very important for this group of patients and comes from strong family support. Patients must have confidence that despite their condition they can still lead productive and happy lives. Staying positive is an important part of this. I wish you and your dad all the best in this!
Posted by Ng Wee Tye (Republished by Forum Admin)
My question :
Is external radiation therapy and targeted radiation therapy available in Singapore government hospital?
If yes where is it available?
Dear Mr Ng
Thanks for the question. External beam radiation therapy (EBRT) and targeted radiation therapy (brachytherapy) for prostate cancer is indeed available at Singapore General Hospital and National Cancer Centre Singapore.
Posted by Kelvin Ang (Republished by Forum Admin)
Dear Dr Raj,
My dd has prostate cancer and has undergone chemo.
May I know what side effects are there after having completed the chemo?
Dear Mr Ang
Thanks for the question. Most patients with advanced
prostate cancer would have undergone hormone treatment in the form of
medication or surgery. Common side effects of hormone treatment include hot
flushes, loss of muscle mass, increased fat mass, osteoporosis, decreased sex
drive and erectile dysfunction, male breast development (gynecomastia) and depression
in some patients. It is important to note that not all patients have these side
Chemotherapy in prostate cancer is used in only 2 groups
of patients. The first are those with newly diagnosed stage 4 prostate cancer
and the second group are those who have stage 4 prostate cancer which is
resistant to hormone treatment (castrate resistant prostate cancer). Chemotherapy
agent used is docetaxel. Based on my knowledge, some side effects include
nausea, vomiting, diarrhoea, loss of appetite, weakness and immune suppression.
In Singapore, chemotherapy for prostate cancer is mostly administered by
medical oncologists and they may be the best ones to check the side effects
from. Do speak to your medical oncologist for further details on this.
I hope this answer has helped you!
Posted by Doubtful and Undecided (Republished by Forum Admin)
I am 73 years old. Last month, I could not urinate and after ultra sound done, my prostate was found to be about 90 mm big. I was given the options of taking medicines or surgery. I chose medicine and was given Duodart 0.5mg/0.4mg. After taking the medicine, I have good urination. After taking the medicine for 2 weeks, blood test for PSA was 14 ( No test was done before taking the medicine ). 3 weeks after the prostate enlargement diagnosis, my left side testicle started to swell and slightly painful. Urologist said it was due to infection and ultra sound showed pus inside. I was warded for a few days where antibiotic and medicine was given. Follow up after a few days showed no more pus and pain. The swelling of the testicle is still the same today ie about 10 days after the treatment for the infection. I am still taking the antibiotic.
I would be very obliged if you can advise me on:
Thank you for the question. It sounds like your questions are not really about prostate cancer and more about benign prostate enlargement and infection of the testis (orchitis). Let me try to answer the prostate-related questions.
Posted by Irene Tan (Republished by Forum Admin)
What are the symptoms of prostate cancer?
Do the men simply ask to be screened for it? When do we screen for it?
Is there any preventive measures for it?
Thanks for the question.
Prostate cancer most of the time has no symptoms. However when symptoms develop they may include urinary problems including difficulty passing urine, fresh blood in urine, blood in semen or bone pain.Screening (testing of patients with no symptoms) of prostate cancer is controversial as the PSA blood test used for screening is associated with a lot of over-treatment and over-diagnosis. Many conditions like benign prostate enlargement or prostate infections can cause raised PSA test not just prostate cancer. In general, we only advise screening of men with risk factors such as family history of African-American race. In these patients, screening starts at age 45 onwards. In general, we do not screen men who have fewer than 15 years of life expectancy.
The role of prevention of prostate cancer with certain foods has been extensively studied. Some dietary factors have been shown to increase the risk of prostate cancer with obese patients, and those with high meat diets having higher risk of the disease. Many other dietary factors have been studied to see if they reduced risk of prostate cancer. Fruit and vegetables (no benefit), beta-carotene (no benefit), lycopene (rich in tomatoes – some mild benefit), vitamin D (no benefit) and selenium (no benefit). As such, from a dietary perspective, we would advise patients to have a healthy balanced diet and regular exercise to avoid obesity. Smoking is also associated with most cancers including prostate cancer and I would recommend all smokers to stop smoking.