Prostate cancer is fast becoming one of the most common cancers affecting Singaporean men as our population ages.

With improved diagnostic techniques including more prevalent use of PSA (Prostate-Specific Antigen) tests, multi parametric MRI scans of the prostate and targeted prostate biopsies, this has led to an increase in the number of cases. However most prostate cancers are low risk, which carries minimal impact on patient survival.

Dr Raj Vikesh Tiwari, Associate Consultant for the Department of Urology at Sengkang General Hospital (SKH), a member of the SingHealth group, answers your queries about prostate cancer screening, diagnosis and treatment.


Posted by Vishal Chand (Republished by Forum Admin)

Dear Doctor,

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)

Hi,

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!

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

Dear Mr Ang, thanks for the question.   

I would divide my answer into 2 parts as you do seem to have 2 issues here.

First the issue regarding the MRI prostate. Currently multiparametric MRI prostate has been a more prevalent tool used by doctors to assess the prostate for suspicious growths like cancer, especially in patients who have had negative biopsies like yourself. The multiparametric MRI prostate is a very good test with sensitivity and specificity levels above 90% (it can rule in or rule out prostate cancer very well). I am not sure what your MRI showed, however, in general suspicious growth on MRI scan are reported based on PIRADS score (from 1 to 5) with score 1 - 2 being unlikely for high-grade prostate cancer, 3 being equivocal and 4 - 5 being highly likely for high-grade prostate cancer. If you are concerned, you should relook at your MRI PIRADS score and discuss with your urologist. MRI findings which are truly not suspicious do not require further biopsy. Of course, your PSA score would also be a factor here.

The second part is on your symptoms of difficulty passing urine and urge. I also note you have been taking Avodart (dutasteride). In general, the symptoms you describe are due to benign prostate hyperplasia which is the benign, non-cancerous growth of prostate related to age which often may cause urinary obstruction and symptoms as you have mentioned. Avodart is a drug used for the treatment of these benign prostate hyperplasia. This condition is unrelated to prostate cancer. Follow up plan should be based on the advice of your urologist after he has assessed you.

I hope this answer has helped you! Regards.


Posted by Michael K (Republished by Forum Admin)

Dr Raj,

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.

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

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)

Dear doctor,

We would be grateful if you could shed some light on this:

  1. What is the current thinking on the PSA test as an indicator or predictor of prostrate cancer?
  2. If one's PSA remains at say 10 for a few years, or increases from 6 to say 12 over 5-6 years, is that cause for concern?
  3. Apart from invasive tests, are there any tests to conclusively test for prostate cancer?

Thank you.

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

Dear Mr Roy,

Thanks for the questions.

  1. PSA test is the most prevalent test used around the world for diagnosis and management of prostate cancer. As such, it has an important place in monitoring patients who already have prostate cancer or have factors that indicate prostate cancer in their medical history or physical examination. Its role in screening for prostate cancer (testing of patients with no symptoms or no risk factors for prostate cancer) however, is controversial. PSA tests can be elevated for many reasons apart from prostate cancer, such as benign prostate hyperplasia or even prostate infections. As such, its use as a screening tests has led to much overtreatment and over diagnosis in patients with added costs and risks to these patients with little benefits. As such, I would recommend any patient who is interested to do PSA screening to discuss the pros and cons with his physician carefully and make a shared decision before doing the test.
  2. Although there is no normal value for PSA, it does have some commonly accepted age-based normal ranges and although I’m not sure of your age most practitioners will accept 4 as a cut off for raised PSA in older men. A PSA range from 4-10 does carry a 30% chance of prostate cancer. This means that with a PSA of 10 there is a concern about prostate cancer although other causes like benign prostate hyperplasia or prostate infections will need to be excluded. A PSA rise from 6 to 12 over 6 years would be concerning especially in a patient who does not have prostate cancer diagnosed as it is a doubling of PSA level. Patients with these elevated PSA readings should certainly seek consultation in the clinic with their urologists and may need a prostate biopsy or further tests.
  3. In the current medical practice, diagnosis of prostate cancer is still based on prostate biopsies. These biopsies may be performed through the anus and rectum (transrectal ultrasound guided prostate biopsy) or through the skin of the perineum (area just below the scrotum and above the anus) (transperineal prostate biopsy). These minimally invasive techniques use needles to infiltrate the prostate tissue and get samples. MRI scan of the prostate is a non-invasive scan that can indicate certain location in the prostate that is suspicious for prostate cancer however patients will still need a biopsy to confirm that those areas are indeed cancer. Only after diagnosis of the grade and stage of the prostate cancer can your urologist decide with you regarding next step in care, as different stages may require different treatments.

I hope this answer has helped you! Regards.


Posted by Mengdong (Republished by Forum Admin)

I had an earlier ultra-sound scan for my prostate, and it discovered some symptom of minor prostatic calcification.

  1. Will this lead to prostate cancer?
  2. What’s the early condition which will lead to prostate cancer?
  3. What’s the preventative measures?
  4. What are the low cost medical check-up options to detect prostatic problems in early stage?

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

Dear Mr Mengdong thanks for the questions.

  1. Prostatic calcifications by themselves do not confer increase risk of prostate cancer. They may be present as a result of age related changes in the prostate. However, if your PSA test is raised you should discuss with your physician about a biopsy.
  2. The 2 known conditions believed to be precursors for prostate cancer are high grade prostate intra-epithelial neoplasia (HGPIN) and abnormal small acinar proliferation (ASAP). Both HGPIN and ASAP are diagnosed after a prostate biopsy. HGPIN carries a 20% chance of diagnosis of prostate cancer on further biopsies and ASAP carries a 40% chance of prostate cancer diagnosis. As such, patients with these conditions would need repeated biopsies usually within 12-18 months of previous biopsy, after consultation with their urologists.
  3. 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.
  4. Any patients with urinary tract symptoms with concern for prostate causes should be evaluated by an urologist. During the evaluation, your urologist will perform a history taking to assess your presentation and risk factors, and a physical examination including a digital rectal examination (finger in anus to feel prostate for nodules and growths) which is inexpensive and easily performed. After discussing with the patient, the physician may order a blood PSA test to assess the patient’s likelihood for having prostate malignancy. The digital rectal examination and PSA are mainstay first line inexpensive investigations for prostate cancer.

I hope this answer has helped you! Regards.


Posted by anthony (Republished by Forum Admin)

How long can a patient live after removed his 3 stage of prostate cancer?

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

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.

I hope this answer has helped you! Regards.


Posted by soh (Republished by Forum Admin)

Dear Dr,

  1. What are the discharge symptoms of prostate cancer?
  2. If there are no symptoms, how does one get a referral letter from the Polyclinic to do a checkup?

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.

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

Dear Mr Soh,

Thanks for your question.

Prostate cancer may present with or without any symptoms. When it presents with symptoms it may be related to urinary tract such as fresh blood in urine, difficulty passing urine, painful urination or frequency and urgency of urination. There may also be blood in the semen. Some patients with advanced prostate cancer may also present with bone pain and retention of urine.

If you have no symptoms then you should discuss with your primary care doctor if there really is a need for you to see a urologist or perform a PSA screening test (a test in patient with no symptoms is called screening). PSA screening is controversial as it is associated with a lot of over treatment and over diagnosis. PSA can be raised for many reasons including benign prostate hyperplasia or prostate infections rather than cancer. The use of PSA tests in patients without symptoms is generally for those with risk factors such as a family history. As such, not all patients require a PSA test.

I hope this answer has helped you! Regards.


Posted by Harry (Republished by Forum Admin)

Good morning.

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.

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

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.

I hope this answer has helped you! Regards.


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?

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

Dear Mr Javier,

Thank you for your question.

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.

I hope this answer has helped you! Regards.


Posted by Michelle (Republished by Forum Admin)

Dear Doctor,

As my father side families have history of prostate cancer, I would like to ask some questions on it.

  • How does prostate cancer comes about?
  • What causes it?
  • Is it an inheritance case?
  • Does any food can prevent it or cause it?
  • Any form of prevention on this?
  • Heard that regular sex can prevent it. Is it true?

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

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 cholesterol diets.   

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! Regards.


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!

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

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.

I hope this answer has helped you! Regards.


Posted by Mr Ahmad (Republished by Forum Admin)

  1. Does this occur in some races more often? I am an Indian. Am I more or less at risk?
  2. What age should I go for the screening?
  3. What are the symptoms that I should look for?

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

Dear Mr Ahmad,

Thanks for your question.

  1. Indeed, in many studies in the West, prostate cancer is known to be more common in African-American populations. However, among our Asian population there is no racial differences found so far.
  2. PSA screening is a controversial area and generally only necessary for those with risk factors (family history, racial background). In those populations, it is advised to start screening from 45 years onwards. As for other patients with no risk factors, patients should discuss with their urologists before doing PSA tests due to high rates of over diagnosis and overtreatment. PSA may be raised for many reasons apart from prostate cancer such as benign prostate enlargement or prostate infections. Only after understanding the pros and cons for testing should patient choose PSA screening. Based on American guidelines, the age group for PSA screening in patients with no risk factors is 55-69. Very elderly patients with decreased life expectancy below 15 years should not do PSA screening.
  3. 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. More advanced cases of prostate cancer may present with bone pain, weight loss and urine retention.

I hope this answer has helped you! Regards.


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?

Thank you.

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

Dear Mr Laurence,

Thanks for your question.

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.

I hope this answer has helped you! Regards.


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.

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

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.

I hope this answer has helped you! Regards.


Posted by peri (Republished by Forum Admin)

Dear Doctor,

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?

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

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.

I hope this answer has helped you! Regards.


Posted by Hanah (Republished by Forum Admin)

Hi Doc,

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?

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

Dear Hanah,

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!

I hope this answer has helped you! Regards.


Posted by Ng Wee Tye (Republished by Forum Admin)

Dear sir,

My question:

Is external radiation therapy and targeted radiation therapy available in Singapore government hospital?

If yes where is it available?

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

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.

I hope this answer has helped you! Regards.


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?

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

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 effects.

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! Regards.


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:

  1. Do I need to have the surgery for my prostate enlargement.
  2. Would the prostate shrink if I continue taking Duodart.   
  3. Any complications later on if I continue taking Duodart.   
  4. At PSA reading of 14, is it necessary for me to go for biopsy for prostate cancer.
  5. How long would it take for my testicle swelling to shrink back to normal size now that no presence of pus.   

Thank you.

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

Dear Sir

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.   

Indication for surgery of the prostate in benign prostate hyperplasia include bleeding in urine, inability to pass urine (urine retention), bladder stone, recurrent urine infections, bladder diverticulum and failure of medical therapy. You will need to discuss with your own urologist about whether surgery is required for you.   

Duodart is a combination medication of dutasteride and tamsulosin. Dutasteride is a medication that indeed helps to reduce prostate volume, however it takes 6 months to start its effect. On average, most patients may see around 25% reduction in prostate volume over 6 months to 1 year.

Duodart is designed as a long-term medication. Side effects of the dutasteride component may include decreased sex drive or erectile dysfunction. Side effects of tamsulosin component may include dizziness, postural blood pressure drop, blocked nose, floppy iris syndrome and retrograde ejaculation (semen pass into bladder instead during sex). It should be noted that not all side effects are seen in all patients.

PSA of 14 is considered high. As you know, there are many causes of raised PSA including benign prostate hyperplasia which you have. Not all raised PSA is due to prostate cancer. You may discuss with your urologist about pros and cons of a prostate biopsy.
Testicular infection should be discussed with your own urologist.

I hope this answer has helped you! Regards.


Posted by Irene Tan (Republished by Forum Admin)

Dr Raj,

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?

Answered by Dr Raj Vikesh Tiwari, Associate Consultant, Department of Urology at Sengkang General Hospital (SKH)

Dear Irene,

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.

I hope this answer has helped you! Regards.


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