Prostate Cancer

Prostate cancer develops when cells in the prostate — a small, walnut-sized gland located below the bladder and in front of the rectum, which produces fluid that nourishes and transports sperm — begin to grow and divide abnormally. It is one of the most commonly diagnosed cancers in men, and rates have been rising in Singapore in recent years, partly due to an ageing population and partly due to greater use of PSA blood testing, which detects more cancers at an earlier, more treatable stage.

Prostate cancer behaves very differently from man to man. Some prostate cancers grow so slowly that they may never cause symptoms or require treatment in a man's lifetime, while others are aggressive and can spread beyond the prostate if not treated. This wide variation is why modern prostate cancer care is not a single pathway, but a highly individualised process — one that weighs the biology of the specific cancer, the man's age and overall health, and his personal priorities, before deciding whether and how to treat it.

Understanding the Prostate and How Cancer Develops

The prostate sits just below the bladder, surrounding the urethra (the tube that carries urine and semen out of the body). Because of this location, changes in the size or structure of the prostate — whether from cancer or from the much more common non-cancerous condition, benign prostate hyperplasia (BPH) — can affect urinary function. Prostate cancer nearly always begins in the gland cells that produce prostatic fluid (adenocarcinoma), and in its earliest stages is typically confined entirely within the prostate capsule, where it is described as localised.

Left undetected or untreated, cancer cells may eventually break through the prostate capsule and invade nearby structures such as the seminal vesicles, or spread further afield through the lymphatic system and bloodstream — most commonly to the pelvic lymph nodes and to bone. This is referred to as advanced or metastatic disease, and it changes the treatment approach considerably, from one aimed at cure to one focused on long-term control and quality of life.

Prostate Cancer vs Benign Prostate Hyperplasia (BPH)

Many men are understandably confused by the overlap between prostate cancer and BPH, as both become more common with age and can cause similar urinary symptoms. However, they are distinct conditions: BPH is a non-cancerous enlargement of prostate tissue that narrows the urethra and affects urine flow, while prostate cancer is a malignant change in prostate cells that, in its early stages, typically causes no urinary symptoms at all. Having BPH does not increase or decrease the likelihood of developing prostate cancer, and one condition does not need to be present for the other to occur — though many older men live with both simultaneously.

Symptoms of Prostate Cancer

Localised, early-stage prostate cancer usually causes no symptoms at all — this is precisely why screening with PSA blood tests and digital rectal examination matters, particularly for men in higher-risk groups. When symptoms do appear, they typically signal that the cancer has grown large enough to affect the urethra, or has spread beyond the prostate.

• Blood in the urine or semen
• Frequent urination, particularly at night (nocturia)
• A weak, interrupted or slow urinary stream
• Difficulty starting or fully emptying the bladder
• Discomfort or a burning sensation during urination
• Erectile dysfunction or painful ejaculation
• Discomfort in the pelvic area
• Unexplained lower back, hip or bone pain — which can be a sign that the cancer has spread to the bones — and, less commonly, unexplained weight loss or fatigue in advanced disease

It is worth noting that difficulty urinating and a generally enlarged prostate are, more often than not, caused by BPH rather than prostate cancer — but any new urinary symptom is still worth having assessed, both to rule out cancer and to treat BPH itself if present.

Risk Factors for Prostate Cancer

• Age: Prostate cancer is rare before age 40, and risk rises steadily thereafter — the majority of cases are diagnosed in men over 65.
• Family history: Having a father or brother with prostate cancer roughly doubles a man's risk, and risk rises further with multiple affected relatives or a relative diagnosed at a young age.
• Inherited genetic mutations: Inherited mutations in genes such as BRCA1, BRCA2 (more strongly linked to prostate cancer than commonly assumed) and Lynch syndrome-related genes are associated with a higher lifetime risk and, in the case of BRCA2, with more aggressive disease. Men with a strong family history of breast, ovarian or prostate cancer may be candidates for genetic counselling and testing.
• Ethnicity: Global data consistently show prostate cancer incidence and mortality varying by ethnicity, with men of African descent facing a notably higher risk of both diagnosis and aggressive disease; population-level risk also varies across Asian ethnic groups, an area of ongoing local research interest.
• Obesity: Men who are obese are more likely to be diagnosed with aggressive prostate cancer and to experience cancer recurrence after treatment.
• High occupational pesticide exposure: Some studies suggest that men in occupations with significant pesticide exposure may carry a modestly elevated risk, although the evidence is less consistent than for age, family history and genetics.
• Diet: Diets high in processed and red meat and dairy, and low in vegetables, have been associated with a modestly higher risk in some studies, although the evidence is less definitive than for the factors above.

Possible Complications of Prostate Cancer

• Local growth into surrounding structures such as the bladder, seminal vesicles or rectum, causing urinary or bowel symptoms
• Spread to pelvic lymph nodes
• Spread to bone (most commonly the spine, pelvis and hips), which can cause pain, an increased risk of fractures, and spinal cord compression in advanced cases
• Spread to other organs, including the liver and lungs, in more advanced metastatic disease
• Urinary obstruction, if the tumour grows large enough to significantly compress the urethra
• Anaemia and fatigue, more common in advanced or heavily treated disease
• Emotional and psychological impact, including anxiety around diagnosis, treatment decisions and the effect of treatment on sexual and urinary function — increasingly recognised as an important part of overall care

Screening and Diagnosis of Prostate Cancer

Because early prostate cancer rarely causes symptoms, diagnosis usually begins with screening tests, followed by imaging and tissue confirmation if results are abnormal. Screening itself is a nuanced decision — PSA testing can detect cancer early, but it can also flag slow-growing cancers that may never have caused harm, so the decision to screen is best made after an informed discussion with a doctor about individual risk, life expectancy and personal preference, typically from age 50 (or earlier, from 40 to 45, for men with a strong family history, known genetic mutation, or African ancestry).

• PSA Blood Test: Measures prostate-specific antigen (PSA), a protein produced by prostate cells. Elevated or rapidly rising PSA can indicate cancer, but can also be raised by BPH, prostatitis (prostate infection or inflammation), recent ejaculation or vigorous exercise — so an elevated result prompts further evaluation rather than an automatic cancer diagnosis.
• Digital Rectal Examination (DRE): A doctor inserts a lubricated, gloved finger into the rectum to feel the size, shape and texture of the prostate, checking for hard areas, lumps or asymmetry that may suggest cancer. Often performed alongside PSA testing as a complementary check.
• Multiparametric MRI (mpMRI): Increasingly used before biopsy to identify suspicious areas within the prostate, helping to target biopsies more accurately, avoid unnecessary biopsies in men with a low-suspicion scan, and improve detection of clinically significant cancer.
• Prostate Biopsy: The definitive way to diagnose prostate cancer. Small tissue samples are taken from the prostate, usually guided by ultrasound and increasingly fused with MRI imaging to target suspicious areas, and examined under a microscope by a pathologist.
• PSMA PET Scan: A specialised imaging test using a radioactive tracer that binds to prostate-specific membrane antigen (PSMA), a protein highly expressed on prostate cancer cells. It is the most sensitive imaging technique available for identifying whether cancer has spread beyond the prostate, and is used particularly in higher-risk or recurrent disease.
• Genetic Testing & Counselling: Recommended for men with a strong family history, certain high-risk or metastatic disease features, or relatives with breast, ovarian or pancreatic cancer, to check for inherited mutations (such as BRCA2) that can affect treatment choice and screening for family members.

Active Surveillance of Prostate Cancer

One of the most important, and often least understood, aspects of modern prostate cancer care is that a diagnosis does not automatically mean immediate surgery or radiation. For men with low-risk, and select favourable intermediate-risk, localised prostate cancer, active surveillance — closely monitoring the cancer over time rather than treating it right away — is now a recommended, evidence-based strategy, not simply "doing nothing."

Active surveillance typically involves regular PSA testing (about every six months), periodic digital rectal examination, follow-up MRI, and repeat biopsy at defined intervals, to watch for any signs that the cancer is becoming more aggressive. If monitoring shows the cancer is progressing, treatment can then be pursued with curative intent — meaning many men are able to avoid or significantly delay the side effects of surgery or radiation without compromising their long-term outcome.

This approach reflects a broader shift in prostate cancer care: the goal is not simply to detect and treat every cancer found, but to match the intensity of treatment to the actual threat the cancer poses.

Managing Side Effects and Life After Treatment

Prostate cancer treatments can affect urinary, sexual and bowel function, and understanding this upfront helps men make an informed choice and plan for recovery. Side effects vary by treatment type and individual factors, and many improve significantly with time, rehabilitation and, where needed, further treatment.

• Urinary incontinence: Temporary or, less commonly, longer-term urinary leakage can follow surgery or radiation; pelvic floor exercises started before or soon after treatment can meaningfully speed recovery, and further treatment options exist for persistent symptoms.
• Erectile dysfunction: Difficulty achieving or maintaining an erection is common after surgery or radiation, particularly in the months following treatment. Nerve-sparing surgical techniques, medication, vacuum devices, injections and other rehabilitation options can help restore function over time for many men.
• Effects of hormone therapy: Hormone therapy can cause hot flushes, fatigue, loss of muscle mass, mood changes, reduced bone density and reduced libido; these are actively monitored and managed, including with bone-protective medication where needed for longer courses of therapy.
• Bowel symptoms: Radiation therapy can occasionally cause temporary bowel urgency, diarrhoea or rectal irritation, which usually settles after treatment ends.
• Emotional wellbeing: A cancer diagnosis and its treatment can affect mood, self-image and relationships; many hospitals, including Farrer Park Hospital, can facilitate access to counselling and peer support alongside physical recovery.

After treatment, regular PSA monitoring continues long-term to check for recurrence — a rising PSA after surgery or radiation is usually the earliest sign that further evaluation or treatment may be needed, often well before any symptoms would appear. This is why long-term follow-up remains an essential part of prostate cancer care, even years after successful initial treatment.