Prostate cancer is a pressing health concern, ranking as the third most common cancer among Malaysian men.
However, the traditional treatment methods for prostate cancer present challenges, including potential side effects that can have a long-term impact on the patient’s quality of life.
Men’s Health Awareness Month in June presents the perfect opportunity to educate and empower individuals about the latest developments in prostate cancer treatment and inspire proactive action for early detection.
Below is CodeBlue’s Q&A with Dr Peter Ng, a consultant urologist from Subang Jaya Medical Centre (SJMC), where we delve into the innovative advancements in prostate cancer treatment and the role of cutting-edge technology in revolutionising patient care.
Can you please provide a brief overview of prostate cancer and its prevalence among Malaysian men?
According to the publication by Jasmine Ng and colleagues, statistics from nine public urology referral centres across Malaysia revealed that between 2016 and 2018, 1,839 new patients were diagnosed with prostate cancer. They estimated that prostate cancer is the third most common cancer in Malaysia, and men have a lifetime risk of 1 in 117.
However, it’s important to note that this study only involved a small number of urology units, and a comprehensive investigation of the prevalence in the wider community is still lacking. Malaysians are not particularly known for their proactive approach to seeking early health care, especially in rural areas where late disease presentation is common.
Currently, there are no widespread screening programs in place to obtain a more accurate understanding of the true prevalence of prostate cancer within the community.
Therefore, it is likely that Jasmine Lim’s studies only captured those who sought care at the six urology centres, leaving undetected cases in the community.
Prostate cancer is more prevalent among Caucasians and Blacks compared to Asians, and its incidence is higher in developed countries compared to developing ones. In Southeast Asia, the incidence is reported to be 11.2 per 100,000 male patients (Martin C.S. Wong, William B. Goggins Harry H.X. Wang, et al * Global Incidence and Mortality for Prostate Cancer: Analysis of Temporal Patterns and Trends in 36 Countries EUROPEAN UROLOGY 70 (2016) 862–874).
Singapore, for example, has an incidence rate of 25 per 100,000 males, which is increasing along with mortality rates. In contrast, Australia has a stable incidence rate of 120 per 25 per 100,000 males.
What are the challenges associated with traditional treatment methods for prostate cancer, and how are these challenges being addressed with advancements in technology?
If we understand “traditional” treatment methods for prostate cancer to refer to current methods of treatment, such as those mentioned in the subsequent questions about Stereotactic Body Radiation Therapy (SBRT), then the challenges associated with these methods are the extended duration of radiation treatment, which currently spans over five weeks with daily sessions lasting 10 to 15 minutes, conducted five days a week, to deliver the necessary radiation dose to the prostate cancer site.
Additionally, there are issues with collateral damage to nearby organs, including the bladder, urethra, and rectum. These effects can be both acute and long-term, leading to debilitation and a decreased quality of life for patients.
Therefore, treatment always needs to strike a balance between delivering an effective radiation dose and minimising the risk of collateral damage.
Another “traditional” or commonly accepted treatment method is brachytherapy, where radioactive seeds are directly implanted into the prostate to emit low-dose radiation, treating cancer from within the prostate rather than using external sources of ionising radiation, as in external beam radiotherapy.
This approach offers the advantage of causing less collateral damage to the surrounding normal tissues.
Newer treatment methods aim to achieve more precise targeting of the tumour to reduce collateral damage.
Could you please explain how Stereotactic Body Radiation Therapy (SBRT) works, and how it enhances precision and safety in prostate cancer treatment?
SBRT is an innovative technique of external beam radiation that allows for the delivery of the entire radiation dose over a shorter period, typically five to six days, compared to the conventional Intensity-Modulated Radiation Therapy (IMRT), which requires 5 weeks of treatment.
This approach has proven effective in certain grades of prostate cancer, demonstrating a high local control rate while minimising toxicity to normal tissues.
SBRT has already shown effectiveness in treating lung cancers and lung metastases, primary liver cancers and liver metastases, pancreatic cancers, prostate cancer, recurrent head and neck cancer, recurrent gynaecologic cancers and various other types of cancer in different regions.
For low and intermediate risk prostate cancers, SBRT has demonstrated biochemical relapse-free survival rates of 90 to 100 per cent, with a median follow-up of five years or more.
Furthermore, there is early evidence suggesting that SBRT is equally effective as brachytherapy, but with lower levels of side effects.
The working mechanism of Stereotactic Body Radiation Therapy involves highly precise targeting of prostate cancer, facilitated by the insertion of gold fiducials into the prostate gland by the Urologist to aid in the targeting process.
Additionally, the injection of a specialised gel into the space between the rectum and prostate creates a barrier that shields a significant portion of the rectum from radiation damage.
What is the role of a gel-like spacer as part of the prostate cancer treatment process?
This procedure involves injecting a gel to create a protective shield, effectively separating the prostate from the front of the rectum. The primary goal is to reduce the damaging effects of radiation on the rectum.
Recent data from overseas has shown promising results, indicating a reduction in the incidence of radiation proctitis from the typical rate of 13.8 per cent to a mere 2.9 per cent with the implementation of this procedure.
This significant reduction in rectal complications allows for the delivery of a higher radiation dose to the prostate, thereby improving the effectiveness of the treatment.
What do you foresee as the future of integrating health tech solutions in cancer treatment and overall patient care?
Indeed, the integration of health tech cancer solutions has played a significant role in advancing cancer treatment and improving overall patient care. MRI imaging advancements in prostate cancer have led to better and safer biopsy techniques.
Specialised scans, such as PSMA scans, have allowed us to explore the potential of focal therapy for prostate cancer. This approach involves targeting individual lesions within the prostate using highly focused ultrasounds, lasers, electroporation or cryotherapy.
By doing so, the surrounding healthy tissue can be spared, minimising collateral damage. Since 2015, there have been nearly 6,000 patient trials and 72 studies on these newer modalities.
Additionally, there is a growing range of options for advanced prostate cancer, including novel drugs like PARP inhibitors. These drugs belong to a unique class of anti-cancer therapy that exploits defects in DNA repair mechanisms.
Radioligand therapy utilising agents like Lutetium 177 specifically targets prostate cancer cells, offering both diagnostic and therapeutic benefits simultaneously. This development has given rise to a new field known as “theranostics”.
The only drawback is that every new healthcare solution is accompanied by an incessant escalation of health care costs.
They say early detection is always the most effective way to combat cancer and other diseases. Do you have any advice you would like to convey to Malaysians in this regard?
The most effective approach to combating prostate cancer is early detection. My advice to all men aged 50 and above is to undergo a simple blood test known as the “Prostate Specific Antigen” test. This test is affordable and can promptly identify the 20 per cent of men who require further investigations for early detection of prostate cancer.
The ProTect trial, one of the longest recorded trials on prostate cancer treatment conducted in the United Kingdom, demonstrated a remarkable 96 to 97 per cent survival rate for clinically localised prostate cancer over a median follow-up period of 15 years, regardless of the treatment assigned.
The encouraging news is that prostate cancer is highly treatable, and it is crucial to prioritise treatment for men with an expected lifespan exceeding 10 years. Prostate cancer at the curable stage typically manifests without any noticeable symptoms.
Therefore, it is essential not to wait until experiencing difficulties in urination or pain. Get your PSA tested and consult your general practitioner or urologist.
For elderly individuals who do not have a realistic life expectancy beyond this timeframe, a more conservative approach may be appropriate, considering that only one out of every seven men diagnosed with prostate cancer actually succumbs to the disease.