A Urologist Addresses the More Controversial Aspects of Prostate Cancer Screening

WORDS PROFESSOR DATO’ SETIA DR TAN HUI MENG

FEATURED EXPERT
PROFESSOR DATO’ SETIA DR TAN HUI MENG
Consultant Urologist
Subang Jaya Medical Centre (SJMC)

Prostate cancer is the third most common cancer among the male population in Malaysia after colorectal and lung cancer.

However, despite these staggering numbers, compared to breast cancer, prostate cancer screening appears to be a very controversial topic in medicine.

THE UNCERTAINTIES SURROUNDING PROSTATE CANCER

To date, most health professionals and the public at large are still lost and uncertain on how to go about preventive measures and the treatment of prostate cancer.

Sometimes, early prostate cancers are localized and contained within the prostate. The cancer grows very slowly and may not cause problems for years or may not even become advanced cancer. In cases like these, patients do not need to be treated.

THE RECOMMENDATION FOR PROSTATE CANCER SCREENING

In the United States, the Preventive Services Taskforce (USPSTF) gave a Grade C recommendation on screening for prostate cancer, which means individuals do not necessarily need to screen for prostate cancer unless they have concerns, and they should discuss their concerns with their physicians.

This recommendation came about to reduce the overdiagnosis and overtreatment of prostate cancers.

This decision, however, has resulted in an increasing trend of prostate cancer mortality and morbidity, causing much suffering and compromising the quality of life for patients.

THE CHALLENGE THAT WE FACE TODAY

The challenge today is to come up with a strategy to screen the right population and find lethal prostate cancers.

Equally important, we will also need new treatments that are less invasive and cause less morbidity in individuals.

IMPROVING SCREENING ACCURACY WITH mpMRI SCREENING

For more than 30 years, the medical profession did not make headway with regard to the diagnosis and management of prostate, other than developing robotic techniques and better radiotherapy to remove the tumours.

The Problem with the ‘Old System’

The diagnosis using systematic non-targeted transrectal ultrasound scan (TRUS) guided biopsy is highly inaccurate as it has high false negative rate. This is dangerous as it misses at least 50% of cancer.

The Development of mpMRI and Its Advantages

The transformative advancement in the diagnosis and treatment of prostate cancer was the development of multiparametric MRI (mpMRI) of the prostate.

Using mpMRI as a triage can spare significant number of men from undergoing unnecessary prostatic biopsies and avoiding both physical and psychological trauma and morbidity, especially if TRUS biopsies are performed.

Many studies have confirmed that mpMRI is highly reliable in identifying more than 90% of men with clinically significant and lethal prostate cancer.

This method was reported to be much more sensitive (93%) in detecting prostate cancers compared to TRUS biopsies (48%).

MpMRI as a triage also detects much fewer clinically unimportant prostate cancer (54% fewer) compared to using the traditional TRUS biopsy.

In other words, mpMRI reduces overdiagnosis of clinically unimportant prostate cancer and improves the detection of clinically significant and deadly prostate cancer.

HENCE, TO SCREEN OR NOT TO SCREEN?

Many screening studies have shown that for men diagnosed with prostate cancers, whether they are treated or not, their survival outcome is generally over 10 years or so.

This shows that a majority of the men with prostate cancer detected by screening do not benefit from treatment.

Instead, they suffer the consequences of treatment, like losing potency and experiencing urinary or rectal symptoms with occasional incontinence!

However, long-term studies show the benefits of screening are observed after consistent follow-ups for 12 years or more.

The Goteborg Randomised Cancer Prostate Screening Trial, done in Sweden, revealed that for men who have undergone over 14 years of follow-up and completed the screening, there was a 66% decrease in advanced prostate cancer in the screened population compared to the population of men who were randomized to the non-screening arm.

Therefore, one can conclude that men who have serial PSA screening and then treated if prostate cancer is detected have a 66% less chance of developing advanced prostate cancer—which often results in very painful bone metastases.

There was also a 56% lower mortality rate in the screened population.

Extrapolating from this result, in the Swedish population, PSA screening can save 5,700 out of 1 million screened men from dying of prostate cancer.

THE BEST WAY FORWARD

In summary, prostate cancer is still a significant life-threatening disease.

Early detection and early prediction of the disease are crucial, whereas screening in men with long life expectancies is beneficial.

Overdiagnosis and overtreatment issues can be addressed with targeted screening and biopsy only for at-risk patients. This aims for early detection & diagnosis of localized lethal prostate cancer, which is fully curable.

If diagnosed with non-lethal prostate cancer (especially low-grade cancer), individuals only require good active surveillance with a follow-up mpMRI. They should also repeat a biopsy of the prostate if necessary.

It is crucial for those with intermediate-grade prostate cancer (ISUP 2) or large volume low-grade prostate cancer (> 6mm core cancer tissue) to receive careful active surveillance paired with good clinical judgement and a follow-up mpMRI as well.

Men with localized lethal prostate cancer will need ablative treatment with surgery, radiotherapy or occasionally brachytherapy. Counselling for adverse events like erectile dysfunction and occasional urinary incontinence following ablative treatments should also be given.

MpMRI has greatly improved the diagnosis of clinically important prostate cancer, and better genomics will help predict the prognosis of the disease. Transperineal mpMRI – ultrasound fusion prostatic biopsy is the way forward. Focal therapy like HIFU, irreversible electrophoresis or targeted ablation will probably play an increasing role, especially for patients with favourable intermediate-risk or low-grade large-volume prostate cancer.

What Happens When Your Prostate Gland Becomes Enlarged? Find Out from A Consultant Urologist

WORDS DR GOH ENG HONG

FEATURED EXPERT
DR GOH ENG HONG
Consultant Urologist
Prince Court Medical Centre
BENIGN PROSTATIC HYPERPLASIA (COMMONLY ABBREVIATED AS BPH) IS A NON-CANCEROUS ENLARGEMENT OF THE PROSTATE GLAND COMMONLY OBSERVED IN OLDER MEN
An overview of benign prostatic hyperplasia. Click on the image for a larger, clearer version.

This condition has become more common due to several factors including:

  • Changes in men’s attitude towards their health and well-being. These changes in attitude led to them seeking medical advice more proactively.
  • Advancements in healthcare have led to a longer lifespan seen among men. Because of this, there is an increase in the number of elderly individuals and consequently has a rise in the incidence of benign prostatic hyperplasia.

By the age of 50, about 50% of men experience prostate enlargement, and this figure rises to about 80% by the age of 80.

This highlights a significant correlation between age and the prevalence of benign prostatic hyperplasia.

COMMON SYMPTOMS OF BENIGN PROSTATIC HYPERPLASIA
Seek medical attention when you experience any of these symptoms over a long period of time or when they interfere with your daily routines.
  • Frequent trips to the restroom
  • A need to wake up from sleep to urinate (nocturia)
  • Weak urine flow
  • Painful urination
  • Blood in the urine
  • A feeling of incomplete bladder emptying
  • Symptoms of more advanced stages of benign prostatic hyperplasia can include high fever and/or an inability to urinate.
SYMPTOMS OF BENIGN PROSTATIC HYPERPLASIA CAN WORSEN OVER TIME

This is especially true as individuals age and potentially encounter other health problems that can worsen their prostate issues, such as diabetes and stroke.

However, if one’s underlying health issues are well-managed and infections are treated effectively, there is potential for improvement in the prostate condition.

AVAILABLE TREATMENT OPTIONS FOR BENIGN PROSTATIC HYPERPLASIA

Treatment involves a comprehensive approach for managing any underlying conditions and considering the extent of the enlargement and its impact on the patient.

If the prostate enlargement is minimal, usually we will monitor for the time being for any further enlargement.

However, if symptoms cause significant discomfort, the doctor will prescribe the appropriate medications to manage these symptoms.

If medications are not effective, we can consider surgery. There are several surgical options to consider, depending on individual circumstances and preferences.

LIFESTYLE & SELF-CARE MEASURES TO MANAGE THE SYMPTOMS OF BENIGN PROSTATIC HYPERPLASIA
  • Adopt a lifestyle regimen that includes reducing the intake of irritants like caffeinated beverages—these irritants can increase the urge to urinate.
  • Reduce consumption of liquids and foods high in water content during the evenings, to help avoid nighttime bathroom visits.
  • Maintain proper hygiene to prevent infections, especially since prostate enlargement increases one’s risk of infection.
TIPS TO REDUCE ONE’S RISK OF BENIGN PROSTATIC HYPERPLASIA

Benign prostatic hyperplasia is associated with ageing. Good habits as above could prevent worsening of the condition.

Additionally, one should seek regular medical check-ups, such as blood and urine tests, to monitor kidney function and identify potential infections early.

Guys, Worried That You’re Shooting Blanks? Here’s Some Advice from a Fertility Specialist!

WORDS LIM TECK CHOON

FEATURED EXPERT
DR EESON SINTHAMONEY
Fertility Specialist
Director of Sunfert International Fertility Centre

According to Dr Eeson Sinthamoney, there are various possible reasons why a man’s fertility can be affected.

“Male infertility can be attributed to various biological factors, including genetic abnormalities, hormonal imbalances, anatomical issues, and underlying medical conditions,” he says.

He adds that lifestyle choices such as smoking, excessive alcohol consumption, and poor diet can also negatively affect a man’s fertility.

“While body weight does not primarily affect infertility in men, activities such as engaging in frequent and long bicycle rides can have an impact,” he further states.

HOW CAN A MAN BE SURE THAT HE IS SHOOTING BLANKS?

“A simple sperm test serves as the initial step in assessing sperm count and overall fertility health,” says Dr Eeson.

Once the test reveals that the man has infertility issues, the fertility specialist will investigate potential underlying issues that could be the cause of these issues, such as hormonal imbalances, genetic factors, and semen parameters.

“This thorough examination enables personalized treatment approaches tailored to address the unique factors affecting male fertility,” Dr Eeson assures us.

GENETIC TESTING CAN HELP DIAGNOSE SEVERE MALE INFERTILITY?

According to Dr Eeson, genetic testing allows the analysis of an individual’s genetic material, such as DNA or chromosomes, to identify any genetic abnormalities that can contribute to infertility.

For such testing, the doctor will obtain blood sample from the man and send it to the laboratory for further analysis.

A genetic counselor will then explain the results once they are available.

Consult a fertility specialist if you and your partner have been trying to conceive a child through normal sexual intercourse but are unsuccessful after 6 months to 1 year of trying. They can help identify possible causes that are keeping you from achieving your dreams of parenthood, as well as to share fertility treatment options that can help you become a parent.

You Aren’t Alone When It Comes to Infertility, Experts Say, So Here’s What You Can Do About It

WORDS DR KHINE PWINT PHYU & ASSOCIATE PROFESSOR DR GANESH RAMACHANDRAN

FEATURED EXPERTS

DR KHINE PWINT PHYU
Senior Lecturer in Obstetrics and Gynaecology
School of Medicine
Faculty of Health and Medical Sciences
Taylor’s University
ASSOCIATE PROFESSOR DR GANESH RAMACHANDRAN
Head of School
School of Medicine
Faculty of Health and Medical Sciences
Taylor’s University
THE INCIDENCE OF INFERTILITY IS ON AN UPWARD TREND WORLDWIDE
  • Infertility is defined as not being able to conceive after 1 year of unprotected sexual intercourse.
  • In women above 35, this duration is sometimes shortened to 6 months.
  • The World Health Organization estimates that 1 in 6 people are affected by infertility.
  • In Malaysia, there is a drop in fertility rates from 4.9 children per woman of childbearing age in 1970 to 1.7 in 2021.
CAUSES ARE VARIED, INVOLVING ISSUES IN EITHER PARTNER OR BOTH AND IN SOME CASES, THE CAUSES ARE DIFFICULT TO IDENTIFY

Female factors of infertility

  • Anovulation, or ovulation disorders, are situations where no eggs are released from the ovaries during the menstrual cycle. These disorders can be caused by:
    • Hormonal imbalances such as seen in polycystic ovary syndrome (PCOS) and excessive prolactin secretion.
    • Eating disorders.
    • Extremes of body weight.
    • Strenuous exercises.
    • Stress.
    • Chronic illnesses.
  • Blockage of fallopian tubes, caused by previous pelvic infections, inflammation of tubes, and pelvic adhesions which may be related to past surgery at the abdomen and pelvis. When the tubes are blocked, it will affect the transport of sperm to meet the eggs to achieve successful implantation and pregnancy.
  • Endometriosis, which is the presence of tissue that is normally found in the inner lining of the uterus, outside the uterine cavity, which may affect the function of the ovaries, uterus, and fallopian tubes.
  • Congenital abnormalities (malformations that develop before birth) of the uterus.
  • Uterine fibroids (non-cancerous growths which develop in and around the womb).

Male factors of infertility

  • Low sperm count, which can be seen in men with genetic defects, chronic health problems such as diabetes, liver or kidney diseases, or sexually transmitted infections like gonorrhoea. Abnormalities such as undescended testis and varicoceles (swollen veins within the scrotum) can also be causes.
  • Premature ejaculation.
  • Blockage or injury to the reproductive organs.
  • Usage of certain medications can affect sperm movement, quality, or lead to coital dysfunction.
  • Environmental and lifestyle factors such as use of tobacco, heavy alcohol, marijuana or steroids, exposure to toxins and exposure of the external genitalia to high temperatures.
BOTH PARTNERS NEED TO BE INVOLVED WHEN IT COMES TO FERTILITY TREATMENT

To support health education and increase awareness regarding numerous infertility issues faced by couples across the globe, World Infertility Awareness Month is observed every year in June. Many couples are not even aware they are infertile; hence this month serves to alert them of issues that may affect them as well as their available solutions.

While the causes of infertility are varied and can affect both partners, the burden and stigma are often shouldered by the female partner. In our part of the world, both issues are particularly pronounced.

Couples with fertility issues should therefore see a doctor in a timely manner to receive a proper assessment and effective treatment. As age is an important factor in conceiving, early medical intervention often leads to positive outcomes in a couple’s fertility journey.

Both partners should be involved in fertility consultation and management. The primary issues to address include if the woman is ovulating regularly, if the sperm cells in semen are healthy, if there are coital issues and any problems with fertilization and implantation, and if the woman is able to maintain the pregnancy.

To answer these questions, thorough evaluation should be done through taking a detailed medical and personal history, sexual history and performing a physical examination for both partners. The next steps would then be to test the couple with baseline investigations as well as specific evaluations.

Some common assessments include tests to ensure the fallopian tubes are patent (open and lacking blockage), tests to confirm ovulation, sperm counts, and ultrasound to look for abnormalities in the uterus, fallopian tubes, and ovaries.

MANAGING & TREATING INFERTILITY

Sometimes, simple lifestyle modification measures such as weight management, adequate exercise, cessation of smoking, and the limitation on alcohol consumption can solve infertility.

As for natural methods, frequency of sexual intercourse can be an issue and it is recommended that at least 3 times a week increases the probability of conceiving.

Timed intercourse during a women’s fertile period may be a strategy as well. Women usually ovulate about 12 to 14 days before the start of a next menstrual cycle and the fertile period is the five days before ovulation, the day of ovulation, and the day after ovulation.

The treatment for fertility issues depends on the cause. For women who experience problems with ovulation, medications to induce ovulation may be employed. As for women with endometriosis, fibroids, or other tubal diseases, surgery may also improve outcomes. For men, prescribing medications to improve sperm quality may help and surgery may be employed for men with structural abnormalities in their reproductive system.

When more simple methods are not successful, more complex procedures may be employed such as intra-uterine insemination (IUI), gamete intra-fallopian transfer (GIFT), and intracytoplasmic sperm injection (ICSI). For couples with unexplained infertility, increasing coital frequency in combination with IUI often results in successful pregnancies.

References:

  1. Ferlin, A., Raicu, F., Gatta, V., Zuccarello, D., Palka, G., & Foresta, C. (2007). Male infertility: role of genetic background. Reproductive biomedicine online, 14(6), 734–745. https://doi.org/10.1016/s1472-6483(10)60677-3
  2. Lipshultz, L. I., Howards, S. S., & Niederberger, C. (2009). Infertility in the male (4th ed.). Cambridge University Press. http://dlib.sbmu.ac.ir/site/catalogue/134959
  3. Krausz C. (2011). Male infertility: pathogenesis and clinical diagnosis. Best practice & research. Clinical endocrinology & metabolism, 25(2), 271–285. https://doi.org/10.1016/j.beem.2010.08.006
  4. Poongothai, J., Gopenath, T. S., & Manonayaki, S. (2009). Genetics of human male infertility. Singapore medical journal, 50(4), 336–347.

How Much Do You Know about Male Breast Cancer? Let’s Find Out!

WORDS LIM TECK CHOON

FEATURED EXPERT
DR NIK MUHD ASLAN ABDULLAH
Clinical Oncologist
Sunway Medical Centre
BREAST CANCER AFFECTS MEN AS WELL AS WOMEN

Breast cancer in both men and women share many similar attributes.

The most common kinds of breast cancer in men are the same kinds that are present in women, namely:

  • Invasive ductal carcinoma
  • Invasive lobular carcinoma
  • Ductal carcinoma in situ (or DCIS)

Dr Nik Muhd Aslan Abdullah says that breast cancer is, however, rare among men.

WARNING SIGNS

According to Dr Nik, many of the most pressing early warning signs of breast cancer in men are also similar to those found in women, such as:

  • Lumps in the breast tissue
  • Skin dimpling or puckering
  • Nipple retraction
  • Unusual discharge from the nipple
HORMONAL CHANGES CAN GIVE RISE TO BREAST CANCER

One reason why breast cancer is rare among men is that the hormone testosterone inhibit the growth of breast tissue, while oestrogen stimulates breast tissue growth.

While men and women have both hormones in their bodies, men have higher levels of testosterone compared to women. On the other hand, women have higher levels of oestrogen.

Some breast cancer cells have special structures at the surface, called hormone receptors. These cells are called hormone-receptor positive (HR positive for short). Oestrogen can bind to these receptors to cause the growth of these cells. Dr Nik explains that men have a higher possibility of developing breast cancer cells that are HR-positive, when compared to their female counterparts.

“Breast cancer cells in men are sensitive to hormonal imbalances,” Dr Nik explains, “so any factors or conditions that can lead to an excess of oestrogen and a lack of testosterone will increase their risk of developing breast cancer.”

What can cause the raise in oestrogen levels in men?
  • Klinefelter syndrome, a rare genetic condition in which a male has an extra X chromosome and produces lower levels of androgens
  • Injury to the testicles
  • Use of androgen inhibitors
  • Liver cirrhosis (scarring of the liver)
  • Obesity 
Family history also plays a factor

About 1 out of 5 men with breast cancer is found to have had a family history of the disease.

This is because men can also inherit a mutation in the BRCA1 or BRCA2 genes or in other genes, such as CHEK2 and PALB2. These mutations will highly increase their risk for breast cancer.

“Unfortunately, we do not have a say in the types of genes we inherit,” Dr Nik says.

He recommends that men with a family history of cancer should consider seeking counsel from their doctors about going for genetic screening tests as soon as they can, especially those over the age of 50.

Genetic screening tests involves taking a blood sample for analysis. A genetic counsellor will then advise the person, based on the results given, on what the next best steps would be for him.

How to conduct self-breast examination for men. Click the image for a larger version.
MEN WITH HR-POSITIVE BREAST CANCER ARE MORE LIKELY TO RESPOND TO HORMONE TREATMENTS

Dr Nik explains that hormone therapy can be used to help lower the risk of the cancer cells spreading or treat cancer that has come back after treatment.

Why then do men with breast cancer have lower survival rate compared to their female counterpart?

“Through many of the studies that I’ve seen, men who are diagnosed with breast cancer have a 8-9% lower survival rate than women,” Dr Nik says.

He attributes this to the fact that men with breast cancer are often diagnosed late.

“Men will sometimes wait too long to seek out a diagnosis for the symptoms they may be experiencing,” he explains, “or not recognize the warning signs of breast cancer in their bodies.”

As a result, they delay seeking help, and tend to do so only when the cancer has become advanced and spread to other parts of the body.

Dr Nik encourages men to seek a doctor’s opinion if they find themselves experiencing any of the mentioned symptoms related to breast cancer. “Breast cancer can be cured, and it is very treatable if detected early on,” he says.