Prostate cancer is a malignant condition that can creep up to men silently. It was the 3rd most common cancer (incidence) in Singapore between 2010 and 2014, but was the 6th highest cause of death (mortality) in men during the same period. Other cancers like lung and colorectal cancers are ranked 1st/2nd in incidence as well as mortality in Singapore between 2010-2014. In other words, prostate cancer is not deadly.
There will be exceptions to this rule, and it’s always important to see a urologist who specialise in the urinary tract after 45 years old to understand your own body better. In many instances, you are generally lost and forced to backtrack when you or your relatives complain about these sudden discomforts and struggle to figure out who to visit, only to find out there is usually a waiting time involved. Prostate cancer found early has more treatment options than cancer found after it has spread.
Dr Jay Lim
MBBS (Syd), MRCS (Edin), MRCS (Glasg), MMed (NUS), FAMS (Urology)
Dr Lim Kheng Sit (Jay) is a prostate specialist in Singapore with subspecialty expertise in the screening, diagnosis and management of prostate cancer. He is trained in modern minimally invasive techniques, including endoscopic and laparoscopic approaches, offering treatment options with reduced recovery time and less disruption to patients’ daily lives.
His clinical approach emphasises on early detection, accurate diagnosis, and collaborative decision-making between patient and doctor.
The prostate is a walnut-sized organ that sits at the opening of the bladder and is located between the bladder and the urethra. For most of our lives, it does not bother men as it is deep inside the body. The prostate is crucial to the reproductive system as it provides nourishment to the sperm as it exits our body and allows sperm to live long enough to swim up and fertilise the egg. Without this organ, humans would cease to exist.
Another important by-the-way role of the prostate is that the internal sphincter sits within the prostate (imagine a door that opens and closes), and removing or disturbing the prostate effectively reduces the control men have over the bladder and our reproduction function as sperm flows backwards into the bladder during ejaculation instead of outwards. This is the reason why the prostate is essential, in case you are wondering why we cannot remove it once we finish having kids.
Early prostate cancer usually causes no symptoms, which is one reason screening is used to identify possible disease before symptoms develop.
When symptoms do occur, they cannot tell you on their own whether prostate cancer is present.
You may notice:
These symptoms overlap substantially with benign prostate enlargement. Rather than relying on symptoms alone, a PSA test can help assess your risk and whether further investigation is appropriate.
Arrange a medical assessment if you develop:
These symptoms do not mean you have advanced prostate cancer. They can have other causes, but should be assessed rather than used to diagnose the condition yourself.
If you think you may be presenting symptoms of Prostate Cancer, schedule a consult as soon as possible.
Your risk of prostate cancer increases with age. Family history also matters, particularly if your father or brother developed prostate cancer at a younger age.
Ethnicity can affect risk, while inherited genetic changes, including BRCA2 variants, are associated with a higher risk of clinically significant prostate cancer.
Risk-adapted screening recommendations generally support discussing PSA testing from around age 50 for men at average risk and earlier for men at increased risk, including those with a family history or other recognised risk factors.
Before we dive into the topic of taking care of your prostate, it is vital to acknowledge the elephant in the room, i.e. “Can Prostate Cancer be prevented at all?” According to the professional bible that most Urologists in Singapore refer to, the European Association of Urology (EAU) guideline states that “No conclusive data exist which could support specific preventive or dietary measures aimed at reducing the risk of developing Prostate Cancer.”.
Certain genetic factors are associated with the risk of aggressive Prostate Cancer, and it is best to speak to your Urologist if you have a family member who has aggressive prostate cancer in their 50s or younger.
For the rest, there are a few ways to monitor the health of your prostate. The most common way of screening is through Prostate Specific Antigen test. PSA is a blood test that measures the level of Prostate Specific Antigen in your body. PSA is a protein that is secreted by both normal and abnormal prostate cells. This blood test is commonly performed as part of health screening packages in the appropriate age group. It is easily performed as it does not require fasting.
PSA can be elevated in BPH, prostatitis and prostate cancer. There is no normal level of PSA as it is a progress measurement of risk; however, 4.0ng/dl is generally accepted as the cutoff between normal and abnormal. An important point to highlight here is that while most commercial labs will highlight values above 4.0ng/dl as red or abnormal, it is not to say that you have prostate cancer, as PSA is a measurement of risk. Similarly, a value of 3.9ng/dl does not guarantee no prostate cancer too. While you may argue that it is a rudimentary interpretation of the cancer marker test for prostate cancer, it remains the screening tool with the largest published evidence base.
Thankfully, PSA is not the only tool that Urologists depend on to assess your prostate cancer. We employ an even more rudimentary (but time-tested) method to screen for prostate cancer. Unfortunately, due to its location, the prostate is most accessible via the rectum, and DRE is an established component of annual physical examinations for men at risk for prostate cancer.
Digital Rectal Examination (DRE) is the most often talked about the part after a visit to the Urologist amongst Singaporean men at the coffee shop and void decks. Some wear it as a badge of honour as the uninitiated cringe while their peers describe the process. This examination is subjected to individual interpretation and is a helpful adjunct if performed by an experienced Urologist.
If your Urologist decides, based on your PSA, DRE and medical history, that there is a risk of prostate cancer, we proceed to the next step of surviving your prostate, which is to perform a prostate biopsy.
A prostate biopsy confirms the presence of prostate cancer and the grade of the cancer (benign sheep vs dangerous wolf). There are a variety of ways that the prostate can be sampled.
In many parts of the world, the prostate is still sampled with a needle via the rectum. A needle is passed through around 12 to 18 times to get prostatic tissue for testing under local anaesthetic. As can be imagined, this route is associated with a risk of sepsis or severe infection due to the presence of stool in the rectum.
Apart from infection, TRUS-guided biopsy is a random process that can miss small cancers as the Urologist is guided by the black-and-white pictures of an ultrasound that does not tell you where the cancer is located.
In recent years, there has been a move toward image-guided biopsy of the prostate. Before any biopsy, Magnetic Resonance Imaging (MRI) of the prostate is performed as the first step. MRI prostate grade regions within the prostate using the PIRADs 3-5 grading. The higher the grade, the more likely the presence of abnormality within the specific region.
Imagine going into battle without knowing where the enemy is and carpet bombing mindlessly in the general direction. With an MRI prostate as a guide, we know where the enemy is and can attack a particular region specifically. There are a variety of imaging-guided prostate biopsy platforms regularly in use, as we do not use TRUS-guided biopsy in private hospitals.
At Dr Jay Lim Urologist, we use the Biobot platform, which was developed locally by Singapore General Hospital. This MRI-guided robotic system allows me to plan my biopsy purposefully. It is simple to use and will enable me to get to within 1-2mm of my intended target due to experience.
Most importantly, the biopsy needle for this platform goes through the skin instead of the rectum and makes two little holes on either side of the perineum. Whether it is 10 or 20 biopsies, you only need a single puncture on the skin, which is dressed with a simple plaster. Minimal infection risk, targeted biopsies and many more areas of the prostate is sampled as you can take up to 50 cores under General Anesthetic, which reduces missed lesions. As the biopsy is performed as a day procedure, you will be discharged home on the same day.
A PSMA PET scan is not typically the first test used to diagnose prostate cancer. Instead, it may be used after cancer has been confirmed when your specialist needs more information about whether it has spread.
The scan detects cells expressing prostate-specific membrane antigen (PSMA) and can help identify cancer in lymph nodes, bones and other parts of the body. PSMA PET can improve the detection of metastatic disease when staging selected patients with prostate cancer.
Your specialist may recommend it when the findings could affect whether treatment focuses on the prostate alone or also needs to address disease elsewhere.
Genomic testing examines molecular characteristics within prostate cancer to provide additional information about how the cancer may behave. It differs from MRI, which shows where suspicious areas are located, and biopsy, which allows the cancer cells to be examined under a microscope.
Genomic testing is not required for every patient. In selected cases, the additional risk information may help when deciding between active surveillance and treatment after prostate cancer has been diagnosed.
If you have been advised to undergo a prostate biopsy in Singapore, your urologist can explain how the biopsy findings and any additional investigations affect your next steps.
If you think you may be presenting symptoms of Prostate Cancer, schedule a Screening as soon as possible.
The biopsy is processed, and results are usually available after a week. Our Pathologist colleagues will review the biopsy and give an all-clear or score your prostate cancer between 6 and 10, which indicates the aggressiveness of the lesion.
If the diagnosis of prostate cancer is confirmed, my practice is to go through the results with my patients patiently within the context of prostate cancer. It is important to reiterate that prostate cancer is a slow-growing cancer and that it becomes a team effort to overcome this challenge. Team “We” (patients and I) can have discussions back and forth before deciding on a treatment course. Family members are invited to sit in at the next session with a list of written questions. There is no one-size-fits-all plan, as everyone is different.
Together with your PSA and biopsy grading, additional scans will be required to accurately ‘stage’ your scan. Staging is a necessary step in the management of cancers. It informs me of the degree of spread of the disease at the point of diagnosis. Staging is typically divided into stages 1 to 4, where Stage 4 is the most advanced.
The Gleason score combines the two main cancer growth patterns identified under the microscope. The first number represents the predominant pattern and the second represents the next most significant pattern.
These scores correspond with ISUP Grade Groups:
Higher Grade Groups generally indicate more aggressive prostate cancer. Grade Group 1 disease may be suitable for monitoring in selected patients, while higher-grade disease is more likely to prompt a discussion about active treatment.
Your grade is considered alongside your PSA, cancer stage, age and general health rather than being used alone to determine treatment.
Together with your PSA and biopsy grade, staging investigations help determine how far the cancer has spread.
The TNM system describes the tumour (T), whether cancer has reached nearby lymph nodes (N) and whether there are distant metastases (M).
MRI assesses the prostate and nearby structures. CT and bone scans may be used in selected patients to assess lymph nodes, organs or bones, while PSMA PET can provide additional staging information.
In practical terms:
There are a variety of treatments available in the armamentarium of a urologist when it comes to prostate cancer treatment. It can range from Active Surveillance to Robotic Surgery, from Watchful waiting to Palliative trans-urethral resection of the prostate (TURP). The final decision is best appreciated through answering a 3-question rule-based approach. Does it need treatment? Is the treatment curative? Does the treatment outweigh the harm that the disease will likely post? Only a limited permutation exists, and I will recommend the treatment plan to the patient, who makes the final decision based on his personal preference and beliefs.
Active surveillance means monitoring prostate cancer closely rather than treating it immediately. It may be suitable for selected men with low-risk localised cancer and some with favourable intermediate-risk disease.
Monitoring typically includes PSA testing every few months initially, together with clinical reviews. MRI and repeat biopsy may be used periodically to check whether the cancer has changed. The exact timing varies according to your risk profile and your urologist’s surveillance protocol.
Radical prostatectomy removes the prostate and seminal vesicles. Nearby lymph nodes may also be removed when indicated.
During robotic-assisted surgery, the surgeon controls robotic instruments through several small abdominal incisions. Patients generally require a short hospital stay, followed by several weeks of gradual recovery. Your return to work depends on your recovery and whether your job is sedentary or physically demanding.
Where the location and extent of the cancer allow, nerve-sparing surgery may be considered to reduce the impact on erectile function. However, removing the cancer safely remains the priority.
Radiotherapy uses targeted radiation to destroy prostate cancer cells. External beam radiotherapy delivers radiation from outside your body over a planned course of treatment sessions. Brachytherapy places radioactive sources within or close to the prostate.
Radiotherapy may be considered instead of surgery for some localised cancers. It may also be combined with hormone therapy when treating selected higher-risk or locally advanced disease.
Treatment planning and delivery are generally managed together with a radiation oncologist. The number and frequency of sessions depend on the radiotherapy technique, cancer stage and treatment protocol.
Prostate cancer cells often depend on male hormones such as testosterone to grow. Androgen deprivation therapy (ADT) lowers testosterone levels or blocks its effects.
Treatment may be given as injections or medication. It is commonly combined with radiotherapy for selected higher-risk cancers and can also form part of treatment when prostate cancer has spread.
Potential side effects include hot flushes, reduced libido, erectile difficulty, fatigue and changes in bone, muscle and metabolic health.
The duration of ADT depends on why it is being used and your individual cancer risk.
Focal therapy treats the cancerous part of the prostate rather than the entire gland. Techniques can include high-intensity focused ultrasound (HIFU), cryotherapy and other forms of targeted ablation.
It may be considered for carefully selected patients with localised disease where the cancer can be identified and targeted. However, focal therapy does not yet have the same long-term evidence base as established whole-gland treatments such as surgery and radiotherapy. Patient selection and continued follow-up are therefore important.
| Treatment | Who It May Suit | Main Trade-Off | Typical Recovery/Follow-Up |
|---|---|---|---|
| Active surveillance | Selected lower-risk cancer | Requires continued monitoring | Regular PSA, MRI and repeat biopsy when indicated |
| Robotic prostatectomy | Selected localised cancer | Urinary and sexual side effects | Short hospital stay followed by several weeks of recovery |
| Radiotherapy | Localised or locally advanced cancer | Urinary, bowel and sexual effects | Planned treatment sessions and follow-up |
| Hormone therapy | Selected higher-risk or advanced cancer | Hormonal and metabolic effects | Monitoring throughout treatment |
| Focal therapy | Carefully selected localised cancer | Less long-term comparative evidence | Depends on technique, with continued surveillance |
The final decision is individualised and tailored to each patient in line with current evidence-based guidance and the agreement of the patient’s loved ones. Regardless of the decision and outcome, my patient is guaranteed to have me walking their cancer journey together henceforth.
Treatment may finish before some of its effects do. Follow-up therefore considers both cancer control and how your urinary and sexual function recover.
Urinary leakage can occur after prostate surgery. Control often improves gradually during the first months of recovery, although the timeline differs between patients. Pelvic floor muscle exercises may support the recovery of urinary continence after radical prostatectomy.
Erectile function can also take time to recover. Your age, erectile function before treatment, whether nerve-sparing surgery was possible and the treatment received can all affect recovery.
If erections do not return sufficiently, options may include tablets, vacuum devices, injections or other treatments for erectile dysfunction. Persistent urinary leakage can also be assessed and treated.
PSA testing continues after treatment to monitor for signs that prostate cancer may have returned.
Your follow-up schedule depends on the treatment received and your cancer risk. PSA is generally checked at regular intervals during the first few years, with the interval potentially becoming longer when results remain stable.
After prostatectomy, PSA is expected to fall to very low or undetectable levels because the prostate has been removed. After radiotherapy, PSA generally declines more gradually because prostate tissue remains.
A confirmed PSA rise after treatment may be described as biochemical recurrence. This does not automatically mean that cancer has spread elsewhere. Your doctor may repeat the PSA and recommend imaging or other investigations to determine what the rise means before discussing further treatment.
The cost of prostate cancer care in Singapore varies according to where you are in the screening, diagnostic or treatment pathway.
Screening may involve a consultation and PSA blood test. If your results require further investigation, costs can include MRI prostate, a transperineal biopsy, anaesthesia, pathology and day-surgery facility fees.
Treatment costs vary more substantially. Robotic prostatectomy may include surgeon, anaesthetist, operating theatre, hospital and pathology fees. Radiotherapy costs depend on the technique and number of treatment sessions, while hormone therapy costs vary according to the medication and duration of treatment.
Your total cost can therefore depend on:
Our friendly team at Urocare is looking forward to serving you.
For urgent enquiries and appointment requests, please call the clinic directly.
PSA stands for Prostate Specific Antigen and is a protein produced by the prostate gland in men. It is a blood test commonly used to detect prostate cancer. with the usual cutoff value of 4ng/dl. The higher the PSA values, the higher the chance of having prostate cancer. However, having a high PSA does not necessarily mean you have Prostate Cancer. Similarly, having a low PSA does not clear you of Prostate Cancer. You will need a physical examination, imaging and biopsy to confirm the presence of Prostate Cancer.
For men at average risk, a discussion about PSA screening generally starts around age 50. If you have a family history of prostate cancer, particularly a father or brother diagnosed at a younger age, or a known inherited risk such as a BRCA2 variant, that conversation may start earlier, around 40 to 45. The decision is shared between you and your doctor after weighing the benefits and limitations of testing.
That will depend on the grading, the stage of the prostate cancer and your physical tolerance. Prostate Cancer is one of those special cancer in that not all cases requires surgery even if diagnosed early. Some Prostate cancers are indolent and can be managed with surveillance of the PSA level before deciding on intervention. However, higher grades of Prostate Cancer will usually require intervention like surgery or radiotherapy. The treatment for Prostate Cancer is tailored to the individual’s needs.
To confirm the presence of Prostate Cancer, a biopsy of the prostate is essential. In Singapore, prostate biopsy is performed in conjunction with an MRI of the Prostate. A robotic platform is commonly used to match and fuse the MRI imaging with the live image of the prostate to sample the most suspicious area of the prostate. The rest of the prostate is also sampled at the same setting to reduce sampling errors.
Prostate biopsy has evolved significantly over the years to be a fast, safe and effective way of diagnosing Prostate cancer. The biopsy is performed via a small skin puncture and is a day procedure. The patient is usually able to return to his normal function the following day.
At Dr Jay Lim Urologist, the transperineal MRI-guided biopsy (Biobot platform) is performed under general anaesthesia as a day procedure, so you do not feel the biopsy itself. The needle passes through the skin of the perineum rather than the rectum, with a single small puncture on each side. Some soreness, mild bruising or blood in the urine or semen can occur for a few days afterwards and usually settles on its own.
A PSA blood test can be arranged through a GP or polyclinic, and many health screening packages include it. If your PSA is raised or your examination is abnormal, you would normally be referred to a urologist for further assessment such as MRI prostate or biopsy. You can also see a private urologist directly without a referral.
Many prostate cancers are curable, especially when found while still confined to the prostate. Localised disease can often be treated with surgery or radiotherapy with the aim of cure, and some low-risk cancers can be safely monitored.
Cancer that has spread beyond the prostate is generally managed as a long-term condition with hormone therapy and other treatments. This is why early detection matters.
Yes, it can. After prostatectomy, PSA should fall to an undetectable level, and a confirmed rise afterwards is called biochemical recurrence. It does not automatically mean the cancer has spread.
Your urologist may repeat the PSA, arrange imaging such as a PSMA PET scan and discuss further treatment, which may include radiotherapy or hormone therapy. Regular PSA follow-up is how recurrence is picked up early.
