Game-changing treatment for advanced prostate cancer

Asian men are often reluctant to seek medical advice on intimate matters due to cultural barriers.

Prostate cancer is the third most common cancer among Malaysian men, with cases rising steadily since 2012.

While it trails behind colorectal and lung cancer, it is still a significant concern.

What’s more worrying is that many cases are detected late.

Early-stage prostate cancer is highly treatable, but late-stage cases are far more difficult to manage.

What is prostate cancer?

The disease begins when cells in the prostate – a small, ­walnut-sized gland below the bladder – start to grow uncontrollably.

In its early stages, prostate ­cancer often causes no symptoms.

But as the tumour grows, it can press against the urethra – the tube that carries urine – leading to changes in urination.

Left untreated, the cancer can spread to nearby tissues, lymph nodes, or even the bones, making it more difficult to treat and manage.

Yet, many men overlook the early signs.

However, symptoms such as difficulty urinating, weak flow, or frequent trips to the bathroom at night may be early warning signs of prostate cancer.

Sunway University consultant urologist and urologic oncologist Professor Dr Tan Guan Hee explains that these symptoms often go unnoticed or are mistaken for benign prostate conditions such as benign prostatic hyperplasia.

“Many men assume it’s just part of getting older and delay seeing a doctor,” he says.

“Unfortunately, this means prostate cancer is often diagnosed at a later stage, when it’s more difficult to treat.”

As Malaysia’s population continues to age, the number of prostate-related issues is expected to rise in tandem.

Despite this, there is a general lack of awareness of the problem, minimal symptoms in early stages, and a cultural reluctance to seek help for intimate health issues.

When prostate cancer is detected early, treatment options such as surgery or radiotherapy are often effective and potentially curative.

However, late-stage prostate cancer, which may have already spread to bones or lymph nodes (metastasised), requires more advanced interventions.

This is where radioligand therapy (RLT) offers new hope.

Overcoming stigma

One significant and often overlooked challenge in managing prostate cancer is cultural reluctance.

Many patients delay seeking care due to embarrassment or denial, particularly Asian men, who may be more reserved about discussing health issues.

Doctors often find that families bring in patients who have ignored symptoms for years.

Prof Tan says: “Addressing this cultural barrier requires greater public awareness, normalising conversations around men’s health, and encouraging routine screening and early intervention.”

Beyond individual awareness, family involvement plays a critical role in detecting early symptoms of prostate cancer and preventing critical outcomes.

“If children notice their father is frequently going to the toilet, they might realise something is amiss and encourage him to seek medical help,” he suggests.

Treatment for prostate cancer depends on what stage the tumour is at. — Photos: Canva

Precision treatment

According to consultant clinical oncologist Dr Nik Muhd Aslan Abdullah, treatment for prostate cancer has come a long way since the 1990s.

While surgery, radiotherapy and hormonal therapy remain standard options, recent advances in precision medicine have led to more targeted, effective treatments.

Choosing the most appropriate treatment depends on several factors, including:

> The stage of the cancer

> The patient’s age

> Personal preferences

> Underlying health conditions that may make certain treatments, such as surgery, unsuitable.

“In the past, our precision treatment options were quite limited.

“But today, we are guided by clearer staging and more accurate tools,” he says.

Dr Nik outlines the four key stages that influence treatment strategy:

> Stage 1: The tumour is confined to the prostate and involves no more than half of the gland.

> Stage 2: The tumour remains within the prostate but is more advanced.

> Stage 3: The tumour has grown beyond the prostate and may have reached nearby structures such as the seminal vesicles, rectum or bladder.

> Stage 4: The cancer has spread to the lymph nodes or distant parts of the body, such as the bones.

“To determine the stage, we typically rely on three approaches: physical examination, blood tests, particularly for prostate-­specific antigen (PSA), and imaging.

“Conventional imaging includes computed tomography (CT) scans, magnetic resonance imaging (MRI), and bone scans,” he explains.

However, these methods have their limitations.

Dr Nik adds: “They may miss early tumours or small areas of spread, and while blood tests are helpful, they cannot show the precise location of the cancer.”

Sharper detection with PSMA PET-CT

A key development is PSMA PET-CT imaging – a powerful diagnostic tool that combines positron emission tomography (PET) with CT to detect prostate-specific membrane antigen (PSMA), a protein found on most prostate cancer cells.

“About 80% of prostate cancer cells have a protein called PSMA on their surface,” explains Sunway University consultant nuclear medicine physician Associate Prof Dr Tan Teik Hin.

“We use this to both detect and treat cancer. The approach is simple: we treat what we see, and we see what we treat.”

PSMA PET-CT works like a GPS for cancer cells.

The CT maps the body’s structure, while the PET scan lights up areas where PSMA-positive cancer cells are present.

It can detect tumours as small as 0.3cm, far smaller than what conventional scans typically reveal.

In an April 2020 ProPSMA study published in The Lancet, researchers found that this method was 27% more accurate than traditional imaging, often leading to significant changes in treatment planning.

What is radioligand therapy or RLT?

Once PSMA-positive cancer cells are identified, patients may be eligible for RLT.

This treatment uses a radioactive compound that binds specifically to PSMA on cancer cells, delivering a precise dose of radiation directly to the tumour while sparing surrounding healthy tissue.

Assoc Prof Teik Hin says: “It’s like sending a guided missile to destroy only the cancer cells.

“RLT is not entirely new. A similar concept – using radioactive iodine to treat thyroid cancer – has been in use for over 80 years.

“What’s new is applying the same principle to prostate cancer using more advanced, highly specific radiotracers.”

After treatment, a follow-up scan (SPECT-CT, a hybrid imaging technique that combines Single Photon Emission Computed Tomography and CT) is conducted to confirm that the radioligand successfully reached and treated the target.

From left: Assoc Prof Teik Hin, Prof Tan and Dr Nik were the three medical professionals who led the roundtable discussion on RLT. — Handout

Fewer side effects

One of the greatest advantages of RLT is its specificity.

Because the therapy targets only cancerous cells, it causes fewer side effects compared to systemic treatments like chemotherapy or hormonal therapy.

Most patients tolerate it well, with mild side effects such as dry mouth, fatigue or nausea.

More importantly, studies show that RLT can help delay disease progression, reduce symptoms like pain, and improve quality of life, especially for men with advanced or castration-resistant prostate cancer.

While RLT is currently used mainly for patients with stage 4 prostate cancer who no longer respond to other treatments, ongoing clinical trials are exploring its use at earlier stages.

PSMA PET-CT is also being studied for its ability to guide biopsies and detect cancer even before a formal diagnosis is made.

“Compared to systemic hormone therapy, which affects the entire body and can cause fatigue and mood changes, RLT offers a more targeted approach with fewer disruptions to daily life.

“We see a marked improvement in quality of life, and patients report less pain, more energy, and better sleep after the therapy,” says Assoc Prof Teik Hin.

The treatment is available at government facilities such as the National Cancer Institute (IKN) in Putrajaya and Hospital Kuala Lumpur, as well as at several private hospitals.

The cost of RLT varies depending on the hospital, the number of treatment cycles, and individual response to the treatment.

As there is no fixed price, patients are encouraged to consult their medical team to discuss affordability and explore available financial support options.

The three experts were discussing “Size Matters in Prostate Cancer: Experts Highlight Advances to Close Critical Gaps in Care,” in a media roundtable held recently at a private hospital in Petaling Jaya, Selangor.