In 2012, prostate cancer accounted for 15% of all cancers found in men globally.
In that year, research from GLOBOCAN (part of the International Agency for Research on Cancer) stated that over one million men were diagnosed with prostate cancer worldwide. It is the second most common strain of the disease among males, with the majority of cases (nearly 70%) discovered in more developed regions such as Australia, New Zealand, North America and Western and Northern Europe. This high level of discovery is due to widespread availability in those regions of prostate specific antigen (PSA) testing and subsequent biopsy.
Okay. So what is the situation in Asia?
By comparison, rates of diagnosis are relatively low in Asian populations with 2012 figures showing 39,000 confirmed cases of prostate cancer in Southeast Asia. What is worrying is that in the same year there were 25,000 deaths attributable to the disease in that region – a rate of 64% of all sufferers. (As a comparison, the US had 233,000 diagnosed prostate cancer patients and 30,000 deaths, a mortality rate of around 12.8%.)
What do we take away from this? When low diagnosis rates are seen with a high mortality percentage, it is common sense to assume a lack of early detection in the region.
Early detection and the prostate cancer situation in Asia
When the figures are broken down across the component countries of the region, the story is fairly consistent. A 2015 study from the University of Indonesia showed that prostate cancer is the sixth most common cancer in that country when overall cancer figures for both sexes are combined, and third when we’re just looking at statistics for men. Levels of incidence of prostate cancer in Indonesia are increasing but the key issue is that most patients are diagnosed in advanced stages of the disease.
In neighbouring Malaysia, in an effort to improve early detection, annual campaigns promote prostate examination for men aged 50 and over. However, after screening and diagnosis, many Malaysian men are reluctant to return for biopsies to be taken and therefore any investigation and potential treatment stops. The condition is the fourth most common disease among men, accounting for 5.7% of all male cancers according to the Malaysian Oncological Society.
As in Malaysia, the disease is the fourth most prevalent cancer in men in Thailand, and once again a lack of early detection means that a significant percentage of patients go undiagnosed until the cancer has reached the advanced stages, when treatment is no longer an option.
South Korea has also seen a rise in cases of the disease – a 13% increase was recorded in the early part of this century according to the Official Journal of the Asian Pacific Prostate Society. PSA screening has played its part in this, but these increases in incidences also have a lot to do with the westernisation of the South Korean population, with changes in dietary habits and an ageing population.
Boosting the chances of survival
The value of early detection cannot be underestimated. Figures show that if a diagnosis and treatment are administered early enough, 99% of patients will survive for at least five years after detection. Of those survivors, 98% will live for at least a decade after the initial identification of cancer. If screening is delayed or treatment delivered at a late stage, the likelihood of the cancer spreading to other areas of the body increases, and the five-year survival rate plummets to 28%.
Figures show that if a diagnosis and treatment
are administered early enough, 99% of patients
will survive for at least five years after detection.
In Southeast Asia, survival rates vary from country to country. In poorer communities, the survival statistics were significantly lower and this may explain the relatively poor five-year survival rate in areas of Thailand, which is between 30% and 40%.
The region as a whole seems to be playing ‘catch-up’ with the West when it comes to detection, treatment and survival of prostate cancer. One of the key, and likely most critical factors for effective treatment of prostate cancer is the extent and spread of the disease at time of diagnosis. The chances of survival are much higher for men diagnosed with localised disease compared with an advanced stage of the disease, regardless of geography. Undergoing timely PSA screening gives the best chance to detect prostate cancer, and therefore the best chance for recovery.
Factors behind the development of prostate cancer
In all countries around the world, diagnosis of prostate cancer is linked to age – with reported incidences of the disease climbing sharply past the age of 50. Since life expectancy is going up, with more people over 50 this starts to become an even more important issue.
The cancer is generally a slow-growing form of the disease, so it is not necessarily immediately apparent. The first noticeable symptoms of having prostate cancer are often problems urinating. The prostate grows to a size that affects the urethra, and hampers the flow of urine from the bladder, causing straining. Although these symptoms do not always mean that prostate cancer is present, it should be a red flag that prompts the patient to seek a professional medical opinion.
What causes prostate cancer is not known. What is known is that certain aspects of your life and lifestyle can increase the risk of contracting the disease. Family history is one. The American Cancer Society concluded that 5% to 10% of incidences of prostate cancer are due to family genetics. Men who have a brother or father who has been affected by the condition also have a slightly higher chance of developing the condition. Age is a factor as touched upon before, and geographical location also plays a part – for reasons not yet known, prostate cancer is found more frequently in those of Afro-Caribbean and African descent, and less common in men of Asian descent. Some studies have found though that instances of prostate cancer in Asian immigrants living in either the US or Europe was a lot higher than the recorded numbers in their native countries – it’s not clear though if this is due to better access to PSA screening in the West.
Finally, diets with a lot of high-fat dairy products and red meat have been identified as potential contributing factors. Because those who consume such diets are also less likely to eat a substantial amount of fresh fruit and vegetables it is not clear whether the risk is associated with the red meat and dairy diet, or the low intake of fruit and vegetables, or a combination of both. This is pertinent to Southeast Asia with countries such as South Korea adopting a more Western lifestyle.
Ultimately, the key challenges to combating prostate cancer in Asia seem to be the attitude and awareness of those in the high risk categories.
The importance of screening
The process of screening aims to test for a disease even before any symptoms are present – and in prostate cancer, as the disease may be present a long time before symptoms show due to slow growth, screening is a fantastic way to identify the disease early.
Both the prostate specific antigen (PSA) test and the digital rectal examination (DRE) are used to screen for prostate cancer. The PSA test is a blood test and the most widely used form of screening. The aim of the test is to measure the level of PSA in the blood. PSA is a protein that is only produced by the prostate, and a low level is a sign of a healthy prostate. A high level or a rapidly increasing PSA level indicates some abnormality with the prostate, but not necessarily cancer. Other possible causes of a high reading are a non-cancerous enlargement of the prostate or inflammation of the prostate.
The other procedure is a digital rectal examination (DRE). This is carried out by the doctor by placing a lubricated gloved finger into the rectum to feel the prostate. The examination looks for any abnormal shaping or thickness of the prostate. The DRE method cannot confirm or rule out the presence of cancer, but can give an indication of a malformation of the prostate. Whether using a DRE or having a PSA test, an accurate diagnosis of cancer can only be determined by following up with a biopsy.
If that biopsy then returns a positive result, treatment to reduce the tumour should begin as soon as possible. There are a number of treatments available for prostate cancer, and the patient’s circumstances should be taken into consideration when choosing the avenue of care. Options include prostatectomy (a surgical option) to chemotherapy, radiation and hormone therapies, as well as active surveillance and new emerging therapies.
Insurers bridging the gap: Making positive changes in Asia
While there is no consensus on when and how often men should get screened for prostate cancer, the American Cancer Society encourages tests to be taken by men at age 50 who are at average risk of prostate cancer and are expected to live for at least another 10 years. They also recommend that those men with an elevated risk (including African Americans and men who have a first-degree relative diagnosed with prostate cancer at an early age) should take earlier tests at age 45. Some men have an even higher risk of developing the cancer (those with more than one first-degree relative who had prostate cancer at an early age) and it is recommended that they take the test at age 40.
The American Cancer Society encourages tests
to be taken by men at age 50 who are at
average risk of prostate cancer and are expected
to live for at least another 10 years.
But this is in the West where testing, awareness and treatment are widespread and often performed as a matter of routine. In Southeast Asia and particularly in those four countries highlighted earlier – Indonesia, Malaysia, Thailand and South Korea – the number one issue in fighting prostate cancer is the late diagnosis of the condition.
So how does that change?
There’s no easy answer. But what is apparent is that the PSA screening is in place and that the governments are making the efforts to promote the service. The major stumbling block seems to be getting men in the ‘at risk’ categories to take the tests as a matter of routine rather than when there is an obvious problem. Culturally, there is not much appetite for screening.
So there is a gap in what needs to happen and what is actually happening – and that provides an opportunity for healthcare to bridge that gap.
Providers of healthcare insurance plans who don’t already include PSA or DRE screening for their members in the region should reassess – surely early detection pays dividends for the patient and the insurer? Not only does the introduction of screening for men at age 50 provide a very marketable benefit to companies, but it also makes a lot of sense for healthcare insurers.
Many cancers, if diagnosed early enough, have a high recovery rate and are treatable. Screening and early diagnosis could improve survival rates and circumvent expensive oncology costs for advanced cases. The cost of the screening could even be shared with the patient if necessary.
Steps in the right direction
Many healthcare plans in the West already provide PSA and DRE examinations. And in general, patients in those regions are more open to screening and examinations than the population of the Asian countries. The results are clearly shown in the survival statistics – those who submit to routine checks that are part of the fabric of medical care in the West have incredibly favourable numbers on their side when it comes to detection, treatment and survival.
The Asian market needs to not only be given that same easy access to prostate care, but the mindset of the population needs to be changed to become more proactive. Education about the condition and the obvious benefits that come with early detection need to be driven home – and health insurers can also play a part in that too, as collaborative projects with employers could be established that serve to inform and educate.
The steps to better prostate care are clear and start with early diagnosis. Early diagnosis starts with more people in the ‘risk’ age band taking the examination. More people taking the examination happens when attitudes change. Attitudes change with education, information and opportunity.