Singapore the first in Asia-Pacific to offer new treatment for prostate cancer

After six years of battling prostate cancer, the remaining options were looking fairly bleak for the 69-year-old New Zealander.

Despite surgery to remove his prostate and hormonal treatment to lower his testosterone level, which can cause prostate cancer to grow, the cancer spread to his bones and doctors were advising chemotherapy to contain the disease.

But for personal reasons, he did not want to undergo chemotherapy if he could help it. He felt such a treatment would weaken him and worsen his quality of life.

Fortunately for this patient, who did not want to be named, a new targeted radioactive therapy was approved by the US Food and Drug Administration in May last year, which has been shown to be helpful for patients like him.

Singapore's Heath Sciences Authority approved it for use here in January this year for men with advanced prostate cancer, in whom hormonal therapy is no longer effective and whose cancer has spread to the bones but not the soft tissues.

Singapore is the first country in the Asia-Pacific region to offer this, so this patient has chosen to travel here once a month for six months to receive outpatient treatment. He has had three sessions so far at OncoCare Cancer Centre at Gleneagles Medical Centre.

The radioisotope radium-223, or Xofigo, is injected to target the bone sites where the cancer has spread and which are not responding to conventional therapy, said Dr David Ng, a senior consultant who heads the department of nuclear medicine at Singapore General Hospital.

Due to its short range, radiation is concentrated on the cancerous sites, with fewer unwanted effects on other normal organs, he said.

It has minor side effects such as diarrhoea, nausea, a transient increase in bone pain and a drop in blood count which is reversible, he added.

It is also safe for others to be around patients who have had the therapy, he added.

This is because the therapeutic dose of radium-223 is 185 times lower in radioactivity than a standard diagnostic bone scan.

"The therapy was so successful in the trial phases that it was stopped early once it became clear that it was effective," said Dr Tay Miah Hiang, a medical oncologist at OncoCare Cancer Centre, who is looking after the New Zealand patient.

It not only prolongs life, but also produces fewer side effects and less pain, giving men a better quality of life, he added.

Nine in 10 men who develop castration-resistant prostate cancer - that is, when hormonal therapy to lower testosterone levels no longer works - will have the disease spread to their bones too, which can be painful and life-threatening, said Dr Tay.

Up till now, there was not much that could be offered to such patients, aside from controlling their pain, he said.

With an ageing population here, he foresees that more men will be diagnosed with prostate cancer, a disease that increases with age. This means that more can be helped by radium-223.

RISING INCIDENCE

More cases of prostate cancer are being observed in Asian countries, including China, Japan, the Philippines, Singapore, South Korea and Thailand.

It is the sixth leading cause of death from cancer in men here.

The Singapore Cancer Registry shows it has overtaken liver cancer as the third most common cancer in men over the last five years with about 650 new cases a year.

The risk of getting the disease for men in their 40s is one in 200,000. This goes up to 12 per 100,000 for men in their 50s.

When they hit their 60s, the rate jumps to 14.6 out of 10,000, said Dr Tay.

Prostate cancer is a slow-growing cancer, often exhibiting no symptoms. Many patients find out only when the disease is advanced.

Dr Tay estimates that radium-223 can help about 165 new cases of advanced prostate cancer a year here.

COMPELLING RESULTS

A total of 921 patients in more than 100 centres across 19 countries were enrolled in clinical trials for the drug from June 2008 through February 2011.

Singapore was one of three Asian countries which took part in the trial, known as the Alsympca - Alpharadin or radium-223 in Symptomatic Prostate Cancer - study.

It was so successful that it was stopped early so that patients being given a placebo could receive the real treatment instead.

Median overall survival was 14.9 months for the men assigned to radium-223 and 11.3 months for those on the placebo.

The treatment benefited every group that received it, whatever the extent of their disease and regardless of whether they had previously received chemotherapy or were being treated with drugs to prevent loss of bone mass.

Men who got radium-223 also had a longer period without a bone-related event - such as spinal cord compressions or bone fractures - than those who got the placebo.

Fewer men in that group experienced serious adverse events than those in the placebo group - 47 per cent versus 60 per cent.

Only 16 per cent had to stop treatment because of adverse events, compared to 21 per cent of men who got the placebo.

The treatment also freed patients from pain relief medication for a longer period of time. The use of opioids to relieve pain dropped by 38 per cent.

The study was funded by drug giant Bayer HealthCare Pharmaceuticals and Algeta ASA, a cancer therapeutics company based in Norway. Both collaborated in the development of radium-223.

The therapy costs around $10,000 to $11,000 per injection, and can be partly paid with Medisave.

Cancer patients can withdraw a maximum of $1,200 per monthly treatment cycle in the outpatient setting, and this includes nuclear medicine treatment.

In addition, most Singaporeans and permanent residents have a basic MediShield plan. The national medical insurance scheme provides claim limits of an additional $1,240 per monthly treatment cycle.

For patients with private insurance plans, the cancer treatment is as charged and subjected to policy year limits, depending on the tier of the insurance coverage they have purchased.

The new treatment has given hope to patients like the 69-year-old New Zealander, who, Dr Tay says, is one of four patients who has been coming from that country for treatment here.

The freelance writer from Auckland told Mind Your Body that he and his partner treat the trips to Singapore as a "mini-holiday".

"It's a great place to hang out, very clean and the food is great," he said.

Since starting treatment, he has noticed some improvements. He used to have a dull ache in his hips whenever he bends down to tie his shoelaces or while walking.

Since the first radium-223 injection, that ache is gone.

"It doesn't even affect me the slightest now. I hope that when I get my next scan, it will show that the cancer spread has retreated, at least a little bit," he said.

This article was published on April 10 in Mind Your Body, The Straits Times.

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