A prostate cancer diagnosis is always difficult to digest. However, a prostate cancer diagnosis does not come close to a death sentence. We need to change the public’s perception of prostate cancer. Of all the cancers, prostate cancer is one of the easiest cancers to treat. Men diagnosed with this cancer need not worry. Many men go back to their normal lives after a prostate cancer diagnosis, either completely healed or living with the cancer in a manageable state.
With prostate cancer, two things determine the prognosis. One of these is the stage the prostate cancer is diagnosed, and the other is the care of the specialist that is directing treatment. For over 15 years, Senior Consultant Urologist and Genito-Uro Oncologist, Dr. Vikas Singh has helped treat men with every stage of prostate cancer.
For your family and your friends with a prostate cancer diagnosis, this page will show the cancer, the treatment, and what to expect in the future. Dr. Vikas Singh will his patients through the next steps.
The prostate is a gland in only in men. It is below the bladder and surrounds the tube that carries urine from the bladder to the penis (urethra). The prostate produces a fluid that nourishes and helps transport sperm.
Cancer occurs when cells in this gland change and grow in an uncontrollable way and a tumor is formed. Prostate cancer tends to be a slower growing cancer. It can be so slow growing that the cancer will not cause any problems during the man’s lifetime. There can also be more aggressive forms of prostate cancer that grow quickly and metastasize to nearby tissues, lymph nodes and to distant organs if not treated.
The incidence of prostate cancer is rapidly increasing in men in India with an increasing awareness and an increasingly aging population. 50 years of age and older is the sharpest increase of incidence. Familial history is also important with men having a father or brother diagnosed with prostate cancer having a double increase to incidence. Lifestyle and dietary choices can also be risk factors but they are significantly lesser in comparison to age and history.
The PSA (Prostate-Specific Antigen) blood test is quite important for the early detection of prostate cancer. PSA tests measure the amount of a particular protein produced by the prostate cells. Even through PSA tests may result in elevated PSA indicating cancer, prostatitis, or Benign Prostatic Hyperplasia (enlargement of the prostate), the PSA test typically produces the most important results. Men are recommended to take annual PSA tests especially if of age (50 years) or of age (45 years) with prostate cancer in the family history. The survival rate after five years is more than 95% if prostate cancer is detected in the early stages (Stage 1 or Stage 2).
Adenocarcinomas make up more than 95% of prostate cancers. They originate from the prostate gland’s epithelial cells. Biopsy samples examined under the microscope have different grades of cancer based on the degree of abnormality in comparison to the original cells in the prostate gland. More pronounced abnormality shows a more aggressive type of cancer.
The Gleason grading system gives a score of 1-5 for both the most common and second most common patterns. The Gleason score is a sum of both. The Grade Group system of modern pathology gives a 1 to 5 score and is more straightforward and consistent.
Less than 1% of prostate cancers are due to small cell carcinoma of the prostate. It can be categorized as a highly aggressive neuroendocrine cancer. Unlike adenocarcinoma, cancer of the prostate small cell carcinomas arise in neuroendocrine cells of the prostate. Small cell prostate carcinoma largely evades detection in PSA testing because, in most cases, small cell carcinoma of the prostate results in a PSA negative carcinoma. Since small cell prostate carcinomas are aggressive, prevalent, and largely non-responsive to the hormone therapies used in the treatment of adenocarcinoma, immediate treatment is warranted and required.
Much like small cell lung carcinoma, small cell prostate carcinoma can be efficiently and effectively treated by an interdisciplinary team, however, in the case of prostate carcinoma, initial line treatment is often chemotherapy that is combined with radiation and/or surgery depending on the disease state. Treatments are initiated without delay because immediate and accurate diagnosis is the goal. Dr. Vikas Singh collaborates closely with the team to construct apt treatment plans to achieve the best possible outcome.
Transitional Cell Carcinoma (TCC) of the prostate, or urothelial carcinoma of the prostate, is a type of cancer that originates from the urothelial cells in the prostatic urethra or in the ducts of the prostate. Glandular cells of the prostate are not the origin. It is akin to the type of cancer that often involves the bladder. Development of TCC of the prostate is possible through direct extension from bladder cancer, or can independently develop from the prostate.
Management of TCC of the prostate is essentially the management of urothelial cancer. Since TCC is not a prostate adenocarcinoma, it is not amenable to management by means of hormone therapy. Addressing TCC is done surgically (radical cystoprostatectomy is done if the bladder is involved) along with management by bladder cancer chemotherapy. Dr. Vikas Singh is proficient in the treatment of both prostate and bladder cancer. Thus he skillfully manages treatment to meet the needs of this condition.
The prostate contains a few scattered neuroendocrine cells. These cells are morphologically a cross between a nerve cell and a hormone cell. Most cases of prostate adenocarcinomas are accompanied by a component of neuroendocrine cells. This component is generally not significant. However, in some cases, generally after prolonged androgen deprivation therapy, the component can involve a conversion of the cancer cells to a dominant neuroendocrine component. This conversion is referred to as neuroendocrine differentiation. In the literature, this is referred to as treatment-emergent small cell neuroendocrine prostate cancer, t-SCNC. This phenomenon is increasingly recognized as a mode of resistance to the contemporary androgenic therapy.
If there are clinical signs of disease progression in a patient, along with a static PSA, this is known as PSA-negative progression. These patients require a more advanced diagnostic and treatment paradigm, in some cases Ga-68 DOTATATE PET, custom treatments, and confirmatory biopsies. These methods are rarely implemented for patients with standard prostate adenocarcinomas.
Differentiating between low-grade and high-grade prostate cancer is a central tenet of effective prostate cancer management because it fundamentally decides the level of urgency and typology of treatment suggested:
Low Grade (Grade Group 1, Gleason 6): Cancers of this grade grow slowly, and their cells are almost identical to regular prostate cells. It is almost impossible for the cells to spread to lymph nodes or other organs. Most men with Grade Group 1 cancer are older, and some have more dangerous health issues. Because of these factors, many men are just given the active surveillance option, which consists of taking regular PSA tests or biopsies, and MRI they choosing to forego immediate treatment. This option is the best and safest in that active surveillance limits the cancer treatments side effects and also offers the option of being monitored for any growing cancer concerns.
High Grade (Grade Groups 3–5, Gleason 7–10): These cancers have a higher rate of abnormal cell division and a greater tendency for metastasizing. Definitive treatment for high-grade prostate cancer includes a radical prostatectomy and/or radiation therapy. Prostate cancer that is high-grade is treated with a combination of therapies rather than radiation therapy. The treatment is determined by the patient’s age, health, the stage of the cancer, and the patient’s personal preferences.
The different stages of prostate cancer indicate how far the cancer has grown and spread. This forms the basis of every treatment option. It is clinically divided into four stages. Each of these stages is indicated by the TNM system (Tumour, Node, Metastasis). There is also risk stratification that uses the PSA level and the Gleason Grade.
Stage | T Category | PSA | Gleason / Grade Group | 5-Year Survival |
Stage I | T1a-T1c (non-palpable) | <10 | Grade Group 1 (Gleason 6) | Near 100% |
Stage II | T2 (palpable, within prostate) | 10–20 | Grade Groups 1–2 | >95% |
Stage III | T3 (beyond capsule), T4 (into bladder/rectum) | Any PSA | Grade Groups 3–5 | 70–80% |
Stage IV | Any T with N1 (lymph nodes) or M1 (distant mets) | Often high | Any grade | 30–35% (improving with modern therapy) |
Stage I prostate cancer is the earliest and most indolent form of prostate cancer. It is not palpable during digital rectal exams. Moreover, advanced imaging techniques will also not reveal these tumors. It is usually diagnosed days during incidental findings during the processing of anatomy evaluations for trans-urethral resection of the prostate performed for benign prostatic hyperplasia. It is also diagnosed during prostatic biopsies not indicated for prostate cancer, but for mildly elevated PSA. Historically, diagnosis of Stage I cancer has had poor differentiation, and PSA levels was about 10. At Stage I prostate cancer, the chance of metastases is extraordinarily low.
For Stage I prostate cancer, active surveillance, prostatectomy, and various forms of radiation therapy have all been indicated. The prepaid of course prostate cancer and age and cancer differentiation are important factors to consider when proposing therapies. Stage I prostate cancer is indolent, and patients on active surveillance often never require invasive treatment.
Stage II cancer is still localized to the prostate but is larger than Stage I in terms of tumor burden or can be classified as more aggressive. It can be classified as stage IIA (Gleason 6 or 3+4=7, with PSA 10-20 gleason), IIB (Gleason 4+3=7) and IIC (Gleason 8 or bilateral, and palpable tumor). Active measures need to be adopted at this stage for treatment of cancer as the risk of metastasis is higher than Stage I, and referral for active surveillance is inappropriate.
For almost all Stage II cancer patients, the only option after detailed counselling is radical prostatectomy or radiation therapy. Dr. Vikas Singh specializes in performing nerve sparing laparoscopic radical prostatectomy. The surgery is performed while preserving the neurovascular bundles that are key to urinary continence and erectile function. This provides patients with the best possible postoperative surgical outcome.
Stage III prostate cancer breaks through the outer layer of the prostate. Stage IIIA is when cancer has spread to the seminal vesicles or periprostatic tissue. Stage IIIB involves the bladder, rectum, or sphincter. Stage IIIC is defined when cancer has spread even a little, involves high-grade local extension, and has a high PSA. Local treatment in isolation is inadequate for most Stage III cancers. A combination of treatments is required.
This stage is most commonly defined by a combination of radiation therapy and ADT – androgen deprivation therapy – for 2 to 3 years. Stage IIIA and some other select Stage IIIs may also be eligible for surgical treatments, and post-operative radiation is heavily employed at these advanced cancer stages. Treatment plans for all Stage IIIs are made in the context of multidisciplinary tumor boards.
Stage IV prostate cancer has reached the lymph nodes (Stage IVA) and/or the bones and organs, like the lungs, liver, and other sites (Stage IVB). This remains the most severe classification of prostate cancer, and is historically known as metastatic prostate cancer. Stage IVB prostate cancer becomes even more severe in the case it becomes castration-resistant. Stage IV prostate cancer isn’t curable, but for many, many years the cancer is highly manageable with the right systemic therapy.
Stage IV prostate cancer is diagnosed and treated with the use of androgen deprivation therapy (ADT). Cancerous prostate cells need testosterone to grow. Use of chemical castration with LHRH agonists, LHRH antagonists, or even surgical castration is used to stop the production of testosterone, and in consequence, cancer. Use of novel hormonal therapy in combination with ADT has shown to be safe and has resulted in great survival success and is used for hormone-sensitive present metastatic prostate cancer. Docetaxel chemotherapy is used in conjunction with seminal hormone therapy in cases with high bone metastatic load.
Perhaps the most disturbing aspect of prostate cancer in general is the fact it is completely asymptomatic in its early and most highly treatable stages. Prostate cancers in Stage I and Stage II are most commonly detected through PSA testing before the cancer becomes symptomatic. The PSA test may be the only way to detect prostate cancer before it grows to beyond the prostate, or more distantly. For men over 50 there is no substitute for PSA testing, even in the absence of symptoms.
Urinary symptoms that include difficulty with the onset of urination, having a weak or interrupted urinary stream, straining to urinate, and feeling of incomplete bladder voiding can occur with prostate cancer, but this is not prostate cancer’s “own” symptoms. More commonly, these symptoms can result from BPH (benign prostatic hyperplasia – non-cancerous prostate enlargement) and/or prostatitis. However, when these urinary symptoms occur in a male over the age of 50 without a prior diagnosis of BPH, or when the symptoms arise suddenly, they require a thorough work-up that includes a PSA test, digital rectal examination, and likely a prostate biopsy to rule out cancer.
While prostate cancer can sometimes explain blood in urine (haematuria – urine may be pink, red or brown) or blood in semen (haematospermia – semen may be pink or red), the symptoms more typically result from other non-malignant disorders, but should always be taken seriously. Visible blood in urine, regardless of the reason, should result in immediate referral for urological assessment, to rule out prostate or bladder cancer, or kidney disease. Seminal blood should be investigated by a PSA and digital rectal examination.
Men suffering any form of prostate disease often report increased urinary frequency with a particular association with nocturia (waking to urinate at night). In the case of prostate cancer, nocturia may be due to the tumor itself compressing the urethra or bladder changes of a secondary process due to urethral obstruction. Men who have to urinate at night three or more times or frequently have a daytime urination interval of an hour or two should be evaluated with a PSA test. While prostate cancer is often not due solely to an increased frequency of urination, the symptom should not be readily dismissed as a bothersome aspect of the aging process.
Bone pain in the lower back, hips, pelvis or thighs can sometimes be an indication that prostate cancer has metastasized. Because of the locations where prostate cancer usually spreads to the bone, for the reasons listed, diagnostic Swollen Uterus and Fallen Bladder should be considered. New, unexplained persistent back or hip pain in a man above 50 that has never had a PSA should be considered for PSA testing immediately.
Cardiovascular disease, diabetes, and ED are common in men over 50, making ED even more common at this age. ED may be the first cancer sign. ED in combination with other urinary symptoms, and in the absence of a ED history, warrants a clinical exam and PSA. ED may be the result of prostate cancer if it grows toward the neurovascular bundles associated with erections. Damaging these bundles will impact ED. Most men with prostate cancer will not present with ED, but PSA screening in the absence of a PSA history will identify men who are a candidate prostate cancer screening.
Definitely. If diagnosed at Stage 1 or Stage 2, prostate cancer is highly curable. The cure rate for localised prostate cancer is greater than 95% over 5 years. Stage 3 cancer is also curable and is often kept in long-term remission with a combination of surgery and radiation. While Stage 4 prostate cancer is metastatic and is not curable, it can also be kept in a long-term manageable state with a combination of hormone therapy, targeting agents, and immunotherapy. If diagnosed earlier, the salvage rate is also proven to be greater.
Active surveillance refers to low-risk prostate cancer cases which are classified as Grade Group 1, PSA under 10, Stage I, or early Stage II, where the treatment is postponed, and the cancer is monitored. The monitored cancer would include PSA tests that are performed as frequently as 6 months, prostate MRI as frequently as 18 months, and biopsy at several intervals. If the cancer becomes progressive, through either PSA or an increase in the biopsy grade, treatment is initiated. In avoiding treatment of these types of cancer, the hope is that patients avoid the treatment and subsequent side effects of non-life threatening cancer. Dr. Vikas Singh has many patients that active surveillance and with that, Dr. Vikas Singh is fully committed.
ADT, one type of hormone therapy, reduces a person’s testosterone to almost nil. As testosterone is utilized by prostate cancer cells to proliferate, reducing this cancer cell ‘food’ stops or massively increases slowing the cancer’s rate of growth. Use of ADT is for advanced or metastatic prostate cancer in conjunction with radiation for high-risk localized cancer, as an or adjuvant therapy for high-risk patients after cancer surgery, and post-surgery or radiation cancer recurrence. Although ADT is not curative for metastatic disease, it can effectively control metastatic disease for many years. Side effects are loss of libido, hot flushes, fatigue, loss of muscle, and loss of density of the bone, which can all be managed by the implementation of the relevant techniques.
PSMA PET-CT is a kind of advanced imaging study in nuclear medicine due to the use of radioactive tracers targeting PSMA, a kind of protein on the cell membrane found on the surface of prostate cancer cells. PSMA PET imaging is a imaging modality which is highly sensitive than conventional CT or bone scan in the assessment of the spread of cancers, including cancer metastasis to the lymph nodes or bones, even at PSA levels that are extremely low. PSMA PET imaging is useful in determining the location of the cancer when the PSA level increases after a surgical or a radiation procedure. It has become available in Kokilaben Hospital, in Indore, and imaging is facilitated for qualified patients by Dr. Vikas Singh.
Absolutely, PSA testing is the best screening tool for prostate cancer detection. Men of average risk should start PSA screening conversation with their doctor by age 50. If the man is of African descent or has a father or brother that had prostate cancer, screening should begin at age 45. Annually PSA testing is encouraged by Dr. Vikas Singh. PSA testing should be conducted routinely every year because the test is a blood test that can detect prostate cancer when it is the most easily treatable, which is often in its early or even asymptomatic stage.
Yes. Dr. Vikas Singh is a surgeon specializing in laparoscopic radical prostatectomy at Kokilaben Dhirubhai Ambani Hospital, Indore, which is a minimally invasive procedure that is performed through small keyhole incisions, compared to an open surgery incision. Laparoscopic radical prostatectomy also comes with a number of benefits, including a significantly faster and easier recovery. Additionally, due to the tools that are able to be used for a robotic-assisted prostatectomy, the surgeon is also able to maximize the number of nerves preserved as well as post-surgery incontinence. Based on the the patient’s unique anatomy and the characteristics of the tumor, Dr. Vikas Singh will suggest the best surgical tactic.
Radical prostatectomy and radiation therapy (be it external beam or brachytherapy) improve the chances of cure for prostate cancer and provide almost identical long-term cancer control for localized and locally advanced cases. However, the side effect profiles differ. The major difference is that surgery causes short- to medium-term urine leak (stress incontinence) more often. Radiation therapy, especially in external beam, is known to affect the bowel and cause urinary problems in the late phase. Both approaches cause erectile dysfunction, and both are possible. Surgery is also often preferred by healthier patients; radiation is preferred by patients who are of more advanced age and/or have more medical problems. He is not afraid to address the options and side effects of both these modalities.
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