According to Dr Khor, a urologist, several key factors contribute to delays or missed opportunities in diagnosing prostate cancer, particularly among men who do not present with symptoms:

1. Lack of a national screening program

   In Malaysia, the absence of a national screening program for prostate cancer reflects the ongoing global debate over population-wide screening using tumour marker - PSA (Prostate-Specific Antigen) testing. Concerns about overdiagnosis and overtreatment have made such initiatives controversial. As a result, early detection depends largely on opportunistic screening, which remains inconsistent in both uptake and implementation.

2. Insufficient PSA testing in high-risk individuals

   Many asymptomatic men, especially those with a strong family history of prostate or breast cancer, are not offered timely PSA testing. This gap is often due to limited public and professional awareness, inconsistencies in primary care practice, and reluctance from patients who may fear a cancer diagnosis or hold misconceptions about the disease.

3. False reassurance from “normal” PSA levels

   PSA is an imperfect tool. Some primary care physicians may not be familiar with age-specific PSA reference ranges, which are sometimes omitted from lab reports. Although a total serum PSA level below 4 ng/mL is generally considered "normal," numerous studies have shown that age-specific PSA reference ranges offer a more accurate assessment. For example, a PSA of 3.9 ng/mL may be considered abnormal in men under 60, and PSA of 4.5 ng/mL might still be acceptable in men over 70. Consequently, clinically significant prostate cancer may be missed in men whose PSA falls within the general "normal" threshold.

   In the diagnostic "grey zone" of PSA levels between 4–10 ng/mL, several adjuncts can improve risk stratification, including the free-to-total (FT) PSA ratio, PSA density (PSAD), and the Prostate Health Index (PHI). However, these adjuncts are not routinely included in standard PSA testing, and many healthcare providers may be uncertain about how to interpret or act on these additional values. These readings — as well as rising PSA trends over time — are often overlooked when clinicians rely solely on a single PSA measurement.

4. Limited training in opportunistic screening

   Many primary care providers in Malaysia are not sufficiently trained to perform opportunistic screening for prostate cancer. Digital rectal examination (DRE), though a useful tool, is underutilised, partly due to patient discomfort and partly due to physician hesitation. Similarly, PSA testing is inconsistently applied, leading to missed opportunity for early detection of prostate cancer in high-risk yet asymptomatic men.

5. Low public awareness and health-seeking behaviour

   Awareness about prostate cancer remains limited, particularly in rural or underserved areas. Many men are unaware of their risk factors or the availability of simple screening test using PSA. Cultural stigma, fear of cancer, and discomfort with urological assessments further deter men from seeking timely medical attention.

6. Symptoms attributed to benign conditions

   When men present with mild lower urinary tract symptoms (LUTS), these are often dismissed as signs of ageing or benign prostatic hyperplasia (BPH). Without further evaluation, such as PSA testing or prostate MRI, opportunities to detect underlying malignancy at an earlier stage of disease, more treatable stage are frequently missed.

Emotional and social factors often play a significant, yet under-recognised, role in why men delay treatment or avoid follow-up for prostate cancer. In clinical practice, these barriers are frequently overlooked, but they can have a real impact on outcomes.

1. Fear and denial

   A prostate cancer diagnosis can carry heavy emotional weight. For many men, it triggers fears of mortality, a perceived loss of masculinity, or anxiety about invasive treatments. Concerns about side effects, particularly sexual dysfunction or incontinence, can be overwhelming. This often leads to avoidance or denial, even in men already flagged as high risk.

2. Stigma around urological symptoms

   Urinary symptoms, erectile dysfunction, and prostate exams remain taboo topics for many. Embarrassment or shame discourages open conversations and delays medical attention, even when symptoms are affecting quality of life.

3. Lack of awareness and misinformation

   Health literacy remains a challenge in both urban and rural settings. Many men are unaware of the benefits of early detection or the range of modern treatment options available. A common belief persists: “If I feel fine, I must be fine”, especially among those who are asymptomatic or have only mildly elevated PSA levels.

4. Concerns about quality of life

   Fear of long-term side effects often leads men to postpone treatment. Worries about sexual health and continence are particularly strong. Without proper counselling, many are unaware that newer approaches, including nerve-sparing surgery, precision radiotherapy, or focal therapy, can offer effective cancer control while preserving quality of life.

5. Social and financial pressures

   Work obligations, financial concerns, or caregiving responsibilities can prevent men from seeking timely care. This is especially true for those who are self-employed, elderly caregivers, or sole income earners. For some, taking time off to be “a patient” simply doesn’t feel like an option.

Addressing these barriers requires more than clinical expertise. It calls for empathy, culturally sensitive communication, and an understanding of each man’s social circumstances.

Personalised counselling and involving family members in treatment discussions can help reduce fear and build trust. Support networks, such as the Prostate Cancer Society of Malaysia (PCSM), as well as testimonies from survivors, can help reduce stigma and motivate action.

Community-based education, led by NGOs, primary care providers, or even religious and community leaders, can further normalise screening and encourage men prioritise their health.

PSA testing remains an important tool for the early detection of prostate cancer, but as Dr Khor explains, it should not be mistaken for a definitive diagnosis. PSA, or prostate-specific antigen, is a protein produced by prostate tissue. Elevated PSA levels can indicate the presence of prostate cancer, but they may also result from non-cancerous conditions such as:

• Benign prostatic hyperplasia (BPH)
• Prostatitis (inflammation of the prostate)
• Recent ejaculation or urological procedures

An elevated PSA level should therefore be viewed as a signal for further evaluation, not as a cancer diagnosis in itself.

Accurate interpretation of PSA results must be individualised and considered in context. Several clinical factors can improve interpretation and help avoid unnecessary interventions:

• Age-specific PSA ranges: PSA levels naturally increase with age.
• PSA velocity or doubling time: A steady rise in PSA over time is often more concerning than a single elevated result.
• PSA density: PSA relative to prostate volume, measured via imaging, provides a more refined assessment of cancer risk.
• Free-to-total PSA ratio (FT ratio): A lower FT ratio may suggest a higher likelihood of malignancy.

Taken together, these tools enhance the specificity of PSA testing and help reduce unnecessary investigations.

PSA testing is now part of a broader, risk-adapted strategy that includes multiparametric MRI (mpMRI) of the prostate. No longer used in isolation, PSA is combined with mpMRI to improve diagnostic accuracy and guide more informed decision-making. This approach offers several key advantages:

• Detection of suspicious lesions that may not be visible through PSA results alone
• Targeted biopsy, allowing clinicians to sample only areas of concern rather than relying on random biopsies
• Avoidance of unnecessary biopsies in men with elevated PSA but normal mpMRI findings

Together, PSA and mpMRI improve the detection of clinically significant prostate cancers while reducing the diagnosis and overtreatment of low-risk, indolent disease.

Inherited risk plays a significant role in the development and progression of prostate cancer. These risks fall broadly into three categories: family history and ethnicity, rare germline mutations, and common genetic variations known as single nucleotide polymorphisms (SNPs).

1. Family history and ethnicity

   Men of African ancestry in Western populations are at increased risk of being diagnosed with more advanced prostate cancer. A small proportion of men meet the criteria for true hereditary prostate cancer (HPCa), which is defined as having at least three affected relatives, diagnoses across three successive generations, or two family members diagnosed before the age of 55.

   In families with this pattern, the risk of developing high-risk prostate cancer by age 65 increases to 11.4%, compared to 1.4% in the general population. The overall risk of any prostate cancer also rises significantly, reaching 43.9% compared to 4.8%, if both a father and two brothers are affected.

   Another category is familial prostate cancer, which includes families with two or more first- or second-degree relatives diagnosed with prostate cancer on the same side of the family tree. This may also be associated with hereditary cancer syndromes, such as hereditary breast and ovarian cancer (HBOC) or Lynch syndrome, although the risk in these cases is generally lower than in HPCa.

2. Germline mutations

   Germline mutations are inherited changes in DNA that originate in the egg or sperm and are passed on to every cell in the body. Some of these pathogenic mutations can significantly increase the risk of developing prostate cancer, particularly those found in genes such as BRCA2, HOXB13, CHEK2, BRCA1, ATM, NBS1, and genes associated with Lynch syndrome.

   Among these, pathogenic variants are most frequently seen in BRCA2 (4.5%), followed by CHEK2 (2.2%), ATM (1.8%), and BRCA1 (1.1%). Notably, BRCA2 mutations are considered an independent predictor of metastasis and are associated with poorer prostate cancer-specific survival.

3. Single Nucleotide Polymorphisms (SNPs)

   SNPs are common variations at a single point in the DNA sequence. While each individual SNP has only a small effect on prostate cancer risk, their cumulative impact can be substantial. These additive effects are believed to account for a large proportion of hereditary prostate cancer cases that are not linked to rare, high-impact mutations.

   Clinical implications

   Men with a strong family history or genetic mutations such as BRCA2 are more likely to develop prostate cancer at a younger age and tend to present with more aggressive disease. These patients are often characterised by:

   • Higher Gleason scores (indicating more aggressive cancer)
   • Increased likelihood of cancer growing its capsular border (extracapsular extension) and spread to the lymph nodes
   • Higher risk of cancer spreading to other parts of body (metastasis) at the time of diagnosis
   • Shorter overall survival

   They may also respond differently to standard treatments. Some may benefit from targeted therapies such as PARP inhibitors, which are designed to exploit tumour-specific vulnerabilities in men with DNA damage repair mutations.

   Given the elevated risk, men with known BRCA mutations or a strong family history should be considered for earlier and more intensive screening. This includes PSA testing beginning in their 40s or even earlier in selected cases, and referral for genetic counselling and testing where appropriate.

Prostate cancer treatment has advanced significantly over the past decade. While surgery and radiotherapy remain foundational, several innovations in hormonal therapy, imaging, and precision medicine are now transforming outcomes, particularly for men with advanced or high-risk disease, says Dr Khor.

1. Advances in imaging and surgical techniques

   Staging and treatment planning have become more precise with the introduction of multiparametric MRI and PSMA PET/CT, both of which allow for more accurate risk stratification. A major breakthrough in biopsy technique is the use of MRI–ultrasound fusion platforms, such as the KOELIS Trinity system. This technology combines real-time transrectal ultrasound (TRUS) with pre-acquired mpMRI images to guide targeted biopsies of suspicious lesions.

   Compared to conventional systematic biopsies, fusion-guided biopsies significantly improve the detection of clinically significant prostate cancer while reducing overdiagnosis of indolent disease. Additionally, KOELIS offers 3D mapping of biopsy cores, which helps clinicians track tumour locations and guide focal therapy or active surveillance strategies.

   In surgery treatment, robot-assisted radical prostatectomy has become the standard of care in many centres. This minimally invasive technique enhances precision, reduces blood loss, and promotes faster recovery compared to traditional open surgery.

2. Next-generation hormonal therapies

   Androgen deprivation therapy (ADT) has long been a mainstay of treatment for advanced prostate cancer. However, the introduction of androgen receptor-targeted agents, including abiraterone, enzalutamide, apalutamide, and darolutamide, has significantly improved outcomes. These agents more effectively inhibit androgen receptor signalling, even in low-testosterone environments.

   When used earlier in the disease course in combination with ADT, these newer agents have been shown to extend both progression-free and overall survival in men with metastatic castration-sensitive and castration-resistant prostate cancer.

3. Precision medicine and genetic testing

   The integration of genomic profiling marks a major advancement in personalised prostate cancer care. Testing for mutations in BRCA1, BRCA2, ATM, and other DNA damage repair (DDR) genes is now standard practice in many settings.

   Patients with these mutations may benefit from PARP inhibitors, such as olaparib or rucaparib, which selectively target tumour-specific vulnerabilities. This shift toward precision medicine enables more tailored treatment strategies and has shown improved outcomes in patients with metastatic or castration-resistant disease.

4. Radioligand therapy and theranostics

   PSMA-targeted radioligand therapy is another promising innovation. Lutetium-177 PSMA therapy (Lu-PSMA) delivers targeted radiation to prostate cancer cells expressing prostate-specific membrane antigen (PSMA), limiting damage to surrounding tissues.

   Clinical trials, including the VISION study, have demonstrated that Lu-PSMA therapy can improve both survival and quality of life in men with metastatic castration-resistant prostate cancer who have failed other therapies.

5. Focal therapy for intermediate-risk prostate cancer

   For men with intermediate-risk, localised prostate cancer, focal therapy is gaining recognition as a less invasive alternative to whole-gland treatment. This approach targets only the tumour-bearing area of the prostate, aiming to preserve urinary and sexual function without compromising cancer control.

   Emerging focal therapy techniques include high-intensity focused ultrasound (HIFU), cryotherapy, and irreversible electroporation (NanoKnife). These options are increasingly being offered to carefully selected patients, particularly those who prioritise quality of life.

   Although long-term oncologic outcomes are still under investigation, early data suggest that focal therapy offers effective cancer control with significantly lower rates of incontinence and erectile dysfunction. It reflects a broader shift toward individualised, risk-adapted care that balances effective treatment with preservation of function.