Summary Cancer is rapidly becoming a public health crisis in low-income and middle-income countries. In sub-Saharan Africa, patients often present with advanced disease. Little health-care infrastructure exists, and few personnel are available for the care of patients. Surgeons are often central to cancer care in the region, since they can be the only physician a patient sees for diagnosis, treatment (including chemotherapy), and palliative care. Poor access to surgical care is a major impediment to cancer care in sub-Saharan Africa. Additional obstacles include the cost of oncological care, poor infrastructure, and the scarcity of medical oncologists, pathologists, radiation oncologists, and other health-care workers who are needed for cancer care. We describe treatment options for patients with cancer in sub-Saharan Africa, with a focus on the role of surgery in relation to medical and radiation oncology, and argue that surgery must be included in public health efforts to improve cancer care in the region.

https://www.thelancet.com/pdfs/journals/lanonc/PIIS1470204512704722.pdf

Treatment of cancer in sub-Saharan Africa

African American men have the highest prostate cancer morbidity and mortality rates than any other racial or ethnic group in the US. Although the overall incidence of and mortality from prostate cancer has been declining in White men since 1991, the decline in African American men lags behind White men. Of particular concern is the growing literature on the disproportionate burden of prostate cancer among other Black men of West African ancestry in the Caribbean Islands, United Kingdom and West Africa. This higher incidence of prostate cancer observed in populations of African descent may be attributed to the fact that these populations share ancestral genetic factors. To better understand the burden of prostate cancer among men of West African Ancestry, we conducted a review of the literature on prostate cancer incidence, prevalence, and mortality in the countries connected by the Transatlantic Slave Trade. Several published studies indicate high prostate cancer burden in Nigeria and Ghana. There was no published literature for the countries Benin, Gambia and Senegal that met our review criteria. Prostate cancer morbidity and/or mortality data from the Caribbean Islands and the United Kingdom also provided comparable or worse prostate cancer burden to that of US Blacks. The growing literature on the disproportionate burden of prostate cancer among other Black men of West African ancestry follows the path of the Transatlantic Slave Trade. To better understand and address the global prostate cancer disparities seen in Black men of West African ancestry, future studies should explore the genetic and environmental risk factors for prostate cancer among this group.

/pdf/prostate-cancer-disparities-in-black-men-of-african-descent-19aibfegwi.pdf

Prostate cancer disparities in Black men of African descent: a comparative literature review of prostate cancer burden among Black men in the United States, Caribbean, United Kingdom, and West Africa

Introduction Prostate cancer is common around the world, but rates of advanced disease differ substantially by race and geography. Although a major health issue, little is known about prostate cancer presentation in West Africa and India compared to the United States (US). Objective The aim of this study was to compare prostate tumor characteristics in four populations of men from the US, Senegal and India. Materials and methods We recruited prostate cancer patients from four hospital-based populations. The sample included 338 African-Americans, 1265 European-Americans, 122 Asian Indians, and 72 Senegalese. Questionnaire and medical record data were collected on each participant. Results We found significant differences in age at diagnosis, BMI, and PSA levels across the groups. Senegalese and Indian men had a higher probability of high stage (T3/T4) disease compared to US men. Gleason grade was significantly higher in Asian Indians compared to other populations. African-Americans, Senegalese, and Asian Indians had a significantly higher probability of metastatic disease compared to European Americans. The odds ratios (OR) for metastasis were consistently higher in Asian Indians compared to American cases. As only 19/72 Senegalese were assessed for metastasis, OR could not be determined for metastasis. Conclusions These results suggest that there are significant geographical and ethnic differences in the presentation of prostate cancer. Men in developing countries tend to present with advanced disease compared to US men. Identifying risk factors for advanced disease may help to decrease the rate of poor prostate cancer outcomes and associated mortality worldwide.

Evaluation of prostate cancer characteristics in four populations worldwide.

Prostate cancer is the leading cause of cancer among Nigerian men. This study assessed the knowledge, awareness, and screening practices among older men regarding prostate cancer in Oyo State, Nige...

Prostate cancer awareness, knowledge, and screening practices among older men in Oyo State, Nigeria.

Background: Recent hospital and cancer registry data show increasing prostate cancer incidence in Nigeria, which was previously regarded as a low incidence region. This study investigates the prevalence of prostate cancer risk in a previously unscreened cohort of rural Nigerians.



Methods: Rural Nigerian men, 40 years and older, were screened by serum prostate-specific antigen (PSA) and digital rectal examination (DRE) and those with PSA ≥ 4 ng/mL and/or abnormal DRE were referred for prostate biopsy.



Results: Of 200 consecutive men invited, 151 (75.5%) presented for screening, the mean age was 56.45 + 15.1 and 95 (61.6%) were ≥ 50 years of age. Of the 140 who consented to a blood test, PSA correlated with age (r = 0.3, P < 0.01), 14 (10.0%) had abnormal PSA ≥ 4 ng/mL, increasing from 3 (3.6%) in men < 60 years to 4 (50%) in men ≥ 80 years. The rate was 13 (15.7%) for men ≥ 50 years and there was no evidence of increased incidence of prostatitis in the community. Mean (median) PSA in ng/mL increased from 1.17 (0.60) in the youngest to 13.75 (4.45) in the oldest cohort. Of those who accepted DRE, 38 (29.0%) had an enlarged prostate, including two who had nodular prostate, one-third with symptoms, increasing from 4 (5.4%) in those < 50 years to 6 (75.0%) in men ≥ 80 years. The proportion of men with PSA ≥ 4 ng/mL among those with enlarged vs normal prostate is 27.0 to 3.4%, P < 0.001, and the pattern was similar for men ≥ 60 years and those < 60 years of age. The 40 (32.0%) men referred for prostate biopsy defaulted mainly because they did not fully understand the need for further investigation because they were symptom free or afraid of the possible side-effects of the procedure or diagnosis of cancer.



Conclusion: The proportion of men with PSA ≥ 4 ng/mL is comparable to that of previously unscreened populations with high incidence of prostate cancer such as African-American men. A larger study is required to confirm these findings and intensify efforts to determine the prostate cancer detection rate by biopsy in this population. A prostate cancer awareness and education campaign will be useful in this community.

https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1442-2042.2003.00633.x

Prevalence of elevated serum prostate-specific antigen in rural Nigeria

362 Background: The aim if this single institute UK-based study was to look at 3-year and 5-year bRFS and toxicity profiles. Methods: It is a prospective data study with a total number of 174 patients who were treated with single-fraction HDR monotherapy between July 2014 and February 2017. Biochemical recurrence is defined using Phoenix criteria. Results: The median age was 67.5 years with the median presenting PSA of 8. Majority of patients were lower risk group with 55% for combined low and favourable intermediate risks. 81 patients had Gleason score 6(3+3) and 77 patients had GS 7(3+4). Total hormone duration was 8 months and median duration of hormone prior to HDR monotherapy was 4 months. Overall bRFS at 3 years was 96% and 5 years was 88%. 5-year bRFS as per risk stratification was 100% in low risk, 92% in favourable intermediate risk, 83% in unfavourable intermediate risk and 79% in high-risk groups. This study had better 5-year overall bRFS compared to published data in single fraction HDR monotherapy (88% vs 73.5%, p value 0.001) (Morton et al., 2020). Despite inferior 5-year overall bRFS in compared to 2-fractionated HDR monotherapy (88% vs 95%) (p value 0.001), no difference in 5-year bRFS noted in low and favourable intermediate risk groups (100% vs 100% and 92% vs 93% respectively) (Morton et al., 2020). Two-thirds (71%) of biochemically recurred patients found to have local recurrence disease. The median time of biochemical recurrence was 47 months. Higher risk groups had higher 5-year biochemical recurrence risk. Acute and late toxicity profiles were minimum with acute G2 GU toxicity (2%) and GI toxicity (1%); late G2 GU toxicity (2%) and GI toxicity (0%) with no G3, G4 GU or GI toxicities. Conclusions: This prospective study had shown better overall 5-year bRFS especially in low and favourable intermediate risk groups with minimal toxicities. Therefore, single-fraction HDR monotherapy could be considered for elderly or patients with significant co-morbidities who are more suitable for single treatment rather than 2 fractions in these risk groups. Further randomised multicentre studies in these risk groups are suggested.

5-Year result of single-institute cohort study in single-fraction HDR monotherapy for localised prostate cancer.

A UK urological cancer centre cystectomy service - What lessons can we learn?

Objective To study the factors associated with morbidity and mortality in benign prostatic hyperplasia (BPH) and carcinoma of the prostate in native Africans.



Patients and methods A prospective study was conducted from 1993 to 1998 at the Ahmadu Bello University Teaching Hospitals, Zaria, Nigeria. During this 5-year period 686 patients were investigated and treated for symptoms and signs of prostatism. They were followed up for a mean (range) of 19.5 (1–60) months.



Results BPH was found in 588 and clinical carcinoma in 98 patients. Adequate results, including a histological diagnosis, were available for 640 patients; there were 545 patients with BPH and 95 patients with histologically diagnosed prostate cancer. Treatment consisted of open prostatectomy for BPH, and subcapsular orchidectomy and/or open bladder-neck wedge resection for patients with prostate cancer and bladder neck obstruction. Within 6 months of surgery, four of 545 (0.7%) patients with BPH and 25 of 95 (26.3%) with prostate cancer had died. Two-thirds of the patients with cancer presented with paraparesis or paraplegia.



Conclusions BPH and prostate cancer cause significant morbidity and mortality in African men. There is a need for health education about the early recognition of symptoms. Provision of facilities for transurethral prostatectomy would minimize the complications of surgery and ensure better use of the meagre resources available for health care.

https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1464-410x.2000.00677.x

Benign prostatic hyperplasia and prostate carcinoma in native Africans.

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5-Year result of single-institute cohort study in single-fraction HDR monotherapy for localised prostate cancer.

A UK urological cancer centre cystectomy service - What lessons can we learn?

Benign prostatic hyperplasia and prostate carcinoma in native Africans.