(UroToday.com) The 2024 Advanced Prostate Cancer Consensus Conference (APCCC) meeting featured a session on global access to advanced prostate cancer in low- and lower-middle-income countries, and a presentation by Dr. Onyeanunam Ngozi Ekeke discussing how we can modify the diagnostic pathway to deal with rising rates of prostate cancer in Africa.
Dr. Ekeke notes that prostate cancer is the leading cause of cancer in men in terms of incidence and mortality in Africa, with an incidence that is still rising. This is coupled with poverty and poor funded, limited insurance coverage, and poor healthcare infrastructure. Moreover, in Africa, there is often late presentation and delayed diagnosis, leading to poor outcomes, thus necessitating the need to adopt strategies to improve diagnosis for better outcomes.
In Africa, there is a lack of prostate cancer knowledge and symptom awareness, which are the major determinants of poor health-seeking behavior. A patient’s inability to make early discernments and the lack of accessible, affordable, and culturally responsive primary care service can result in delays with more men presenting to emergency care with advanced or terminal stage disease. Patient education is crucial and raising awareness about prostate cancer risk factors, symptoms, and the importance of early detection can lead to earlier presentation and diagnosis. Community-based campaigns, media outreach, and educational programs can also help to disseminate information.
Dr. Ekeke notes that screening is beneficial to Africans, which leads to early detection, and shared decision-making for treatment. There is a push for implementing targeted screening programs for high-risk populations to improve specificity and avoid over-detection. This includes men with a family history of prostate cancer, older age groups, and those of African descent.
There is a need for development of risk stratification models specific to African populations that include the patient’s age, race, family history, PSA, DRE, and prior biopsy status in order to produce a risk score for having both low- and high-grade prostate cancer on a biopsy. This includes careful utilization of:
- Risk calculators for screening in combination with other factors
- PSA kinetics
- PSA velocity
- PSA density
- Free versus total ratio (< 10%)
- Age-specific and race-specific PSA levels
- Yearly for specific groups of men
Screening for prostate cancer in Africa means for men >40 years of age to 75 years, as well as those with a family history of prostate cancer (40 years old), and men carrying BRCA2 mutations (initiate at 40 years of age). There also needs to be age-specific thresholds developed and assess who can have interval testing of 1 year versus 2 years. Dr. Ekeke states that it is important to increase access to biopsy services:
- Ensure availability of prostate biopsy services across Africa
- Promote training for healthcare professionals to perform biopsies and interpret results
- Lack of access to biopsies hinders accurate diagnosis
- Advocating for image-guided biopsies
For prostate biopsies, the gold standard in most parts of Africa is an ultrasound-guided, systematic biopsy of at least 12 cores, although mpMRI biopsies are preferred and should be used where available. With regards to imaging for staging, conventional imaging includes ultrasounds, X-rays, CT scan, and MRI (which is mostly a 1.5 T MRI), as well as bone scan, which are available but limited. Next-generation PSMA PET scan is very limited in Africa.
Collaboration, regionalization, and referrals are advocated, specifically to assist with immunohistochemistry services, tele-pathology, genetic testing, and multidisciplinary tumor boards. The development of local guidelines for optimal diagnostic pathways should be based on available resources.
Dr. Ekeke concluded his presentation discussing how we can modify the diagnostic pathway to deal with rising rates of prostate cancer in Africa by emphasizing that this will require a comprehensive approach involving awareness, infrastructure development, workforce training, research and collaboration, and policy changes towards strengthening the capacity for early prostate cancer diagnosis that are essential to address the rising burden of prostate cancer in Africa.
Presented by: Professor Onyeanunam Ngozi Ekeke, MD, University of Port Harcourt Teaching Hospital, Alakahia, Port Harcourt, Nigeria
Written by: Zachary Klaassen, MD, MSc - Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the 2024 Advanced Prostate Cancer Consensus Conference (APCCC) Meeting, Lugano, Switzerland, Thurs, Apr 25 - Sat, Apr 27, 2024.