September marks the global prostate cancer awareness month and brings the disease into the national limelight. In my new 900-page book yet to be launched on 26th September 2020, page 1, I said that “every man has a prostate, but every prostate doesn’t have to make a man’s life miserable. However, this small gland is a source of men’s grief if it goes wayward. I likened Prostate cancer in black men to some supervillains in a fictitious book. Hence, Prostate cancer strikes a special chord with me, why? It is a very aggressive cancer in black men, in part because it’s discovered at very late stages when it’s highly advanced and appears as if there is nothing to be done to cure it. There is also another headache for black men: After conventional treatment, this cancer comes back for 75 percent of black patients. And this time, it usually comes back in a drug-resistant form. High-grade prostate cancer appears as one of the biggest supervillains out there in comic books”.
The stats not favorable for Ghanaian men
Prostate cancer affects about 60% of black men. The Ghana Cancer Control Strategy plan document revealed the following incidences of prostate cancer in Africa: Ghana >200/100,000, Nigeria 127/100,000 and Cameroun 130/100,000. Prostate cancer in Ghana appears as ‘no one care’ business! Interesting, a survey by the Korle-Bu Teaching Hospital has revealed in 2006 that Ghana has exceeded global prostate limits as the country records 200 cases out of every 100,000 men as against 170 worldwide.
This revelation was released by Dr Mathew Kyei, a Urologist, at a Ghana Health Service monthly programme in Accra. According to the urologist, the situation called for immediate attention from the government and the public to reverse the trend (Modernghana 2007). Speaking on the topic, “Cancer Disorders in Ghana”, he said in 2006, 60 per cent of all cancers reported at the Korle-Bu Teaching Hospital were prostate cancers, adding that 27 people died from the disease in 2005 alone.
Also, Hsing et al 2014 performed a population-based screening study with biopsy confirmation in Ghana. The research aims to estimate the prostate cancer burden in West African men. The study authors randomly selected 1,037 healthy men 50 to 74 years old from Accra, Ghana for prostate cancer screening with prostate-specific antigen testing and digital rectal examination. Men with a positive screen result (positive digital rectal examination or prostate-specific antigen greater than 2.5 ng/ml) underwent transrectal ultrasound-guided biopsies.
Their result revealed that of the 1,037 men 154 (14.9%) had a positive digital rectal examination and 272 (26.2%) had prostate-specific antigen greater than 2.5 ng/ml, including 166 with prostate-specific antigen greater than 4.0 ng/ml. A total of 352 men (33.9%) had a positive screen by prostate-specific antigen or digital rectal examination and 307 (87%) underwent biopsy. Of these men 73 were confirmed to have prostate cancer, yielding a 7.0% screen-detected prostate cancer prevalence (65 patients), including 5.8% with prostate-specific antigen greater than 4.0 ng/ml.
They concluded that in this relatively unscreened population in Africa the screen-detected prostate cancer prevalence is high, suggesting a possible role of genetics in prostate cancer etiology and the disparity in prostate cancer risk between black and white American men.
After hepatocellular cancer, prostate cancer is the second leading cause of male cancer deaths in Korle Bu Teaching Hospital (Wiredu 2005). In 2009, 185 new cases of prostate cancer were diagnosed at Korle bu teaching hospital with 37 deaths. The number of prostate cancers reported has generally risen annually possibly due to earlier detection using the prostate-specific antigen (PSA) blood test, increased patient awareness, increased lifespan, and possibly environmental factors.
The burden of prostate cancer is likely to increase with the ageing of the Ghanaian population, and this has major public health and economic implications. Evidence of early prostate cancer can be found at any adult age (WA et al 1996) but it is more common in men over 60 years of age(Yarney et al 2011). When it progresses and becomes more advanced, prostate cancer can kill men of any age.
A report from the Daily Guide newspaper also indicated that seventy percent of cancer deaths in Ghana could be prevented if healthy lifestyles are adopted and early detection is made, this was attributed to Dr Efua Commeh of the Non-Communicable Disease (NCD) Programme, Ghana Health Service (GHS). Dr Commeh indicated that of the 16,000 new cancer cases recorded yearly in the country, more than 44 percent results in deaths.
Data from the Ghana Health Service (Fig 2, fig 4) shows that 3052 cases of cervical cancer were recorded in 2015 out of which 1556 died, representing 51 percent, breast cancer also recorded 2260 cases with 1021 deaths, representing 45 percent, prostate cancer has 912 cases being recorded with 680 deaths, representing 75 percent.
Recent Prostate Cancer Studies:
Prostate cancer is underestimated subject in Ghana, yet more men are battling with the disease. There are also more studies revealing the high incidence and death of the disease in Ghanaian men. For instance, one 6-year research studies by Egote et al 2019, aimed at reducing the paucity of data on prostate cancer by assessing the incidence, patterns and presentation in the Brong Ahafo Region of Ghana and also sought to provide region-specific hardcore data that will help to assess the issue and provide remedies.
The study authors reviewed all prostate disease cases recorded from the year 2009 to 2014. They employed men from 40 years (based on previous studies) and above were eligible for screening. Diagnostic and screening tools for prostate cancer at the study site were family history, serum prostate-specific antigen (PSA) test, digital rectal examination, urological ultrasound scan and histopathology (biopsy).
Age, PSA values and year of screening/diagnosis were also retrieved from their folders/archives for the purposes of the study. Histological findings and parameters considered in the study included diagnosis, carcinoma grading, perineural invasion (PNI)- and percentage of affected tissues (%TA).
The researchers revealed that Prostate cancer constituted 236 cases (40.07%) of the 589 prostate diseases reviewed. The highest annual prevalence was recorded in 2014 with an incidence rate of 21.6% (51 cases). Interestingly enough, the ages of patients ranged from 46 to 101 years with a modal age range of 70 – 79 years. The mean PSA value recorded was 37.5 ng/ml with predominance in the 11 – 20.9 ng/ml (61 cases/patients) (27.9%) range. Moderately differentiated adenocarcinoma (intermediate grade) was the dominant grade of prostate cancer accounting for 61.4% (145 cases) of the 236 cases.
There was a significant correlation between grading of prostate cancer and perineural invasion. The study authors further revealed that only 21.2 percent of graded cancer cases had perineural invasion with >50% affected tissues found in half of them.
The study authors concluded that “there is a high incidence (40.07%) of prostate cancer in the Brong Ahafo Region of Ghana, presenting mostly with advanced prostatic carcinoma. Reported cases also show high %TA (Tissues Affected and PNI (Perineural invasion). Development and implementation of public health interventions are needed to address some of these issues”. The study authors proposed the development and implementation of public health interventions to address this.
Interesting, in a more recent 10-year study conducted by the same author, Egote et al, 2020, affirms that Prostate cancer is gradually reaching a very high incidence in Africa, especially in the Sub-Saharan region. This same study was conducted in the Brong Ahafo Region of Ghana. All prostate disease cases recorded from the year 2009 to 2018 were retrospectively reviewed. Subjects from 40 years and above were eligible for screening. The result revealed a high incidence of prostate cancer in the Brong Ahafo Region of Ghana (32 per 100,000).
DISCUSSION
Prostate cancer Mortality compared to Liver Cancer
Liver cancer had the highest fatality (Fig 2, Fig 3) rate of 97 percent, claiming 1,856 lives out of 1923 cases recorded with 1,000 childhood cancers being recorded. With liver cancer only 3% are able to survive it, 49% survive cervical cancer, 55% survive breast cancer and only 25% also do survive prostate cancer. This is very worrying as the country itself has no well-defined national cancer register to be able to collate all the figures. This assessment is based on the Ghana Health Service data in 2015 published in the Daily Guide newspaper.
There is currently no effort to tackle the high mortality rates in the country. Prostate cancer is a major problem in Ghana, yet fewer men receive regular screening. Incidence and mortality rates are among the highest in the world, with the age-standardized mortality rate from prostate cancer reported as being more than three times the global rate.
The reasons for these high rates include a lack of investment and weak governance in the recent past. Interestingly enough, there is only one active prostate cancer charity fighting the disease; Men’s Health Foundation Ghana. The charity has become the national peak body of prostate cancer pushing for national policies. The problem with the charity has to do with funding and government support.
Prostate Cancer death rate beats Breast and Cervical Cancer.
Interesting, Prostate cancer mortality rate in Ghana supersedes breast and cervical cancer (Fig 6). This means that more men are dying from Prostate Cancer than women cancers (fig 2, fig 3, fig 4). Prostate cancer mortality rate is as high as 75% compared to Cervical,51% and Breast Cancer, 45% respectively (fig 3). This also means that a Ghanaian man’s chances of surviving prostate cancer if diagnosed is very slim 25%, compared that to women’s’ cancers in Ghana (fig 3). This could be akin to Real Madrid or Barcelona football stars playing a local team in Ghana; obviously, many would tip or bet for Real Madrid or Barcelona to win the game. This is our situation or story as men when we are faced with prostate cancer in Ghana. With women’s cancers, it almost 50:50 affairs in Ghana; anyone could survive with the right tactic and support (fig 3)
Prostate Size in Ghanaian Men
Egote et al, 2018 also reported a patient with prostatic hyperplasia weighing exactly 700g. Prostatic hyperplasia of enormous size is very uncommon and to the best of their knowledge, only ten of such cases have been previously reported. Their case reported constitutes the eleventh heaviest prostate reported in medical literature and also forms the first case report of giant prostatic hyperplasia from Ghana.
Age as a risk factor for prostate diseases in Ghana
To assess the risk age for prostate diseases in Brong Ahafo Region, Egote al 2018 research further employed a selective prospective study to review prostate cases from 2009 to 2014. Subjects were selectively recruited for the study using the reference age of the study location (40 yrs) – men from 40 years and above were eligible for testing. They concluded that Ghanaian men between the ages of 50 and 89 are highly predisposed to prostate diseases compared to those <50 years and >89 years. “This observation may provide a rationale for effective medical or preventive interventions especially among Ghanaian Adults”. They added.
Increased risk in military occupations in Ghana
Adler et al 2019 study this case and revealed that risk was increased among men in management and military occupations. Risks were also elevated for management and military-specific jobs based on 3-digit level Standard Occupational Classification definitions. Sensitivity analyses accounting for access to medical care did not show significant differences. The study authors aimed to evaluate the association between usual adult occupation and Prostate cancer risk in Ghanaian men, a population with historically low rates of Prostate cancer screening.
The study dubbed the Ghana Prostate Study, a case-control study of Prostate cancer that was conducted from 2004 to 2012 in 749 cases and 964 controls. In-person interviews were conducted to collect information from participants, including longest-held job. Industrial hygienists classified job titles into occupational categories. Unconditional logistic regression was used to calculate ORs and 95% Cis(Odds ratios (ORs), confidence intervals(Cis)) for the association between longest-held job and Prostate cancer risk (overall, aggressive (Gleason≥7)), controlling for potential confounders.
The study provides some evidence for increased risk of Prostate cancer among men in management and military occupations, which is consistent with the published literature. However, they concluded, “Additional research is needed to clarify the drivers of the associations between these occupations and Prostate cancer risk”.
Prostate cancer also tops in Men in Kumasi Municipality
Another 2019 recent study by Amoako et al, revealed that prostate cancer had the highest incidence of 10.5 per 100,000. The mean age of all cancer cases was 51.3 years (with a range of 1 to 99 years). The study authors reviewed data from the Kumasi Cancer Registry for the year 2015. Data collected included clinical and demographic information, laboratory reports and source of case information. Data was entered into the Canreg-5 software. Data were initially analyzed using Canreg-5 to estimate the incidence and age-standardized rates (ASR) for various tumours. Data was also exported to Microsoft Excel for further analysis using Epi Info version 7.1.4. Microsoft Excel was used to generate charts and graphs. Aggregated data for the years 2013 and 2014 were also analyzed for trends in cancer incidence and ASR.
One interesting thing about this Kumasi’s study that focused on all cancers is that the study authors also found that, lung and skin cancers are rare. Here is what they said “Our report indicates that breast cancer is the commonest female cancer in Ghana and is consistent with other evidence. The leading male cancer reported in this study is consistent with other local and international reports. Lung and skin cancers are rare in Kumasi”.
Challenges
The country Ghana is limited with cancer centers and the treatment cost also being expensive. A lack of coverage for cancer treatment under the NHIS in Ghana makes it difficult for the less privileged to access and sustain cancer care at any stage of the disease. Counselling centers or quality of life care (QOL) support systems are virtually non-existent in all regions of the country and our cancer treatment centers. Post-treatment support is a huge challenge to men diagnosed with prostate cancer dealing with managing side effects.
A lack of affordability for the treatment then results in high rates of treatment abandonment, which in turn leads to patients seeking traditional and other means of treatment from unqualified traditional and alternative practitioners. Records at the nation’s cancer centers indicate that majority of cancer cases are presented late when the disease has reached terminal stages.
Many of these late presentations are attributed to factors such as inadequate or lack of cancer awareness and the inability of most patients to finance their cancer care. As many advanced cancer cases are presented for treatment, palliative care and pain relief become very critical. At those stages, effective treatment of the condition eludes the hardworking cancer care professionals.
Ghana falls in the category of countries with less than 25 per cent of cancer patients able to access radiation treatment and with a population of over twenty-nine million, out of these cases, more than half would require radiation therapy for treatment. However, not more than 5,000 new cancer cases are treated per year in the country’s three radiotherapy centres. This leaves the country with an average shortfall of about 30,000 new cancer cases that would require radiation treatment yearly.
Cancer Treatment Centres
In Ghana, The Ghana Atomic Energy Commission (GAEC), in partnership with the Ministry of Health, in order to address the national cancer challenges established two national radiotherapy centres at the Korle Bu and Komfo Anokye Teaching hospitals, in assistance from the International Atomic Energy Agency (IAEA).
There is also one privately-owned Sweden Ghana Medical Centre (SGMC) Cancer Centre. The pathology units in the nation’s major hospitals with these cancer treatment centers have contributed immensely to cancer care in the country over the years.
Data from the International Atomic Energy Agency (IAEA) suggests that developed countries averagely have one radiation therapy machine per 250,000 populations. According to the 2017 IAEA publication, in high-income countries, one radiotherapy machine is available for every 120 000 people. In middle-income countries, one machine serves over 1 million people. In low-income countries, about 5 million people rely upon a single radiotherapy machine. Ghana with a population of over thirty million has only three radiation centers
In the wake of increasing cancer incidences in the country, challenges such as improperly coordinated cancer awareness programme, lack of dedicated cancer prevention and screening centres, inadequate medical imaging and cancer treatment centres, and over-aged cancer management facilities and equipment should be well addressed.
Population at Risk of Prostate Cancer in Ghana
In this area, the methodology will be based on taking a cue from the final results of the 2010 Population and Housing Census (PHC). It showed that the total population of Ghana as at 26th September 2010 was 24,658,823. The results indicated that Ghana’s population increased by 30.4 percent over the 2000 population figure of 18,912,079. The recorded annual intercensal growth rate in 2010 was 2.5 percent as against 2.7 percent recorded in 2000.
The results revealed that there were 12,633,978 females and 12,024,845 males. This implied that females constituted 51.2 percent of the population and males 48.8 percent, resulting in a sex ratio of 95 males to 100 females. It also showed an increase in population density from 79 people per square km in 2000 to 103 per square km in 2010.
Fig 1 indicates Prostate Cancer Life Time Risk Calculation using projected Population growth (2010-2019) and Egote et al 2019 Brong Ahafo Study
National Breakdown (2010)
Sex Figure Percentage Ratio Annual
Growth Rate
Females 12,633,978 51.2% 0.100 2.5%
Males 12,024,845 48.8% 0.95 2.5%
24,658,823
Projected Population growth for 2019
Brong Ahafo (B/A) National
Male Population (2010) 1,145,271 12,024,845
Male Population (2019) 1,402,957 14,730,435
[Projected at 2.5% p.a.]
Population at risk of Prostate Cancer in 2019 Egote et al
Brong Ahafo [40.07%] 562,165
National [40.07%] 5,902,485
Working out the Ghanaian Men Life Time Risk of Prostate Cancer
- The researcher used different types of data about who gets prostate cancer annually in Ghana based on the literature reviews
- The number of men diagnosed with prostate cancer and their ages annually
- Information on annual deaths from Prostate cancer based on the Ghana Health Service(GHS) 2015 report
- Information about the population of Male in Ghana (from the Population and Housing Census 2010 report (PHC) and projected 2.5 annual growth rate.
- Egorte et al 6-Year Single-Center Retrospective Study, 2019 findings which placed Men in the Brong-Ahafo Region to 40.07% of been affected by prostate cancer to represent the national outlook of the disease.
Results:
- The Researcher used all this information to calculate Ghanaian men’s lifetime risk of getting prostate cancer.
- The Researcher found out that 4 out of every 10 male or 2 out of every 5 Ghanaian men will be diagnosed with prostate cancer at some point in their lives.
- The researcher will regularly review this work to make sure that men get the most up-to-date information about prostate cancer risk in Ghana.
- Using the Brong Ahafo figure of 40.07% as national average brings 5,902,485 of the estimated current male population of 14,730,435 (based on the 2010 PHC male figure of 12,024,845 as adjusted by 2.5% annual growth rate) at risk of the disease.
- Using the Brong Ahafo figure of 40.07% as national average brings 5,902,485 of the estimated current male population of 14,730,435 (based on the 2010 PHC male figure of 12,024,845 as adjusted by 2.5% annual growth rate) at risk of the disease. This implies that 4 out of every 10 male or 2 out of every 5 male of whatever age in Ghana are at risk of getting prostate cancer and this must call for national dialogue by all the stakeholders.
- This means 4 out of every 10 male or 2 out of every 5 male of whatever age in Ghana is at risk and this must call a national dialogue of all stakeholders.
- Annual prostate cancer death is 75% in Ghana based on Ghana Health Service 2015 data (fig 3, fig 4)
What is Lifetime Risk?
There are different ways of explaining a man’s risk of getting prostate cancer. For instance, according to research studies, Black men have three times chances more likely to develop prostate cancer than white men of the same age. This way of explaining risk is called relative risk and it means the difference in risk of one group of people compared to another. According to the Prostate cancer UK, “This information is still correct – it is just a different way of explaining a man’s risk of getting prostate cancer”.
So we know that 4 out of every 10 male or 2 out of every 5 Ghanaian male will be diagnosed with prostate cancer at some point in their lives. This is their lifetime risk of getting prostate cancer. What it means is that, the risk that a Ghanaian male has of being diagnosed with the disease at some point during their life. According to reviews, people find lifetime risk a clear way of understanding their chances of getting a disease such as prostate cancer.
Fig. 4 Annual Prostate Cancer incidence rate in Ghana: More men die of prostate cancer now in Ghana according to Ghana Health Service 2015 report
Fig 5
Ghanaian Man’s Risk of Getting Prostate Cancer by age 50
2 in 5
♂♂
♂♂♂
Don’t Let it Be You!
Fig 6. Comparing fatality: Prostate cancer topples Breast and Cervical Cancer
Conclusion:
The study author, a prostate cancer researcher and advocate in Ghana, has been looking at ways to explain to Ghanaian men their risk in a clear way that they can help them relate to the disease. This will help us raise awareness of prostate cancer and help men understand their risk. The researcher finally worked out that 4 out of every 10 male or 2 out of every 5 male will be diagnosed with prostate cancer at some point in their lives.
Using the Brong Ahafo figure of 40.07% as national average brings 5,902,485 of the estimated current male population of 14,730,435 (based on the 2010 PHC male figure of 12,024,845 as adjusted by 2.5% annual growth rate) at risk of the disease. This means 4 out of every 10 male or 2 out of every 5 Ghanaian male of whatever age in Ghana is at risk and this must call a national dialogue of all stakeholders. Now the message is simple: Time to take action on prostate health in Ghana!
National Intervention Needed
In 2015, during the John Dramani Mahama’s administration, I proposed Fathers’ Day to be declared as National Day for Prostate Awareness; but it later turned into ‘Medical Politics’. I think this is the right time for corporate entities, political parties to prioritized men’s health and consider the proposal for Fathers’ Day to be declared to raise awareness of prostate cancer. The current government also promised a special cancer policy in their 2016 Manifesto, yet nothing has been done! Egote el al research studies on the state of prostate cancer in Ghana would have been given priority in a different jurisdiction.
The national intervention should also incorporate all healthcare sectors. The Urological community cannot WIN this war on prostate cancer in Ghana alone without engaging those in traditional and alternative medicine sector. The fight against prostate cancer is a holistic approach and not a single enterprise affair. I was very impressed in 2018 at the Prostate Cancer Transatlantic Consortium Conference at the University of Ilorin, Nigeria, when, a renowned Professor of Urology confirmed that there is no way anywhere the fight on prostate cancer can be won without engaging traditional medicine practitioners as they are the first place patient visits, besides, traditional and alternative medicines have been accepted and recognized in Ghana based on the statute (Traditional Medicine Practice Act 575).
Besides, the Ghana Health Service Patients Charter also affirms that the patient has the right to know of alternative treatment(s) if it will improve on his quality of life. Additionally, gone way the days where people are of the view that these practitioners are unschooled. It gradually becoming a thing of the past! I studied the first-ever Master’s module program in Prostate Cancer care at Sheffield Hallam University, UK, coupled with my background in Holistic Medicine. So you can’t say, I have no knowledge in prostate cancer because am a holistic doctor!
Additionally, in 2017, a research conducted by Kyei et al aimed at identifying Ghanaian traditional medicines used for the management of prostate diseases and their constituents affirms this admission: “In our experience some patients request to be offered an option of traditional medicine in the normal urology clinics for prostate diseases. (Personal communications) Knowledge of the currently available traditional medicines for the management of the prostate disease will equip practicing Urologists and Medical practitioners to enable them to appropriately counsel patients on the use of these medications”.
We need a clear pathway to prostate cancer in Ghana. This is the time for the urological community to develop policies and work with all healthcare sectors in the country. In the UK, there is the Prostate Cancer Risk Management Program for black men 40 years and above, likewise in Jamaica, the Urological community have developed programs on prostate cancer. Training should be provided to all healthcare workers who have interests in men’s health
Corporate Entities
For the corporate world, this is the time to put the health of your men; organize annual screening and awareness program. Healthy prostate should start from 30 years now!
In submission, Everyman has a prostate; but every prostate doesn’t have to make a man’s life miserable. The prostate gland is the ‘powerhouse’ of every man. Angela Culhane of Prostate Cancer UK 2016 article “Ignoring Prostate Cancer Won’t Beat It, Joining the Fight Will” drew my attention to the prostate cancer situation in Ghana. According to Angela, “Size definitely isn’t everything where the prostate is concerned. This little gland, hidden from sight just below the bladder, is only about the size of a walnut. But when it goes rogue, a man’s life can be over”.
Further, she said, “Surely men wouldn’t ignore the prostate if they knew what it could do to them. So why do they? Is it because the gland is invisible and out of sight is out of mind? Or that men don’t want to think about any problem below the belt? Or they don’t believe prostate cancer is a real problem because it doesn’t hit the headlines? Or perhaps the myth has taken hold that prostate cancer is a disease that men die with and not from”
Ghanaians have ignored prostate cancer. Prostate cancer in Ghana appears as ‘no one care’ business! Interesting, a survey by the Korle-Bu Teaching Hospital has revealed in 2006 that Ghana has exceeded global prostate limits as the country records 200 cases out of every 100,000 men as against 170 worldwide. This revelation was released by Dr Mathew Kyei, a Urologist, at a Ghana Health Service monthly programme in Accra. According to the urologist, the situation called for immediate attention from the government and the public to reverse the trend (Modernghana 2007)
Speaking on the topic, “Cancer Disorders in Ghana”, he said in 2006, 60 per cent of all cancers reported at the Korle-Bu Teaching Hospital were prostate cancers, adding that 27 people died from the disease in 2005 alone. Egote et al, 2019 and 2020 work has provided the rare picture of the state of affairs of prostate cancer in the then Brong Ahafo Region, which I have truncated it into the national picture. According to Egote et al 2019, 40% of men in the then Brong Ahafo region were affected by prostate cancer after their 6-year study. What are we doing as a nation?
I, therefore, end with this legal phrase, res ipsa loquitur- Latin for “the thing speaks for itself,” and from the prostate cancer studies, the situation is speaking for itself in Ghana. Time to wake up to fight it!
>>>Dr. Raphael Nyarkotey Obu is a renowned holistic doctor and Vinnytsia State Pedagogical University, Ukraine, honorary professor of holistic and Naturopathic Medicine and currently pursuing, LLB law/MBA concurrently. President of Nyarkotey College of Holistic Medicine & RNG Medicine Research Lab, Tema community 18. He is the formulator of FDA approved Nyarkotey Hibiscus Tea for Cardiovascular Support and wellness, Men’s Formula for Prostate Health and Women’s Formula for wellness. Contact: 0241083423/0541234556
