Advanced prostate cancer results in castration

BY: Dr Kwaku Addai Arhin Appiah
Normal prostate and benign prostatic hyperplasia (BPH).  A normal prostate does not block the flow of urine from the bladder
Normal prostate and benign prostatic hyperplasia (BPH). A normal prostate does not block the flow of urine from the bladder

Globally prostate cancer is of significant public health importance. In the United States (US), it is the most commonly diagnosed cancer in men besides skin cancer.

The disease disproportionately affects black men and it tends also to be more aggressive with poorer prognosis.

It is a leading cause of cancer deaths in men in the US and second only to liver cancer in Ghana.

In countries with formal screening programmes for prostate cancer, the cancers are detected in the early stages, which allows for curative treatment.

Non-curative

This is in sharp contrast to what pertains in most developing countries such as Ghana where majority of patients present late with advanced disease.

This makes non-curative treatment the usual form of treatment for prostate cancer in these countries. Prostate cancer can be divided into three distinct stages.

The localised prostate cancer, locally advanced prostate cancer and the advanced or metastatic prostate cancer stages. The localised prostate cancer stage implies the cancer is confined to the prostate gland and can be completely cured by either surgery or radiotherapy or both.

Most patients at this stage have no symptoms and are only picked up through regular screening programmes.

The basic requirements for screening include annual digital rectal examinations and PSA testing. The normal PSA level is between 0–4ng/ml and patients with abnormal digital rectal examination findings, elevated PSA levels or both are subjected to prostate biopsy to either confirm or rule out prostate cancer.

Advanced stage

In the locally advanced stage, cancer usually has spread to adjacent organs such as the rectum and the bladder neck and may present with symptoms of trouble passing urine such as frequency, nocturia, urgency, urge incontinence, straining, hesitancy, intermittency, poor stream, incomplete bladder emptying, post-void dribbling, referred to as Lower urinary tract symptoms (LUTS) and constipation, etc.

Patients at this stage require multiple treatment modalities which may still not guarantee a cure. In the advanced or metastatic stage, the cancer has spread to distant sites including the bones, lungs, liver, brain, etc.

Such patients may present with bone pains, weight loss, symptoms of anaemia such as dizziness, palpitations and breathlessness on exertion, etc.

Patients at this stage cannot be cured of their cancer and are treated palliatively with castration, which can be medical or surgical.

In a study carried out at the Komfo Anokye Teaching Hospital, Kumasi, by Dr Addai Arhin and his colleagues (2014), the youngest person to have been diagnosed of prostate cancer was 43 years, and the commonest age group for prostate cancer was between 50 and 80 years.

Only about 10 per cent of the study population was screened detected. The rest presented with symptoms and complications that were indicative of advanced disease.

Common symptoms

The commonest symptoms at presentation were LUTS 87.5 per cent, Waist/bone pains 66.7 per cent and urine retention 43.3 per cent.

Other less common presentations included haematuria 30.8 per cent, impotence 20.8 per cent and paraplegia/weakness in the lower limbs 12.5 per cent.

Castration

In Ghana, boys are trained to endure pain and not to show weakness and it is no wonder that men will endure debilitating changes in their urination pattern and yet not report to the hospital.

The prostate-specific antigen (PSA) values ranged from 2.5 to 9,600ng/ml. The modal PSA value was between 20 – 50ng/ml.

This is not surprising as most men do their first PSA test when they get urine retention. Again, 78 per cent of our patients presented with high grade tumors ranging from Gleason score seven to 10 which tend to have poor prognosis.

Castration was the mode of treatment for more than half of the study population. Of such patients, 75 per cent had surgical castration while a quarter had medical castration.

The rest had either Radical Prostatectomy or Radiotherapy which was curative.

Recommendations

In conclusion, majority of Ghanaian men with prostate cancer report late with advanced disease and with unfavourable tumor characteristics amenable only to Castration.

We, therefore, recommend more public health education on prostate cancer and screening programmes to ensure early detection of prostate cancer and curative treatment for at risk patients.

It is also recommended that prostate cancer treatment should be listed on the National Health Insurance Scheme (NHIS) just as breast and cervical cancers to remove the cost barrier to easy access to health care.

The writer is a Senior Lecturer, School of Medicine and Dentistry / Head of Urology Unit, Department of Surgery, KNUST /Komfo Anokye Teaching Hospital. He is also the Vice President, Ghana Association of Urological Surgeons (GAUS)

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