Over the last few decades, there has been a noted increase in the burden of chronic diseases, especially cancer, in Africa . Simultaneously, trends in other factors such as extensive urbanization and lifestyle changes, including smoking, alcohol consumption, and the adaptation of a Western diet, have been linked to an increased risk of cancer . Prostate cancer contributes significantly to these patterns. A recent report on the cancer mortality pattern in Ghana following a 10-year review of autopsies and hospital mortality revealed that prostate cancer was the second leading cause of death from cancer among men in Ghana . Furthermore, the incidence of prostate cancer is on the rise in Ghana, due in part to the fact that the life expectancy of working men has increase over the last decade and better health care facilities have improved detection of disease .
The current study describes characteristics of prostate cancer patients referred to KBTH in Ghana and provides insight into early clinical outcomes for the treatment of advanced disease in this population. These data are significant, in terms of defining priorities for cancer care in West Africa, since the majority of the prostate cancer literature originates from the United States and Western Europe and there is an increasing awareness that results obtained from one ethnicity may not necessarily apply to individuals from a different ethnic origin. Over the last two decades, data have emerged from hospital-based cancer registries in a few African countries that provide valuable information. Data from several articles on prostate cancer from 1981 to 2005 indicate an increased prostate cancer risk and mortality among Nigerian men [29–31]. Another study among Senegalese men with prostate cancer revealed worse tumor stage and median PSA when compared with that of African American men . Data from the current study suggest similar findings in our cohort of Ghanaian men. Although this study was done in the largest cancer center in Ghana generalizing this data to all Ghanaian men with prostate cancer must be done with caution. In this section, we will apply these data toward consideration of research priorities aimed at improving prostate cancer diagnosis and treatment in Ghana.
In our study population of Ghanaian men with prostate cancer, >90% of patients with available data presented with intermediate- or high-risk disease, >95% with clinically T2 or greater disease, and 70% with PSA > 20 ng/ml. In contrast, in the US population, 40-60% of prostate cancer patients present with clinically inapparent disease, mostly diagnosed as T1c upon trans-rectal ultrasound guided (TRUS) biopsy [32, 33]. Furthermore, less than 15% of prostate cancer patients in the US population present with PSA > 20 ng/ml . This may be attributed to PSA screening efforts and more frequent TRUS biopsies of prostate in developed countries. Currently, routine yearly PSA screening is a source of controversy in the United States , but this approach is not feasible in Ghana where the costs would be prohibitive. Moreover, the effect of PSA screening on prostate cancer mortality in the United States and Europe has been inconclusive. Data from the Prostate Lung Colorectal and Ovarian (PLCO) trial did not show a survival benefit from screening, however the European Randomized Study of Prostate Cancer (ERSPC) trial demonstrated a 31% reduction in the risk of death from prostate cancer in men that had PSA screening .
There are major concerns that PSA screening leads to over-diagnosis and overtreatment of indolent prostate cancer in men which if left untreated would have little or no impact on life expectancy . However, in men of African descent who may demonstrate more aggressive disease, the lack of screening could result in an increased number of patients presenting with high risk disease, which would adversely impact prostate cancer mortality rates. This is exemplified in the analysis of our patient cohort showing a strong correlation between PSA levels at diagnosis and advanced clinical T stage as well as Gleason score. Based on trends of prostate cancer mortality in Ghana and the vast majority of patients presenting with high risk disease, it would be advantageous to develop a healthcare policy that will allow for PSA screening along with DRE in a selected cohort of men. Although annual PSA screening would likely exceed financial constraints in Ghana, it may be worthwhile to consider a program that includes less frequent screening. Determining the appropriate initial age for screening and the appropriate time interval for PSA screening in Ghana is beyond the scope of this study, but future studies should address these considerations.
Challenges to treatment delivery
Out of 251 patients eligible for definitive radiation treatment with curative intent only 141 patients (56.2%) actually received EBRT. A number of factors acting as barriers to treatment delivery include the use of alternative medicines and traditional healing methods coupled with inadequate health education, which often delays correct diagnosis and initiation of treatment. Furthermore, taboos, stigmas, and false beliefs that cancer is a “curse” often lead to delayed diagnosis and non-adherence to treatment. Other barriers specific to radiation treatment delivery among Ghanaian men included fear of radiation, inflated perception of the cost of treatment, difficulty with access to transportation to and from daily treatments, and loss of income due to absence or inability to work.
Ghana has a population of 24 million serviced by only two megavoltage machines in two radiation treatment centers 250 kilometers (180 miles) apart. The lack of accessibility to treatment centers as well as time loss and costs incurred by patient transportation presents a huge barrier for compliance to daily treatments. Furthermore, the national health insurance re-imbursements payment rate to the health care facilities is very low, which in turn renders the out of pocket cost per treatment course per patient enormously expensive for the average working-class Ghanaian man. Currently, shorter course (“hypofractionated”) treatment schedules are being explored for prostate cancer, in an effort to improve patient convenience, reduce costs, and to take advantage of unique radiobiological characteristics of prostate cancer that make large fractions potentially more effective . The adaptation of a hypofractionated schedule for treatment in Ghana would offer a profound advantage in not only decreasing healthcare delivery costs but also improve access to treatment by reducing transportation time and expense for patients during radiation therapy. This represents a potential for implementing tailored prostate cancer treatment schemes for developing countries, an important focus for future studies. To this end, we propose to develop and conduct clinical trials of shorter course radiation therapy schedules tailored to the needs of Ghanaian prostate cancer patients.
To date, the data presented in this article provides the only source of published information on outcomes for prostate cancer treatment in the West African region. Our results showed that the 3- and 5-year FFbF for Ghanaian men with mostly intermediate to high risk prostate cancer receiving EBRT +/− ADT was 73.8% and 65.1% respectively. In light of differences in patient disease characteristics at diagnosis and older treatment techniques one must consider whether to evaluate these outcomes with respect to the latest published data using dose escalation as reported by Zietman et al.  that demonstrated a 80-90% biochemical control as opposed to older experiences from randomized trials such as RTOG 9202  and EORTC 22863  showing biochemical failure rates as high as 50-76% for patients with advanced tumors. A major drawback to this retrospective study is the limited ability to assess important end points such as impact of treatment on cause-specific survival and distant metastases free survival due to a median follow up data of only 3 years. Nevertheless, there is valuable information presented in this article that will aid in the strategic development of a roadmap for prostate cancer research in Ghana, with a focus on improving therapeutic approach as well as fostering a prudent allocation of scarce resources.
Future research needs
Results presented in this study have demonstrated that the majority of Ghanaian men diagnosed with prostate cancer present with very advanced stage disease. Current treatment recommendations for advanced stage prostate disease are based on clinical trials that include conventionally-fractionated radiation therapy and long-term ADT [39–41]. However, the availability of modern treatment technologies and the more recent interest in hypofractionation for prostate cancer offer an opportunity to develop studies aimed at improving the treatment and outcomes for Ghanaian patients with advanced stage prostate disease. The Ghanaian prostate cancer patient population is in need of clinical trials that seek to develop novel, shorter course treatment regimens for locally-advanced prostate cancer. We have established collaboration between two institutions with the hope of improving prostate cancer treatment in Ghana and plan to develop clinical trials that can be conducted in tandem between our two institutions. Our group encourages approaching the design of clinical trials in a way that includes perspective of the public health burden of prostate cancer in Ghana and the specific barriers to care. We hope to achieve progress by involving stakeholders in a coordinated fashion to develop tailored radiation treatment techniques that are cost-effective and well-suited for the needs of Ghanaian men.