BENIGN PROSTATIC HYPERPLASIA AND PROSTATE CANCER IN AFRICANS AND AFRICANS IN THE DIASPORA

E Yeboah

Ann Hsing

^{Department of Surgery, School of Medicine and Dentistry, Korle Bu Teaching Hospital, Accra, Ghana.}

^{Stanford Cancer Institute, Formerly of CPIC California and NCI, Bethesda, Maryland, USA.}

^{Corresponding author.}

*To whom correspondence should be addressed.E-mail:moc.liamg@kubeyifok, ude.drofnats@gnishnna

Benign prostatic hyperplasia (BPH)/benign prostate enlargement (BPE) and prostate cancer (PC) - two common urological conditions in Western society - have been considered to be uncommon in African populations. Recent data, both clinical and epidemiological, albeit sparse, suggest that both conditions are quite common in African men. In fact, clinical data suggest that, in most African countries, prostate cancer is the most common cancer in African men, similar to that in Western population1³¹.

BENIGN PROSTATIC HYPERPLASIA

The prevalence of both histological and clinical benign prostatic hyperplasia (BPH) is on the rise among men of all races4,5,6,9,10. Studies in Caucasian men have shown that histological BPH increases dramatically as men get older. Prevalence has been reported to be 20% at age 40, 30% at age 50, and by ages 70 and 80, the likelihood of BPH increases to 70% and 80% respectively, and by age 100, the prevalence is 100%1,2,3,4.

The prevalence of symptomatic (clinical) BPH is high among living men in Western Countries and among men of other races as well. Studies on symptomatic BPH have used various criteria, such as International Prostate Symptomatic Score (IPSS), prostate size and features from digital rectal examination (DRE), prostate volume by ultrasonography estimate1,2,4,5,6,8,9,10. As such, published data on prevalence in living men varies ranging from 20 to 60% depending on age and criteria used4,5,6,7,8,9,10. Studies conducted in the USA, South Africa, and Ghana have shown BPH prevalence of 20 to 60% among Africans and Africans in the diaspora and their descendants4,5,6,7,9,10.

These data reinforce that clinical or symptomatic BPH is a major public health problem in elderly men in most countries of the world. The costs associated with managing BPH are significant, considering the financial burden of medical and surgical interventions and the loss of productivity from absenteeism and early retirement. The costs involved in providing care and treatment for Africans in Africa need to be established in order to provide better data for resource allocation and management within the African health care system11,12.

BENIGN PROSTATIC HYPERPLASIA CO-EXISTING WITH PROSTATE CANCER

The co-existence of prostate cancer (PC) in the living being treated for BPH is between 3 – 20%. This has been found in chippings from transurethral resection of the prostate (TURP) for BPH or simple prostatectomy specimens for BPH. Patients after TURP or simple prostatectomy can develop PC years after the procedure from the peripheral zone which is left behind as false capsule3,13,14,15. Although these two conditions, BPH and PC, are major urological conditions within the prostate gland and can co-exist, currently, there is no data to suggest a causal link. As BPH occur mostly in the transitional zone, PC occurs mainly in the peripheral zone although PC can occur in the transitional and the central zones3,13. The prostate gland with BPH may have more inflammation or hormonal milieu changes that might be conducive for neoplastic or malignant changes thereby increasing the risk of developing PC but whether BPH is a co-factor for PC risk needs to be clarified in future14,15.

PROSTATE CANCER

For a long time, it has been considered that men in the African continent are at lower risk of prostate cancer (PC), although African American (AA) men have the highest incidence and mortality rates of PC, recent clinical data suggest something quite different. PC is now the leading cancer in men in most African countries, despite the lack of population-based cancer registration data.

Ghanaians, Caribbeans and African-American men have a higher prevalence of PC than men in Europe and the United States16³¹.

In a recent report in Ghana where PSA screening was conducted, the prevalence of PC was as high as 6.3 – 7% in men 50 years of age and older. This is higher than rates of 2 - 5.1% observed in African-Americans, but lower than the 10.4 percent rates observed in Caribbean Africans16²⁷.

In contrast, Caucasian American men have a prevalence of prostate cancer of 1.5 - 2.5%. Although population-based data are lacking, it has been documented that Caribbean Africans have very high risk of PC, and in Martinique, for example, the incidence of PC has reached as high as 120 cases per 100,00016,17,21,22,24.

Multiple studies have shown that African men typically have lower reported incidence of PC but present with advanced and aggressive disease, with Gleason scores greater than ≥7 and high mortality rates16,21,26,27,28,29,30,31. The more advanced clinical presentation is attributed to lack of early detection and timely treatment. The lower reported incidence of PC in African men has been attributed to a lower doctor-patient ratio, less frequent screening and a lower early detection rate, which also accounts for the disease being more aggressive and advanced at time of diagnosis16,21,27. In addition, the lack of population-based cancer registries, incomplete reporting, or lack of autopsy data, also contribute to the much lower reported incidence in Africa. This argument is supported by reports from Washington D.C., USA, Ghana, and Nigeria, where Jackson28 reported that the clinical incidence of PC was higher among blacks in the Washington area than among blacks in Accra, Ghana and Ibadan, Nigeria, but autopsy incidence of the disease was similar in blacks in Washington, Accra and Ibadan28,29,30,31.

The high prevalence and rising incidence of prostate cancer suggest a serious public health problem for Africans if rates are replicated in countries like Nigeria and others in Central, East and Southern Africa. Most African countries have limited facilities for PSA testing, prostatic biopsy and histological diagnosis of PC, and preferred treatment modalities are limited as well. Treatments such as radical prostatectomy and radiation therapy (external beam and brachytherapy) for early PC, or hormonal and chemotherapy for advanced and metastatic PC, are not easily available or affordable. Treatment of PC is expensive and not currently covered by limited National Health Insurance Schemes in Africa32,33,34.

Conclusions

Recent evidence and reports suggest high prevalence of benign prostatic hyperplasia (BPH) and prostate cancer (PC) in Africans and men of African descent in the diaspora4,5,6,9,10,16²²,25³¹. Factors predisposing to BPH and PC include dietary, environmental, hormonal and genetic factors1,2,3,4,9,13,35,36,37. The low reported prevalence/incidence of both BPH and PC from African countries is probably due to under reporting9,10,16,19,20,21,23,24,25,27,28. It is our opinion, based on recent reports, that serious efforts should be made at population-based studies in several African countries to unravel the prevalence of both BPH and PC in Africans. Armed with data gathered through studies of African men, both living and deceased, we can begin to understand the true prevalence of BPH and PC in Africa, take steps to improve education and early detection, and influence positive outcomes for the future.

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