Prostate cancer and the mortality rates associated with it, particularly among black men, are on the rise in South Africa, regardless of the existing national guidelines for prostate-specific antigen (PSA) screening. These increases represent a significant public health concern.
This is according to a recent study by Dr Matthew Benedict, Senior Lecturer and Medical Specialist in the Department of Family Medicine in the Faculty of Health Sciences at the University of the Free State (UFS). Dr Benedict graduated with a Doctor of Philosophy degree at the December 2023 graduation ceremonies. Alongside his colleague, Dr Chika Egenasi, they became the first PhD holders with a specialisation in Clinical Family Medicine at the UFS.
This study could help elevate awareness around prostate cancer and ultimately enhance screening practices aimed at black men.
Dr Benedict says prostate cancer cases increased from 29 per 100 000 men in 2007 to 68 per 100 000 men in 2018. PSA screening remains a practical method for early detection and improved outcomes, despite the risks of overdiagnosis and overtreatment. The existing approach to prostate cancer screening, however, fails to adequately address the unique challenges faced by black men.
Underrepresentation of men's health issues
Dr Benedict says his study therefore sought to identify gaps relating to the prostate cancer screening approach in the Free State by simultaneously exploring two perspectives – that of primary healthcare providers and black men (healthcare users) – and the proffered strategies to address the identified gaps.
The decision to embark on this research stemmed from the observed underrepresentation of men's health issues in South African healthcare systems and media. Dr Benedict highlighted that despite the existence of national registries for breast and cervical cancers, there is a notable absence of a similar registry for prostate cancer (PCa).
“This lack of prioritisation and emphasis on secondary prevention strategies tailored to PCa is evident. Additionally, the racial disparities in PCa morbidity and mortality are exacerbated by inadequate representation of black men in research on this disease,” he says.
Low screening uptake
In the Free State, which has the lowest life expectancy compared to the national average, the black population faces disproportionate challenges related to lower socioeconomic status and poorer health outcomes. Prioritising equitable access to essential primary healthcare services, including screening, is crucial in this context.
Dr Benedict explained that the findings of his research revealed that aggressive prostate cancer is prevalent among black men in the study setting, with poor knowledge and awareness of the disease and low screening uptake being observed. “Factors such as dietary habits, lifestyle, and presentation time were associated with aggressive disease at diagnosis, and cultural beliefs influenced screening uptake among men.
“Factors associated with a higher intention to screen included reduced fear, perceived benefits, situational barriers, and perceived risk of developing prostate cancer. The majority of the primary healthcare providers demonstrated poor knowledge (64.8%), neutral attitudes (58.6%) and poor practice (40.0%) related to prostate cancer screening. Female providers, lower cadre nurses and community health workers had lower knowledge scores.”
The study also found lack of prostate cancer-related continuing education was significantly associated with poor knowledge, negative attitudes, and poor practice among healthcare providers. The study proposed strategies to address the identified gaps among black men and primary healthcare providers. Community-oriented approaches involving the active participation of both healthcare providers and community members were emphasised. These strategies focused on the discussion of prostate cancer health education topics in public spaces, employing diverse, comprehensive, user-friendly, and culturally sensitive methods.
Delay in diagnosing
According to Dr Benedict, the delay in diagnosing prostate cancer among South African individuals is linked to the absence of a dedicated screening programme, and a predominantly rural population facing challenges like low socioeconomic status, high unemployment rates, and limited health literacy. Cultural perceptions of the disease, men's perspectives on masculinity and illness, a hesitancy to seek help, and a reluctance to assume the sick role also contribute.
“Furthermore, adherence to strong traditional beliefs often steers individuals towards consulting traditional healers instead of seeking medical assistance in clinics or hospitals. Numerous barriers to accessing health services in impoverished rural communities compound the issue, leading to instances of ‘lost to follow-up’ [patients who drop out of research studies or treatment programmes].”
Symptoms of prostate cancer
Prostate cancer might not exhibit noticeable symptoms during its initial stages, explained Dr Benedict, but as the condition progresses patients may experience diverse symptoms. The majority of these patients commonly experience signs of bladder outflow obstruction, such as a weakened urine stream, hesitancy in urination, nocturia, and a sense of incomplete bladder emptying. In certain instances, the tumour can lead to acute urinary retention. Advanced prostate cancer may present with symptoms linked to ureteric obstruction or bony metastasis. Night-time pain that alleviates with movement can result from bone metastasis.
According to the researcher, the primary focus of the research is on screening and early diagnosis. Screening involves assessing apparently healthy individuals for the presence of a disease, even if symptoms are not evident. While specific symptoms like lower urinary tract symptoms may indicate conditions such as benign prostatic hyperplasia or urinary tract infections rather than prostate cancer, the presence of more advanced symptoms like lower back pains, weight loss, and bloody urine often suggest a more progressed stage of the disease.
Enhanced screening practices
The study highlights deficiencies in prostate cancer screening of black men in the Free State, and Dr Benedict said he anticipates receiving support to facilitate the implementation of the recommended strategies stemming from this research. Implementing the proposed targeted strategies designed for black men and their primary healthcare providers has the potential to elevate awareness and knowledge and ultimately enhance screening practices among black men.