Pattern and management of prostate cancer in Rwanda: a multicenter prospective study

Abstract

Background: Prostate cancer remains a global health burden. It is aggressive among black of African ancestry. Inadequate awareness as well as insufficient diagnostic and management capacity, lead to its delayed presentation with associated morbidity and mortality in SubSaharan Africa and Rwanda in particular. This study describes the burden, characteristics and management options of prostate cancer in Rwanda. Method: This observational prospective descriptive study included all Rwandan patients diagnosed histologically with prostate cancer over 6 months, from September 2018 to February 2019 in the 3 national urology units. We described their demographic and clinical characteristics and estimated age standardized incidence rate of prostate cancer referring to the WHO average standard population between 2000-2025. Results: The study enrolled 108 Rwandans whose biopsies were positive out of 153 taken. Their mean age was 71.3 years (SD=8.5). The most affected age group was 61-70 years having 42.59% (46/108) patients. The age range was 44-89 years. Almost everybody consulted because of symptoms related to urinary flow. Thus 99.07% (107/108) had lower urinary tract symptoms (LUTS); 46.3% (50/108) had acute urinary retention (AUR) and 21.3% (23/108) had neurological impairment of lower limb related to spinal metastasis. Only 12.96 % (14/108) had a positive family history and 39.81% (43/108) didn’t know about their family history. Delay of the consultation was common with mean symptoms duration of 12 months and 90.74 % (98/108) had symptoms more than 3 months prior to the consultation. The Prostate specific antigen (PSA) was high with 85.05 % (91/107) having PSA >20 ng/ml. A total PSA >20 ng/ml correlated with having metastatic disease (adjusted odd ratio (aOR) = 13.22, p-value = 0.026). The mean PSA was 100ng/ml; range 1.69-10000 ng/ml. Most patients presented with advanced disease as 37.96% (41/108) were metastatic; 26.85% (29/108) locally advanced; 18.52% (20/108) were localized and 16.67% (18/108) were not fully staged. The majority had high grade tumor where 74.07% (80/107) had Gleason score of 8 or more and a mean Gleason sum of 8. Among 67 patients treated, androgen deprivation therapy (ADT) was offered to 76.12% (51/67) as primary treatment and 14.92% (10/67) were on ADT while waiting for combining with curative radiotherapy; 8.96% (6/67) underwent radical Prostatectomy during the study period. Bilateral orchidectomy was offered to 54.1% (33/61) and medical ADT in 45.9% (28/61). Medical ADT included goserelin which follows bicalutamide in 53.57% (15/28); cyproterone acetate in 35.71% (10/28) and ketoconazole in 10.71% (3/28). The age standardized incidence rate of prostate cancer in Rwanda is estimated at 13.56 per 100000men above 45 years. Conclusion: Late presentation of patients with prostate cancer generally in LMICs; Rwanda included leads to the detection of mainly advanced and high grade tumors making the clinician short of treatment options. It is imperative to increase access to specialized health care facilities while raising awareness of prostate cancer among the general population to tackle the mortality and morbidity associated with unnecessary delays.