Practical approach to advanced prostate cancer management in community in Rwanda

Abstract

ABSTRACT Background: Prostate cancer is the second most common cancer in men and 6th leading cause of mortality. If not recognized early, patients with advanced disease can get debilitating complications such as spinal cord compression and fractures which can otherwise be prevented by early androgen deprivation therapy. Our research intends to contribute more knowledge about the practical approach to the management of advanced prostate cancer in the community for the prevention of debilitating complications. Objectives: To determine clinical parameters and PSA threshold for effective clinical diagnosis of advanced prostate cancer in the community. Methods: A prospective cross-sectional observational study was conducted at three referral hospitals in Kigali on patients who presented with clinical suspicion of advanced prostate cancer from October 2018 to February 2019. All patients underwent prostate biopsy as well as metastatic work up, for those who were eligible. Statistical analysis was done using STATA 14.2. Results: During the study period, we enrolled 114 patients. The median age was 70 years (IQR 65-79 years) and mean (±SD) age was 71 ± 9 years; 75 (65.8 %) patients were enrolled from CHUK, 35 (30.7%) from RMH and 4 (3.5%) from KFH. In total 14 (12.3%) patients and 100 (87.7%) patients were found to have benign disease and cancer respectively. Among those who had cancer, 85 (85%) had advanced prostate cancer (locally advanced and metastatic); All the 10.5% of patients with family history of prostate cancer were positive (both first and second level) however, 34.2% of respondents didn’t remember about family history of prostate cancer; 75.5% were unemployed or not working because of the illness; 110/114 (96.5%) were symptomatic at presentation while 3/4 were discovered through systematic screening. Common presenting symptoms were: lower urinary tract symptoms (80.7%), back pain (54.4%) and urine retention (36.8%). All patients with paraplegia had advanced cancer and all who reported weight loss had cancer. The mean duration of symptoms before consultation was 14.2 months. On DRE examination, 102/114 patients were found to have abnormal prostate with at least one palpable nodule and 75.3% had multinodular prostate which involved both lobes in 71 (70.3%) patients. Abnormal digital rectal examination (DRE) was a strong risk factor for both cancer and advanced disease. Prostate cancer was found in 92.2% of those with abnormal DRE compared to 41.7% in those with normal DRE (p=0.001). Also, cancer was significantly found in 96.1% of those with multinodular prostate (p=0.02) and had high odds (OR: 14.6; CI 3.41-62.25) of having advanced prostate cancer (p<0.001). The mean (±SD) PSA was 643.3 ± 1829.8 ng/ml and the median (range) was 100 ng/ml (9.05-10,000ng/ml) for the whole study population. PSA levels of patients with histologically confirmed benign disease had a mean of 35.8ng/ml (9.05 - 98.5ng/ml) and none had PSA> 100ng/ml. Patients with localized prostate cancer had mean PSA of 66.3ng/ml while those with advanced prostate cancer had mean PSA of 841.4 ng/ml respectively. All patients with PSA of 100 ng/ml or above had cancer and advanced prostate cancer. 49/85 that had complete metastatic workup had bone metastasis; 77.5% had back pain (p=0.001) and 47/49 had abnormal DRE. Conclusion: The results show that there is a significant correlation between back pain and bone metastasis in patients with prostate cancer. All patients with abnormal DRE and PSA above 100 ng/ml had advanced prostate cancer. There is correlation between back pain, abnormal DRE and PSA above 100 ng/ml with advanced cancer and bone metastasis.