The Covid-19 pandemic has left hospitals overwhelmed, with scarce resources, exhausted doctors, and many health care workers already infected with the virus. Despite a nationwide lockdown and a reinstated ban on alcohol, hospitals are showing signs of systemic failure and a health service near collapse. But with South Africans staying home, many ‘less urgent’ conditions are being ignored. In doing so, men are not getting the necessary screenings needed to detect a host of health problems, with prostate cancer being at the forefront, according to Dr Kgomotso Mathabe, acting head of the Department of Urology at Steve Biko Academic Hospital. Prostate cancer has a ’10 year’ lead time, with men asymptomatic until it’s too late. With heightened anxieties, more men avoiding their GPs, and black men at a higher risk for the disease, Dr Mathabe tells broadcaster Tim Modise what needs to be done. More of Modise’s work can be found under the SA Renewal banner on BizNews.com. – Nadim Nyker
Tim Modise: The COVID-19 pandemic has become the global number one issue facing humanity in South Africa. It has affected how government, business and society work. It has also overshadowed other diseases such as HIV-AIDS, TB and non-communicable diseases such as diabetes, cardiovascular, cancers, etc.
I’m joined by Dr Kgomotso Mathabe of Steve Biko Academic Hospital in Tshwane. She is acting head of the Department of Urology, and she joins me to talk about how some of the diseases, specifically prostate cancer, have been displaced and how we can learn a bit more about this disease. Thank you very much, doctor, for joining me. Is that what you are seeing at the hospital, that other diseases have been displaced by the focus on Covid-19?
KM: Thank you for this opportunity to talk on this. Yes, for us at Steve Biko, we are a designated Covid Centre. What has happened is certainly that we’ve seen some of the less urgent conditions being displaced by Covid. Certainly at the heart of the lockdown, when everybody was advised to stay home unless they were seriously ill.
Our patients followed suit and the problem with prostate cancer, my particular area of interest is that it is asymptomatic until very late. Patients might not feel as though anything is wrong, even when it is quite advanced. They certainly would be amongst a group of patients who did not feel as though anything very serious was going on and therefore stayed home and did not get the treatment that they deserve.
What is the prevalence of prostate cancer amongst men in South Africa and in the world generally? It appears it is more prevalent in certain parts or sectors of men than the global community of men. In other words, it may be more prevalent in Africa than it would be in Asia or elsewhere.
Yes, that is true.
There is a difference in the clinical appearance in the symptoms of prostate cancer between the various races. Black men are most afflicted by this condition. There are theories as to why this is so, and there’s a lot of research that still needs to go into exploring this topic. Unfortunately, I can’t give you the exact figures and the problem is that in South Africa we do not have an adequate cancer registry.
It is pretty good, but it does not fulfil the criteria of a robust cancer registry. All our cancers across the various fields, and not just within urology, but all our cancers that are registered on our national cancer registry are histology based, meaning that you have to have taken a piece of cancer, sent it away to the laboratory and had it confirmed that it is cancer and what kind of cancer it is.
With the health care services around the country, we know about their disparities in the distribution of such services, meaning that a lot of people do not have access to tertiary centres, and there aren’t many across the country and they are all concentrated in the major cities.
Patients who do not have access to tertiary centres, who therefore will not have the cancers biopsied, are not being captured on the cancer registry. An ideal cancer registry should also focus on community conditions and community diagnoses so that it does not necessarily have to have a biopsy or a lab report confirming the condition.
We know that our numbers are not optimal but if you look at the National Cancer Registry as well as Stats SA, I think at the last count they probably would have had a total of about 10,000 prostate cancer cases in the country, which is not a true reflection of what is going on.
Another indicator that this is not a true reflection of what’s going on is that the numbers of prostate cancer amongst white men as captured in the registry is higher than in black men. With an 80%-90% black population, with cancer being more common in black men and more aggressive and black men, there’s no way that that is a true reflection, but the majority of black patients do not have access to tertiary centre services and therefore their cancers are not being captured.
You say that it is difficult to unmask the prostate cancer, in particular in the earliest stages. But is it possible for an average person to tell whether they are developing cancer in their system or not, specifically prostate cancer?
Two parts to that question, one is just to illustrate a point and then I’ll answer that question. We all know that we should have our blood pressure checked and every contact with a healthcare provider has a blood pressure check.
That is because high blood pressure is asymptomatic. Nobody knows that they’ve got a high blood pressure until you collapse from a stroke or you have a heart attack, therefore we screen for it. Every contact with a person, not necessarily a patient, every contact with a person with a health care provider, we check the blood pressure so that you can catch it before it becomes a problem. We call that screening and, unfortunately, we do not provide such facilities for prostate cancer within the state sector.
In private, patients have got access to this. One has got the ability to go and screen before prostate cancer becomes clinically prevalent. Therefore, symptomatic and problematic for a patient to know that something is going on. You’ve got a lead time of a good 10 years with the patient feeling absolutely fine but there is actually something going on in the body.
We would be able to pick this up with a visit to a regular GP or urologist where they can do a test, including a blood test to check. Depending on what those values are, we can then determine that likelihood of prostate cancer, and can they do more invasive testing. The initial screening is not very invasive, but it can be done and we can get a pretty good idea whether we need to be worried or not.
Is it avoidable or is it something that will happen, and all you do is to wait and see whether you are developing cancer?
The screening definitely is available.
It is as simple as a blood test. So there are two things that we do and I’m gonna get a little bit graphic and your listeners must bare with me.
We do a test with a finger where we feel the prostate that can give us an indication of whether there is anything wrong with the prostate. Then we can also supplemental to that do a blood test, and both of these are available in every single healthcare practitioners rooms from your local clinic to any fancy hospital. Both of those can be offered. Both of those can be done.
I think the problem, though, is that we suspect that if we were be looking for all the cancers, all the potential prostate cancers that are present in the country, that might possibly overwhelm our health care system. If we go looking for it, we’re going to find it and we are not necessarily adequately resourced to be able to handle that.
The problem might perhaps be that men don’t know enough about this and are not going for screening, but if men knew about this, and were all going for these screening, there’s a possibility that the health care system would not be able to handle that.
We need to work on other parts of completing this picture and it is having more urologists trained, having more screening being done, having more oncologists being trained because once we make the diagnosis, we then need to deal with it.
The general societal view of cancer is that it is lethal and this includes prostate cancer. I can imagine a lot of people are thinking to themselves, it’s one thing to wait until all these tests are done but can I avoid this cancer? Is there anything one can do to make sure that you do not develop prostate cancer?
No, unfortunately, at this point, we don’t know of anything that prevents it. There’s been a lot of studies done and these various things that they’ve tried to figure out will prevent it. The problem with prostate cancer is that it afflicts older men. Typically people in the late 50s, 60s, in the highest age range is in the 60s and 70s.
The problem is it is very difficult to have somebody who has lived 60, 70 years doing all sorts of things, eating all kinds of food and lifestyle that might or might not have been particularly healthy as to what is that along the way that may possibly have led to the development of this cancer. So, unfortunately, we do not have that figured out yet.
There is a drug which we use because the prostate, we can have benign conditions where it’s not cancer, it is still a problem that it’s not cancer or it can then be cancerous. One of the drugs that we used to treat it or just an enlarged prostate was found to help with reducing the risk of prostate cancer, but it did not bring it all the way down to zero. So it helped and it certainly did not take the risk away completely.
What can people do to help themselves in this regard? Those particular age categories that you have mentioned, are there any practical things they can do to check whether they are developing prostate cancer or whether they have problems with their prostate or not?
We don’t have our own South African guidelines for many medical conditions. We tend to use American and European guidelines and this for me is a point of great pain. We do need to start putting out African guidelines because the things we see here are not necessarily what they see in the global north. In any case, we use the American and European guidelines and the risk factors that identify therefore the development of prostate cancer is your race so, number one, if you’re black, you’re at a higher risk. Age older than 55 and then also family history. If you’ve got any of those, you should see your urologist or GP.
We encourage that men see their GP or urologist at around age 40. If we see you at around age 40 and we do our baseline blood test, depending on what that number shows, we might not need to see you again for another four or five years.
That we can just all be relaxed and that you know your risk is very low. Unfortunately, we can’t prevent the development of prostate cancer, our next best bet is to catch it early. How we catch it early is by screening and looking for it before it becomes symptomatic.
If you have risk factors, age and family history, we definitely want to be seeing you sooner rather than later. I know it’s hard to think about something that is potentially lethal, but it is better to know because if we know that there’s a problem or you’ve got prostate cancer, it’s so much easier to figure it out and possibly do something less radical than when it’s advanced because advanced prostate cancer can be a truly debilitating and devastating condition you have to live with.
Is it a death sentence? Another thing, I suspect: people have fear going for medical attention because they don’t want to be told that they have developed prostate cancer, which might spell a death sentence for them. Are there any therapies, treatments that help manage it?
Lots of therapies. Here’s the interesting thing, sometimes intervention after making the diagnosis might be that we’re right to do nothing. Depending on some features, we might say, ok, you’ve got cancer, we’re not particularly worried and we’ll keep an eye on it. It might be as simple as we’ll just keep an eye on it to surgery, to chemotherapy.
There is a lot that can be done. In terms of it being a death sentence, we actually say that more men die with prostate cancer than because of it, it is not often the actual cause of death.
People can live with this condition for years and it’s not proved to be lethal and it does not prove to be that which eventually takes their lives. It is not a death sentence. If people have got the diagnosis of prostate cancer, we’ve got patients who have lived 20+ years with the condition.
One of the things of prostate cancer and one of the things that we as urologists need to be comfortable with, in raising with our patients is the complication of erectile dysfunction.
We know that that’s a big deal. If a man can’t get erections, we know that this is a life-altering thing.
Some of the treatments that we use for prostate cancer do impact on your retail function. However, we need to weigh that up against the fact that cancer itself will do the same.
One can’t say, I won’t go for the treatment because it might cause this problem. It might or might not but certainly, cancer on its own can do that as well. There are also ways to deal with this particular problem and it is better if you are in the care of a urologist who can look after all these aspects for a patient’s well-being.
Are there any initiatives underway in the health environment to spread awareness about prostate cancer, and is there anything that communities, members of society can do to participate in such initiatives?
We are trying to build up some momentum around this to increase awareness. There is an American Prostate Cancer Foundation that have got a local branch as well who are doing good work in the space.
Really trying to get the word out to the communities but I think we’ve got to do better. One of my things is that every woman knows that they must have screening for breast cancer and cervix cancer, but not every man knows this about their prostate.
We need to just begin to have more conversations with men and dispel some of the myths and just get more awareness out there.
So there certainly are efforts, they need to perhaps be better coordinated and just to be done more. Efforts are underway that more can most certainly be done. More research needs to happen.
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