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

Abstract

Background

There have been several publications on population or community prevalence of benign prostatic hyperplasia and prostate cancer from various countries and races but few reports are from Africa on Africans.

Aim

A review on the prevalence of benign prostatic hyperplasia and prostate cancer in Africans and other races.

Methodology

The current literature on prevalence of benign prostatic hyperplasia (BPH), prostate cancer (PC), and benign prostatic hyperplasia co-existing with prostate cancer in Africans and other races is reviewed.

Results

Benign prostatic hyperplasia (BPH) prevalence in Ghana is responsible for 60% acute retention of urine and 28.6% of haematuria. Worldwide prevalence of BPH varies from 20 – 62% in men over 50 years and this includes USA, UK, Japan and Ghana. Reports from South Africa indicate prevalence of over 50% in adult males of 60 years.

BPH co-existing with PC – Reports from USA, UK and Japan and Ghana reveal moderate association of BPH and PC. The co-existence of PC in patients being treated for BPH is 3 – 20%

Prostate Cancer prevalence – There is high prevalence in USA, Scandinavian Countries, African Americans (AA) and Caribbean blacks. Ghana, Trinidad & Tobago have reported high prevalence of 6 –10% in men aged 50 years and above but others reported low prevalence in Africans from Africa. The low reporting from Africa of 10 – 40:100,000 is attributable to under reporting, absence of PSA screening/testing, lack of reliable cancer registries and poor medical facilities.

Economic Costs of BPH and PC: BPH in the USA national direct costs are estimated at U$4Billion and individual costs of US$1536 annually. In Ghana, individual costs for BPH medications range from US$300 – 550 per year and cost for simple prostatectomy/TURP is estimated at US$1100. For prostate cancer, individual direct costs from Europe range from 6,575 – 12,000 euros, £2818.00 UK and over U$12,000 – 20,000 in USA per annum. In Ghana, individual direct costs ranges, for radical prostatectomy and external beam radiotherapy US$1250 – 1500, for brachytherapy 9,000 Euros, for hormonal therapy US$1600 – 3200) per year and US$510 for orchidectomy.

Conclusion

Recent evidence although sparse indicate there is high prevalence of BPH and PC in Africans and men of African descent in diaspora, the low prevalence of BPH and PC reported from some African countries is likely to under reporting and future prevalence studies both in the living and deceased are recommended to reveal the true prevalence of BPH and PC in Africans though screening for PC in the living remains controversial.

Introduction

The morphological anatomy of the prostate gland has been established1,2. They are the peripheral zone (PZ), transitional zone (TZ), central zone (CZ), the anterior fibromuscular area and the pre prostatic area. The contributions of zonal areas in a normal gland are PZ 70 – 80%, TZ 10%, CZ 20%. In benign prostatic hyperplasia/hypertrophy/enlargement (BPH/BPE), only the transitional zone is affected and constitutes 100% of BPH. In the development of prostate carcinoma (PC), more than 70% arise from the PZ that is the outer part of the gland, TZ account for 20% and CZ 10%, Table 11, 2. Prostatitis affects mainly the PZ. Because the PZ is left behind after TURP/simple prostatectomy, patients after these operations can develop prostate cancer in the PZ zone left behind. Population based reports of the prevalence of BPH and prostate cancer varies with different geographical locations and races1,2.

Table 1. MORPHOLOGICAL ANATOMY AND ORIGIN OF BPH/CAP IN PROSTATE GLAND.

Normal
Origins	Gland	BPH/BPE	Prostate Cancer (PC)
PZ	70 – 80%	-	> 70%
TZ	10%	100%	20%
CZ	20%	-	10%

Aims And Objectives

BENIGN PROSTATIC HYPERPLASIA/HYPERTROPHY/ENLARGEMENT (BPH/BPE) – to review the published work prevalence of histological (fibromyoadenoma) BPH in autopsy and clinical BPH/BPE cases in Africa and other races. In the living, there is no globally accepted definition of BPH/BPE so the prevalence rates are reported by the definition chosen by the investigator3,4,5. The prevalence of clinical BPH/BPE may be assessed by digital rectal examination (DRE) of the gland showing features of rubbery enlarged prostate gland. The size may be normal size mls/g, Grade 1<20mls, Grade 2: 20 – 29mls, Grade 3: 30 <49mls, Grade 4 ≥50mls enlargement. The size of the prostate gland can also be assessed by transrectal ultrasound (TRUS) or trans abdominal ultrasound (ABDUSG) Grade 1: <20mls (normal), Grade 2: 21 – 29mls, Grade 3: 30 – 49mls and Grade 4: ≥50mls. Prevalence studies can also be assessed by the degree of lower urinary tract symptoms (LUTS) as measured by International Prostate Symptom Score (IPSS) 0-7 mild, 8 – 19 moderate and 20 – 35 severe in absence of urethral obstruction and other causes of bladder outlet obstruction. Quality of life /bothersome QOL/BS assessment 0 – 6 QOL/BS (Delighted 0, Pleased 1, Mostly satisfied 2, Mixed 3, Mostly unsatisfied 4, Unhappy 5, Terrible 6) Score ≥3 being used as significant symptom3,5.

BENIGN PROSTATIC HYPERPLASIA (BPH/BPE) co-existing with prostate cancer. This will be reviewed as patients with clinical BPH and abnormal DRE and PSA found to have histological concurrent prostate cancer6,7,8.

PROSTATE CANCER (PC) Review of literature to find prevalence population based on histological cancer of prostate in the living and autopsy studies in Africans and other races2.

As previously stated benign prostatic hyperplasia/hypertrophy/enlargement (BPH/BPE) is diagnosed on finding symptoms of LUTS/IPSS QOL/BS in absence of other causes bladder outlet obstruction such as urethral stricture and PC and may or may not be supported by DRE or ultrasound size. It is also confirmed by PSA ≥1.5ng/ml as surrogate measure of volume ≥30mls as well as peak flow rate and post void residual urine9, 10 and by autopsy studies showing histological BPH.

Management of symptomatic BPH is initially by alpha adrenergic blockers (alfuzosin, doxazosin, terrazosin, tamsulosin) or by combination of α blockers and 5 alpha reductase inhibitors (Finasteride, dutersteride). Surgery is indicated in refractory urine retention, recurrent UTI, diverticulum, stones, obstructive nephropathy and haematuria. The surgical approaches are transurethral resection of prostate gland (TURP), transurethral incision of prostate gland (TUIP) or open suprapubic prostatectomy11,12. Benign prostatic hyperplasia may co-exist with PC6,7,8. The methods of management follow protocols for PC13,14.

Prostate cancer (PC) prevalence/ incidence is based in all cases on histological proven carcinoma. The incidence may be based on hospital, clinic or unit cases and the prevalence studies are based on population screening or from autopsy screening studies. The management of PC depends on stage, physique and age of patients. For early PC, treatment is by radical prostatectomy (RP), brachytherapy or external beam radiotherapy (EBRT). Treatment for locally advanced PC is by neoadjuvant hormonal or chemotherapy salvage RP, brachytherapy/EBRT or hormone therapy. For advanced and metastatic cases, hormonal or chemotherapy treatment is used13,14.

MATERIALS AND METHODS

The literature review was from Medline from 1969 to present involving work done on prevalence of BPH, BPH co-existing with prostate cancer and prostate cancer from USA, UK, Europe, West Indies, West Africa, South Africa and other parts of Africa, Japan, Asia and others were used. Published reviews on prevalence in Caucasians, Caucasian Americans, African Americans, West Indians, Africans in the diaspora, Africans in Africa, Hispanics, Asiatics and others were identified and appraised, and described the quality of the evidence base used. The reviews and their conclusions were summarized and compared; the strengths of the conclusions were discussed.

STATISTICAL METHODS

The data obtained including demographic clinical features relevant investigations, management offered and outcomes were analysed using Statistical Package for Social Sciences (SPSS) version 20. Data results were expressed as percentages and means ± standard deviations. A P-value of less than 0.05 was considered significant.

Results

BENIGN PROSTATIC HYPERPLASIA (BPH)

At Korle Bu Teaching Hospital (KBTH), clinical BPH is the leading cause of retention of urine in adult men and haematuria in adult men based on DRE ultrasound abdominal/transrectal CT scan/MRI scan, urethrocystoscopy, biopsy and histology15,16,17 as shown in fig 1, fig 2, fig 3.

Fig 1: Changing patterns of the causes of retention of urine.

Fig 2: Common causes of haematuria in Accra, Ghana.

Fig 3: PREVALENCE BPH/BPE/NCPE GREATER ACCRA POPULATION 2,905,736 GPHS MEN 50-74 – 125,443 (2002 – 2007) UGMS NCI/NIH.

In the Ghana Study18 the burden of BPH/BPE and LUTS in 1038 subjects aged between 50 – 74 years who were screened for PC + BPH/BPE revealed 73 cases with PC and cases with PSA ≥20ng/ml were 15. These were excluded leaving 950 men screened for BPH/BPE. The results are shown in Table 2, Table 3 and Table 4. The prevalence of BPH was 20 to 62% depending on the parameter used. The prevalence of BPH rises to 35 – 60% in individuals aged over 70 years. The estimated prevalence of BPH /BPE in Greater Accra 2000 census with 2,905,736 population in men aged 50 – 74 being 125,443. The prevalence of BPH cases was 77,775(62%) BPH on DRE and 20% symptomatic BPH with IPSS 8 – 35 making 20% of 125,443 that is, 25,089. This makes BPH of public health concern (fig 3).

Table 2. PREVALENCE BPH/BPE AND LOWER URINARY TRACT SYMPTOMS (LUTS) IN GHANA WEST AFRICA18.

	Age GP in years
Definition BPH LUTS	Overall(n=950)	50 – 59	60 – 69	70 – 79
DRE/BPE ≥ 30cc	62	59	68	60
IPSS
Mild (0 – 7)	74	79	73	61
Moderate – severe ≥ 8	20	15	23	35
IPSS – QOL
0 – 2 Delighted satisfied	81	84	80	70
≥ 3 mixed terrible	18	15	19	29
DRE BPH vs IPSS ≥ 8	14	9	17	22
PSA ≥ 1.5ng/ml ≥ 30cc	36	25	43	58
Imputed prostate vol. ≥ 30cc n = 281 data set	30	15	41	58

Table 3. % Prevalence BPH/BPE in Various Gp years.

Parameter	Overall	Age Gps yrs
		50 – 59	60 – 69	> 70
BPH/BPE	62	59	68	60
IPSS ≥ 8	20	15	23	35
PSA ≥ 1.5ng/ml	36	25	43	58
Imputed prostate vol. ≥ 30 cc	30	15	41	58
The findings have been adjusted by 2000 WHO World health Population ages

Table 4. Previous Population Based Studies, % Prevalence of BPH/LUTS.

Study/Yr	Place/Pop/Race	Parameter	Overall	Age GPS in Years
				50-59	60-69	>70
Sarma et al 200340	USA MichiganBlacks 369 men	IPSS ≥8	45	42	51	40
Guess et al 199036	Baltimore USA all Races 1057 men	DRE/BPE	36	27	45	52
Truemann et al 1999	UK 1115 men	IPSS ≥8	37	29	38	41
Rosen et al 2003	Multinational Europe USA 12,815 men	IPSS ≥8	29	22	33	45
Nashlund et al 2007	USA all races 444 men	IPSS ≥8	41	33	50	46
		DRE/BPE ≥ 30cc	42	32	50	63
		PSA>1.5ng/ml ≥ 30cc	36	24	46	61
ChokkalinghamGPHS UGMS/NCI/NIH	Ghana Africans 950 men	IPSS ≥8	20	15	23	35
		DRE/BPE ≥ 30cc	62	59	68	60
		PSA >1.5ng/ml ≥ 30cc	36	25	43	58

In South Africa, reports by South African Urological Association indicate that 1:3 men 45 years old experience LUTS due to BPH and 50% of men at 60 years have symptoms due to BPH and have issued guidelines for management11,12.

CO-EXISTENCE OF BPH and PC

The Ghana Study19,20established that all the 73 cases of PC had in addition histological evidence of BPH. Armenian6 found that retrospective and prospective studies of patients being followed and treated for symptomatic BPH showed evidence PC. It has also been found that BPH and PC show parallel prevalence7 and that autopsy studies show 82.2% BPH and 43.6% - 80% PC at 90 years. PC has been found in 3% –20% of TURP chippings for BPH. Clinical evidence for PC in surgically treated BPH is >3% and so it is important to exclude PC in patients being treated for BPH. In Japan, Suzuki8 reported that the prevalence of BPH by autopsy studies is at 40 years 20%, 50 years 40%, 60 years 70% and 70 years 80%. PC prevalence at 90 years 100%, 70 years 40%, and 50 years 30%, confirming the importance of looking for PC in clinical BPH cases by biopsy and histological studies in cases with abnormal DRE and PSA5,6,7,8,19,20.

PROSTATE CANCER

In Ghana Population based study the screen detected PC using PSA ≥4ng/ml was 6.3% but using PSA >2.5ng/ml was 7%. The Stages were T1 24.6%, T2 56%, T1 – 2 81%, T3 11%, T4 3%, T1 – 4 M1 4% (fig 4)19,20

Fig 4: Postrate cancer screening in Ghana.

Other findings from Ghana Study were down migration of stage at diagnosis in retrospective versus population and case expansion studies was statistically significant. The studies were retrospective, population and case expansion and the stages were early 15%, 81%, 62%, locally advanced 30%, 15%, 25%, and metastatic 55%, 4% and 13% respectively. Risk factors identified were high basal metabolic index (BMI), advanced age >60 years, Chromosome 10p14 associated with PC in Ghana, aggressive PC disease, GS ≥7 (68%) and PSA >52ng/ml associated with chromosome 5q31.3, low grade PC GS <7 (32%) associated with chromosome Xq2817, 19, 20 and 6q2121, 22,23,24,25,26,27

Prevalence of PC in Africa as globally reported in Globocan28 is as follows per 100,000 population. The highest prevalence of 227:100,000 was reported from Martinique, Norway, Sweden, Trinidad and Tobago 123.4:105,000 in Australia and 129.7 – 98.2 per 100,000 in the USA. The report includes prevalence in black Africa which was low at 20 – 37 per 100,000 in West Africa and East Africa whilst South Africa has 61.8 per 100,000. The mortality figures were highest in Caribbean and Sub Saharan Africa, 19 – 29 per 100,000 due to more aggressive disease and advanced stage at presentation and lower in America and Europe 10 per 100,000. The low mortality in Europeans and Americans is due to detection of early PC by PSA testing and screening and availability of curative treatment modalities as RP, Radiation therapy (brachytherapy & external beam radiation EBRT). The low prevalence reports from Africa are probably due to under reporting – lack of cancer registries, less screening and low PSA testing. SEER29 report similar problems in African American men. Prevalence of PC in men with PSA ≥4ng/ml has been reported in USA by Thompson30 as 15%. Develongchamps31 also reports that there is low incidence of PC in men >50 years in Senegal, Mali, Guinea, Gambia but high in men in Ivory Coast and Zimbabwe, but most African countries have incidence below 40:100,000 whilst in South Africa the prevalence is 40:100,000. The low figures are again due to low PSA testing and screening and lack of reliable cancer registries and autopsy prevalence studies. Autopsy histological PC prevalence studies by Delongchamps31 showed high prevalence in African Americans than Caucasian Americans some due to socio cultural reasons, dietary, hormonal and genetic factors.

But true prevalence in Africans can be found from screening which is controversial, PSA testing in the living or population based autopsy histological studies. As previously stated, prevalence studies from population studies in African migrants and descendants worldwide show relatively high prevalence in African Americans (AA), and descendants of Africans; in Jamaica 227:100,000, Martinique 227:100,000, Trinidad & Tobago and Barbados 123: 100,00028

Jackson32 reported that the autopsy prevalence rate in AA in Washington DC 40.6 per 100,000 was similar to 36.7:100,000 in Nigerians and Ghanaians even though incidence in the living was higher in AA men.32, Heyns33 reported that black South Africans presented with the aggressive and advanced disease PC and high PSA compared to Whites but there was no report about prevalence. Osegbe34 reported from Lagos that the histological proven hospital incidence was 127:100,000 but no mention of population based studies. Haas35reported from autopsy prevalence studies that in USA the high incidence of PC is declining after a rise due to PSA testing and 90% PC cases diagnosed at early stage T₁T₂ making survival rate higher in USA, a consequence of early detection by PSA testing and screening.

Discussion

Benign prostatic hyperplasia (BPH/BPE) Table 4

By DRE the prevalence of BPH in Ghana was 62%18. In the USA it ranges from 36%. Guess36 and Nashlund3742% all races. The prevalence of BPH symptoms using IPSS ≥8 as moderate to severe LUTS in Ghana18 was 20%, but others using the same criteria reported various values; in the UK by Truemann 37%38, in Europe by Rosen39 multinational 29% and Sarma’s40 report in Michigan Blacks was 45% fig 1, fig 2 Table 2,Table 3,Table 4. 15, 16,17,18,19,20,36^–40

In South African black men 1: 3 >45 years have moderate to severe LUTS due to BPH and 50% of men at 60 years have symptomatic BPH and there is also annual increase in black men with symptomatic BPH.11

Using PSA ≥1.5ng/ml ≥30mls prostate volume the prevalence in Ghana18 was 36% while Nashlund37USA reported prevalence of 36% in all races, using imputed prostate volume from PSA ≤1.5ng/ml, TRUS prostate Vol 30 ml and IPSS ≥8 report Ghanaian prevalence as 30%. Table 2,Table 3,Table 4 fig 2,fig 3, fig 4, 15, 16,17,18,19,20,36^–40

In the USA the incidence of acute retention (ARU) is 34.7/1000 men >70 years and also 27 Million Caucasians aged 50 – 79 years have symptomatic BPH requiring treatment in 2000. Other USA statistics indicate 8 million visits for primary assessment and diagnosis for BPH and 87,410 TURPS are done each year for BPH41,42

ECONOMICS – COSTS OF MANAGEMENT OF BPH

In the USA, national direct cost of management of BPH medications, hospital procedures, imaging and office visits amount to U$4 Billion annually. This excludes indirect cost of loss of earnings from absenteeism, pain and discomfort Taub and Wei41. Saigal & Joyce42 by examining medical claims calculated the incremental cost associated with diagnosis of BPH was U$1536 annually excluding surgical procedures.

In Ghana currently, head of Urology Unit at Korle Bu Teaching Hospital reports that individual costs for BPH medications range from Gh¢1200 – 2200 (US300 – 500) per year and costs for simple prostatectomy TURP Gh¢4500 (US1100).

Treatment of complications such as UTI, acute retention of urine (ARU), erectile dysfunction/ impotence, obstructive uropathy and affordable medications all have their role and may cause pain and absenteeism from work. Deaths from complications such as uraemia, septicaemia and haemorrhage have economic impacts.

For direct medical costs including investigation, medications and surgical treatment is enormous. In USA 1.1 BN U$ associated with work absenteeism due to BPH/BPE. It also limits the quality of life and lead to premature retirement from morbidity in <60 year old men. Others are UTI causing pain and ill effect of quality of life. There are however no comparable figures from African countries.41,42

CARCINOMA OF PROSTATE

Overall PC causes 18% of disorders of the prostate gland. The worldwide incidence in men over 50 years is 11.7% that is 15^th commonest of new cancers worldwide, 19% of new cancers in developed countries and 5% in developing countries.28 The prevalence per population is lowest in Asia/China 1.9% or 10/100,000 in Caucasian Americans 1.4 – 2.4% or 104/100,000, African Americans 2.2 – 5.1% or 272/100,000, in Caribbean Men about 5 – 10% and we have established in Ghanaian Men from 6.3% - 7% which is on the high side. fig 4, fig 520,28,29, 33, 35, 43,44, 45, 46, 47, 48. Osegbe34 reported highest hospital incidence of PC in Lagos. Heyns33 reported from South Africa that black men had significantly more advanced stage of PC with high PSA than whites and coloured in Western Cape. Jackson32 reported that even though clinical incidence of PC was higher in African Americans in Washington than blacks from Nigeria and Ghana, the autopsy prevalence was similar. In review of the literature, Angwafo49 pointed out the high incidence in North Americans, intermediate incidence in Europe but low incidence in sub Saharan Africa and Asia may be because of environmental factors. Rebbeck50 and Jalloh51 also report of high aggressiveness (high Gleason scores G>7 and advanced clinical stages) in men of African descent. Table 5 47, 50 They also blame late reporting and more locally advanced or metastatic cases and more aggressive tumours from Nigeria and Senegal but no population based screening or autopsy prevalence have been reported from these countries by the authors.

Fig 5: Screen-Detected Prostate Cancer Prevalence (%).

Table 5. SUMMARY OF AGGRESSIVENESS OF PC IN MEN OF AFRICAN DESCENT.

Table 5
REGION	Mean Age years	Median PSA ng/ml	Median GS	Tumour Stage at presentation
AFRICA	69	59(R0.5 – 14,390)	≥7	↑T3 – T4
CARIBBEAN	72	32	≥7	↑T3 – T4
UK BLACKS	71	107	≥6	↑T3 – T4
USA AFRICAN AMERICANS	69	7	≥7	↑T1 – T2
Limitations in finding true picture in populations with high mortality – No PSA screening for population prevalence, No autopsy data, absence of reliable Cancer Registries Rebbeck

Examination of data from USA, Caribbean, SSA indicate tumour stage and Gleason Grade were highest in Sub-Saharan Africa (SSA). Table 5 47, 50 In USA death rates have been declining from 1990 due to early detection and it is hoped this can be emulated by Ghana (fig 4) and other African countries. There is higher proportion of organ confined disease in USA and advanced countries than in Caribbean and Sub Saharan Africa (SSA) (Table 5)47, 50.

Mortalities for Prostate Cancer

The 5 year survival rates of newly diagnosed PC are estimated at 80 – 90% in USA and under 40% in Denmark, Poland and Algeria. Regions with higher proportions of advanced PC in SSA reported lowest mortality figures because of under reporting, lack of cancer registries, lack of PSA screening and lack of autopsy data. Table 5 47, 50

Future prevention measures include diet with low fat, low red meat, low BMI, stopping smoking and chemoprevention by high Vit E, high intake of lycopene, selenium, finasteride, oestrogens, genes manipulation and prevention by Vaccinia immunisation.20, 28, 29, 31, 35, 43, 44, 46, 47, 48

ECONOMICS – COST OF MANAGEMENT PC

From Europe and USA the costs of management of PC are as follows: in Italy from 6575.31 euro, in UK from 2818 pounds, and in France 12731 euro, and in USA from $12,000.52, 53, 54 These costs are very high for low and low middle income countries. There have not been comparable figures from Africa. In Ghana, the head of Urology Unit in KBTH reports individual direct costs for radical prostatectomy or EBRT ranges from GH¢5000 – 6000 (US1250 – 1500), for Brachytherapy the cost is GH¢30,000 – GH¢32,000 i.e. 9000 Euros. For hormonal therapy the cost is from GH¢6400 – 12400 (U$1600 – 3200) per year and for Orchidectomy the cost is GH¢2000 (U$500).

Conclusions

BENIGN PROSTATIC HYPERPLASIA (BPH/BPE).

Reports of studies among races in USA, UK and Asia or black communities in these countries and Ghana fig 1, fig 2, fig 3, Table 4 18, 36 ^– 40and other reports from Africa confirm the high prevalence of BPH/BPE in Africans and men of African descent, Caucasians and other races.1, 2, 3, 4, 8, 10, 11, 15, 16, 17, 18, 19, 20, 36 ^- 40. The reports though sparse indicate high prevalence of BPH in Africans, the prevalence in the living and dead has to be investigated in other parts of Africa.

BENIGN PROSTATIC HYPERPLASIA CO-EXISTING WITH CARCINOMA OF PROSTATE

Reports 1, 2, 3, 4, 6, 7, 8, 30 have indicated that there is relatively moderate incidence of PC among subjects being treated for BPH. The prevalence of PC among TURP chippings for treatment of BPH has been reported as 3 – 20%. Other reports indicate that the incidence of PC in patients being managed as BPH has been recorded.

PROSTATE CANCER

Africans, African Americans and Africans in the UK and diaspora and those born in the Caribbean and their descendants have high prevalence of PC as well as having more aggressive, G>7 and higher PSA values >52ng/ml and more locally advanced (T3 T4) and metastatic disease as well as having higher mortality rates than Caucasians and Asiatics fig 5 and Table 5.20, 28, 43 ^– 51 The wide use of PSA testing, PSA screening in USA, Europe and other advanced countries have led to higher detection of early PC and stage down migration of PC at presentation and higher rates of curative treatment such as radical prostatectomy and radiation therapy. These have reduced the mortality of PC in USA men. The reports of low prevalence in Africa is attributable to absence of cancer registries and less use of PSA testing and PSA screening in African countries. Where ever there has been PSA screening and testing and established cancer registries in Africa or Caribbean or autopsy population based studies such as Trinidad and Tobago and Ghana, have reported higher prevalence or incidence of PC in Africans in Africa fig 4, fig 5 Table 5 and the diaspora. Future studies are recommended in Africans to have true prevalence of PC in Africans even though screening for PC remains controversial19, 20, 28, 29, 31, 32, 33, 34, 35, 43 ^– 51

ECONOMIC COSTS OF BPH AND PC

In addition to the public health aspects of BPH and PC, both of them have high economic cost estimates, regarding direct costs, clinic attendance, cost of treatment by medications and surgical procedures and morbidity as reported from USA and Europe. Unfortunately, there are no comparable figures from Africa. Knowing the true prevalence of BPH and PC in Africa and their economic costs will help in the planning of health budgets and health insurance in African countries41, 42, 52, 53,54