Test in time - prostate cancer mortality

20 July 2016



The prostate cancer mortality to incidence rate is five times greater in the MENA region than in the US, but despite the number of deaths, and the significant prostate cancer rate in general, awareness of the disease in the region is low, with many opting out of seeking regular check-ups. James Quentin examines how hospitals and governments can reach out to men effectively in order to encourage regular examination and try to catch the disease early.


Prostate cancer is a major issue in the Middle East, with a variety of factors leading to the majority of Arab Peninsula countries appearing high up the list when it comes to deaths caused by the illness. Over the next several decades, as life expectancies in the region increase further and it begins to experience the top-heavy population-age pyramids experienced by Western nations, cancer rates are set to continue to rise.

There are barriers in getting people to go to the doctor in the first place, and the disease must be better screened once they do actually get there, in a way that is not frightening or off-putting for the patient.

The high population growth rates that are currently being seen are expected to level off soon, meaning that the Middle East is set to have a much higher proportion of over-65s than it does currently – and with an older population comes higher rates of diseases associated with elderly communities.

Worldwide, more than 1.11 million men were estimated to have been diagnosed with prostate cancer in 2012. With the current demographic, socio-economic, geopolitical and technological state of affairs, most Middle Eastern countries require the cooperation of international agencies in order to cope with these novel challenges to their health systems. In Lebanon, for example, it was reported in 2004 that prostate cancer made up 7.7% of all cancer diagnoses in the country. 

Prostate cancer is the second-most-frequently diagnosed cancer and the sixth-most-common cause of cancer death among men worldwide. Much of the international variation in prostate cancer incidence reflects differences in the use of prostate-specific antigen (PSA) testing, which detects indolent prostate cancer cases that may not otherwise have been picked up. According to recent estimates, 23–42% of prostate cancer cases in Europe and the US could be due to overdiagnosis. The vast majority of prostate cancers, 92%, are found when the disease is confined to the prostate and nearby organs.

However, in the Middle East, we find that prostate diseases are underdiagnosed. A recent study by Health Authority – Abu Dhabi revealed that male UAE nationals were diagnosed with cancer at a rate of 75 in every 100,000 of the population. The total reported cancer incidence in men – including UAE nationals and expats, an important consideration in a nation with a significant number of expat workers – was 805 people, with the total reported cancer incidence of UAE nationals accounting for 181 of those cases.

Overall, cancer is the third leading cause of death in the UAE. The report also indicates that of the cancer cases reported in Abu Dhabi, 20% were cancer of the prostate. While the survival rate of prostate cancer is high if diagnosed early, many patients in the UAE visit their doctor presenting symptoms in later stages of the disease. In contrast to the Middle East’s high mortality rate, 84% of men diagnosed with prostate cancer in the UK survive the disease.

The test ahead

This all raises two related questions: why are rates of prostate cancer mortality higher than in the Western nations? And how can this be tackled and brought down?

We have all seen the sitcoms about prostate checks. It’s one of the most common clichés in the old bookof TV plots: the implied emasculation and invasive procedure needed to be performed by a doctor to determine the health of the prostate. It’s a trope that exists in every corner of the globe, so it’s no wonder it has found purchase in traditional areas.

How this cultural issue can be addressed in order to find new ways to help prevent the disease is a problem that has been perplexing professionals for several years. Local expert Dr Ashraf J Abusamra, a urology and oncology consultant at King Abdul Aziz Medical City in Jeddah, Saudi Arabia, spoke in 2015 of the importance of reaching out to men and creating new programmes to break down communication barriers

“There is a lack of awareness about prostate cancer and other prostate diseases in the region,” he said. “A simple PSA blood test is recommended after the age of 50 as early-detection screening for prostate cancer. It is a tumour marker for the prostate gland. Based on the result of the test, a physician can decide on the frequency of repeat tests,” he said.

PSA detection is being heralded worldwide, with many healthcare systems looking to include it in their prevention and early-signs programmes. While the test is able to spot prostate cancer, it cannot tell how dangerous it may be or whether small malignancies could cause trouble later on – a similar issue to breast cancer mammograms revealing blemishes and cells that look abnormal and must be extracted, even though they may not develop, with great upheaval for the patient.

Some believe this to be a problem with PSA, and that some prostate cancers are slow-growing and may never cause problems. Due to a high PSA level, many men will be found to have a cancer that would never have led to their death, yet they are being treated with surgery or radiation because they are uncomfortable at the thought of not leaving the cancer to grow. Doctors and patients are still struggling to determine when it may be best to treat these cancers and when they could be safely left.

Presenting first

However, all of the potential screening procedures rely on getting the men to the doctor in the first place, and making them sit through invasive procedures and personal questions. It is common knowledge in medical fields that the more convenient and less intrusive a medical procedure is, the more likely you are to get patients to agree to it – if a procedure can be done in seconds rather than minutes, it could also help.

The probability of getting prostate cancer increases as a man gets older. Research from the American Cancer Society shows that about two out of every three prostate cancers are found in men over the age of 65 and, although most studies have not found a link with exercise, a recent one reported that men over the age of 65 who exercised vigorously had a lower rate of prostate cancer.

Is this a sign that, like many cancers, we should be investing in healthy lifestyle advice and encouragement in earlier stages of life rather than trying to search for genetic risk factors?

Prostate cancer is a problem all over the world, with men being reluctant to seek help for it no matter where they are. A British charity released statistics backing a claim that deaths from prostate cancer could be halved if screening, prevention and treatment were sufficiently improved.

The same charity, Prostate Cancer UK, has also helped to roll out a new computer detection program for GPs to use when they have older male patients they believe could be at risk. The program uses several factors – like a man’s age, ethnicity, family history and PSA level – and then gives an indication of his individual risk of having aggressive prostate cancer.

The charity also plans to look at prevention, including investigating whether there are any events that trigger prostate cancer growth. In addition, the planned changes to coverage will also examine whether diet, exercise or environmental factors play a role in prostate cancer.

While these steps might have an effect in the UK, with its comparatively open views on healthcare and entrenched knowledge of prevention, they might not work in the Middle East. Healthcare systems and government’s in the Middle East have been reluctant to take the so-called ‘nanny state’ approach that many European governments have adopted in attempting to rectify their citizens’ more detrimental lifestyle habits.

There is also an increasing push to have a more complex and invasive medical plan to help get rid of tumours once diagnosed. While this could mean more lives are saved if the disease is caught later on, it is receiving less attention than the strategies to catch prostate cancer early.

In the future?

In the UAE, 88% of people don’t go for cancer screening; that was the shocking statistic provided by the largest English-language newspaper in the GCC, Gulf News, in late 2015.

The survey that provided the numbers proved sobering reading and exposed several key areas of weakness. One of the local experts cited, Dr Mohanad Diab, a consultant oncologist at NMC Speciality Hospital in Abu Dhabi, told Gulf News: “The cost of preventive cancer screening is prohibitive as these are not covered by insurance. A mammogram costs a minimum of AED500, while a PSA test for prostate cancer costs AED300. People feel reluctant to spend such amounts from their own pockets.”’

If cancer screening is not covered by insurance, then it stands to reason that many will not partake in preventive healthcare. In essence, the high prostate cancer mortality rate in GCC countries is a two-step problem: firstly, there are barriers in getting people to go to the doctor in the first place; and secondly, the disease must be better screened once they do actually get there, in a way that is not frightening or off-putting for the patient, but that is cost-effective and not overly labour-intensive for the medical system.

Only once these two key issues are addressed in the Middle East, as they increasingly are being in other parts of the world, can the full extent of prostate cancer be tackled and the treatment – and access to it – for those suffering it be improved.   



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