PROSTATE CANCER’S HIDDEN STRUGGLES, URGENT NEEDS

MBABANE - Prostate cancer is a silent health threat to men in Eswatini, where its shadow quietly affects the lives of many.

Despite being the third most diagnosed cancer among the top five, its prevalence among males is staggering. Almost 10 per cent of all new cancer cases in the country are prostate cancer, constituting nearly 30 per cent of all male cases. Yet, the struggle against this silent epidemic is largely hidden, marked by the intersecting challenges of stigma, limited healthcare infrastructure, limited awareness and the disruptions caused by the COVID-19 pandemic further compounding the urgency of addressing this issue.

Early diagnosis, improved access to healthcare, enhanced healthcare infrastructure, and increased awareness can reduce the burden of prostate cancer in Eswatini.

Joel Hlophe from Mbabane, tragically lost his father, Julius, to stage four prostate cancer in November 2020, when he was 72. Julius’ battle paints a vivid picture of the hidden struggles of stigma until it reaches advanced stages, significantly diminishing chances of survival.

“My father started feeling unwell a few years ago, but he struggled to disclose his symptoms on time, but rather relied on over-the-counter pain relief and traditional medication. His only complaint was a persistent headache, which he dismissed as a minor illness,” says Joel.

Most men often struggle to disclose their illnesses and often prefer to rely on self-remedy, seeking their cures after consulting with older men, who are perceived as approachable and trustworthy sources of guidance. Traditional medicine remains highly esteemed by some individuals, who regard it as superior to Western medical practices.

“Without knowing what was wrong with my father, things took a turn for the worse towards the end of November 2019, and he was taken to Mbabane Government Hospital in the first week of December, where he was diagnosed with prostate cancer at stage four,” says Joel.

Disaster

A few months later, Covid-19 was declared a national disaster, adding another layer of complexity to Julius’s already difficult circumstances. The healthcare landscape shifted dramatically, with hospitals overwhelmed, resources stretched thin, and stringent safety measures implemented to curb the spread of the virus. Navigating cancer treatment amid the backdrop of a global pandemic posed unique challenges, as accessing medical care became more complicated.

“With appointments rescheduled, procedures delayed, and concerns heightened about potential exposure to the virus, we totally lost hope for my father’s survival. The anxiety and uncertainty brought on by the pandemic worsened the situation,” says Joel.

As COVID-19 restrictions were gradually lifted between 2021 and 2022, it is undeniable that the provision of cancer prevention, screening, and diagnosis services was significantly disrupted by the pandemic’s impact on health services.

An Epidemiologist at Eswatini National Cancer Control Unit, Xolisile Dlamini, notes that: ‘The COVID-19 pandemic had a major role in cancer treatment, access to healthcare and survival. Most of the cancer patients were vulnerable to COVID-19, which increased the mortality rate, mostly between 2020 and 2022’.

A fight for early detection

According to the Eswatini National Cancer Control Registry (NCCR), data spanning from 2018 to 2022 reveals that the years 2021 and 2022 showed the highest incidence of stage four diagnoses, representing a critical stage in cancer progression. This trend primarily impacted men aged 66 to 79, at the time of diagnosis. The youngest individual diagnosed at this advanced stage was 43, while the oldest was 98.

Nkosingiphile Zwane, 63, was diagnosed with stage two prostate cancer in 2021. However, this diagnosis came after multiple visits to Mbabane Government Hospital, during which the condition remained undetected. This highlights a troubling issue of limitations in healthcare infrastructure, which leaves many men battling with an unseen enemy.

“When I first went to Mbabane hospital in March 2019, my issue was unrelated to prostate cancer, even though it was one of those male health issues. I got worried when the doctors gave me a date to visit the hospital again for prostate cancer screening,” notes Zwane.

Difficult

It is challenging for most men to know that they have symptoms of cancer in the early stages without timely checkups.

“At 63, I felt fit and healthy. The signs of prostate cancer were not obvious to me. When I was instructed to return to the hospital for prostate cancer screening, I became frightened. I visited the hospital three times without receiving a proper diagnosis, which left me unsettled about my health status,” says Zwane.

With the mandatory procedures for prostate cancer screening in Eswatini, coupled with the associated costs of the disease, Zwane found himself with no alternative but to impatiently wait for the scheduled dates. Zwane encountered a common challenge shared by many individuals grappling with undiagnosed illnesses, resulting in delayed diagnosis and treatment. Those seeking to speed up the process often rely on private healthcare, a costly alternative.

As indicated in the NCCR data, there is a significant number of patients with unknown stages of prostate cancer. This trend has been present over the years, as highlighted in the  2018 data, peaking in 2020 and decreasing in 2022. The medical records for these patients did not indicate the stages of their prostate cancer, meaning the stages were not yet detected, says Dlamini. This raises concerns about the high number of undetected stages, indicating potential gaps in early detection and diagnosis.

Factors

A study, The Burden of Prostate Cancer in Eswatini', highlights that this concerning trend can be attributed to various factors, including limited diagnostic and treatment capabilities. Inadequate cancer screening and diagnostic infrastructure in healthcare facilities worsen the situation. For instance, the country’s screening test, prostate-specific antigen (PSA), has been criticised for potentially overdiagnosing low-risk cancers that may not have clinical consequences if left untreated. Ezulwini Private Hospital, Urologist, Mthokozisi Dube notes that: ‘In case of abnormalities in screening, elevated PSA does not always mean it is prostate cancer’.

According to Dlamini, the reduction in undetected stages in 2022 can be attributed to the implementation of a patient navigation system by the Cancer Control Unit. This system tracks patients to ensure follow-up, provides feedback to referring facilities, and facilitates client navigation, thereby assisting patients in managing their healthcare needs across various facilities, following diagnosis without any hassle.

“Early diagnosis is crucial for successful prostate cancer treatment. When detected early, many men can be effectively cured. However, if diagnosis is delayed until the cancer has advanced, treatment options become more limited, and survival rates decrease significantly,” says Dube.

Regional disparities

NCCR data highlights regional disparities in the distribution of prostate cancer cases, stage at diagnosis, and survival outcomes. The data shows that Manzini and Hhohho regions have the highest number of cases, while Lubombo has the fewest. Population density has been identified as the major factor influencing these disparities. Eswatini people flow to Manzini and Hhohho for economic opportunities, industrial and commercial activities, and educational access, among others.

The data shows the survival status, which indicates variation by region with Manzini having the best outcomes in terms of survival rates, while Shiselweni and Lubombo show higher mortality rates with above 50 per cent of patients deceased. This is attributed to factors such as access to healthcare, treatment efficacy, and early detection programmes tailored to each region’s needs.

Access to cancer healthcare facilities poses a significant challenge for many men, especially those residing in remote areas. Most of these diagnostic and treatment facilities are in Mbabane and Manzini. Mpedulo Shongwe, a 67-year-old prostate cancer survivor from Palala in the Lubombo Region, faced difficulties in accessing the necessary medical facilities for his treatment.

“The treatment journey was very difficult for me. In my condition, I had to travel to Mbabane Government Hospital which was far and costly,” says Shongwe.

Many prostate cancer patients like Shongwe rely on the public health system, which is cheaper compared to the private sector. However, navigating the public system’s complex referral process can be daunting.

“The whole process for me was complicated. Dealing with the diagnosis, and waiting to be told what to do next felt like trying to find myself through a maze. When I was told that I had to travel to South Africa for additional treatment, that was another big problem on top of everything else,’’ notes Shongwe.

Prostate cancer technologies pose a serious challenge in Eswatini. According to a study titled ‘Prostate Cancer Disparities and Management in Southern Africa, radiation treatment is not accessible in Eswatini, and patients are instead referred to private hospitals in South Africa through the Phalala Fund, incurring an annual cost of US$4.7 million to US$7.8 million. Unfortunately, this fund has ceased accepting new applicants due to financial constraints. However, other surgical interventions to alleviate symptoms, such as transurethral resection of the prostate (TURP) or bladder (TURB), are performed locally. Chemotherapy is available through both a government chemotherapy unit and a local private clinic, however, many patients still seek chemotherapy treatment in South Africa.

Increased awareness initiatives required

Socio-economic, geographic, and educational factors significantly influence men’s adoption of good health practices. It is well-documented that, overall, men demonstrate poorer health-seeking behaviours compared to women, and this trend is evident among men in Eswatini as well. Dominant masculinity strongly influences key men’s health behaviours, emphasising the expectation for men to display strength, especially among older men who are particularly vulnerable to prostate cancer.

Another often overlooked issue is the dominance of women in most local clinics in Eswatini, which serve as the primary point of contact for prostate cancer diagnosis. From nurses to counsellors and users, women predominate, creating an unfavourable environment for men. In many African cultures, it is considered demeaning for men to disclose sexual or reproductive health issues to women, exacerbating this challenge.

While there are prostate cancer awareness and screening programmes, the majority of cases remain undiagnosed and consequently unreported due to stigma and limited awareness. Considerable efforts are still needed to raise awareness about the seriousness of the disease in men and to achieve a level of awareness comparable to that of women’s cancer such as breast and cervical cancer, that have been attained through high levels of funding.

“Awareness campaigns with roadshows come in handy in the education of the public, which has not yet happened in Eswatini while involving cultural and traditional leaders in the process to demystify myths circulating about prostate cancer and prostate cancer screening,” says Dr Dube.

The Eswatini Ministry of Health’s standardised cancer care and guidelines for 2020 recommend routine prostate cancer screening only for men aged 50 and above, to be conducted every two years. However, data from 2018 to 2022 revealed the youngest individual diagnosed at an advanced stage was 43 years old. In contrast, in South Africa, men of African origin undergo PSA testing starting at the age of 40, as recommended by the Prostate Cancer Foundation of South Africa.

Dr Dube highlights the importance of international standardisation in cancer guidelines to ensure early detection of the disease. Also, educating clinicians is required to ensure an understanding of these guidelines for better screening. “Clinician education can be done through workshops with experts which can also help to deal with issues of physicians’ beliefs regarding screening,” says Dr Dube.

It is important to bridge the gap in understanding, break down barriers to screening, and empower men with knowledge to ensure early detection and improved outcomes in the fight against this insidious disease. To be able to do that “collaborations between the public sector, private sector as well as non-profit organisations may assist in resource mobilisation to ensure access to screening facilities. As resource constraints are hindering the roll-out of screening,” says Dr Dube.

This work was produced as a result of a grant provided by the Wits Centre for Journalism’s African Investigative Journalism Conference and supported by the Bill and Melinda Gates Foundation.

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