Letter of the Day | The realities rural patients with prostate cancer face in Jamaica
THE EDITOR, Madam:
The year is 2014. The setting is St Elizabeth and Manchester. B.W. (not his real initials) is a robust and active 69-year-old man who lives in St Elizabeth. He is in a good state of health with no chronic illnesses and is employed by the bauxite industry. He is happily married and enjoys an active sex life with his wife who is eleven years his junior.
B.W. visits his general practitioner for a routine check-up and is discovered to have an elevated prostate-specific antigen (PSA) of 11 ng/ml (normal is 0-4 ng/ml). He is subsequently referred to a general surgeon in Manchester for further evaluation and treatment (referral to a general surgeon instead of a urologist is not unusual in this part of the island, as there is only one part-time urologist in Mandeville who provides care for a population of 738,000 people in southwestern Jamaica).
The general surgeon does a prostate biopsy, taking seven cores of tissue (the standard is 12 cores) which returns a diagnosis of prostate cancer of low grade (low likelihood of aggressive behaviour). Instead of referring the patient to the sole urologist in Mandeville or to one of the many urologists in Kingston and Montego Bay for expert care, the general surgeon decides to treat the patient himself.
Despite diagnosing early prostate cancer that is confined to the prostate and therefore imminently curable by either surgery-radical prostatectomy (complete removal of the prostate) or radiotherapy, the general surgeon proceeds to offer the patient non-curative treatment in the form of oral medication typically reserved for men with prostate cancer that has spread to involve other parts of the body (metastases). He does this because his general surgical training does not equip him to offer radical prostatectomy.
The medication causes a medical castration that will make the patient lose interest in sex, lose his ‘nature’ (erectile dysfunction), gain significant weight, predispose to diabetes, elevate his cholesterol, and predispose to heart disease. And despite all these ill-effects, it will not cure him.
The patient is reviewed by the general surgeon with a PSA reading and it has fallen to 0.1ng/ml, which is expected. Seeing that the medical castration of the patient has worked so well, he exacerbates the situation and offers the patient surgical castration (removal of the testicles), as this will obviate the need for further medication.
The patient’s daughter gets wind of what’s about to happen and frantically reaches out to a friend who is a general practitioner who subsequently arranges for the patient to be seen by a urologist in Kingston.
The urologist in Kingston confirms early prostate cancer, offers the patient the choice of radiotherapy or radical prostatectomy; the patient chooses surgery and has a successful procedure.
Seven years later (2021), the patient is cancer-free, sexually active with no erectile dysfunction, fully in control of his urine, and is enjoying life with a PSA of 0.1ng/ml.
STILL NO CHANGE
This true story highlights the problems prostate cancer patients have accessing urological care in rural Jamaica. The story could easily be multiplied more than 100-fold across the length and breadth of Jamaica.
Despite The University of the West Indies (UWI) starting a programme of training urologists in 1995, 26 years and 21 graduates later, the situation in rural Jamaica has not changed. Urology graduates have tried to get posts in hospitals such as St Ann’s Bay and have been met with resistance. It is only this year (2021) that a single urologist was employed to Spanish Town Hospital.
The entire northeastern part of the island and St Thomas is without a single hospital urologist. This does not bode well for patients in rural Jamaica with prostate cancer or other urological problems.
LEAD TO A DECLINE
Urological diseases such as an enlarged prostate (BPH), prostate cancer, kidney stones, bladder cancer, and recurrent urinary tract infections are highly prevalent and will become increasingly so with the documented ageing of our population.
Research done by The UWI demonstrates that:
• 16 per cent of 2,000 men 55 years and older surveyed in St Catherine had cancer as a health condition;
• 12.7 per cent had kidney/bladder conditions;
• 7.3 per cent had prostate problems (these are problems treated primarily by urologists).
Research from The UWI also demonstrated that:
• Rural-dwelling men present with 70 per cent more locally advanced prostate cancer than urban-dwelling men.
If the Ministry of Health and Wellness favourably considers employing more urologists in hospitals outside of Montego Bay and Kingston, thereby improving access to urological care in rural Jamaica, perhaps we would begin to see a welcome decline in prostate cancer mortality in Jamaica.
WILLIAM D. AIKEN,
Professor of Urology
The University of the