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In what seems to be a nationwide epidemic of prostate enlargement and cancer cases among men, the urology clinics of government-owned tertiary hospitals can no longer contain the teeming numbers of patients seeking attention from only 260 registered urologists available in the country. JANET OGUNDEPO reports
After being seated for several hours, awaiting his name to be called, a dark-complexioned middle-aged man, Mr Habeeb Adedayo, wondered aloud at the number of patients waiting to see the doctor.
To meet the appointment time, Adedayo had left his home in Sango at 5am and was one of the early birds that warmed the still-cold benches of the waiting area at the Urology Clinic of the Lagos State Teaching Hospital, Ikeja.
Bored with the long queue of patients and uncertain when he would be called to see the doctor, he picked up a conversation with his neighbour.
“I opened my mouth wide and had to cover it with my hands when I saw the number of men who came to see the urologist,” he quipped.
Upon hearing this, our correspondent, who visited the clinic, feigned as a patient relative, engaged Adedayo in a conversation.
“I came here last week but I was asked to go for a scan and return today. So, I have been here since morning but when I saw the people here again, I wondered what was happening to us men nowadays to make us this many in the hospital,” he continued in Yoruba language.
The middle-aged man narrated that after several visits to both private and general hospitals in the state about his frequent urination which comes in trickles and sometimes accompanied by blood, he was referred to see the urologist.
Adedayo, who spends about N10,000 on transportation, said his second visit was to further confirm his enlarged prostate diagnosis or the verdict the doctor gave.
Our correspondent’s visit to the tertiary hospital’s urology clinic was to investigate the seeming rise in prostatic diseases amid the fewer urologists in the country.
To the doctor’s credit, they listened to the patients and assured that they would all be attended to.
To further examine the situation at other government-owned tertiary hospitals in Lagos, our correspondent visited the urology clinic days of the Lagos University Teaching Hospital, Idi-Araba, and the Federal Medical Centre, Ebute-Metta.
Visiting these hospitals was because they were the only government-owned tertiary hospitals that offered urology care in the state, aside from other private clinics.
The situation was the same.
Same at LUTH
Also attending the urology clinic at LUTH as a patient’s relative, our correspondent observed the crowd and interacted with some patients and relatives.
About 40 men, a mix of old and middle-aged men sat on long brown benches and white plastic chairs as they listened for their names to be called.
Some young men seen in the clinics were later observed to accompany their older relatives.
A new patient to the Thursday urology clinic, Mr ‘Goke Alabi, told our correspondent that he had been at the clinic since past 7am but was unsure when he would be attended to.
His son, who helped him in the registration process, paid occasional checks on him as he went about his activity.
Alabi lives in Ikorodu and was referred to the clinic from the general hospital after he complained of slow and incomplete urination.
He stated that he was placed on medication and got better but his symptoms returned after some time, leading to his referral.
Although tired of waiting and uncertain of when it would be his turn, Alabi stated that he had done his prostate-specific antigen test and would be presenting it to the doctor.
Before coming to the clinic, Alabi stated that his friend’s biopsy result, which came out negative for cancerous cells, gave him hope.
“I have made up my mind regardless of the outcome,” he opined.
Filled and overflowing
The relative of a 75-year-old patient, with prostate disease, Mr Adekunle Bankole, began an open interaction with other patients and relatives after waiting at the clinic for more than three hours.
He wondered about the lesser numbers in attendance that day and pinned it on the heavy downpour that had begun at about 6am.
“This place is always filled to the brim and overflowed to the corridors,” he said, describing how a typical clinic day was.
Bankole, who said that his father had undergone radical prostatectomy, a surgery to remove his enlarged prostate and seminal vessels, testified that his father had a better health outcome.
More cases in FMC Ebute – Metta
A Consultant Urologist at FMC , Dr Kehinde Apata, also confirmed the rise in the facility.
For example, last Tuesday’s clinic recorded over 120 patients with about 40 patients newly referred to the clinic.
A patient, identified as Honourable, who came to the clinic around 11am, was asked to get another appointment date because the number of patients yet to see the doctor was many.
10 to 12 new prostate cancer cases
Of the 40 new patients, about 12 of them presented with diagnosed prostate cancer cases.
However, “Prostate cancer and enlargement cases recorded of both new and old patients combined were about 55,” the specialist said.
He further noted that other cases of urinary problems without evidence of cancer were also witnessed in the hospitals.
Apata, however, pinned the rising incidence on increased access to PSA screening tests and risk factors such as genetics and familial history, belonging to the black race and the high consumption of Western diet which has led to reduced consumption of vegetables and fruits.
The urologist noted that prostate enlargement cases were higher because a man aged 50 and above will begin to experience an increase in prostate size.
“That is the normal natural process. But not everybody will come down with symptoms of that enlargement,” the physician noted.Wide use of PSA test
For a Consultant Urologist at the Lagos University Teaching Hospital, Dr Rufus Ojewola, prostate cancer was a common cancer worldwide and was particularly common in black communities, which are African countries including Nigeria.
Prostate cancer, according to the American Cancer Society, is a form of cancer that begins in the gland cells, the prostate, which is found only in males.
The prostate is a small walnut-shaped gland in males that produces the seminal fluid that nourishes and transports sperm.
The National Cancer Institute says it is the most common cancer among American men.
Several reports show that in Nigeria, prostate cancer was the leading cause of cancer deaths in men mostly aged 55 years and above.
Although the weekly figure of patients in the LUTH clinic could not be ascertained, the specialist confirmed an increase in patient’s diagnoses of prostatic problems.
He pinned this rise on the “Widespread utilisation of one of the available prostate screening tools, prostate-specific antigen, unlike it used to be in the past. So people now go for PSA and it’s usually the first thing to be detected even when patients are not having any symptoms. That is to say one can have prostate cancer and there are no symptoms. You only get to know if you submit your specimen for analysis and they discover that your PSA is high, then we begin to evaluate and eventually do a biopsy to confirm that there is prostate cancer.”
This testing tool, Ojewola stated, has helped in the increase of early hospital presentation and diagnosis, leading to better treatment outcomes and cures.
He further submitted that more awareness campaigns about cancers and prostate diseases have led to the rise of men coming to the hospital for diagnosis and treatment even before they have symptoms.
Awareness, population driving increase
Confirming the rising hospital visits, a Professor of Urology at LASUTH, Stephen Ikuerowo, attributed it to the rising population in the state and visits from patients who are not residents of the state.
He further noted that the increased hospital visits could be attributed to the rise in awareness about prostatic problems and PSA testing which allows for early detection and, subsequently, early hospital presentation.
“With improved awareness, what you then have is an increasing number of cases that you detect early, which is what we are seeing now. Unlike in the past when we used to see late presentations, now you see patients who come early,” the don said.
He further confirmed that the clinic saw about 126 new cases weekly, noting that two clinic locations had been situated to accommodate the demand.
Five to 10 new prostate cancers
At LASUTH Punch Healthwise learnt that between five to 10 new cases of prostate cancer were recorded weekly in the hospital.
The consultant urologist however noted that prostate enlargement cases were more common among other urinary problems.
“I think on average, you probably see maybe five new prostate cancers every week. But of course, prostate enlargement that is not cancer is more common and you probably have like double that. But those that are prostate cancer, maybe five, at most 10 every week,” the don said.
Two to four new prostate cancers
AT LUTH, PUNCH Healthwise learnt that in one of the clinics, about two to four prostate cancer cases were newly recorded in every clinic.
“But on average, the new cases for every clinic, I would say between two and four cases that are new prostate cancer. I’m not talking about prostatic diseases but about cancer,” Ojewola confirmed.
A further analysis of the figures obtained from the clinics revealed that about 26 cases of prostate cancer were recorded every week in public specialists’ clinics in Lagos State.
What are men doing wrong?
The rise, the urologists asserted, was not due to wrongdoings, actions or negligence from men.
He noted that aging, genetics, familial history and the black race were triggers or risk factors.
On prevention, Ikuerowo said, “In terms of can you prevent yourself from developing prostate cancer, maybe the answer is no. But if you develop prostate cancer, can we catch it early? That is the question we should be asking and which will come under secondary prevention. If we can catch it early, then we can treat it to prevent other consequences.
“So that is early detection. Early detection is the main thing, not that we want to prevent you from having it because it has to do with your genes, you being a man and getting older. There is nothing you can do about those factors.”
36, 37-year-olds with prostate cancer
In further interactions with the urologists, PUNCH Healthwise further learnt that although most patients with prostatic problems were between the ages of 50 and above, exceptional cases have been witnessed.
For Prof Ikuerowo, his youngest patient with prostate cancer was a 36-year-old man.
He described it as unusual.
“The youngest I have seen is 36. But it is unusual to have it before the age of 50. If one has a family history of it one may likely have it earlier but just happens in some people,” he explained.
For Ojewola, his youngest patient was a 37-year-old male.
Early detection equals cure
Once detected early, prostate cancer can be treated and cured. However late presentation limits the treatment to management.
The Ikuerowo further noted that in the past years, about 80 to 90 per cent of patients presented late to the hospital.
But this trend has changed, bringing about patients who now present early and can undertake curative treatment.
The doctor attributed this to increased awareness campaigns and advocacies targeted at early testing.
Available curative treatments in Nigeria are surgery or radiotherapy.
Surgery could be “Open or laparoscopic surgery. What we offer in LASUTH is open surgery but laparoscopic surgery is also available in the country. There is the robotic-assisted laparoscopic surgery but it is not available in Nigeria.
“What do we do in surgery? We remove the prostate and the lymph nodes. This is what is done whether you are doing an open, laparoscopic or robotic surgery. So, it’s the same, it’s just the access to doing it that is different.”
An expensive treatment
“When you have prostate cancer, it’s an expensive disease. Whether it is surgery or radiation or hormonal therapy, they are quite expensive,” Ikuerowo said.
As a result, many patients cannot afford their treatment, noted, calling on government intervention in terms of funding or subsidy to reduce the burden of treatment costs.
At LUTH, available treatment options for early detected cases are open surgery and radiotherapy.
Ojewola explained, “For the early disease, it simply means that the prostate cancer has not gone out of the prostate. It is still confined within the prostate. We will have done other tests like Magnetic Resonance Imaging, and CT scan to check the status of other parts of the body and there is a conclusion that it has not affected other parts of the body. That is what we call early cancer of the prostate.
“So what are the treatment options for cure? First is operation. The operation is to remove not only the prostate but also seminal vesicles, which are attached to the prostate. We now reconstruct a way for urine to be coming out of the bladder. That is what we call radical prostatectomy or radical surgery generally.”
Other forms of less invasive and technologically enhanced techniques for radical prostatectomy are laparoscopy and robotics.
The consultant urologist further explained that patients unfit or who reject surgery, have the option of radiotherapy, “which is an artificially generated radiation directed to the site of the cancer to kill the cancer cells.”
For the management of late-detected cases, Ojewola mentioned the use of hormonal therapy, which was to remove or counteract the effect of the male hormones, androgens, feeding the cancer.
However, when initial treatments fail, chemotherapy and other drugs are introduced.
“There are newer drugs now in the market. They are efficacious, but they are quite expensive. You can imagine a tablet costing about N500,000 and having to use it for one year, or 18 months,” the specialist added.
Cost of care
PUNCH Healthwise gathered that the cost of radical surgery in a government hospital costs between N500,000 and N1,000,000. In private facilities, it costs about N3M to N4M.
The average cost for laparoscopic radical prostatectomy, which is only available in two centres in Lagos is about N15 to N18M.
Robotics is not available in Nigeria.
At LUTH, radiotherapy costs about N1.6M and N2M.
Migrating specialists, japa workload
Despite the teeming patients, Ikuerowo stated that many trained specialists at the hospital were migrating, leaving fewer practising specialists to handle the teeming number of patients.
Conversely, Ikuerowo, noted that to further reduce the teeming population at the hospital, the government has transferred some trained consultants to some general hospitals in the state.
One urologist to 800,000 Nigerians
The President of the Nigerian Association of Urological Surgeons, Prof Nuhu Dakum, confirmed to PUNCH Healthwise that there were only 260 urologists registered with the association.
He, however, confirmed that there could be other urologists not registered with the association, who worked in private clinics and centres.
But with Nigeria’s over 230 million population, this implied that one urological surgeon would have to attend to about 800,000 patients; a ratio grossly unmatched to meet the rising needs.
“Assuming a population of 200 million people, it would be 260:200,000,000 = one urologist to 769,230 people,” the president said.
He further confirmed the rise in prostatic diseases, stating that it was due to more awareness of the diseases, improved diagnostic facilities and wider spread of urologists.
“As of the last count, those that are registered with us are about 260 but the number may be higher than that because it’s not everybody that is registered with us, some are practicing in some places and they are yet to register.
“If you look at the population of the country, it’s still not enough. It is still one urologist to millions of people which is grossly inadequate,” Dakum said.
The Japa syndrome, the NAUS president said, has led to many urologists of varying cadres leaving the country, consequently leading to fewer remaining practising urologists.
This situation, the urological surgeon said, has increased the burden on the urologists such that in some clinics, “especially in northern Nigeria sometimes we even have to restrict the number of new and old patients that are booked for us to see because if we allow the records people to book everybody as they may want to, we will be less efficient because we will be overburdened and overstress with a lot of patients and not able to give our best. But I think it’s taking a toll on the remaining urologists in the country.”
