With increasing trends of prostate cancer in the Saudi Arabia and Arab World: Should we start screening programs?

Abstract

Incidence rate for prostate cancer in the Arab World is significantly lower than United States and Europe, it ranges from 5.5% to 39.2%. However, the incidence and the number of deaths is expected to increase. In Saudi Arabia, the crude incidence rate and age standardized incidence rate of prostate cancer are reported to be steadily increasing in between 2001-2008. Only two screening trials were attempted in 2001 and 2009 which yielded an incidence rate of 1.17% and 2.5% respectively. Men in the Arab world are sharing a common characteristic of poor knowledge and poor attitude towards prostate cancer examination and screening practices. They are ill-informed about the PSA test’s strengths and drawbacks because the doctors are not talking to them about the importance of counselling. Men should be encouraged to do PSA testing before the age of 50 and till the age of 70 years. This could be achieved by enhancing their attitude and enriching the knowledge of the physicians towards PSA testing, harms and benefits, through shared decision making, which would increase men’s knowledge scores, reduced their decisional conflict and promote greater involvement in decision making.

Key Words: Prostate cancer; Incidence; Arab World; Screening

Core tip: Despite the very low incidence and the number of deaths from prostate cancer in the Arab World, it is expected to increase. In Saudi Arabia, the crude incidence rate and age standardized incidence rate of prostate cancer are reported to be steadily increasing in between 2001-2008. Men in the Arab world are characterized by poor knowledge and poor attitude towards prostate cancer examination and screening practices. We recommend against mass screening, but men should be encouraged to do PSA testing before the age of 50 and till the age of 70 years, through shared decision making.

INTRODUCTION

Prostate cancer is representing a major public health problem in the developed world, the figures reported from Europe and United States indicated a higher age standardized incidence rate (ASIR) and mortality rate. The incidence varies more than 25-fold worldwide, where the rates are higher in Northern American, Australia, and northern Europe, because of the practice of PSA testing and biopsy which has become widespread in those areas. The reported mortality rates paralleled the incidence rates, with a considerable decrease in most of the countries except Eastern Europe[1,2].

The corresponding reported figures from the Arab World is much and significantly lower. The ASIR rate ranged from 39.2% in Lebanon to 5.5% in Saudi Arabia, while the data on mortality rates are not available[3] (Figure 1).

Figure 1 Age standardized incidence rate (%) of prostate cancer in the Arab World during the period 2010-2014.

Access to the health care and accuracy of the cancer registries in the Middle East is affecting the ASIR of prostate cancer reported from such countries. However, GLOBOCAN, 2012 reported that prostate cancer incidence in the Middle East North Africa (MENA) region is expected to increase from 29377 new cases in 2012 to 38562 new prostate cancer cases in 2020 along with an increase in mortality from prostate cancer from 15422 prostate cancer deaths in 2012 to 19681 deaths in 2020[1]. In Saudi Arabia, the crude incidence rate and ASIR of prostate cancer are reported to be steadily increasing in between 2001-2008 and then after[4].

No screening programs were adopted in the Arab world except for breast cancer. The first screening trial for prostate cancer was attempted in Saudi Arabia in 2001 and yielded an incidence of 1.17%[5]. Nine years later Rabah reported an incidence of 2.5%, in a larger sample and in a different health facility, amongst the studied cohort; and 27% were metastatic[6]. In Saudi Arabia, Many confirmed cases of prostate cancer were diagnosed before the age of 50, in addition, the distribution of the PSA levels among the Saudi men was lower than other European countries[7].

The men in the Arab world are sharing a common characteristic of poor knowledge and poor attitude towards prostate cancer examination and screening practices[8]. Such poor behavior towards their health could be ascribed to their level of awareness, or different barriers which may prevent them from seeking early detection and diagnosis of prostate cancer, i.e., mistrust of physicians, fear of diagnosis, fear of testing procedures, DRE threatens sexuality and others[9].

The men in the Arab world remain ill-informed about the PSA test’s strengths and drawbacks because the doctors are not talking to them about the importance of counseling. The results of a survey on the primary health care physicians in Saudi Arabia about their knowledge and behavior on prostate cancer counseling and screening indicated that nearly 55% were practicing counseling and they had a poor attitude and deficient knowledge towards counseling and referring patients[10]. The decision to provide screening would be influenced by factors related to the physicians, patients and screening guideline. Physicians who have good scientific evidence are more likely to practice informed decision making with their patients as they believe that men need to know about the Pros and Cons of PSA testing to make their decisions[10].

A recent review concluded that the evidence does not indicate that the benefits of using PSA for prostate cancer screening outweigh the harms[11]. In the same context, in our Arab countries, the incidence of prostate cancer is still low, but the trend is increasing in the last few years, however, we recommend against mass screening, but encourage men to do PSA testing before the age of 50 and till the age of 70 years. This could be achieved by enhancing their attitude and enriching the knowledge of physicians towards PSA testing, harms and benefits, through shared decision making, which would increase men’s knowledge scores, reduced their decisional conflict and promote greater involvement in decision making.