SCIENTIFIC ARTICLE

With the rising trend of prostate cancer, where does northern Sri Lanka stand?
a cohort study from a tertiary care centre.
B. Balagobi1, S. Gobinath2, C. Rajasooriyar2, A. Jenil2, J.M.M. Theepan1, T. Gowribahan2, P. Shathana2,
1
S. Abirame
1
University of Jaffna, Sri Lanka
2
Teaching Hospital Jaffna, Sri Lanka,
Keywords: prostatic carcinoma, high risk, polymetastatic programmes with PSA in near future to detect cancer at early
disease, androgen deprivation therapy stages, implementation of cancer awareness programmes as
practised in Western countries and strict adherence to national
Abstract guidelines on management and referral pathways
Introduction
Prostate cancer is the second most common cancer among Introduction
males all over the world in 2020. As per the global cancer Prostate cancer is the second most common cancer among
observatory 1, 414, 259 (7.3%) cases were diagnosed in 2020 males and the fourth most common cancer all over the world
worldwide. The study aims to analyse the variations in in 2020. As per the global cancer observatory 1, 414, 259
demographic and clinico-pathological characteristics of (7.3%) cases were diagnosed in 2020 worldwide. It is the fifth
prostate cancer in the Northern Province. most common cancer among males in Sri Lanka with an
incidence of 896 (6.3%) in 2020. 364 deaths have been
Methods reported due to prostate cancer in 2020 in Sri Lanka [1].
This is a cross-sectional descriptive institution-based study
that recruited all the prostate cancer patients who were treated There is a geographical variation in the incidence and
at the Teaching hospital, Jaffna from August 2019 to August prevalence of prostate cancer worldwide. It is said that the
2022. Data were extracted retrospectively from the clinic incidence is higher among African American men and their
records of the patients as well as histopathology documents. mortality is nearly double than of white men [2]. As per the
GLOBOCAN estimate the highest incidence of prostate
Results cancer is in Europe followed by Asia and the mortality is
A total of 141 diagnosed patients at Teaching Hospital Jaffna highest in Asia leaving Europe in second place [1,3].
were analysed. The mean age of the sample was 70.11± 8.43
years. Out of 141 patients, 30.49% were diagnosed to have Over the last three decades, there is a dramatic increase in the
localized disease and 26.24% and 43.26% with locally incidence of prostate cancer due to increased detection by
advanced and metastatic disease respectively. Out of those means of serum prostate specific antigen (PSA) testing and
who had localized disease 68.5% were managed with the incidental detection from the specimens of transurethral
radiotherapy, 23.25% with active surveillance and 11.6% resection of prostate (TURP) specimens as a treatment of
with radical prostatectomy. The mean value of PSA was symptomatic enlarged prostates, increased awareness of
70.11±8.4. The majority 97.2% had small acinar adeno prostate cancer among public and also due to increase in the
carcinoma as histology. As per the D'Amico classification elderly population [4]. Development of prostate cancer has a
system for prostate cancer, 2.83% belonged to low-risk multifactorial aetiology. They are age, ethnicity, family
category, 80.1% belonged to high-risk category. history, environmental factors, obesity and dietary factors [4].
Prostate cancer is more common in those above 75 and less
Conclusion likely in those less than 40. The age coincides with the years at
which the androgen/ oestrogen level reverses. It is said that
There is a rising trend in the incidence of prostate cancer in Sri
Afro-Caribbean men are at greatest risk of prostate cancer
Lanka over the recent past. Most of the cases are advanced at
than Caucasian men and Japanese men have the least risk than
the initial presentation. It implies the need for screening
others. Anyhow Japanese men living in other parts of the
Correspondence: B. Balagobi world have an increased risk which shows a strong geographic
E-mail: b.balagobi@yahoo.com and environmental influence on the development of prostate
https://orcid.org/0000-0001-7632-9644 cancer [4-6].
Received: 21-04-2023 Accepted: 29-07-2023
DOI: http://doi.org/10.4038/sljs.v41i2.9056
The Sri Lanka Journal of Surgery 2023; 41(2): 21 - 25 21
The objective of this study is to analyse the variations in Results
demographic and clinico-pathological characteristics of A total of 141 diagnosed patients at Teaching Hospital Jaffna
prostate cancer in the Northern Province. were analysed. The mean age of the sample was 70.11± 8.43
years. Out of 141 patients, 43 (30.49%) were diagnosed to
Methodology have localized disease and 37 (26.24%) and 61(43.26%) with
This is a cross-sectional descriptive institution-based study. locally advanced and metastatic disease respectively. Among
The study population was all the prostate cancer patients who those with localized disease, 4 had T1 and 39 had T2 stage, in
were treated at the Teaching hospital, Jaffna. The study period those with locally advanced disease 18 had T3 and 19 had T4
was from August 2019 to August 2022. The sample size was and in those with metastatic disease 8 had T3 and 53 had T4
all the patients who were diagnosed and treated for prostate stage on Digital Rectal Examination (DRE) (Table 1)
cancer during the study period. Data were extracted
retrospectively from the clinic records of the patients as well The mean value of PSA was 70.11±8.4. 38 (26.9%) patients
as histopathology documents. A data extraction sheet was had a PSA value of more than 100, 44 (31.2%) ranging
used to collect socio-demographic details and clinical details between 51 and 100, 36 (25.53%) between 11 to 50 and
at initial presentation, imaging data and histopathological 23(16.1%) less than 10.
data during clinical reviews. The data were analysed using the
Pearson chi-square test, and graphical illustrations.

Figure 1. Age distribution of patients.

Figure 2. Distribution of PSA value among

the localized, locally advanced and
metastatic patients

The Sri Lanka Journal of Surgery 2023; 41(2): 21 - 25 22

Table 1: Distribution of clinical T staging with the localize, locally advanced and metastatic patients.

Clinical Stage Total

T Stage Localize Locally advanced Metastatic

T1 4(2.8%) 0 0 4(2.8%)
T2 39(27.7%) 0 0 39(27.7)
T3 0 18(12.8%) 8(5.8%) 26(18.4%)
T4 0 19(13.5%) 53(37.6%) 72(51.0%)
Total 43(30.5%) 37(26.2%) 61(43.3%) 141(100%)

Out of the 38 patients who had a PSA of more than 100, 33 Out of those who had localized disease 28 (68.5%) were
were diagnosed to have metastatic disease, 4 had locally managed with radiotherapy, 10 (23.25%) with active
advanced and one had localized prostate cancer. Among those surveillance and 5 (11.6%) with radical prostatectomy.
who had a PSA value ranging between 51 and 100, 17 had Patients with locally advanced disease were offered androgen
metastatic disease and 15 and 12 had locally advanced and deprivation therapy followed by radiotherapy. Among the 61
localized disease respectively. Of those who had a PSA value with metastatic disease, 50 had poly metastatic disease and 11
ranging between 11 and 50, 9 had metastatic disease, 11 and had oligometastasis. Nine (6.1%) had metastasis to the para
16 had locally advanced and localized disease respectively. aortic lymph nodes (M1a), 42 (29.6%) had metastasis to
Of those who had a PSA less than 10, 2 had metastatic disease, bones only (M1b) and 8 (5.6%) had metastasis to distant
7 and 14 had locally advanced and localized disease organs with or without involvement of bones (M1c).
respectively. Among the 141 patients 27 (19.15%), 15 Polymetastatic disease were managed with Androgen
(10.64%), 29 (20.57%), 44 (31.21%) and 26 (18.44%) had an Deprivation Therapy (ADT) alone or ADT followed by
ISUP grade group of 1,2,3,4 and 5 respectively. 19 (73%) systemic chemotherapy depending on the performance score
patients who had an ISUP grade group of 5 had metastatic of the patients. Oligometastatic disease were treated with
disease. 25 (56.8%) patients who had an ISUP grade group of ADT followed by radiotherapy to the prostate gland in
4 was found to have localized disease. 19 (65.5%) patients selected patient.
who had an ISUP grade group of 3 had metastatic disease. 9
(60%) patients with ISUP grade group of 2 had metastatic The majority 139 (97.2%) had small acinar adeno carcinoma
disease. as histology whereas 2 (2.8%) had ductal adenocarcinoma.

As per the D'Amico classification system for prostate cancer,

2.83% (n=4) belonged to low risk category, none in the
intermediate category and 80.1% (n=113) belonged to high
risk category (Table 2).

Table 2: The D' Amico classification system of prostate cancer

Risk category Localize Locally advanced Metastatic
Low risk 4 (2.83%)
Intermediate Risk 0
High Risk 15 (10.6%) 37 (26.2%) 61 (43.3%)

The Sri Lanka Journal of Surgery 2023; 41(2): 21 - 25 23

Discussion
The incidence of prostate cancer in the Asian population In countries where routine PSA screening is practised, more
seems to be much lower than in the Western population. than 90 per cent of prostate cancers are detected as localized
Anyhow with the increase in the aging population, increase in disease and only 4 per cent of prostate cancers present with
PSA screening and disease awareness, increase in imaging metastasis[11]. In India where routine screening with PSA is
modalities and incidentalomas and the westernization of not practised, the majority of patients present in advanced
Asians results in the progressively rising incidence of prostate stages [12]. Similarly in Sri Lanka, we see a majority of cases
cancer in recent years [7]. A review by Ha Chung et al. showed with an advanced disease which might be due to the absence
a general increase in prostate cancer incidence across China, of screening programmes. In this analysis more than two third
India, South Korea, Vietnam, Japan, and Singapore [8]. of our patients presented with advanced disease, 61 (43.3%)
with metastatic disease and 37 (26.2%) with locally advanced
Sri Lanka also shows a rising incidence of prostate cancer in disease. Out of the patients with localized and locally
recent years. The crude incidence rate of prostate cancer in Sri advanced disease, a majority (n=52) belong to D' Amico high-
Lanka was 3.1 per 100 000 population in 2005, while it was risk category.
9.5 per 100 000 population in 2019, thus it shows a three-fold
increase over the last 14 years[3]. A similar incidence can be Recent guidelines by the national cancer control programme
noticed in India, which was 9.47/100000 population [1]. 141 of the Ministry of Health, Sri Lanka recommends
patients diagnosed over the last three years in a tertiary care opportunistic screening with PSA for those with LUTS
hospital in Northern province is indeed a big number. A having clinically malignant or suspicious prostate gland on
similar trend has also been noted in a tertiary care hospital in digital rectal examination or benign prostate on digital rectal
the south of Srilanka, with 386 cases over 5 years [9]. examination but age below 70 years [13]. The true incidence
of prostate cancer in Sri Lanka is underestimated in most
Prostate cancer is the most common malignancy among older instances due to a lack of proper referral pathways and it is
men. 64% of new prostate cancer cases in the United States being managed by non-urological surgeons as well.
were diagnosed in men older than age 65 years, and 23% in
men older than age 75 years [10]. In a recent Sri Lankan study Conclusion
based on national cancer registry, the age at diagnosis was 65 There is a rising trend in the incidence of prostate cancer in Sri
years and above in almost 76.8% of cases and the highest Lanka over the recent past. Most of the cases are advanced at
number of cases was seen in the age group of ≥75 years. In this the initial presentation. It implies the need for implementation
study, the mean age at diagnosis is 70.11+± 8.43 years. It of screening programmes with PSA in near future to detect
seems patients from the northern part of Sri Lanka develop the cancer at early stages, implementation of cancer awareness
disease fairly at a younger age compared to the other parts of programmes as practised in Western countries and strict
Sri Lanka. Of the patients metastatic disease, the majority of adherence to national guidelines on management and referral
them belongs to an age group of 63 to 75 years (57.3%, n=35) pathways.
and the majority of patients with locally advanced disease
belongs to an age group of 63 to 75 years (56.7%, n=29).
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