The Current State of Prostate Cancer Treatment in Trinidad and Tobago

The current state of prostate cancer treatment in Trinidad and Tobago

Satyendra Persaud1,2, Maliza Persaud, Lester Goetz1,2 and Dylan Narinesingh3

1Department of Urology, San Fernando General Hospital, San Fernando, Trinidad and Tobago 2Division of Clinical Surgical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago 3National Radiotherapy Centre, Port of Spain

Correspondence to: Satyendra Persaud. E mail: [email protected]

Abstract

Prostate cancer mortality in the Caribbean region is among the highest in the world and prostate cancer is the most common cancer in Trinidad and Tobago. There is a two-tiered healthcare system in Trinidad and Tobago, and prostate cancer related issues account for a significant percentage of urologists’ workload. Delivery of care is sometimes constrained by limited financial resources. Prostate-specific antigen testing is widely available but there is no national guideline. Treatment options available include active surveillance, radical prostatectomy, external beam radiotherapy and brachytherapy. Patients have access to androgen deprivation, chemotherapy and palliative care for the management of advanced disease. Generally, the infrastructure for treatment in Trinidad and Tobago is satisfactory but would benefit from further investments in technology and human resources.

Keywords: prostate cancer, Trinidad and Tobago, Caribbean Review

Published: 24/04/2018 Received: 09/01/2018 ecancer 2018, 12:828 https://doi.org/10.3332/ecancer.2018.828

Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1 300 km the population consists of persons of mixed descent, European, Chinese and Middle Eastern ancestry. Tobago comprises approximately are Indo-Trinidadians whilethesecondlargestgroup, Afro-Trinidadians and Tobagonians, accountforabout36.3%. The remainderof population withthetwodominantgroupsderivingfromSouth Asian and African heritage. Approximately 37.6%ofthecountry’s inhabitants of residents,therewillhopefully training presently standsat1:47000.Withthecontinued ratio ofurologiststomalepatientsinthepopulation is theSFGH.However,of theWestby theUniversity was approved centre, EWMSCinthenorth oftheisland another in2015 Indies. The so far,training. have completed foururologists stages oftraining. at various tenresidents There arepresently centre The primarytraining in Urology.the DoctorofMedicine is awarded the candidate and from the programme graduated urologist trained In2015,thefirst locally long with the first 2 years focusing on coresurgicalrotations. At the end of residency, and followingsuccessfulcompletionof examinations, The Universityof the Westin urology2006. residency trainingprogramme Indiescommencedapost-graduate is 5years The programme and Tobago—three ofwhomaresolelyinprivatepractice in urologists are 14practicing there training, completed recently have who of twourologists sectors. Inclusive public the privateand Trinidad sector,in theprivate solely that areemployed care byurologists urological provide the countryalso in both practice as thosewho aswell regard toprostatecancerscreeningandtreatment.Various of across thegeography distributed facilities thatarewidely privatehealthcare difficultiesservices acrossthecountryhasresultedinsubstantial of urological The skeweddistribution care with optimal health inproviding at theSangreGrandeorPointFortinHospitals. each. urologists two consultant both unitshaving POSGH with at theEWMSCand available also service urological There is noconsistent training facilityandisstaffedSociety ofUrologyapproved certified asanInternational services are byfourconsultanturologists.Urological Ward Urology unitislocatedattheSFGHwhichhouses24-bed largest urological theatres—this hospitalis urology aswelltwodedicated GeneralHospitalislocated in Point FortinHospital.Scarborough Tobago andserves asthemainhealthcarefacilityfor Tobagonians. The are Port of Spain GeneralHospital(POSGH), SFGH, Medical SciencesComplex(EWMSC), Eric Williams Sangre GrandeHospitaland goals andtargetsset by theMinistrybasedonanassessmentof health needsof each region. The mainhospitalson theislandof Trinidad healthauthorities (RHAs).ResourcesareallocatedbytheMinistryto these RHAsto as regional finance theiroperationsto labelled meet entities thatare separate into several it hasdevolved public, care forthegeneral of freehealth for theprovision responsible is ultimately in system inplace There isatwo-tieredhealthcare Trinidadand Tobago—publicof Health Ministry the government–run While private. and Human resourcesandprostatecancertreatment lation countofjustover1.3millionspreadthecountry’s 5,128km north-eastern coastofVenezuela. The mostrecentdecennialPopulationandHousingCensusconductedin2011 documentedapopu- Trinidad and Tobago, a twin island English speaking republic, are the southernmost islands of the Caribbean, located about 11 km off the Introduction screening, treatmentandoutcomesin Trinidad and Tobago. and radiationoncologists,palliativecarephysicians. The followingarticledetailsthecurrentsituationwithregardto prostate cancer Prostate cancer managementrequiresa effortmultimodal approachandinvolvesthe collaborative of medical our urologists,pathologists, to havepoorlydifferentiated tumours,highPSA valuesandD’Amicohigh-riskcancers among prostate cancerwasthreetimesascommon Afro-Trinidadiansto Indo-Trinidadians.compared Afro-Trinidadiansmore likely were (SFGH) reportedthat risk ofmortality[3].RecentworkattheSanFernandoGeneralHospital andultimatelyanincreased gen (PSA)values among five timesascommon almost Afro-Trinidadians.In thisstudy, Afro-Trinidadiansanti- scores, prostate-specific Gleason higher had disparity inprostatecancer of aracial evidence There isestablished Trinidadand Tobago.found thatprostatecancerwas Mungrue Cancer Registry].Mortalityfromprostatecancerhasbeenpreviouslydescribedasamongthehighestinworld and accountedfor39%ofallcancerrelatedmortalityamongmen[Data–National 2000–2002 for theperiod was documented 60.4/100,000 of allcancersinthecountry,as thecommonestcancerinmen. as well makingthisthecommonestcanceroverall rate of An incidence Registryof According todatafromtheElizabethQuaminaNationalCancer Trinidadand Tobago, prostatecanceraccountedfor22% 2 or6%ofthesurfaceareacountryandisuniqueinthat95%populationare African descent[1]. 2 www.ecancer.org 2

[1]. Trinidad and Tobago iswellknownforitsethnicallydiverse [4]. ecancer [2] 2018,12:828

Review intensity focusedultrasound,radiofrequencyablationandcryotherapy arenotavailablein Trinidad and Tobago. in practiced widely and all available radiation—are beam and external tate radiation/brachytherapy Trinidadand Tobago. At present,high prostatectomy,radical surveillance, prostate cancer—active for localised treatment modalities recommended The standard interstitialpros- Treatment oforganconfinedprostatecancerin Trinidad and Tobago The contributionofthelateDr Alan Patricktothis projectcannotbeoverstated. RANSELand such astheELAC2 influences of genetic the role and with lycopene virus 8, chemoprevention of humanherpes genes[10]. Tobagothe role aspects ofprostatecancer including genetic and metabolic several investigated Studyhasalso Screening Prostate Cancer in of prostatecancer The incidence Tobagothan thatamong to behigher estimated has been African or Caucasians Americans prostate cancerscreeningstudy in Tobago [10, 11]. The prevalence of prostate cancerwas10%amongthe 2484 menscreened[12]. a needsassessmentin1995,the Following Tobagoa with theUniversityofPittsburghestablished Health ServicesUnitincollaboration screening inthiscountryisprimarilyculturalbeliefandnotnecessarilyalackofknowledge to theassumptionthatmajorbarrierprostatecancer leading and an‘assaultonmanhood’, with homosexuality around itsassociation with prostatecancer[9].SpecificDRErelatedconcernsrevolved of beingdiagnosed about theDREandnegativeimplications hension to utilise theseservices,citingappre at older ages[9].Despitethis,menwereunwilling the needforprostatecancerscreening,especially A yearsin 19–60 aged of males groups sociodemographic studyofvarious Trinidadand Tobagothat avastmajoritywereawareof revealed as welltemplatebiopsiesarenotpresentlycarriedoutin Trinidad and Tobago. the biopsytechniqueandourdetectionrates. Toof anykind (MRI)-guided biopsies imaging thebestofourknowledge,magneticresonance However,machine. ultrasound improved has significantly which the standard, are currently biopsies guided ultrasound transrectal 12-core and POSGHaswellmostmajorprivateinstitutions.Initially, ofan were doneintheabsence prostate biopsies guided single coredigitally PSAin testingiswidelyavailable Trinidadand Tobago servicesmaybeaccessedviathethreemajorcentres—SFGH,EWMSC and biopsy history,family and on ethnicity risk based high PSAserum and DRE annual an tohave encouraged being years. of 45–50 by theage done exists for No formalscreeningrecommendation Trinidad and Tobago. Screeningprotocolsaresimilarin Trinidad and Tobago, with men at screening intheregion urologists supportPSAand mostCaribbean population in aCaribbean been concernsovertheexternalvalidityoftheserecommendations sentation of blacks in thesestudies as wellthe well describedheightenedriskof prostate cancerinmalesof African heritage,therehave discussion on patient–clinician based 55–69 among menaged approach an individualised noting thattheharmsoutweighbenefits[6]. cancer screening, They haverecentlysoftenedtheirstanceonscreening,recommending PSAmissed byutilising potentially alone (DRE) andPSArectal examination cancers maybe significant of clinically by manyexpertssinceaproportion testingisrecommended of digital by acombination States [5].Screening in theUnited stage overthepasttwodecades of prostatecancer migration tial downward remains atopicforhotdebate,thereisnodoubtthatPSAEven thoughtheprostatecancerscreening has resultedinasubstan- screening Screening andprostatecancerinTrinidad andTobago no trainedclinicalnursespecialistsoradvancednursingpractitionerstothebestofauthors’ knowledge. is staffedunit each for patients,while services support In termsofnursing currently there are nurses, urology to dedicated amounts bywhat President. The secretariatoftheCaribbeanUrological Association isbasedattheSFGHin Trinidad. Urological Association wasformed. Dr LesterGoetz was electedas its first President andDrHopeRussell(Jamaica)wasits first Vice President andViceinaugural President,respectively.to this,on17 Subsequent hotel in April 1999attheCascadia Trinidad, theCaribbean The Trinidad and Tobago Urological was createdonthe13February1998withDr.Association LesterGoetzandDrHassanKhanthe resultant improvementinthemanagementoflargenumbersprostatecancerpatients. be anincreasein the number of urology careproviderswitha dissemination of more homogeneous servicesthroughoutthe country anda [8]. [5]. The UnitedStatesPreventativeServices Taskforceagainst prostate issuedarecommendation 3 www.ecancer.org [7]. However, repre- the disproportionate given [9]. ecancer 2018,12:828 [10]. The -

Review safe optionforourpatientsbutfurtherstudyisneeded. was notedinonepatient with threereportsstilloutstanding[16]. upgrading These findingshavehintedthat may be a active surveillance practice. consultants Twenty-fourbiopsy—pathological repeated had 12 have of whom and 2 yearsoffollow-up completed have patients the treatingurologist. At the SFGH, is offeredactive surveillance to our lowriskpatientsandasmallstudyof patients enrolledinasingle [15]. is anoptionto patients throughoutthecountryalthoughthereisnouniformityandprotocolsareat Active surveillance the judgmentof to menof surveillance men is asafeoption forourCaribbean whether activesurveillance African descentanditisthereforestillunclear cancersandwithit the adverseeffectsinsignificant clinically of prostate cancertreatment. of active There is concernabouttheapplication cores positive with ≤50% of core involvement and PSA density ≤ 0.15ng/mL. The aim of active surveillance is to avoid the overtreatment of patients should be classified as low-risk, low-volume prostate cancer with clinical stage of T1- T2a, PSA ≤ 10 ng/dL, Gleason score ≤ 6, <3 for Active surveillance prostate canceris practised in Trinidad andpatientsaregenerallyselectedbasedonEpstein'scriteria[4].These Active surveillance of patientsbetween2002and2009showedthat80%weretreatedwithhormonaltherapy. world to thedeveloped compared disease with advanced men presenting proportion of The high men beingtreatedprimarilywithhormonaltherapyisnot surprising giventherelativelyhighnumberof Trinidadian prostatectomy,treated withradical brachytherapy, externalbeamradiotherapy,respectively [13]. therapy andactivesurveillance, hormonal A review of database of the uro-oncology the SFGH revealed that from 2010 to 2017, 5.1%, 1.9%, 34.7%, 48.2%and10%of men were having grades1and2urinarydysfunction(personalcommunication). with thosereportedinthe literaturewith24%ofpatients rates havebeeninkeeping relapse. Complication were twocasesofbiochemical on hold. patient wastreatedin2001 and241patientsweretreatedbetween20072012.Inthisseries,there The firstbrachytherapy Patients in Trinidad and Tobagopartnership althoughthelatteriscurrently accessbrachytherapyeitherprivatelyorthrough a public–private Gy.is 145 prescribed the dose and utilised is thesource (I 125) 125 Iodine implant. seed treatment withapermanent as themonotherapy in of prostatecancerwithbrachytherapy Trinidadand Tobagoto patientswithlow-riskprostatecancer. isavailable Brachytherapyisused guidance seeds intotheprostateandisdoneunderX-rayultrasound Brachytherapy involvestheinsertionofradioactive Brachytherapy tomy isunavailablein Trinidad and Tobago. dure hasnevercaughtonlikelydueto the prolonged learningcurve required to achieve competenceinthe procedure. Roboticprostatec- radical prostatectomiesweredemonstratedto Although laparoscopic urologists at the SFGH via severalmentoredworkshops,the proce- leagues inJamaicawhichdemonstrateda5-yearbiochemicalfreesurvivalof78.4% at ratesof70%and12%,respectively.were documented incontinence These dataarecomparedtotheworkdonebyMorrisonandcol- persistent and dysfunction erectile onset of new complications months. Postoperative of 41 failure time tobiochemical mean and of 70% recurrence-free survival reported figures,witha5-year biochemical outcomeswere [18]. comparable withotherinternationally Oncological patient ageof67years reported anaverage prostatectomy overa12-yearperiod the outcomesofradical Data fromtheSFGHreviewing are notcurrentlyregulated. with Tobago. Radicalprostatectomiesarecarriedoutat several privateinstitutions. as The fee structures cost is stillprovider-dependent in Hospital Tobago.In thecaseof Tobago,by a areperformed prostatectomies radical Trinidadianarrangement has avisiting who urologist dates by Walshretropubic prostatectomyasdescribed Open nervesparingradical in 1980s, isoffered andcolleagues candi surgical toeligible Radical prostatectomy [17]. Currently, isoffered theprocedure General as theScarborough (SFGH, EWMSC,POSGH)aswell atthethreemajorhospitals 4 www.ecancer.org [4]. This trendis,however,review as asimilar slowly changing [19]. ecancer 2018,12:828 [5]. Treatment -

Review A combinationofotherdrugsistriedonprogressionincludingketoconazoleanddiethylstilbestrol. this drugmustdosobytheirownpurchase. but ispresentlynotfundedbytheministryofhealthandthereforepatientsrequiring available in Hospital as theScarborough as well Centre Radiotherapy National Hospital, Grande Sangre Hospital, Fernando Tobago. is Abiraterone Patients withcastrateresistanceareusuallyofferedcan beaccessed attheSan progression. Chemotherapy docetaxelonbiochemical Castrate resistantandmetastaticdisease is offered onprogression.Similarly, goserelinisavailableinthepublicsectorfreeofcharge. Trinidadand Tobagoblockade androgen Combined anaesthesia. under local procedure as aday-case orchidectomy carryoutsubcapsular In the palliative settingandrogendeprivationmay be achievedby an LHRHagonistor by an orchidectomy. All major publichospitalsin above. as outlined agonist, e.g.,goserelin by aLHRH achieved is almostuniversally deprivation androgen tive treatmentwithradiation, setting. Inthedefini or inthepalliative treatment with radiation as partofdefinitive in twosettingseither may beused deprivation Androgen launched intheisland2013butisnotcurrentlywidespreaduse. bicalutamide andcyproteroneacetate. the goserelinalongwiththe LHRH antiandrogens analogue was The LHRH antagonistdegarelix castration for chemical many menhaveopted today. therapy deprivation role ofintermittentandrogen impact oforchidectomy aswelltheemerging Given thepotentialpsychological and isstillwidelyperformed deprivation method ofandrogen orchidectomy wastheoriginal Surgical castrationintheformof bilateral Androgen deprivation Treatment ofadvancedprostatecancer for CancerControl of diagnosis prostatecancerto the first fraction of radiotherapy, a far cry Strategy from the recommended4-weekinterval bytheCanadian for prostatecancer.not only country and study,Canadian Inone from thebiopsy days wasreported of 127 treatment interval amedian weeks. is about6–8 across the patients cancer by all are utilised that thesefacilities considering period short waiting This isarelatively The average wait-timefor patients from the processing of by the applications Ministry of Health to the first scheduled radiotherapysession form oftheluteinizinghormonereleasing(LHRH)agonistGoserelin. at leastatotalof3yearsdeprivation. risk patientsreceiving treatment withhigh adjuvant in the is almostalways deprivation Androgen hormonal therapyalongwithconcurrent and Patients withintermediateandhigh-riskprostatecancersreceivebyprotocol,neoadjuvant prostate dosetakentoatleast74Gy. Traditionally, patientswithintermediateandhigh-riskprostatecancerhavetheregionalnodestreated. prostate cancer requiring definitive radiation in Trinidad and Tobago will receive treatment with an IMRT technique (or more complex) with the of Healthprogrammewherethefullcosttreatmentisbornebygovernment. Therefore, 100%ofpatientsfrom2009topresentwith complications (personal communication). Patients requiring treatment at either of these centres may do so privately or through the Ministry patients havebiochemicalrelapseandtherewere2.1%caseswithgrade2–4genitourinary2.8%gastrointestinal and patients at BLCTC are treated with IMRT. Of the 94 patients referred to the SMC for treatment between the periods 2010–2012, four Patients at SMC are treated either with volumetric modulated arc therapy or intensity modulated radiotherapy technique (IMRT) techniques Medical Clinic (SMC) and one is at the Brian Lara Cancer Treatment Centre (BLCTC) in the south and north of the island, respectively. Patients requiring definitive radiotherapy are treated on one of three linear accelerators (linacs) in the island. Two linacs are at the Southern both asprimarytherapyandsalvagefollowingradicalprostatectomy. Palliativeradiotherapyisalsowidelyutilisedanddiscussedbelow. In Trinidad and Tobago externalbeamradiation isthemostcommonmodalityusedintreatmentofprostatecancer. Radiotherapyisused External beamradiation [20]. [21]. in deprivation for androgen used The mostcommonagents Trinidadand Tobagoare 5 www.ecancer.org ecancer 2018,12:828 -

Review References room forimprovement. vider ratioandleadtomoreuniformaccesscare.Whileallmenhavetreatmentwithcurativeintent,there remainssignificant ers haveyet training at to the Universityof be adoptedonanysignificantscale.Urological the West Indies shouldimprovepatient to pro- such astheuseofMRIornewerbiomark in diagnosis on screening.Morerecentdevelopments policy orcoordination there isnonational in concern health a significant public remains Prostate cancer Trinidadand Tobago.screening, access toPSA-based have patients While Conclusion treatment forpalliativecaseswas3hoursin2015. the publicservicewithacobaltmachine. Centre (publichospital)revealedtheaverage timeto An auditdoneat the NationalRadiotherapy is efficiently orin accelerator with alinear privately are treatedeither therapy palliative Patients requiring by theoncologists. coordinated at all majorhospitals andemergencyradiotherapy In servicesareavailable the caseof malignant spinalcordobstruction,neurosurgical primarily radiologistled. prostate cancer. Currently, this service is offered on a regular basisat the SFGH and ona very limited basisat the EWMSC where it is ureteric obstructioninadvanced in thecaseofmalignant SFGH acquired theskillstoprovidenephrostomytubesforurinarydiversion atthe urologists and inthefaceofgreatneedforprocedure, radiology of interventional Because ofinconsistencyintheavailability at their16-bedfacilitywhichwasopenedin1983.OperatedbytheCatholiccommunity, thisfacilityisheavilydependenton volunteers. of thefacilitiesatCaura andVitasteers. Priortothecommissioning Water House,theLiving offered Hospice ill patients careforterminally of 6monthsorlessandisstaffedpatients withalifeexpectancy staffwith administrative nurse along bytwodoctorsandone volun and care clinic.Vitaspalliative as anout-patient beds aswell and alsohas12in-patient in 2008 in StJameswasopened House accepts House offersand in 2014 was opened facility which is a12-bed Unit inCaura Care The Palliative basis. Vitas treatmentonaninandout-patient 1 yearfollowingtheintroductionofapalliativecareservice. care unitsintheisland. begun toservicethepalliative from 85%to20%in The admissionrateforendoflifeeventsattheSFGH dropped Medicine. Palliative in programme The UniversityoftheWest have from thisprogramme The graduates started aMaster’s 2013 in Indies care. support forpalliative and technical careasahumanright.Sincethen,theMinistryofHealthhasworkedtoregulatory ing palliative services. clinics orcommunitypalliative The Trinidad and Tobago government in2014signedonto the UnitedNationsresolutionrecognis and oneisrunbythestate. organizations two arerunbynon-governmental outpatient All majorpublichospitalshaveassociatedpalliative Palliative carein Trinidad and Tobago canbeaccessedbyallnationals free of charge. There arethreehospicesin Trinidad and Tobago, Palliative care the scansdoneintheseprivatefacilities. Technetiumsector.in theprivate is available scintigraphy bone tohave by theMinistryofHealth scans arefunded Publicpatientsrequiring

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