CAPITULO 3: TALENTO MATEMATICO
3.5 Análisis de estudios empíricos en la identificación y tratamiento de los
3.5.1 Talento matemático y su relación con la creatividad, inteligencia y
8-hourly and capsules of piroxicam 20mg daily for 5 days. Each patient was also placed on oral metronidazole 400mg 8-hourly and ciproxin 500mg 12-hourly both for 5 days. The specimen was labelled and sent to the histopathologist with request for histology. Patients were monitored for possible complications of needle biopsy.
A stage was given to each tumour as much as possible, based on the Whitmore Jewett system.
CHAPTER FOUR 4.0 RESULTS
One hundred and fifty four (154) patients were evaluated in this study. Six patients (4 from University of Port Harcourt Teaching Hospital UPTH and 2 from Nnamdi Azikiwe University Teaching Hospital NAUTH, Nnewi) did not have histological confirmation of diagnosis and were excluded from analysis. One hundred and forty-eight (148) patients analyzed comprised 78 from UPTH and 70 from NAUTH. In Port Harcourt patients were from 13 different ethnic groups. In Nnewi all patients were Ibos. (Table 4.1)
TABLE 4.1 DISTRIBUTION OF ETHNIC GROUPS OF PATIENTS WITH ADENOCARCINOMA OF THE PROSTATE IN PORT HARCOURT (PHC) AND NNEWI (NWI).
ETHNIC
GROUP PHC NWI
NO % NO %
Ikwerre 22 28.2
Ibo 15 19.2 70 100
Kalabari 13 16.7
Bayelsa Ijaw 6 7.6
Okrika 6 7.6
Ogoni 5 6.4
Etche 2 2.6
Ndoki 2 2.6
Ibibio 2 2.6
Delta State Ijaw 2 2.6
Urhobo 1 1.3
Efik 1 1.3
Opobo 1 1.3
TOTAL 78 100.0 70 100.0
The three most commonly affected ethnic groups were Ikwerre with 22 (28.2%) patients, Ibos 15 (19.2%) and Kalabari 13 (16.7%).
The age distribution of the patients were as follows (Table 4.2) TABLE 4.2 AGE DISTRIBUTION OF PATIENTS WITH ADENOCARCINOMA OF THE PROSTATE IN PORT HARCOURT (PHC) AND NNEWI (NWI).
ETHNIC
GROUP PHC NWI P
NO % NO %
30 – 39 - - - -
40 – 49 1 1.4
50 – 59 14 17.9 10 14.3 > 0.50
60 – 69 30 38.5 10 14.3 < 0.01
70 – 79 24 30.8 36 51.4 < 0.05
80 – 89 10 12.8 13 18.6 < 0.50
90 – 99 - - - -
100 - Above - - - -
TOTAL 78 100.0 70 100.0
In Port Harcourt the youngest patient was 50 years old and the oldest was aged 89 years. The peak incidence 30 (38.5%) was in the 7th decade. Thirty-four (43.6%) patients were aged 70 – 89 years. In Nnewi on the other hand, the youngest patient was aged 49 years, the oldest also 89 years, but peak incidence was in the 8th decade with 36 (51.4%) patients. Forty-nine (70%) patients were aged 70 – 89 years. The mean age of Nnewi patients was 72.0 years (SD = 9.3 years). Of the most commonly affected ethnic groups in Port Harcourt the mean age of Ibos was 73.8 years (SD = 8.8 years), Ikwerres 69.8 years (SD = 7.7 years), and Kalabari 65.6 years (SD = 9.3 years). The mean age of all patients from Kalabari, Okrika, Bayelsa Ijaw, and Ogoni combined was 66.0 years (SD = 6.9 years). The differences
between the mean ages of patients who were Ibos in Port Harcourt, Nnewi Ibos and Ikwerres were not statistically significant. However, there was statistically significant difference between the mean age of Nnewi patients and the mean age of patients from Kalabari, Okrika, Bayelsa Ijaw, and Ogoni put together. (P < 0.05, confidence interval = 95%).
The age distribution of patients of six most commonly affected ethnic groups in Port Harcourt were analyzed. Results were expressed graphically (Figure 4.1).
In Port Harcourt farmers, fishermen, retired soldiers / police personnel, artisans and clerical workers were 57 (72.9%) patients. In Nnewi traders, artisans, farmers, teachers, and clerical workers were 64 (91.5%)
TABLE 4.3 OCCUPATIONAL DISTRIBUTIONS OF PATIENTS WITH ADENOCARCINOMA OF THE PROSTATE IN PORT HARCOURT AND NNEWI
OCCUPATION PHC NWI P.
NO % NO %
Farming 15 19.2 16 22.9
Fishing 14 17.9 0 0 P < 0.50
Security Military /
Police 10 12.8 5 7.1
Artisans 9 11.5 17 24.3 P < 0.10
Clerical works 9 11.5 5 7.1 P < 0.50
Trading 8 10.3 17 24.3 P < 0.50
Sailing 4 5.1 0 0
Teaching 3 3.9 9 12.9
Civil contracts 3 3.9 0 0 P>0.50
Oil servicing 2 2.6 0 0
Surveying 1 1.3 1 1.4
TOTAL 78 100.0 70 100.0
One patient in PHC was a retired health officer who studied in the USA and was the 9th of his parent’s siblings. He married 5
No of patients
1 2 3 4 5 1 2 3 4 5 6 No of Wives of patients (PHC) No of Wives of patients (NWI)
46 (58.9%)
46 (65.7%)
17 (21.8%)
7 (9.0%)
7 (9.0%)
1 (1.3%)
17 (24.3%)
5 (7.1%)
2 (2.9%) 10
20 30 40 50 60
wives and had 25 children. In Port Harcourt 46 (58.9%) patients married one wife, 32 (41.1%) married between 2 to 5, and 59 (75.6%) had at least 6 children. At Nnewi on the other hand, 46 (65.7%) patients married one wife, 24 (34.3%) married between 2 to 4 and 61 (87.1%) had at least 6 children.
FIGURE 4.2 MARITAL STATUS OF PATIENTS SEEN AT NNEWI AND PORT HARCOURT.
Three patients at Nnewi and two in Port Harcourt took tobacco as snuff. Other users of tobacco were smokers.
TABLE 4.4 CIGARETTE SMOKING HABITS OF PATIENTS WITH ADENOCARCINOMA OF THE PROSTATE IN PORT HARCOURT (PHC) AND NNEWI (NWI)
SMOKING STATUS PHC NWI P
NO % NO %
NON-SMOKING 46 59.0 29 41.4 > 0.10 SMOKERS
Light 10 12.8 14 20.0 > 0.10
Moderate 10 12.8 11 15.7 > 0.50
Heavy 8 10.2 9 12.9 > 0.50
PAST SMOKERS
Light - - 3 4.4
Moderate 2 2.6 2 2.8
Heavy 2 2.6 2 2.8
TOTAL 78 100.0 70 100.0
In Port Harcourt 46 (59.0%) patients were non-smokers, 28 (35.8%) current smokers, while 4 (5.2%) were past moderate – to – heavy smokers who had abstained from smoking for at least 6 months at the time of assessment. At Nnewi on the other hand, non-smokers were 29 (41.4%), current smokers 34 (48.6%), and past smokers 7 (10.0%).
TABLE 4.5 ALCOHOL-DRINKING HABITS OF PATIENTS WITH ADENOCARCINOMA OF THE PROSTATE IN PORT HARCOURT (PHC) AND NNEWI (NWI)
DRINKING HABIT PHC NWI P
NO % NO %
NON-DRINKERS 19 24.3 16 22.9 > 0.50 DRINKERS
Light 38 48.7 23 32.9 < 0.50
Moderate 6 7.7 14 20.0 < 0.50
Heavy 11 14.1 13 18.6 > 0.50
PAST DRINKERS
Light 1 1.3 2 2.8
Moderate 1 1.3 2 2.8
Heavy 2 2.6 - -
TOTAL 78 100.0 70 100.0
Fifty-five (70.5%) patients in Port Harcourt and 50 (71.5%) at Nnewi were drinkers of alcohol. Various types of alcoholic drinks – palm wine, local gin, beer, wine; different brands of dry-gin were involved. Past drinkers who had abstained from alcohol drinking were classified (Table 4.5).
SYMPTOMS AND SIGNS
Lower urinary tract symptoms (LUTS) were the most common symptoms with frequent micturition the most common.
TABLE 4.6 SYMPTOMS OF DISEASE IN PATIENTS WITH ADENOCARCINOMA OF THE PROSTATE IN PORT HARCOURT (PHC) AND NNEWI (NWI)
SYMPTOM PHC NWI P
(1) LOWER URINARY TRACT SYMPTOM (LUTS)
NO % NO %
Frequent micturition 51 65.4 42 60.0 > 0.50 Poor stream of urine 50 64.1 37 52.9 > 0.50
Urgency 38 48.7 30 42.9 > 0.50
Nocturia 34 43.6 18 25.7 < 0.10
Hesitancy 32 41.0 34 48.6 > 0.10
Feeling of incomplete voiding
24 30.8 25 35.7 < 0.50
Urge incontinence 21 26.9 16 22.7 > 0.50
Dysuria 20 25.6 15 21.4 > 0.50
Intermittency 18 23.0 17 24.3 > 0.50
Haematuria 18 23.0 18 25.7 > 0.50
Straining at micturition 14 17.9 25 35.7 > 0.10 Acute retention of urine 18 23.0 16 22.7 > 0.10 Chronic retention of urine 7 9.0 5 7.1 < 0.50 Bone pains, erectile dysfunction, inability to walk, poor appetite and lethargy were the other common symptoms in patients of the two centres (Table 4.7)
Table 4.7 OTHER SYMPTOMS
SYMPTOM PHC NWI P
NO % NO %
Bone pain 27 34.5 19 27.1 < 0.50
Poor penile erection 23 29.5 19 27.1 < 0.50 Inability to walk 19 24.4 13 18.6 < 0.50 Poor appetite 18 23.0 10 14.3 < 0.50
Lethargy 16 20.5 11 15.7 > 0.50
Weight loss 15 19.2 10 14.3 > 0.50
Headaches 11 14.1 8 11.4 < 0.50
Numbness in lower limbs 11 14.1 13 18.6 > 0.50 Constipation 10 12.8 12 17.1 > 0.50
Dizziness 10 12.8
Fever 9 11.5 5 7.1
Chest pain 6 7.7 4 5.7
Pruritus 2 2.6
Partial deafness 2 2.6
Hiccup 1 1.3
Vomiting 1 1.3
Blindness 1 1.3
Excessive sweating 1 1.3
Tremors 1 1.3
In the two centres, on digital rectal examination (DRE) findings were similar (Table 4.8).
Table 4.8 DIGITAL RECTAL EXAMINATION FINDINGS
SIGN PHC NWI P
NO % NO %
Enlarged prostate 72 92.3 63 90.0 > 0.50 Nodular prostate 42 53.8 27 38.6 < 0.50 Hard prostate 35 44.9 32 44.3 > 0.50 Firm prostate 35 44.9 27 38.6 > 0.50 Asymmetrical enlargement
of the prostate
18 23.0 11 15.7 < 0.50
Lax anal sphincter 15 19.2 17 24.3 < 0.50 Obliterated median sulcus 12 15.2 9 12.9 > 0.50
Haemorrhoids 8 10.3 - -
Tender prostate 2 2.6 - -
Pallor, paraplegia, paraparesis, pedal oedema were frequently found in those with spinal metastases.
Table 4.9 OTHER FINDINGS ON PHYSICAL EXAMINATION
SIGN PHC NWI P
NO % NO %
Pallor 39 50.0 35 50.0 > 0.50
Pedal oedema 11 14.1 6 8.6 < 0.50
Paraparesis 7 9.0 4 5.7
Paraplegia 6 7.7 6 8.6
Pathological fractures 3 3.8 - -
Rectal bleeding 1 1.3 - -
Rectal prolapse 1 1.3 - -
Hyperkeratosis in the lower
limb 1 1.3 - -
Jaundice - - 1 1.4
Family History of Prostate Cancer.
In Port Harcourt 8 (10.2%) patients had family history, of prostate cancer, 58 (74.4%) had none, 12 (15.4%) were unsure.
At Nnewi 7 patients (10.0%) had family history of the disease, 49 (70.0%) had none, but 14 (20.0%) were unsure.
Haemoglobin Levels
Seventy four patients in Port Harcourt and 63 at Nnewi had their haemoglobin levels measured at first presentation. Results were expressed as bar charts (Figure 4.3).
FIGURE 4.3 HAEMOGLOBIN (HB) LEVELS IN PATIENTS WITH ADENOCARCINOMA OF THE PROSTATE IN PORT HARCOURT (PHC) AND NNEWI (NWI) P > 0.50)
10
0-7 8-11 12-14 0-7 8-11 12- 14 (PHC Hb level g/dl NWI
33
(44.6%) 30 (40.5%)
11 14.9%
12 (19.0%)
25 (24.3%)
26 (41.3%)
Number of Patients
20 30 40 50
Moderate and severe levels of anaemia occurred in 44 (69.5%) patients in Port Harcourt and 37 (58.7%) at Nnewi. Severe anaemia occurred in 11 (14.9%) in Port Harcourt and 12 (19.0%) at Nnewi.
Sixty three (63) patients in Port Harcourt and 56 at Nnewi had their serum creatine levels measured at first presentation.
TABLE 4.10 SERUM CREATINE LEVELS IN PATIENTS WITH CARCINOMA OF THE PROSTATE IN PORT HARCOURT (PHC) AND NNEWI (NWI)
SERUM CREATINE
LEVEL (MOL/L) PHC NNEWI P
NO % NO %
60 – 120 31 49.2 28 50.0 < 0.10
121 – 240 18 28.5 19 33.9 > 0.50
241 – 360 3 4.8 4 7.1
361 – 480 3 4.8 3 5.4
481 – 600 5 7.9 - -
601 and Above 3 4.8 2 3.6
TOTAL 63 100.0 56 100.0
Thirty-one patients (49.2%) in Port Harcourt and 28 (50.0%) at Nnewi had creatine levels within the Normal Reference Value. The rest had hypercreatinaemia of varying degrees as shown above.
Serum PSA was raised above (4ng/ml) in 75 (96.2%) patients in Port Harcourt. At Nnewi only 62 (79.5%) patients had serum PSA measured at first presentation. All (100%) had serum PSA above their Normal Reference Values. Serum PSA values were above 100 ng / ml in 16 (20.5%) patients in Port Harcourt and 8 (12.8%) in Nnewi.
TABLE 4.11 SERUM PSA IN PATIENTS WITH CARCINOMA OF THE PROSTATE IN PORT HARCOURT (PHC) AND NNEWI (NWI).
SERUM PSA (ng/ml) PHC NWI P
NO % NO %
0 – 4 3 3.8 - -
5 – 10 11 14.1 8 12.9 < 0.50
11 – 20 18 23.0 10 16.1 < 0.50
21 – 50 22 28.3 22 35.6 < 0.50
51 – 100 8 10.3 14 22.6 < 0.10
101 – 150 15 19.2 6 9.6
150 and above 1 1.3 2 3.2
TOTAL 78 100.0 62 100.0
Sixty-one (78.2%) patients in Port Harcourt and 50 (71.4%) in Nnewi presented with urinary tract infection. The uropathogens isolated are shown in Table 4.12.
TABLE 4.12: UROPATHOGENS IN PATIENTS WITH CANCER OF THE PROSTATE IN PORT HARCOURT (PHC) AND NNEWI (NWI).
PATHOGEN PHC NWI P
NO % NO %
Mixed growth of coliforms 8 10.3 20 28.6 < 0.02
E. Coli 17 21.8 11 15.7 < 0.50
Pseudomonas 14 17.9 9 12.8 < 0.50
Klebsiella 10 12.8 5 7.1 < 0.10
Proteus 6 7.7 2 2.9
Staph-aureus 4 5.1 2 2.9
Candida sp 2 2.6 1 1.4
No growth 17 21.8 20 28.6 <0.50
TOTAL 78 100.0 70 100.0
< 0.50
E. Coli was the commonest single uropathogen cultured at the two centres. Mixed growth of pathogens accounted for 20 (28.6%) of urinary tract infections at Nnewi.
PLAIN CHEST RADIOGRAPHIC FINDINGS
In Port Harcourt salient findings on plain chest radiographic examination were lung metastases in 2 (2.6%) patients, unfolded aorta in 18 (23.1%) and cystic bronchiectatic changes in the lung fields of one patient. At Nnewi of 35 patients whose chest radiographic examinations could be done at presentation, 11 patients had cardiomegaly with unfolded aorta. Basal atelectasis or pleural effusion occurred in one patient each. Hyperinflation of the lung fields suggestive of chronic obstructive pulmonary disease (COPD) was seen in 5 patients. The rest (17) had normal chest radiographic findings.
PLAIN SKELETAL RADIOGRAPHIC EXAMINATION RESULTS Twenty-two (28.2%) patients in Nnewi had skeletal radiographic examinations for suspected metastatic carcinoma of the prostate.
Nineteen (86.4%) were osteoblastic lesions, 1 (4.5%) mixed and 2 (9.1%) osteolytic metastases. Bones involved were the vertebrae 11 (50.0%), femur 6 (27.3%), ribs 4 (18.2%), ilium 2 (9.1%) and acromio-clavicular bones and joints 1 (4.5%). Of the vertebrae, the most commonly involved were the lumbar 5 (62.5%), lumbosacral 3 (37.5%), whole vertebral column 1 (12.5%), thoracic 2 (25.0%) and sacrum 1 (12.5%). Generalized involvement of the vertebrae, pelvic bones and upper femur were seen in 5 patients.
Sixteen (20.5%) Port Harcourt patients had plain skeletal radiographic examination at presentation. Osteoblastic lesions occurred in 12 (75.0%), mixed osteolytic and osteoblastic
metastases in 2 (12.5%). Vertebral metastasis occurred in 8 (50.9%) patients, 4 of which were lumbo-sacral. Other involved bones were the ischium 2 (12.5%), and ilium and pubis 2 (12.5%). The femur was involved in 4 (25.0%) cases and ribs in 1 (6.3%).
HISTOLOGY
All cases of carcinoma of the prostate seen in this study were adenocarcinomas. Other prostatic malignant tumours, primary or secondary, were not encountered.
TABLE 4.13: DISTRIBUTION OF GRADES OF TUMOURS IN PATIENTS WITH ADENOCARCINOMA OF THE PROSTATE IN PORT HARCOURT (PHC) AND NNEWI (NWI).
GRADE PHC NWI P
NO % NO %
Well differentiated (G1) 10 16.1 11 20.8 > 0.50 Moderately differentiated
(G2)
6 9.7 4 7.5 > 0.50
Poorly differentiated (G3) 46 74.2 38 71.7 > 0.50
TOTAL 62 100.0 53 100.0
G1 = grade 1; G2 = grade 2; G3 = grade 3.
Sixty-two (79.5%) patients in Port Harcourt and 53 (75.7%) at Nnewi were graded. Forty-six (74.2%) patients in Port Harcourt and 38 (71.7%) at Nnewi had poorly differentiated (grade 3) adenocarcinoma of the prostate. Well differentiated (grade 1) lesions affected 10 (16.1%) and 11 (20.8%) patients respectively in the two centres.
Poorly differentiated adenocarcinoma of the prostate occurred in 21 (45.7%) patients aged 60 to 69 years in Port Harcourt but in 25 (65.8%) patients aged 70 to 90 years in Nnewi. The
distribution of ages of the patients and grades of tumour are further illustrated with the scattergram below (Figure 4.4)
FIGURE 4.4 SCATTERGRAM SHOWING VARIATION OF AGE OF PATIENTS WITH GRADE OF THE TUMOURS IN THE TWO CENTRES
PHC NWI
Tumour Grade
Stages C. and D adenocarcinoma of the prostate were seen in 58 (74.4%) patients in Port Harcourt and 56 (80%) in Nnewi.
1 2 3 1 2 3
Age of Patients (years)
100
90
80
70
60
50
40
30
20
10
TABLE 4.14: STAGES OF TUMOURS IN PATIENTS WITH ADENOCARCINOMA OF THE PROSTATE IN PORT HARCOURT AND NNEWI
STAGE PHC NWI P
NO % NO %
A 5 6.4 4 5.7 > 0.50
B 15 19.2 10 14.3
C 31 39.8 24 34.3 > 0.50
D 27 34.6 32 45.7 > 0.50
TOTAL 78 100.0 70 100.0
A number of lesions were seen on evaluation of the patients. Some of these were complications of the prostatic malignancy while the others were different diseases, which co-existed with it (Tables 4.15 and 4.16).
TABLE 4.15 COMPLICATIONS OF ADENOCARCINOMA OF THE PROSTATE IN PATIENTS SEEN IN PORT HARCOURT AND NNEWI (NWI)
COMPLICATION PHC NWI P
NO % NO %
Urinary tract infection (UTI)
61 78.2 50 71.4 > 0.50
Anaemia 44 69.3 37 58.7 > 0.50
Bone pains 27 34.3 19 27.1 < 0.10 Erectile dysfunction 23 29.5 28 40.0 < 0.10 Chronic renal failure 15 19.2 16 22.7 < 0.05
Hydrocele 9 11.5 7 10.0 < 0.10
Haemorrhoids 7 9.0 5 7.1 > 0.50
Paraparesis 7 9.0 4 5.7
Epididymo –orchitis 6 7.7 5 7.1 > 0.50
Paraplegia 6 7.7 6 8.6
Urethral stricture 5 6.4 3 4.3 Congestive cardiac failure 4 5.4 7 10.0
Hernia 4 5.1 6 8.6
Decubitus ulcers 4 5.1 - -
Pathological fractures 3 3.8 - -
Bladder calculus - 1 1.4
Hydronephrosis - 1 1.4
Metastatic lung disease 1 1.3 - -
TABLE 4.16, CO- MORBIDITIES OF ADENOCARCINOMA OF THE PROSTATE IN PATIENTS SEEN IN PORT HARCOURT AND NNEWI (NWI).
CO- MORBIDITY PHC NWI P
NO % NO %
Cerebrovascular disease 1 1.3 1 1.4 Fournier’s gangrene 1 1.3 -
Allergic dermatitis 1 1.3 -
Bronchiectasis 1 1.3 5 7.1
Parkinsonism 1 1.3 2 2.9
Osteoarthritis 1 1.3 -
Schizophrenia 1 1.3 1 1.4
Dilated cardiomyopathy 1 1.3
Liver cirrhosis 1 1.3
Hepatorenal syndrome 1 1.3
Anal warts 1 1.4
Anal fissure 1 1.4
Hepatitis 1 1.4
Cataract 1 1.4
Glaucoma 1 1.4
Ischiorectal abscess 1 1.4
Empyema thoracis 1 1.4
Renal cysts 1 1.4
Bronchopneumonia 1 1.4
Bladder calculus 1 1.4
Intestinal obstruction 1 1.4
Urinary tract infection was the most commonly found urologic condition in these patients. It accounted for 61 (78.2%) cases in Port Harcourt and 50 (71.4%) in Nnewi. Others included hypertension, erectile dysfunction and chronic renal failure (Table 4.15).
Forty one (52.6%) patients in Port Harcourt and 34 (48 .6%) in Nnewi had had catheterisation at the time of evaluation. Of these 5 (12.2%) in Port Harcourt and 3(8.8%) in Nnewi had suprapubic cystostomy. The indications for catheterisation included the following; Port Harcourt patients - Acute retention of urine 18(43.9%), chronic retention of urine 7 (17.0%), urinary incontinence 6(14.6), urethral stricture 5(12.2), and haematuria 5(12.2). At Nnewi indications for catheterisation were acute retention of urine 16(47.0%), incontinence of urine 6(17.6), chronic retention of urine 5(14.7%), haematuria and pre-operative fluid monitoring 4(11.8%), and urethral stricture 3(8.8%).
CHAPTER FIVE DISCUSSION
The fact that carcinoma of the prostate is a serious public health problem with ominous prognosis among elderly black men world wide has been proved by various studies2,3,6,50. The specific objective of this study has been to detect any specific differences in the clinical and pathological characteristics of the disease that may form the basis for further research.
The various ethnic groups listed in Table 4.1 are mostly communities in the Niger Delta, either in Rivers State or neighbouring states in Southern Nigeria. The Ikwerres inhabit various communities that are within the City of Port Harcourt and its environs. The Ikwerre Area shares geographical contiguity with Ibo communities of the neighbouring Imo and Abia States.
The relatively higher number of patients from Ikwerre, Ibo, Kalabari, Okrika, Ogoni and Bayelsa Ijaw might have been due to a number of factors. These include the relatively higher population of these ethnic groups than others in Port Harcourt and its environs, closeness to the hospital in Port Harcourt and ability to pay high hospital bills. However further investigations are required to find out if genetic susceptibility had effects on the development of carcinoma of the prostate in these patients.
Figure 4.2 shows the distribution of ages of patients of the two centres. The distribution shown agrees with observations elsewhere3,4,5,. The mean age of Nnewi patients of 72.0 + 9.3 years agrees with the findings of Nwofor et al97 who reported the mean age of 71.0 + 10.9 years for patients with carcinoma of the prostate in NAUTH Nnewi and Eke et al4 who observed the mean
age of 71 years for patients with the disease in Port Harcourt. The latter was a retrospective study and patients were not analyzed according to their different ethnic groups. A significant finding was that majority of Ibos in Nnewi developed carcinoma of the prostate at much higher ages than those of the affected Port Harcourt ethnic groups (Table 4.2). Another significant observation was that when the ages of patients of the six most commonly affected ethnic groups in Port Harcourt and Ibos of Nnewi were displayed graphically (Figures 4.1), Nnewi Ibos, Port Harcourt Ibos and Ikwerres were found to have similar patterns of distribution. Nnewi Ibos, Port Harcourt Ibos and the Ikwerres had highest number of patients with carcinoma of the prostate in the 8th decade. This is different from patterns of distribution of ages of other ethnic groups in Port Harcourt. This finding suggests that ethnic and hereditary factors had more effects than environmental factors in the development of carcinoma of the prostate in these patients. Other variables to consider in this conclusion include the sample size (which is small in this study), the latent period when environmental variables eventually cause detectable malignancy of the prostate in the individual patient, and the length of residency of the patients in Port Harcourt compared with the latter.
The occupational distribution of patients of the two centres does not reveal any link of carcinoma of the prostate to particular occupations. Farming and fishing are the major occupations of the communities of the Niger Delta. Similarly farming and trading are the major occupations of Nnewi communities. The distribution seems to reflect the pattern of distribution of occupations within the populations of the catchment areas. This
observation negates the findings of those who linked the development of carcinoma of the prostate to particular occupational hazards 5,6,59. However, occupational variables are difficult to evaluate with respect to their causal relationship with malignancies. It usually requires time, quantification of degrees of exposure and other variables. Definite conclusions cannot therefore be drawn from the current study.
Another feature of this occupational distribution is that majority of the patients were those of middle and low socio- economic classes. It is common knowledge in this country that many highly skilled professionals, administrators, and rich politicians hardly patronize public health institutions for various personal reasons.
This in itself is a limitation of this study.
The distribution of the marital status and number of children of patients of the two centres showed a similar pattern. The two groups demonstrated a high rate of polygamous marriages – 32 (41.1%) and 24 (34.3%) in Port Harcourt and Nnewi patients respectively. This finding agrees with that of Okafor7 who compared cancer of the prostate in patients of University of Nigeria Teaching Hospital (UNTH) Enugu with features of the disease in patients seen in Western General Hospital (WGH) Edinburgh (UK). He found that 28.9 % of U.N.T.H. patients with the disease married more than one wife while 100% of WGH patients married one wife. The fact that polygamy is common in Nigeria is well known. However, the extent to which this practice increases sexual activity among Nigerian men and the relationship between such activity and prostatic androgen metabolism in Nigerians require further studies.
Good sexual activity and fertility are dependent on optimal hormonal balance28. However, low level of androgen activity in Asians with its effect has been reported by Makridakis et al98.
They postulated that the lower incidence of carcinoma of the prostate in Asian populations, compared with other races was due to low androgen activity in the prostate glands of Asians.
They attributed this low activity to a mutation in 5 alpha-reductase type II gene in males of Asian populations. In this mutation leucine replaces valine in codon 89 of the DNA molecule. This variant of 5-alpha-reductase, product of this mutation, has lower activity in vivo. This enzyme (5 alpha reductase type II) is responsible for the conversion of testosterone to its more bioactive form dihydrotestosterone (DHT). The level of prostatic activity in Nigerians merits detailed studies.
Cigarette – smoking and alcohol drinking as possible risk factors for carcinoma of the prostate have often generated much interest67. The distributions of smokers of cigarette and drinkers of alcohol with carcinoma of the prostate in the two centres are similar (Table 4.4 & 4.5). In each institution more current smokers of cigarette and current drinkers of alcohol had the disease than past smokers and past drinkers. This trend suggests a diminished risk of developing carcinoma of the prostate when drinkers and smokers give up those habits.
However, such conclusions may not be drawn from this study because of the small sample size. Secondly some of the current smokers might have started smoking after they had developed subclinical prostate cancer. Thirdly some past smokers might have stopped smoking because of symptoms of the disease. The same can also be said of alcohol drinking. A longitudinal study of
the effects of cigarette smoking or alcohol drinking on the development and natural history of prostate cancer would be more informative.
Lower urinary tract symptoms (L.U.T.S) were the most common presenting features in the two groups of patients. This observation is similar to those made in many studies in this environment 4,5,97,99 Frequency of micturition was the most common presenting lower urinary tract symptom, the second most common being poor stream of urine. These two taken together suggest that bladder outlet obstruction by the hyperplastic prostatic tissue has been the principal underlying mechanism of occurrence of the symptoms. Others include urinary tract infection, neurogenic bladder dysfunction, and other concurrent bladder lesions.
Bone pains and low backache commonly occur in elderly patients and were frequent complaints of patients in the two hospitals.
They often result from spondylosis and other degenerative diseases of bone, tendons and ligaments. However, as has been pointed out by previous workers 3, 100, 101, low backache in males above 50 years old should be an indication for digital rectal examination and serum PSA assay. Such pains may be early manifestations of vertebral/spinal metastases and often precede paraparesis and paraplegia102. In a study in Port Harcourt Eke101 observed a duration of 3 weeks to 5 months from the onset of the first symptom attributable to spinal cord compression to the onset of paraplegia. Recovery of ambulation following treatment is unpredictable with poor prognosis once paraplegia has set in100,102.
The pattern of occurrence of anaemia (Figure 4.3), renal dysfunction, serum PSA elevation, urinary tract pathogens in UTI, skeletal spread of carcinoma of the prostate, distribution of tumour grades and co-morbid conditions are similar for patients of the two centres (Tables 10 -16). The high incidence of renal failure, urinary tract infection and anaemia in the two groups justifies routine assay of renal function (electrolyte, urea and creatinine), urine culture and sensitivity and full blood count in these patients.
Urinary tract infection (UTI) occurred as the most common finding in patients of the two centres. It affected 61(78.2%) patients in Port Harcourt and 50 (71.4%) in Nnewi. The predisposing factors include bladder outlet obstruction by the hyperplastic malignant prostatic tissue, catheterisation, advancing age, decreased immune mechanisms and co-morbid conditions. An important feature of the distribution of the pathogens is the relatively high proportion of Pseudomonas and Klebsiella species in relation to E. coli species. The former are usually associated with chronicity of infections and multi-drug resistance 106. Bonadio et al 106 examined data on age, sex, current and previous bladder catheterisation, some underlying diseases, such as diabetes mellitus previous antibiotic therapy and distribution of bacterial isolates. He found that, especially in male patients, prolonged indwelling catheters have positive correlation with emergence of multi-drug resistant pathogens e.g.
Pseudomonas. Urinary tract infections usually have the effects of increased morbidity, mortality and the cost of treatment of patients.
Certain characteristics common to patients of both hospitals are notable. The serum PSA values are high compared with reports from Caucasian populations103. The high PSA values are probably, in part, a reflection of the high grades and stages of the disease at presentation, since serum PSA is known to increase with tumour burden and tumour grade 33,35,37,55. The high serum PSA values and high tumour burden might have been due to late presentation since most of the patients presented with advanced disease (Table 4.14). However, serum PSA values also depend on methods of assay and studies103, 104 have shown that there are racial differences in its values. Blacks have correspondingly higher values than Caucasians104. Most of the published normal reference ranges of serum PSA values have been derived from studies in Caucasian populations105. In other tertiary hospitals in Nigeria (as in these two centres), in agreement with predictions of Osegbe3 in 1996, the use of serum PSA is now routine. With accumulating experiences problems with the use of serum PSA will emerge. Standardization of serum PSA normal reference values for the Nigerian population will optimize the use of this tumour marker in this country.
Another notable observation common to patients of both centres is the preponderance of poorly differentiated (grade 3) lesions occurring with high stages (C and D) of the disease. This is in agreement with earlier findings in Calabar5 and the observations of Nwofor et al97 at Nnewi that poorly differentiated adenocarcinoma of the prostate constituted 78.6% of cases of carcinoma of the prostate seen at Nnewi. Late presentation has often been blamed as a reason for the occurrence of high stage lesions often seen in Nigerian and other black populations with carcinoma of the prostate. Another important factor that
determines the tumor burden at presentation is an inherent high growth rate, which is a known characteristic of poorly differentiated tumours75. The significance of this factor needs to be highlighted. Further studies are needed to find out the cause of the observed preponderance of poorly differentiated adenocarcinoma of the prostate in patients with prostate cancer in this environment.
The high incidence of co-morbid conditions – hypertension, heart diseases, stroke, chronic renal failure and prostate cancer is notable. These diseases are more common in elderly patients.
However these observations agree with the findings of Mouton104 in African- American elders with cancer of the prostate. He attributed his observations to poor socio-economic factors poor health status and poor levels of financial strain and caregiver burden. The two groups of patients – of Nnewi and Port Harcourt - have high incidence of polygamous marriages with many children and are mainly of low socio-economic status. These observations agree with findings of Mouton. Additionally such other conditions as urinary tract infections, chronic renal failure, erectile dysfunction and pathological fractures arose partly from obstructive and metastatic complications of carcinoma of the prostate.
CONCLUSION / RECOMMENDATIONS:
This study suggests that the clinical and pathological characteristics of carcinoma of the prostate in Port Harcourt and Nnewi are similar. This is in spite of the fundamental differences in ethnic composition, environmental variables, geographical location and industrialization. Patients of Ibo origin (in Port Harcourt and Nnewi) and Ikwerres of Port Harcourt presented
with carcinoma of the prostate at older ages (in the 8th decade) than patients of the other major ethnic groups in Port Harcourt.
However, this study has the limitation of small sample size that may cause errors in conclusions on this finding. Ethnic and genetic factors and a high level of prostatic activity are suggested to be more important than environmental and occupational variables in the evolution of carcinoma of the prostate in these two populations. It is suggested that serum PSA which is now in routine use in Nigeria be standardized to optimize its value in the diagnosis and treatment of carcinoma of the prostate in the country. It is further suggested that androgen metabolism and the levels of sexual activity in males and hereditary factors in prostate cancer be investigated in Nigerians. Such efforts should be sponsored by the Federal Ministry of Health and the Organized Private Sector, considering the enormity of the health problems posed by prostate cancer.