Grassroots research gives a voice to the plight of men at risk of a silent killer: prostate cancer

While discussing mother and baby health at a community gathering in the rural Vhembe District of Limpopo, one of the male traditional leaders asked when we are going to do something for men.

It’s an excellent question as men’s health doesn’t receive the same attention as women’s in the public arena. But as researchers we are certainly doing something for men’s health. Since 2008 we have been researching prostate cancer, the silent killer of Southern African black men, of whose potential danger many of them are unaware. As such, we set out on the journey of ‘dzomo’, which in Tshivenda means to ‘give a voice’.

According to the latest GLOBOCON 2020 figures, men from Southern Africa are twice as likely to die from prostate cancer than the global averages. Within the United States, African American men are at  2.4- to 5.0-fold increased risk of death from prostate cancer, compared to men of European and Asian ancestry, respectively. This places African ancestry as a significant risk factor for prostate cancer and associated mortality, along with increased age and a family history of prostate cancer.

At the outset we want to emphasise that regular prostate cancer PSA screening is fundamental in diagnosing cancer in an early stage as elevated levels indicate that a prostate biopsy should be done. The South African Prostate Cancer Foundation recommends that PSA measurements and digital rectal examination in black men should start after the age of 40 years and in all other men at 45 years. Men should know their PSA levels and testing should be available at all healthcare facilities. 

While this can be expected for men on medical aid, most South African men are are dependent on public healthcare facilities, of which only selected clinics offer testing. This leaves many black men, who are in the high-risk category, with reduced chances of the possibility early diagnosis for intervention. Coordinated efforts are critical to address this incongruity, while all populations may benefit from creating awareness of the disease.

Symptoms of prostate cancer can include painful emptying of the bladder and            complaints about erectile dysfunction. There can also be no symptoms whatsoever, which is why the annual testing, a thorough examination and history-taking are so important.

To try and understand why men of African ancestry develop more aggressive prostate cancer, we used seed funding from the Medical Research Council and CANSA to determine the impact of this disease in South Africa. Our initial study of 837 men recruited from urological clinics across Limpopo and Gauteng, of which 522 had prostate cancer, showed Black South African men were at 2.1-fold greater risk of presenting with aggressive prostate cancer than African Americans.

This difference was further exacerbated in men from rural areas. This calls for additional research into environmental factors in our communities.

More recently we have been funded by both the Australian and USA governments to the value of R22 million to use genomic profiling and data science to identify both genetic and environmental drivers of aggressive disease within our rural communities. The project will identify patterns of exposure left within the DNA of the developing tumour. Specifically, we are intensively researching exposure patterns of chemical pollution from DDT that is sprayed in Vhembe to control for malaria. Other research has found that breast cancer in women is associated with in utero exposure to DDT. The same may apply to the development of prostate cancer.

While the use of DDT as an insecticide has been banned in many countries around the world, in the malaria-endemic region of South Africa, DDT is sprayed as an economical method of mosquito vector control. DDT is a toxic chemical and a known endocrine-disrupting chemical (EDC) as it interferes with hormones. The World Health Organisation is working on finding alternatives that are not harmful to human and environmental health. In the meantime, DDT has been in use in the Vhembe region since 1945, resulting in men over 70 years having a lifetime of exposure.

The SAPCS is combining demographic and lifestyle data with biochemical and genetic data to get to the bottom of what is causing lethal prostate cancer in our population. Having recruited over 2 500 men, with over 60% from the rural areas of Limpopo, what is critical to our research is that we have formed deep, longstanding relationships of trust within their communities, including the traditional leaders and traditional healers. It is through this retained partnership with the Vhembe community that the SAPCS has more recently been in a position to attract international funding.

We are proud of our ‘grassroots to cloud’ approach – our study is designed on the ground with the people for the people, which is then merged with state-of-the-art genomic technologies and big data analytics. While the research is always brought back to the people, with the ultimate aim to improve health outcomes for South African men, the international funders also recognise the global benefit. In the United States, the Department of Defence recognised the significance for the African American population. In Australia the National Health and Medical Research Council recognises that the knowledge gained from this project builds knowledge for all men. 

Our latest study is the SAPCS Target Africa project – this will be the biggest study of its kind, including eight academic institutes from four countries – the USA, Australia, the UK and South Africa. The goal is to bring global minds together to find the answers to this ethnic and global disparity. The three-year project has just started; we have a lot of work to do.

Professor Riana Bornman is co-principal investigator and clinical leader of the Southern African Prostate Cancer Study (SAPCS), which is investigating the factors, both genetic and non-genetic, driving aggressive prostate cancer in African men.  This is being done in partnership with Professor Vanessa Hayes from the University of Sydney in Australia, as SAPCS Scientific Director and University of Pretoria Extraordinary Professor.

Researchers

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  Professor Riana Bornman

  Professor Riana Borman’s research seeks to understand the effects of endocrine-disrupting chemicals (EDCs) on human and environmental health, with a special focus on male reproduction. Most of her research is carried out in the rural areas of the Vhembe District in Limpopo, in communities where insecticide is sprayed to control malaria-carrying mosquitoes.
  She began her career in the Department of Urology at the University of Pretoria (UP) in 1980 and had a research topic to explore within the first week, which triggered a career-long curiosity. “I am still researching the role of EDCs on human health today,” she says.
  
  Prof Bornman, who obtained an MBChB at UP, says her research focus developed from her experiences in managing patients in clinical settings. “As a clinical physician, I realised that human and environmental health was intricately affected by environmental pollution, especially exposure to EDCs. Being a clinician at UP has created unique opportunities to conduct research in the Limpopo province.”
  
  Her field of research addresses the unintentional health consequences of annual indoor residual spraying of insecticides to control malaria-carrying mosquitoes. In the Vhembe District, dichlorodiphenyltrichloroethane (DDT) is sprayed to control these mosquitoes and reduce cases of malaria and death. While DDT is largely a banned chemical, according to the Stockholm Convention on Persistent Organic Pollutants, it is allowed in some countries, including South Africa, for malaria vector control.
  But there is growing concern around the adverse health effects associated with DDT. Scientific evidence from South Africa is crucial and contributes to the body of evidence that is calling for safer alternatives to DDT for malaria vector control.
  
  The chemical is effective for about six months and needs to be sprayed every year. Prof Bornman’s research shows that annual spraying has negative, long-term consequences for pregnant women and young children. “We are seeing these consequences in children, possibly persisting into future generations, suggesting long-term health effects. Our research collects important irrefutable scientific evidence of the health impacts of EDCs in communities exposed to insecticides.”
  
  Prof Bornman is the co-principal investigator for the Venda Health Examination of Mothers, Babies and the Environment (VHEMBE) study, which is being conducted in collaboration with Prof Brenda Eskenazi of the University of California, Berkeley in the US and Dr Jonathan Chevrier of McGill University, Canada. The VHEMBE study is the first birth cohort from a population that is currently exposed to DDT via annual spraying and is the biggest longitudinal birth cohort from Africa. The study group recruited and enrolled 752 mother-child pairs at Tshilidzini Hospital in Thohoyandou and have monitored the children up to eight and a half years of age for various possible health impacts.
  
  She hopes to continue doing research that contributes to improving the health of those whose voices are not often heard.
  
  She is also co-principal investigator and clinical leader of the South African Prostate Cancer Study, which is investigating the genomics of prostate cancer in African men; this is being done in partnership with Prof Vanessa Hayes, Scientific Director of the Garvan Institute of Medical Research in Sydney, Australia. A recent highlight in their research work has been funding awards from major international bodies to investigate the development of aggressive prostate cancer in black African men. “We are extremely motivated to continue with this research,” says Prof Bornman. “Successful awards reflect that the scientific leaders in our field support our approach.”
  
  Over the past 18 months, the prostrate cancer study group began a new project that focuses on the mutational signatures of DDT and the possible role of this EDC on prostate cancer aetiology. Prof Bornman is also the study leader for a new study on knowledge, attitudes and practices of traditional healers, primary healthcare service providers and men in the rural Vhembe District.
  
  She says in her research work she was inspired by Prof Dion du Plessis, former Head of Urology and Dean of the Faculty of Health Sciences at UP, who taught her to think beyond the obvious, to dream big and to just DO it!
  Her academic role model was Prof Carl Franz, former Head of Surgery at UP. He was a prime example of how to integrate laboratory and clinical medicine in an academic career, she says.
  
  Her message to school learners or undergraduates who are interested in her field is: “Every one of us, irrespective of our discipline, can make a difference in the lives of people. My research aims to improve the lives of people living with the constant threat of malaria under unforgiving environmental and socio-economic conditions. We can all do research that makes a difference. One just has to care enough about people.”
  
  Her hobbies are photography and travel.
  
  
  

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