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17.12.2014 Feature Article

Transforming The Future For Prostate Cancer In Ghana

Transforming The Future For Prostate Cancer In Ghana
17.12.2014 LISTEN

Prostate cancer behaves differently in individuals and most of the research is based on how the disease behaves in white men and not black men. In most countries services such as treatment and policies are targeted for men in that geographical area so what should Ghana and men in West Africa and their service providers do now?

The Prostate Cancer UK has Projected that Prostate cancer will be the leading cancer by 2030.In Ghana closed to about 1000men diagnosed with the disease yearly and closed to about 800 men die yearly of the disease in the country. According to research 1 in 4 black men will be diagnosed with prostate cancer in his lifetime. According to the Ghana News Agency 2007, Ghana has exceeded the global prostate cancer limit as the country records 200 cases out of 100,000 as against 170 worldwide.

In response to this it has become necessary in training professionals in the field of Prostate cancer for the management of the disease and providing treatment options for patients. Black men have 60% chances of getting prostate cancer and twice likely to die of prostate cancer than white men. This means Black men must be more proactive when it comes to health issues.

Black men have significantly higher rates of prostate cancer.

Black men have lower rates of screening for prostate cancer.

Black men have, on average, more advanced and harder to cure prostate cancer at the time of diagnosis.

Black men have a higher chance of dying from their prostate cancer

Men's Health Foundation Ghana Goal 2025
Men's Health Foundation Ghanais Ghana's leading charity working with people affected by prostate cancer. The charity provides support and information and campaign to improve the lives of men with prostate cancer. We were set up in 2013 with the broad concern of improving the care and welfare of Ghanaian men affected by prostate cancer. The charity now provides the most comprehensive range of services in prostate cancer in Ghana.

Prostate cancer is the most common cancer in men. Each year almost 1,000 men in Ghana are diagnosed with prostate cancer and approximately 800 men die from it.

Men's Health Foundation Ghana believes that there are cancer inequalities. With the Charity concerned about men's prostate health in other to transform the future for prostate cancer in Ghana has set up some goals to be met by 2025 and we need support and collaboration from individuals and corporate institutions to achieve our objectives.

The 2025 goals and 2015-2016 strategy, Transforming the future for prostate cancer, sets out a framework for tackling inequalities and improving care and treatment for men with prostate cancer. The goals are:

1. By 2025, significantly more men will survive prostate cancer

2. By 2025, society will understand the key facts about prostate cancer and will act on that knowledge

3. By 2025, Ghanaian men of West Africa descent and women will know more about prostate cancer and will act on that knowledge

4. By 2025, inequalities in access to high quality prostate cancer services will be reduced

5. By 2025, people affected by prostate cancer will have their information and support needs addressed effectively by Men's Health Foundation Ghana.

What is a cancer inequality and what are the main cancer inequalities?

1.1.1 A cancer inequality can take many different forms. For example inequalities can exist between the level of care provided for different cancers, between individuals within a tumour group, between different social groups or between geographical locations. An inequality disadvantages people in terms of the level of treatment and care they receive and can impact on their treatment outcomes, survival, and experience.

1.1.2. There are a number of specific inequalities that relate to prostate cancer. The Men's Health Foundation Ghana Charity feels that the most significant inequalities for prostate cancer relate to the areas of ethnicity, patientexperience, research spend, and geographical variations in treatment and outcomes and we will outline our concerns around these areas below.

1.2 Inequalities relating to ethnicity in prostate cancer

1.2.1. African Caribbean men are at a three times greater risk of being diagnosed with prostate cancer than White men. They also present at first diagnosis at a younger age than White men. On average African Caribbean men present at 67.9 years compared with 73.3 years for white men. However increasing age remains the biggest risk factor for prostate cancer across all ethnic groups. At present it is not clear what factors cause incidence levels to vary with ethnicity and further specific research is needed in this area.

1.2.2. Despite the higher risk of prostate cancer for Black men of African Caribbean and West African origin there is poorer awareness of prostate cancer among this group than among white men. In a recent UK study only 37% of Black men had heard of prostate cancer compared to 64% of White men. White men also showed a greater awareness of the signs and symptoms of prostate cancer compared to Black men. Research commissioned by The Prostate Cancer Charity in 2008 found that 58% of African Caribbean men correctly identified prostate cancer as the most common form of cancer in men, compared (in a different study commissioned by the Charity) to 69% of the general male population. Additionally the Charity's research found that only 15% of African Caribbean men knew that they had an increased risk of developing prostate cancer. It is very concerning that African Caribbean men who are at greater risk of prostate cancer are less aware of prostate cancer than white men, they should have equal if not higher levels of awareness. This suggests an inequality in levels of awareness and that messages about prostate cancer are not reaching this group.

1.2.3. Existing evidence from the UK does not show any difference in stage of disease at diagnosis between African Caribbean and White men, nor does it show any significant differences in access to diagnostic services. There is evidence that African Caribbean men are more aggressively managed in treatment than White men, however this is likely to be because they are diagnosed at a younger age and it is common to treat younger men more aggressively. However, the evidence in the UK on these issues is currently based solely on the PROCESS study (although a study by the Thames Cancer Registry is due to be published soon). Therefore more in depth research is needed to confirm these results and investigate these areas more extensively to ensure there is equality of access to treatment and care between different ethnic groups, particularly for those increased risk.

1.2.4. In order to address this area of inequality relating to prostate cancer we would like:

Increased funding for awareness work targeted at Ghanaian men of West African men

• More research into the treatment and patient experience of African Caribbean and Black African men

• More research into the cause of the greater incidence of prostate cancer for African Caribbean and Black African men.

1.3. Inequality in patient experience relating to prostate cancer

1.3.1. Men with prostate cancer consistently report a significantly worse patient experience than people with other common cancers. Both the 2005 NAO report Tackling Cancer: Improving the Patient Journey and the NHS National Cancer Patient Survey of 2000 reported that prostate cancer patients responded less positively than patients with other cancers on a range of measures.

• Fewer men with prostate cancer received information on side effects or how their treatment had gone

• Fewer men fully understood the explanation of how their treatment had gone

• Fewer men had a named nurse in charge of their care

• Fewer men were given information about self-help groups

• More men were likely to have to wait longer for their treatment

Although there were improvements in experience between 2000 and 2005 these were minimal, and the percentage of men given information about self-help groups actually decreased from 36% to 34% (this was compared with 66% and 64% for patients with other cancers). The poorer patient experience reported by men with prostate cancer suggests they do not have access to the same level of information and support as patients with other common cancers.

1.3.2. A recent survey (2009) carried out by the Prostate Cancer UK into the experiences of men with prostate cancer who are undergoing hormone therapy echo the results of the NAO survey and suggest that men on hormone therapy treatment are still not getting access to the information and support they need. Hormone therapy is a very common treatment for prostate cancer, especially for men with advanced or locally advanced disease, and in many cases it is the only treatment available. However, it can cause significant side effects on physical, sexual and mental wellbeing and can impact substantially on quality of life.

Men participated in the survey and the results from the survey are alarming and present a very concerning picture of the experiences of men receiving hormone therapy for prostate cancer. The key results are:

• 55% of men reported receiving too little information and support

• 51% of men were not asked whether they were experiencing any side effects from treatment on their sexual function or desire

• 67% of men were not asked whether they were experiencing any effects on mental well-being

• 52% of men were not told about written information on hormone therapy

• 32% of men did not have access to a Clinical Nurse Specialist

• 41% of men were not told about support groups
• 62% of men were not told about general counseling services

These results indicate that key recommendations on access to information and support from both the NICE Improving Outcomes in Urological Cancers (2002) and the Improving Supportive and Palliative Care for Adults with Cancer (2004) have not been fully implemented for men with prostate cancer in the UK. There are unacceptable gaps in care and men with prostate cancer are missing on vital information and support to help them cope with their treatment. It is crucial that this situation is remedied.

1.3.3. Another serious inequality in access to care is that prostate cancer patients have poorer access to Clinical Nurse Specialists (CNS) than some other major cancers. Research shows that men with prostate cancer who have access to a CNS report a better patient experience than men who do not.CNS's provide essential care including the provision of comprehensive information, support with making complex treatment decisions, advice on managing side effects, and emotional and psychological support. However Tackling Cancer reported that only 50% of prostate cancer patients had access to a named nurse compared with 61% of other common cancer patients in England in 2004. These findings were supported by the Prostate Cancer UK recent (2009) survey into the experiences of men receiving hormone therapy for prostate cancer, which found that 32% of respondents did not have access to a specialist nurse.

1.3.4. In addition to the high number of men without access to a CNS evidence has shown that the caseloads of CNS's working in urological cancers in England are significantly higher than in other areas of cancer. In 2007 there were 250 uro-oncology CNS posts in England compared to 434 breast cancer CNS's.The case-load for uro-oncology CNS's is also significantly higher; there is more than double the number of newly diagnosed patients per uro-oncology CNS than there is for a breast care CNS (203 compared to 110). This shortfall in CNS's for men with urological cancers was highlighted in the Cancer Reform Strategy.In addition to new patients CNS's look after men throughout their treatment and care, therefore actual caseloads are far greater, particularly as they include men living with locally advanced or advanced prostate cancer.

1.3.5 There are also significant geographical variations in the number of CNS's within different cancer networks across England for instance. In 2007 all cancer networks had at least one Whole Time Equivalent (WTE) CNS working in uro-oncology, however national research has shown a substantial disparity in the number of posts between networks. The cancer network with the highest provision of uro-oncology CNS's has 23 WTE nurses, whereas the lowest has only one. Even discarding the top and bottom 10% of the networks in terms of provision there is a threefold variation in uro-oncology CNS provision across England. This variation in provision may go some way to account for the lower levels of men who report access to a CNS and for the lower levels of patient satisfaction.

1.3.6. The lower numbers of CNS's and the size of the uro-oncology CNS case-load is undoubtedly a major difficulty in achieving NICE recommendations on patient-centred care made in Improving Outcomes in Urological Cancers (2002) and Improving Supportive and Palliative Care for Adults with Cancer (2004). As a result of this men with prostate cancer are missing out on vital support, which significantly impacts on their patient experience. There are a number of specific actions that can be taken to improve this situation:

The numbers of CNS's working in urological cancers must be increased to be on par with the best of the other cancers.

• The distribution of CNS's must match the incidence of prostate cancer to ensure and equal level of access across the country and Ghana needs more urgent actions

1.3.7. It is clear that men with prostate cancer are facing significant inequality in terms of access to support and information compared to other common cancers. This is unacceptable and action must be taken to improve the patient experience of men with prostate cancer in Ghana:

• Men with prostate cancer must be provided with adequate support and information at all stages of their treatment and care.

• there should be a guidance on patient centered care and in Improving Outcomes in Urological Cancers, Improving Supportive and Palliative Care for Adults with Cancer and Prostate cancer diagnosis and treatment must be fully look into it and implemented across the country in Ghana.

• The National Cancer Plan Strategy must be implemented urgently to monitor patient experience.

1.4 Inequality in research spend on prostate cancer

1.4.1. Historically prostate cancer has been a neglected area of research compared to some other common cancers. This has led to many unanswered questions about prostate cancer diagnosis and treatment. Funding for research into prostate cancer still lags behind funding for some other common cancers.

1.4.2. Data published by the NCRI shows that prostate cancer research accounted for only 7.9% of the overall NCRI spend on site specific research in 2007, compared to breast cancer which accounted for 18.7% and colorectal cancer which accounted for 10.9%.

1.4.3. The smaller spend on research into prostate cancer is all the more concerning because of the continuing lack of an effective test for prostate cancer. The only test currently available is the PSA test. However the PSAtest does not specifically diagnose cancer but identifies a problem with the prostate that could be cancer. There are also problems with the reliability of the PSA test. There is currently no national screening programme for prostate cancer despite it being the most common cancer in men because of the lack of an effective enough test. More research is needed into developing a better test for prostate cancer that can differentiate between slow-growing and aggressive prostate cancer. This would enable treatment to be targeted more effectively and reduce the level of over-treatment that currently occurs. A greater spend on prostate cancer research is needed to support the development of this test. There must also be screening guidelines for Ghanaian men.

1.4.4. Men's Health Foundation Ghana believes that to improve the level of research into prostate cancer and answer key questions on testing and treatment the following needs to happen:

• The spend on research into prostate cancer must be increased to be no par with the amount spent on other common cancers like breast cancer in Ghana.

• There must be increased research directed at developing a new, specific diagnostic test for prostate cancer, capable of distinguishing aggressive prostate cancers from slow growing forms of the disease for black men.

• There must be increased research into prostate cancer prevention.

• There must be increased research into the improvement of survival and quality of life for men who have advanced prostate cancer in Ghana.

Geographical differences in outcomes for prostate cancer

1.5.1. Ghana must also speed up with a cancer register because there are considerable variations in death rates from prostate cancer across the country, which suggests variations in treatment and care. For instance, in the UK a recent report from The Prostate Cancer Charter for Action demonstrates that the gap between the highest and lowest prostate cancer mortality rates in England in 2007 was 45 per 100,000 populations. The gap increased by 14 deaths per 100,000 from 2006. At least 18% of England's 529 parliamentary constituencies have a death rate from prostate cancer more than 25% above the England average, with men in Tottenham almost 5 times more like to die of prostate cancer than men in South East Cambridgeshire. This geographical variation means that 300 deaths a year from prostate cancer could be prevented if all Cancer Networks across the country performed at the level of the nine best-performing Cancer Networks.

1.5.2. The Prostate Cancer Charter for Action's report also suggests that a failure to implement the NICE Improving Outcomes in Urological Cancers Guidance by some cancer networks has a negative effect on patient outcomes. The average age-standardized mortality rate from prostate cancer in those cancer networks which have implemented the guidance is 4% higher than those networks which have met the deadline.

1.5.3. The NICE Improving Outcomes in Urological Cancer Guidance highlights a link between the volume of radical prostatectomies carried out in a center and the mortality rate. Centers with a low or medium volume of prostatectomies had a higher mortality rate than centers with a high volume of prostatectomies. Although the number of centers with a low or medium volume of prostatectomy's has decreased since 1997/98, in 2007/08 there still 65 Trusts carrying out fewer than 40 procedures a year (it is recommended that each team carrying out prostatectomy's should carry out a cumulative totally of at least 50 operations per year).

1.5.4. In order to reduce the level of geographical variations in outcomes for prostate cancer it is vital that:

• Ghana health system needs a check and balance and the country probably needs a version of The Improving Outcomes in Urological Cancer Guidance introduce and be fully implemented as a matter of urgency, so as to ensure consistent care across the country and patients confidence will be boasted when they visit urologist in the country.

• Services and treatment be available at the same level quality across all the country.

1.6. Other areas of inequality
There are also two additional areas of inequality that the Charity would like to highlight:

1.6.1. Gender
1.6.1.1. Prostate cancer only affects men and there are a number of inequalities that are linked to gender within health. Men access healthcare, especially primary care, significantly less than women across a range of health conditions, and it has been suggested that they often wait until they are in considerable pain or are convinced they have a serious problem before consulting a health professional.

This delay in seeking help can impact on the stage at which cancer is diagnosed in men and later diagnosis can reduce treatment options and survival chances. Research has shown that men are at significantly greater risk of dying of all the common cancers that occur in both men and women (except breast cancer). For example, UK and Europe-wide data on malignant melanoma shows that while women are more likely to develop this type of cancer, men are more likely to die from it. This is almost certainly because men present when the cancer is more advanced and harder to treat. There are number of potential reasons for the delay in seeking help. Men often find themselves faced with a number of practical barriers to accessing healthcare, including the demands of long working hours and problems with accessing primary care services near the workplace. Therefore the government must ensure that services are accessible to men in the locations and at times that will encourage them to use services

1.6.1.2. Very little is known about how men deal with cancer and what their support needs are. It is known that the psycho-social aspects of cancer diagnosis and treatment may affect men and women differently, and that there is a gender difference in terms of the psychological responses and social factors that may impact on progress post-diagnosis. These may include differences in access to social networks and levels of emotional support between men and women and differences in help-seeking behaviors; however the exact nature of these differences is not fully understood and there is a lack of research into the best methods to support men. This lack of knowledge about men and cancer has the potential to cause inequalities in access to support for men.

1.6.1.3. In order to enable the gender inequalities in cancer care to be addressed a number of actions needs to be taken:

• There must be an increase in research into how men deal with cancer and their support needs. Ghana must also set up a National Cancer Equalities Initiative and the National Cancer Survivorship and these Initiatives should lead on this area of work.

• The government must ensure that they do all they can to ensure services are fully accessible to men.

1.6.2. Sexual alignment and prostate cancer
1.6.2.1. It is not known how many gay and bisexual men are living with prostate cancer in Ghana because of lack of cancer registries to collect data on sexual orientation. However as prostate cancer is the most common male cancer, we can assume that a significant number of gay and bisexual men are also affected by the disease. There are a number of potential inequalities that may be faced by gay and bisexual men, for example gay men may have difficulties dealing with health professionals who are likely to assume a female partner. The impact of side effects of treatments on relationships and identity may also differ, and may lead to different support needs. There is also some evidence of homophobia among health professionals which impacts on the ability of gay and bisexual men to access healthcare generally. Unfortunately there is, a severe lack of research addressing the question of potential inequalities relating to sexual orientation. A Department of Health review of the publications database Medline did not find any research on prostate cancer among gay and bisexual men.

1.6.2.2. In order to begin to address the inequalities in prostate cancer care for gay and bisexual men Men's Health Foundation Ghana believes that research is needed into the experience of gay and bisexual men specifically living with prostate cancer so that we can identify any inequalities experienced and ensure their needs are being addressed.

2. Why Men's Health Foundation Ghana think cancer inequalities exist?

There are a number of potential reasons why inequalities exist in relation to prostate cancer treatment and care which are provided below:

2.1 In order to reduce inequalities in access to care for instance the UK NICE produced a series of guidance for commissioners on commissioning services for cancers called Improving Outcomes Guidance. The recommendations in the guidance focus on aspects of services that are likely to have a significant impact on health outcomes for patients. These include measures to improve patient-centered care like better support and information, and recommendations about Multi-Disciplinary Teams such as their staff make-up, role and operational levels.

2.2 Prostate cancer was one of the last major cancers that NICE produced Improving Outcomes Guidance for (in 2002 compared to the Improving Outcomes in Breast Cancer which was published in 1996).

In the UK for instance The NHS has therefore not had as long to implement the recommendations for prostate and urological cancers as they have had for other cancers and only 30% of cancer networks in England met the December 2007 deadline in the Cancer Reform Strategy for implementing the guidance.

2.3 The provision of services for prostate cancer is also dependent on how local health commissioners choose to use their budgets and whether prostate cancer is a local priority. This means there is considerable potential for geographical variations in service provision to develop. Variation in service provision at a local level has the potential to impact on patient experience, treatment, care and outcomes. It appears that variation in service provision does not always relate to incidence or level of need. This is demonstrated by the variations in the provision of CNS's between Cancer networks, i.e. the networks with the highest incidence of prostate cancer do not necessarily have the highest numbers of CNS's. This again demonstrates why it is so important that Ghana needs the Improving Outcomes guidance and other guidance such as the NICE clinical guidelines for prostate cancer, Prostate cancer: diagnosis and treatment, to create a consistent level of treatment, care and service provision and providers must implement it.

The Nation Health Insurance Authority must also make prostate cancer a priority in Ghana and can incorporate free prostate cancer screening into their services for men 40years and above.

2.4 The smaller amount spent on research into prostate cancer compared to some other common cancers leads to gaps in knowledge both about the disease and also about the needs of men with prostate cancer. This may have an impact on the provision of support services for men with prostate cancer compared to the provision of support for patients with other cancers. For example insufficient research into the psychological effects of prostate cancer is a barrier to the development and widespread adoption of a range of services and interventions similar to those available for breast cancer to be developed for prostate cancer.

Inequalities specific to cancer or do they imitate wider health and socio-economic inequalities?

3.1 Some inequalities discussed are specific to cancer and in particular to prostate cancer whereas others reflect wider health and socio-economic inequalities. For example that men with prostate cancer experience inequality in patient experience compared to other common cancers is a specific issue. Whereas the lower levels awareness of prostate cancer in African Caribbean communities may be viewed as part of wider issues about awareness ofhealth messaging generally in black communities. Also, gender inequalities in prostate cancer tend to reflect wider health inequalities.

3.2 Geographical variations in service provision exist across a wide range of health services and are not specific to prostate cancer. However, there may be particular reasons for these variations that are specific to prostate cancer, such as the delay in full implementation of the National guidelines on Improving Outcomes Guidance and National Cancer Plan Strategy

4. What Men's Health Foundation Ghana think cancer equality look like?

There are a number of aspects of cancer equality:
• Equality of access to high quality treatment and care regardless of where you live and your individual background.

• Equality of knowledge, research and services between different cancers.

• Equality of treatment outcomes between different cancers and irrespective of geographical location.

• An equally high satisfaction with patient experience for all people irrespective of cancer type, geographical location, ethnicity, age, gender, sexual orientation or any other dividing factors.

5. What Men's Health Foundation Ghanathink should be the priorities for research into cancer inequalities?

5.1. Men's Health Foundation Ghana has identified the following priority areas that we believe should be prioritized for research into cancer inequalities:

• Research into why men access healthcare services less than women in order to enable the development of strategies to improve men's access to healthcare.

• Research into what the particular support needs of men are in order to develop support services, including psychosexual support, that meet men's needs and improve their patient experience.

• Research into incidence, survival, awareness, barriers to accessing services and support needs of different ethnic groups, including Men of West African descent communities so as to enable action to be taken to minimize the impact of the increased incidence in African men.

• The extent of and the reasons for the geographical variations that occur in terms of provision of services.

5.2. It is vital that regular patient experience surveys are carried out and their results reported so that areas with lower patient experience can be tackled and the success of work to do so, monitored.

5.3. It is vital that research spend between different cancers be evened out and the amount spent on prostate cancer research to be increased to a comparable level with the highest of the other common cancers. Without this the historical legacy of neglect and underfunding of prostate cancer will continue.

Do Men's Health Foundation Ghana think that better data collection help in tackling cancer inequalities in Ghana? If so, how and why?

6.1. Better data collection would help considerably in tackling cancer inequalities. Currently data is not consistently collected in Ghana on a number of areas relating to inequalities such as ethnicity, sexual orientation, or the patient experience of older men. The lack of comprehensive data collection hinders attempts to accurately track and identify variations in incidence, to monitor access to services and treatment, and rates of survival and prognosis between different groups. It also impedes attempts to measure whether targeted work to improve equality have made a difference.

6.2. It is vital that the National Cancer Plan Strategy in Ghana look at issues of ethnicity, sexual orientation, geographic location ,stage of cancer and age or the data will be meaningless in terms of tracking cancer inequalities.

What evidence does Men's Health Foundation Ghana have of cancer inequalities in access, treatment, patient experience and outcomes in either health or social care services?

The evidence of cancer inequalities supporting the issues discussed in this submission are referenced at the end, however there are a number of reports that Men's Health Foundation Ghana feels are central to this issue:

• Tackling Cancer: Improving the Patient Journey (UK National Audit Office, 2005) provides evidence of a worse patient experience by men with prostate cancer.

• Hampered by hormones? Addressing the needs of men with prostate cancer (The Prostate Cancer UK, 2009) reports on research into the experience of men on hormone therapy for prostate cancer and access to information and support to help them live with the impact of hormone therapy treatment on their lives (provided).

• To What Outcome? An audit of cancer networks' implementation of Improving Outcomes Guidance (Prostate Cancer Charter for Action, 2008) provides evidence of the geographical variations in the implementation of the recommendations of NICE in Improving Outcomes in Urological Cancers and the impact that this has on patient outcomes and mortality - http://www.prostatecharter.org.uk/.

• Because Men Matter: the case for Clinical Nurse Specialists in prostate cancer (Prostate Cancer Charter for Action, 2007) provides data on the differences in provision of CNS's and the size of CNS workloads between prostate cancer and other common cancers, and on the geographical variations in the provision of CNS's for prostate cancer.

• The Real Man's Prostate Cancer Journey (The Prostate Cancer UK, 2005) highlights areas where standards need to be improved, such as information provision.

• Research by Ethnibus commissioned by The Prostate Cancer UK (2008) into the levels of awareness of prostate cancer in African Caribbean men.

How should the NHIS work with Men's Health Foundation Ghana to reduce cancer inequalities?

8.1. It is vital that the NHIS work with a wide range of organizations to enable them to reduce cancer inequalities in Ghana. This includes working in a co-ordinated way with cancer charities, for example, using their expertise to gather evidence on patient experience and need, and to provide better access to information and support for patients. In addition to working with cancer charities it is important that the Ghana Health service and NHIS work with a wide range of community organizations to maximize the number of different groups they are able to reach with cancer awareness messages and support services. It is important that whichever organizations the NHIS works with they do so in a sustainable way, for example offering longer term funding rather than short term grants, as often expertise on inequalities is lost because staff are only able to be employed on short term contracts.

8.2. It is also vital that patients and the public are involved in the commissioning of local services and setting priorities. Although there is patient and public involvement in the health service this is not always conducted in a meaningful way and more must be done to ensure it is not tokenistic. Charities have the potential to enable widespread involvement in healthcare by patients and the public, and it is essential that the Ghana Health Service and NHIS do everything possible to ensure they can be effective. Additionally it is vital that patient and public representatives are drawn from a cross section of service users to reach minority groups and ensure they are empowered to participate fully in involvement opportunities.

8.3. Many organizations working in healthcare have developed excellent examples of best practice. For instance Men's Health Foundation Ghana is well placed to identify, co-ordinate and facilitate sharing of best practice work on inequalities and should undertake this role.

Do you have any examples of good practice in tackling inequalities?

Men's Health Foundation Ghana has developed a number projects that provide examples of good practice in tackling inequalities in Ghana.

9.1. One of the Charity's five strategic goals is that by 2025 all Ghanaian men and women will know more about prostate cancer and will act on that knowledge, as they are at higher risk of prostate cancer. In order to achieve this we have undertaken a number of projects within the Ghanaian community. The focus of the Charity's work with Men of West African descent communities is on working directly with the community – with men and their families, support groups, community centers, faith groups – as well as raising awareness amongst health professionals about the increased risk of prostate cancer.

9.2. The Men United V Prostate Cancer campaign was staged this year to raise awareness of the increased risk of prostate cancer in men from the West African descent and promote access to health care services.

9.3. The charity will also be training Ghanaian men in various communities to become “community champions”, delivering awareness sessions about prostate cancer to their own communities.

9.4. High quality training for health professionals is crucial in tackling inequalities. The charity will also be collaborating with some institutions of higher learning in the country to deliver a course in prostate cancer. The course will provide health professionals with advanced training in prostate cancer and new ideas and resources to enhance service delivery and meet the needs of men with prostate cancer. Training such as this can help improve standards of care, and similar training for health professionals across the country has the potential to make some impact on the geographical variations in prostate cancer outcomes and experiences.

9.5. To address the issue of access to support for men with prostate cancer Men's Health Foundation Ghana established the first free prostate cancer screening center in the country at Dodowa-Akoto House and integrative oncology clinic to address men's prostate cancer needs.

What realistic goals can be set for reducing cancer inequalities? What should be the priorities for action? What is one thing you would do to reduce cancer inequalities?

10.1. In Transforming the future for prostate cancer: Men's Health Foundation Ghana 2025goals and 2015-2016 strategy we set out a series of realistic goals for improving prostate cancer treatment and care, of which most had targets for tackling inequalities in prostate cancer (a copy of the strategy is provided).

• Goal 1 – By 2025, significantly more men will survive prostate cancer.

In order to achieve this more research is needed to develop a new, specific diagnostic test for prostate cancer.

• Goal 3 – By 2025, Ghanaian men and women will know more about prostate cancer and will act on that knowledge.

In order to achieve this work must be done to increase awareness in Ghanaian communities as to their heightened risk of prostate cancer, and the support and information needs of West African black men must be identified and incorporated into service delivery.

Goal 4 – By 2025, inequalities in access to high quality prostate cancer services will be reduced.

In order to achieve this all men affected by prostate cancer, regardless of where they live in Ghana, must have access to the same range of treatment and services, and the patient experience of men with prostate cancer must be increased to be at least equal to that of other common cancers.

• Goal 5 – By 2025, people affected by prostate cancer will have their information and support needs addressed effectively.

In order to achieve this all men diagnosed with prostate cancer must have their information and support needs assessed throughout their treatment and care, they must be provided with high quality information and have access to a CNS.

Men's Health Foundation Ghana believes meeting these goals will significantly improve the experience of all men with prostate cancer including those who currently experience inequalities.

10.2. Men's Health Foundation Ghana believes Ghana needs National Survivorship Initiative (NCSI) and the National Awareness and Early Detection Initiative (NAEDI). These institutions needs to set up projects to tackle the worst inequalities in cancer care and use these projects to promote and facilitate sharing of best practice on tacking inequalities both within the NHIS and within external organizations.

10.3. If all the groups and organizations involved in cancer and equality work can start to work together in a co-ordinated way under strong national leadership we can start to make a meaningful impact on cancer inequalities.

In tacking inequalities we often put people into 'equality categories' and tackle one issue at a time. We need to remember that individuals are multifaceted, for example someone can be of West African ancestry, African Caribbean, homosexual etc.

Dr. Raphael NyarkoteyObu:ND(TAP 00396)
Integrative Oncologist/Prostate Cancer Community Champion

MSc Prostate Cancer
Sheffield Hallam University, UK
Policy Officer
Men's Health Foundation Ghana
[email protected]
0541090045
References:
Yoav Ben-Shlomo et al. The risk of prostate cancer amongst Black men in the United Kingdom: The PROCESS cohort study. European Urology 2008; 53 99-105

Yoav Ben-Shlomo et al. The risk of prostate cancer amongst Black men in the United Kingdom: The PROCESS cohort study. European Urology 2008; 53 99-105

Rabjabu K et al, Racial origin is associated with poor awareness of prostate cancer in UK men, but can be increased by simple information, Prostate Cancer and Prostatic Diseases 2007; 10, 256-260

Ethnibus research for The Prostate Cancer Charity, February 2008

I to I research for The Prostate Cancer Charity, November 2008

Ethnibus research for The Prostate Cancer Charity, February 2008

C Metcalfe, S Evans, F Ibrahim et al. Pathways to diagnosis for Black men and White men found to have prostate cancer: the PROCESS cohort study. British Journal of Cancer 2008, 99; 1040-1045

National Audit Office, Tackling Cancer: Improving the patient journey. The National Audit Office, London, 2005

The Prostate Cancer Charity. Hampered by Hormones? Addressing the needs of men with prostate cancer, Campaign Report, 2009

National Institute for Health and Clinical Excellence. Improving Outcomes in Urological Cancers: the Manual. National Institute for Health and Clinical Excellence, London 2002

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