31 Less than a quarter (22.3%) of the participants had ever heard of PCa prior to diagnosis. This is in keeping with 41 42, 43 local and international studies that have shown poor knowledge and awareness of PCa among Black men. Almost half (47.4%) of the 76 participants who had earlier heard of PCa had ever screened for the disease; there may be the lack of screening opportunities in the 13 public sector. Also, in a Kenyan study, despite massive education campaigns on PCa awareness, the screening rate was still low. Hence, apart from a knowledge gap, certain cultural factors were found to be responsible for the low turn-up for PCa screening. Risk factors for prostate cancer Certain modiable factors such as diet, lifestyle habits, infections and environmental exposure to chemicals or 9, 14 radiation, for PCa have been described. Positive associations between STDs have been 44, 45 described in studies. In our study, over a quarter (26.1%) of the participants reported past history of STDs. Regarding nonmodiable risk factors, about 15% of the participants gave a positive history of cancer among rst- degree family members. Literature has shown that a history of PCa in a rst-degree relative is associated 46 with aggressive disease. Likewise, a history of female breast cancer in rst- degree relatives was associated with an increased risk of PCa, often of a high grade. Stage and grade of prostate cancer among participants In this study, 39.0% of the participants presented with T stage ≥ T3, 22.0% presented with metastatic disease, and 48 24.6% had Gleason score ≥ 8. In a similar local study, 62.3% had T stage ≥ T3, and 43.7% had a Gleason score ≥ 8. This above-mentioned study included men of other races, and only participants on treatment were included; this may explain the differences in the stage and grade of the disease. Prostate cancer stage and grade at diagnosis and associations with participants' background characteristics and risk factors Marital status has been shown to be an important factor associated with PCa stage and grade at diagnosis. In a 49 study on marital status and PCa incidence, widowers were shown to have worse cancer stage at diagnosis. Although there was no association of statistical signicance between marital status and disease grade in this study, married participants were more likely to be aware of PCa (p = 0.034). Level of education and health literacy are risk factors for 50 a higher stage of PCa at diagnosis. Although there was no association of statistical signicance between education level and disease grade in this study, participants with at least asecondary level education were more aware of the disease (p < 0.001) and were more likely to have been previously screened for the disease (p = 0.001). The earlier the diagnosis, the better the prognosis. Worse prognosis has been shown where there is a decreased 14 awareness of the disease and late presentation. Our study showed that symptomatic men who presented earlier (within 6 months) were more likely to have T1 stage (p < 0.001), low grade disease, that is, Gleason grade 1 (p = 0.016), absence of lymph node metastasis (p = 0.010) and absent distant metastasis (p = 0.001). A study conducted in the United States showed an association between exposure to cadmium and 51 aggressiveness of PCa. In our study, participants with less than 10 years mine exposure were more likely to present with PCa without lymph node metastasis (p = 0.020). Participants with a negative history of PCa among rst- degree family members were more likely to present with UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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