32 low grade disease, that is, Gleason grade 1 (p = 0.028) and absent lymph node metastasis (p = 0.016). Those with negative history of breast cancer among rst-degree family members were more likely to have T1 stage (p = 0.002), low grade disease, that is, Gleason grade 1 (p = 0.006) and absent lymph node metastasis (p = 0.018). Certain smoking patterns (onset, intensity and frequency) have been shown to be associated with higher poorly 52, 53, 54 differentiated Pca. Just over half of the participants in our study had never smoked cigarettes. Of the group that smoked, the majority smoked 6–10 cigarettes daily. Smoking ≥ 6 cigarettes per day was associated with metastatic PCa (p = 0.035). Vitamin D deciency has been associated with certain 55 cancers, including PCa. Sunlight exposure is a vital process in producing vitamin D3 in the skin from 7-dehydrocholesterol, which is metabolised in the liver 56 and kidney into the active form. Sun exposure in early life has been shown to protect against PCa. Frequent sun exposure in adulthood has been shown to be associated 57 with a signicantly reduced risk of fatal PCa. As shown in Table 2, the majority of the participants younger than 50 years report 2 h – 5 h of weekly exposure to sunlight. Participants in their 50s and older mainly reported less than 2 h sun exposure per week. A decreased exposure to sunlight was associated with T3 or T4 tumour stage (p = 0.003) and metastatic disease (p = 0.032). Physical activity helps to decrease the deposition of central adipose tissue. It also lessens circulating levels of inammation, insulin and unfavourable sex hormones, 58 thereby preventing PCa progression. As seen on Table 3, the majority of the participants engaged in weekly physical activities of ≤ 5 h across the life phases. Less than 2 h walk per week was associated with T3 or T4 tumour stage (p = 0.019). Certain diets or eating habits have been associated with 14, 54 an increased risk of developing Pca. The staple foods in most Southern African nations are corn, wheat-based and dairy products. Also, agriculture and farming are among the prevalent industries in the Free State province; these may therefore explain the reason for the majority of the participants consuming carbohydrates (96.4%) and dairy products (80.5%) 1–3 times daily. Certain cultures believe a meal is incomplete without meat. Also, as earlier stated, the province is notable for agriculture and farming; hence, there may be a relative increased access to these food products, including fruits and vegetables. As shown in Table 4, the majority of the participants consumed red meat (57.9%), poultry (90.8%), sh (47.2%), fruits and vegetables (60.7%) 2–6 times per week. The majority (72.9%) of participants in their 20s and 30s ate fast food less than once a week. This may be because of a lack of affordability. The frequency of consuming fast food, however, increased to once a week (55.7%) in those over 40 years of age. Eating fruits and vegetables 2–4 times per week was associated with T1 tumour stage (p < 0.001) and grade 1 or 2 disease (p = 0.009). Also, eating sh 2–6 times per week was associated with T1 tumour stage (p < 0.001), grade 1 or 2 disease (p = 0.005), absent lymph node metastasis (p = 0.031) and absent distant metastasis (p = 0.021). On the contrary, daily consumption of red meat was associated with T3 or T4 tumour stage (p < 0.001), grade 4 or 5 disease (p = 0.007), lymph node metastasis (p = 0.005) and distant metastasis (p = 0.033). Also, the use of dairy products ≥ 2 times per day was associated with T3 or T4 tumour stage (p < 0.001) and grade 4 or 5 disease (p = 0.008). While treatment delay of several months or even years may not affect outcomes of men with low-risk PCa, the 59 same cannot be said when the PCa is not low-risk. In a study among patients who underwent radical prostatectomy, a surgical delay time of up to six months after diagnosis was not associated with higher risks of having any adverse pathological outcomes or worse 60 61 overall survival. In another study among patients who underwent low-dose-rate brachytherapy, treatment delay of more than six months appeared to adversely correlate with biochemical recurrence- free survival. Therefore, it was suggested that even low-and intermediate-risk PCa patients should have brachytherapy performed within six months of the diagnosis. Our study showed that most (93.5%) of the participants had histological conrmation of the disease within three months of referral from a primary health care facility. Also, the majority (98.8%) had commenced treatment within six months of diagnosis. Therefore, there seem to be no signicant systems delays in the diagnostic and therapeutic process relating to PCa at the higher healthcare facilities of the Free State province. Strengths and limitations As far as we know, this is the rst study in the study setting focusing on the more vulnerable group, that is, men of African descent. However, several limitations of this study should be noted. Firstly, certain relevant information was absent in the patients' case les, making it mandatory to interview live subjects; the use of case les (alone) would have increased the sample size, giving more credence to the study. However, all possible subjects were included in the study and data collection continued until data saturation was reached. Secondly, this was a crosssectional descriptive study; therefore, a cause–effect relationship cannot be claimed. Lastly, with a median age of 66 years among the participants, recall bias was possible. Conclusion and recommendations Late-stage (T3 or T4), poor grade (Gleason ≥ 8) and metastatic PCa disease are not uncommon among men ≥ 60 years in our study setting. The majority had LUTS prior to diagnosis but were of poor health-seeking behaviour. Certain modiable risk factors associated with advanced disease such as smoking, decreased sunlight exposure, decreased physical activity and increased ingestion of red meat and dairy products were established in this study. Despite poor awareness of the participants prior to PCa diagnosis, once diagnosed, there was no delay in treatment. Because of the high prevalence of advanced and high-grade PCa disease and the possible associated modiable risk factors along with poor awareness of the disease, a prompt community-specic health promotion strategy is needed. Also, targeted PSA screening should be considered among men with nonmodiable risk factors and even more promptly in the presence of LUTS. Acknowledgements The authors would like to thank the medical, nursing and administrative staffs of the urology and oncology clinics for their support during this study. Thanks also goes to the Departments of Family Medicine, Urology and Biostatistics for their support. They also wish to thank Mr C. van UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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