Cancer in men

1. REPRODUCTIVE CANCER FOR MEN
WAKHONDERACHI LIKHA
LINUS SAKANDA
MERCY NANDOLO KALANJE
June 1 st 2023

2. OUTLINE
• Introduction and background
• Statistics
• Current global and local policies
• Programmes
• Evaluation of programmes; opportunities, challenges, areas of research, leadership
roles
• Recommendations

3. BACKGROUND
• Cancer is a major cause of morbidity and mortality worldwide, with approximately 14
million new cases in 2012 and 8.8 million deaths in 2015 and it is the second leading
cause of death globally.
• Nearly two thirds of cancer cases and deaths occur in low- and middle-income
countries (LMICs) where resources available for prevention, diagnosis, treatment and
palliation are limited.

4. BACKGROUND
• Cancer is a leading cause of death worldwide, accounting for nearly 10 million deaths in 2020, or nearly
one in six deaths.
• The most common cancers are breast, lung, colon and rectum and prostate cancers.
• Around one-third of deaths from cancer are due to tobacco use, high body mass index, alcohol
consumption, low fruit and vegetable intake, and lack of physical activity.
• Cancer-causing infections, such as human papillomavirus (HPV) and hepatitis, are responsible for
approximately 30% of cancer cases in low- and lower-middle-income countries.
• Many cancers can be cured if detected early and treated effectively. (WHO 2022).

5. BACKGROUND
• In sub saharan Africa, cancer is a major public health problem, affecting many of
the region’s 1 billion inhabitants.
• The disease is among the three leading causes of premature death (i.e. at ages 30–
69 years) in almost all constituent countries.
• It is responsible for 1 in 7 premature deaths overall and 1 in 4 deaths from
noncommunicable diseases.
(Lyon et al., 2022 )

6. BACKGROUND
• Estimated cancer incidence has doubled in sub-Saharan Africa over the past 30 years,
leading to more than 520 000 deaths in 2020.
• Unless steps are taken to reverse the trends, annual cancer deaths in sub-Saharan
Africa will likely reach 1 million by 2030 and incidence will likely double again by
2040, according to a comprehensive report by The Lancet Oncology commission.
Larkin et al., (2022)

7. BACKGROUND
• In Malawi cancer is of growing concern, causing significant morbidity and mortality
due to lack of comprehensive cancer prevention, early detection, treatment and
palliative care services.
• The IARC GLOBOCAN estimates for Malawi indicate total annual new cancer cases
at 15,349, with 5966 cases among men and 9383 in women around 2012.

8. BACKGROUND
• Cancer registration activity in Malawi dates back to 1980, when pathologists at
Queen Elizabeth Central Hospital (QECH) began reporting on surgical specimens
received at the hospital from districts across the country.
• Later in 1985, a formal pathology-based cancer registry was established within the
histopathology department at QECH.
• In 1993, the registry was expanded to become population-based (PBCR) with the aim
of complete registration of all incident cancer cases occurring within the population
of the city of Blantyre and its surroundings, to enable calculation of incidence rates

9. BACKGROUND
• During the period 2008–2010, a total of 3711 cases were recorded among residents of
Blantyre (both urban and rural), 1,643 males corresponding to an ASR of 169.8 per
100,000.
• (Chasimpha et al.2018).

10. MALE REPRODUCTIVE CANCERS
There are a few different types of reproductive cancers that occur in men. The most
common ones are:
● Testicular cancer – begins in the testes, the two egg-shaped glands that make sperm in
the scrotum (ball sac) near the base of the penis
● Penile cancer – begins in the penis, part of the external genitals.
● Prostate cancer – begins in the prostate, a gland inside the pelvis (the area in the
lower belly between the hip bones) that surrounds the urethra (the tube that empties
the bladder)

11. TESTICULAR CANCER
● Testicular cancer is a disease in which malignant (cancer) cells form in the tissues of
one or both testicles.
● Health history can affect the risk of testicular cancer.
● Signs and symptoms of testicular cancer include swelling or discomfort in the
scrotum.
● Tests that examine the testicles and blood are used to diagnose testicular cancer.
● Certain factors affect prognosis (chance of recovery) and treatment options.
● Treatment for testicular cancer can cause infertility.

12. TESTICULAR CANCER STATISTICS; GLOBAL
• Testicular cancer is relatively uncommon and accounts for <1% of all male tumors.
• However, it is the most common solid tumor in men between the ages of 20 and 34
years, and the global incidence has been steadily rising over the past several decades.
• White men are four times more likely than Black men to have testicular cancer.

13. TESTICULAR CANCER STATISTICS; GLOBAL
• In 2020, the International Agency for Research of Cancer (IARC) recorded 74,458
new cases worldwide.
• Incidences vary greatly across the globe, ranging from 3 to 12 new cases per 100,000
males/per year in Western societies.
• In contrast, figures are very low in Asian and African countries. European White men
seems to be more affected overall, independently of the country of residence and
migration compared to other ethnicities.

14. TESTICULAR CANCER STATISTICS; GLOBAL
• Incidence is increasing worldwide, and some countries, such as Slovenia and the
Netherlands, registered a doubling of testicular cancer cases in the last two decades.
Reasons are still unclear.
• An estimated 9,560 new cases of testicular cancer will be diagnosed in the United
States in 2019, resulting in approximately 410 deaths, which reflects the excellent 5-
year survival rate for this disease (∼95%).

15. TESTICULAR CANCER STATISTICS; AFRICA
• The incidence of testicular cancer in Africa is among the lowest worldwide; however,
it is highly likely to be underreported.
• It ranges between 0.3 and 0.6 cases per 100,000 .
• According to IARC, the African continent accounted for 3302 cases which
represented the 4.4% of the total in 2020.
• Data from GLOBOCAN 2008 show relatively high mortality rates in Sub-Saharan
countries like Mali, Ethiopia, Niger, and Malawi.
• Mortality rate has shown a reverse trend to its incidence with higher rates in low- and
middle-income countries (0.5 per 100 000) than in high-income countries.

16. World map of estimated number of new testicular cancer cases in
2020

17. The most common risk factors contributing to testicular cancer
development (Int. J. Mol. Sci. 2015,)
Int. J. Mol. Sci. 2015,

18. DIAGNOSING PENILE CANCER
• Medical history and physical exam.
• Biopsy; Incisional biopsy, Excisional biopsy, Lymph node biopsy.
• Imaging tests; Computed tomography (CT), Magnetic resonance imaging (MRI),
Ultrasound, Chest x-ray.
,

19. TREATMENT FOR TESTICULAR CANCER
Treatment of recurrent testicular cancer may include the following:
• Combination chemotherapy.
• High-dose chemotherapy and stem cell transplant.
• Surgery to remove cancer that has either: come back more than 2 years after
complete remission.
• Clinical trials of a new therapy are underway.

20. PENILE CANCER
• Penile cancer is a disease in which malignant (cancer) cells form in the tissues of the
penis.
• Human papillomavirus infection may increase the risk of developing penile cancer.
• Signs of penile cancer include sores, discharge, and bleeding.
• Tests that examine the penis are used to diagnose penile cancer.
• Certain factors affect prognosis (chance of recovery) and treatment options.

21. PENILE CANCER
• Penile cancer is rare in North America and Europe.
• It's diagnosed in fewer than 1 man in 100,000 each year and accounts for fewer than
1% of cancers in men in the United States.
• Penile cancer is much more common in some parts of Asia, Africa, and South
America.

22. PENILE CANCER STATISTICS
• The estimated age-standardized incidence of penile cancer worldwide was 0.80 per
100,000 person-years in 2018, and the incidence is predicted to increase by more than
56% by 2040, according to the Global Cancer Registries (GLOBOCAN) Cancer
Tomorrow prediction tool.
• In certain Asian, African, and South American countries, the incidence of penile
cancer constitutes up to 10% of malignancies in men.
• The 5-year survival rate of penile cancer is about 65% but greater in countries with
greater access to treatment .

23. PENILE CANCER STATISTICS
• The incidence of penile cancer has been increasing in many areas in the past
few decades.
• There was a 21% increase, from 1.1 to 1.3 per 100,000, in penile cancer
incidence in England between 1979.
• and 2009 ; in Norway, the incidence of penile cancer increased from 0.6 to
0.9 per 100,000 between 1956 and 2015;
• the incidence of penile cancer in Germany increased from 1.2 per 100,000 in
1961 to 1.8 per 100,000 in 2012.

24. PENILE CANCER STATISTICS
Prediction of Incidence and Mortality Patterns in 2020
• The global estimated ASIR of penile cancer was 0.8 (per 100,000) in 2020, with estimates
indicating 36,068 newly diagnosed cases.
• The ASIR of penile cancer varied among 5 continents, with higher ASIRs being observed
in Southern Africa, South Asia, and South America. In 2020, the largest number of
incident cases was estimated to have occurred in India (n=16,677), China (n=4628), and
Brazil (n=1658).
• The highest ASIRs were found in Eswatini (7.0 per 100,000), Uganda (4.6 per 100,000),
and Botswana (4.4 per 100,000), while the lowest were mostly concentrated in countries in
Northern Africa, such as Nigeria and Libya (less than 0.01 per 100,000).

25. PENILE CANCER STATISTICS
• Estimates suggest that 13,211 men with penile cancer died in 2020 globally,
corresponding to an ASMR of 0.29 cases per 100,000 .
• Geographical patterns of ASMR were similar to those of ASIR, and the highest penile
cancer ASMRs were noted in Eswatini (3.5 per 100,000) and Uganda (2.4 per
100,000).
• The largest number of deaths occurred in India (n=4760), China (n=1565), and Brazil
(n=539) in 2020.

26. cont…

27. RISK FACTORS FOR PENILE CANCER
• Infection with human papillomavirus (HPV)
• Smegma and uncircumcised penis
• Age more than 70 years
• Smoking

28. DIAGNOSING PENILE CANCER
• Medical history and physical exam.
• Biopsy; Incisional biopsy, Excisional biopsy, Lymph node biopsy.
• Imaging tests; Computed tomography (CT), Magnetic resonance imaging (MRI),
Ultrasound, Chest x-ray.
,

29. TREATMENT OF PENILE CANCER
• Surgery is the main treatment for most men with penile cancers
• radiation therapy may be used, either instead of or in addition to surgery.
• Other local treatments (circumcision) might also be used for early-stage tumors.
• Chemotherapy may be given for some larger tumors or if the cancer has spread.

30. PROSTATE CANCER
• Prostate cancer is a disease in which malignant (cancer) cells form in the tissues of
the prostate.
• Signs of prostate cancer include a weak flow of urine or frequent urination.
• Tests that examine the prostate and blood are used to diagnose prostate cancer.
• A biopsy is done to diagnose prostate cancer and find out the grade of the cancer
(Gleason score).
• Certain factors affect prognosis (chance of recovery) and treatment options.

31. PROSTATE CANCER STATISTICS
•Prostate cancer is the second most commonly diagnosed cancer and the fifth leading cause of cancer death
among men worldwide, with an estimated 1.41 new cancer cases and 375,304 deaths in 2020 (WHO 2022) .
•Prostate cancer is the most frequently diagnosed cancer in 112 countries, and the leading cause of cancer
death in 48 countries .
• It is worth noting that the burden of prostate cancer is supposed to increase owing to the population aging
and economic growth.
(wang et al.,2022).

32. PROSTATE CANCER STATISTICS
• The incidence rate of prostate cancer varies across the regions and
populations .
• Prostate cancer incidence rates are highly variable worldwide. The age-
standardized rate (ASR) was highest in Oceania (79.1 per 100,000 people)
and North America (73.7), followed by Europe (62.1).
• Conversely, Africa and Asia have incidence rates that are lower than those
from developed countries (26.6 and 11.5, respectively) .
(Globocan 2018).

33. PROSTATE CANCER STATISTICS
• International mortality rates for prostate cancer vary considerably worldwide. In 2018, the
highest mortality rates were recorded in Central America (10.7 per 100,000 people), followed
by Australia and New Zealand (10.2) and Western Europe (10.1).
• The lowest rate was reported in the countries of Asia (South-Central, 3.3; Eastern, 4.7 and
South-Eastern, 5.4) and Northern Africa (5.8).
• One-third of the deaths for prostate cancer occurred in Asia (33.0%, 118,427 of deaths),
followed by Europe (29.9%, 107,315 of deaths).
• The mortality rate of prostate cancer rises with age, and almost 55% of all deaths occur after 65
years of age . (Globocan 2018).

34. PROSTATE CANCER STATISTICS
• Interestingly, a trend towards an increase of prostate cancer incidence worldwide with
1,017,712 new cases (+79.7% overall change) up to 2040 is estimated.
• The highest incidence of prostate cancer will be registered in Africa (+120.6%),
followed by Latin America and the Caribbean (+101.1%) and Asia (100.9%).
• On the contrary, the lowest incidence will be registered in Europe (+30.1%).
(RawlaP.2019)

35. Malawi Prostate cancer
• Number of new cases of prostate cancer in 2020 were 934 (13.8%) of all male
cancers. (Globocan 2020)
• The incidence of prostate cancer in malawi is at 2.7% with a mortality of 2.6%
(Cancer Country Profile 2020)
• According to the latest WHO data published in 2020 Prostate Cancer Deaths in
Malawi reached 271 or 0.28% of total deaths.

36. Fig. 1: World map showing age standardised world incidence rate of prostate
cancer (WHO,2018)

37. Fig. 2: World map showing age standardised world
mortality rate of prostate cancer (WHO,2018)

38. The most common causes contributing to prostate cancer development (Int. J. Mol. Sci.
2015,)

39. DIAGNOSIS OF PROSTATE CANCER
• Medical history and physical exam.
• Digital rectal examination.
• Biopsy; Incisional biopsy, Excisional biopsy, Lymph node biopsy.
• Imaging tests; Computed tomography (CT), Magnetic resonance
imaging (MRI), Ultrasound, Chest x-ray.
,

40. TREATMENT PROSTATE CANCER
• Cryotherapy. Placing a special probe inside or near the prostate cancer to freeze and
kill the cancer cells.
• Chemotherapy. Using special drugs to shrink or kill the cancer.
• Biological therapy.
• High-intensity focused ultrasound.
• Hormone therapy.

41. POLICIES AND GUIDELINES
GLOBAL
• National cancer control programmes; policies and managerial guidelines, second
edition, WHO, 2002.
• Cancer control; knowledge into action; WHO Guide for effective programmes; early
detection, 2007.
• Cancer control; knowledge into action; WHO Guide for effective programmes;
diagnosis and treatment., 2008

42. POLICIES AND GUIDELINES
• Cancer control; knowledge into action; WHO Guide for effective programmes;
palliative care, 2007.
• Guide to cancer early diagnosi, WHO 2017.
• WHO list of priority medical devices for cancer management; WHO Medical device
technical series, 2017
• Road map towards a national cancer control programme, WHO 2019.

43. POLICIES AND GUIDELINES
LOCAL
• Malawi National Reproductive Health Service Delivery Guidelines, 2014-2019.
• National cancer control strategic plan; Malawi, 2019-2029.

44. National cancer control strategic plan; Malawi, 2019-2029.
Has 6 themes
1. Cancer prevention
2. Screening and early diagnosis
3. Palliative care and survivorship.
4. Governance and financing of cancer control.
5. Cancer control research, monitoring and evaluation.

45. National cancer control strategic plan; Guiding principles
1. Equity and universal coverage
2. National ownership and leadership.
3. Primary health care.
4. Human rights based approach.
5. Gender sensitivity.
6. Ethical considerations.
7. Efficiency and effectiveness.
8. Coordination and collaboration.
9. Community participation.
10. Evidence based decision making.
11. Decentralization.
12. Appropriate technology.
13. Accountability for results and
expenditures.
14. Sustainability.

46. WHO FOCUS
• Prevention
• Early detection.
• Screening.
• Diagnosis and staging
• Treatment.
• Palliative care.
• Survivorship care.

48. PREVENTION
• Eliminating or minimizing exposure to the causes of cancer and reducing
susceptibility to the effects of such causes.
• This approach offers the greatest public health potential and generally the most cost-
effective interventions.
• Common priority cancer prevention activities include: controlling tobacco use
through the Framework Convention for Tobacco Control (FCTC); reducing alcohol
consumption; promoting a healthy diet and physical activity, reducing obesity; and
vaccination for hepatitis B and the human papillomavirus.

49. EARLY DIAGNOSIS
• Priority public health activity aimed to raise awareness of signs and symptoms
consistent with cancer, increase access to care, and diagnose and treat cancer at the
earliest possible stage.
• The primary objective of early diagnosis is to improve survival and quality of life of
individuals with cancer, by detecting and treating the cancer at its earliest possible,
potentially curable, stage.

50. SCREENING
• Public health programmes intended to identify and treat patients at risk, at an early
stage of cancer, should be done in an organized manner.
• That includes systematic invitation to a defined target population, application of a
screening test to asymptomatic individuals, notification of the results, diagnostic
examination of the screen positives, and treatment of the screen-detected cases.
• The primary objective of cancer screening is to reduce cancer-specific mortality at a
population level, by detecting the cancer at its earliest curable stage.

51. DIAGNOSING AND STAGING
• Accurate cancer diagnosis is essential for effective cancer management.
• This calls for a combination of careful clinical assessment and diagnostic
investigations including endoscopy, medical imaging, histopathology, cytology and
laboratory studies, which are selected taking into account the disease being evaluated.
• Once a diagnosis has been established, it is necessary to determine the location of the
disease and its spread (staging), in order to help in the selection of the appropriate
therapy and to establish the prognosis.
• Diagnostic techniques are also essential in the follow-up of patients to detect early
relapses and evaluate the efficacy of the established treatment.

52. TREATMENT
• Interventions intended to cure, prolong life, and/or improve quality of life. Treatment
may involve surgery, radiation therapy, chemotherapy, hormonal therapy, or a
combination of these.
• Supportive care is an essential component of cancer treatment.

53. PALLIATIVE CARE
• Palliative care is an approach that improves the quality of life of patients and their
families facing the problems associated with life threatening illness, through the
prevention and relief of pain and symptoms.
• Palliative care services should be available in every country and should be given high
priority, especially in resource-limited settings where cure of the majority of cancer
patients is likely to remain beyond reach for years to come.

54. SURVIVORSHIP CARE
• Set of services that include surveillance for recurrence or new primaries; prevention,
detection of new cancers; monitoring and managing long term toxicities; and
coordination of care to ensure survivor care needs are met.
• Survivorship care includes a detailed plan that contains a summary of the patient’s
treatment and follow-up care.

55. STUDIES ON MALE REPRODUCTIVE CANCERS
• Msyamboza, K. P., Manda, G., Tembo, B., Thambo, C., Chitete, L., Mindiera, C., Finch, L. K., & Hamling,
K. (2014). Cancer survival in Malawi: a retrospective cohort study. The Pan African medical journal, 19,
234. https://doi.org/10.11604/pamj.2014.19.234.4675.
• Mukhula, V., Sibale, D., Tarmahomed, L., Dzamalala, C., Msyamboza, K., & Chasimpha, S. (2017).
Characterising cancer burden and quality of care at two palliative care clinics in Malawi. Malawi medical
journal : the journal of Medical Association of Malawi, 29(2), 130–135.
https://doi.org/10.4314/mmj.v29i2.10
• Msyamboza, K. P., Dzamalala, C., Mdokwe, C., Kamiza, S., Lemerani, M., Dzowela, T., & Kathyola, D.
(2012). Burden of cancer in Malawi; common types, incidence and trends: national population-based cancer
registry. BMC research notes, 5, 149. https://doi.org/10.1186/1756-0500-5-149
• Makene, F.S., Ngilangwa, R., Santos, C. et al. Patients’ pathways to cancer care in Tanzania: documenting
and addressing social inequalities in reaching a cancer diagnosis. BMC Health Serv Res 22, 189 (2022).
https://doi.org/10.1186/s12913-021-07438-5

56. STUDIES ON MALE REPRODUCTIVE CANCERS
• Makau-Barasa, L. K., Manirakiza, A., Carvalho, A. L., & Rebbeck, T. R. (2022).
Prostate Cancer Screening, Diagnostic, Treatment Procedures and Costs in Sub-
Saharan Africa: A Situational Analysis. Cancer control : journal of the Moffitt
Cancer Center, 29, 10732748221084932.
https://doi.org/10.1177/10732748221084932
• David P Weller, Julietta Patnick, Heather M McIntosh, Allen J Dietrich (2009),
Uptake in cancer screening programmes,The Lancet Oncology, Volume 10, Issue 7,
Pages 693-699, ISSN 1470-2045, https://doi.org/10.1016/S1470-2045(09)70145-7.

57. PROGRAMMES EVALUATIONS
PROGRAMMES
• Prostate cancer awareness month, November 2019, ‘no shave’(by FDH BANK)
• Opening of the National Cancer Treatment Centre (NCTC) in Lilongwe, early 2020.
• Palliative care

58. NATIONAL CANCER CENTER
● The National Cancer Treatment Center (NCTC) in Lilongwe which was earmarked
for opening in 2019.
● The development and operationalization of the cancer centre is the single most
important initiative in the national cancer control program of Malawi given the fact
that cancer treatment is currently highly fragmented and provided in overextended
hospitals with limited infrastructure, consumable supply chain problems and limited
skilled and experienced human resources.
● The cancer center is planned within the campus of KCH, as a matrix type of cancer
centre with its own cancer surgery, radiotherapy, chemotherapy, hormone therapy,
palliative care, pathology and other allied diagnostic services, medical records and
hospital cancer registry services.

59. PALLIATIVE CARE
● Government of Malawi recognizes the importance of palliative care to improve the
quality of life and symptom burden for all patients and families affected by life
threatening illnesses including cancer.
● In October 2014, Ministry of Health, Government of Malawi formulated a national
palliative care policy to take forward the national agenda for the health sector.
● In Malawi, palliative care has a desk officer under the nursing directorate of Ministry
of Health.

60. PALLIATIVE CARE
● Palliative care services are conducted either as home visits, hospital visits or outreach
clinics in about 78 nationwide sites in 2016.
● This represented an increase of 15% from 72 sites in 2015.
● There were 1141 trained service providers in the same reporting period.
● There were 61,323 patients that accessed palliative care services representing 36% of
the cases that needed it. Adults contributed 76% while 24% were children.

61. CHALLENGES FOR CANCER TREATMENT
• Lack of awareness about male cancer among the general public, health care providers
and policy-makers
• Unavailable or non-existent high quality male cancer prevention and control services
• Fragmented or dysfunctional healthcare infrastructure
• Lack of effective referral systems
• Lack of appropriate public health policies
• Other competing health priorities (Inequalities)

62. CHALLENGES
Key challenges in the provision of cancer treatment services in the country include;
• High rate of late diagnosis while other cases go undiagnosed due to inadequate cancer services,
low awareness of symptoms;
• Low rate of treatment acceptance and adherence because of challenges of geographical access
,personal resources and use of alternative therapy instead of conventional therapies.
• Low index of suspicion by health providers;
• Inadequate and deficient diagnostic and treatment infrastructure;
• Poor referral systems, inadequate cancer specialists, lack of effective patient navigation systems
and direct and indirect costs associated with cancer treatment.

63. CHALLENGES
• Anti-cancerous drugs are in short supply with erratic supply chain, despite the
availability of the national essential medicine list.
• There are no radiotherapy services in the country.
• Significant proportion of patients present in advanced clinical stages and do not
complete the prescribed course of treatment due to various barriers, limitations and
challenges.

64. AREAS FOR RESEARCH
• Laboratory (e.g. biological mechanisms underlying cancer)
• Epidemiological (e.g. environmental or human behavioral factors)
• Clinical (e.g. determining most effective treatment)
• Psychosocial and behavioral (e.g. factors impacting on prevention, the response to
screening and impact of diagnosis and treatment)
• Health systems and health policies (e.g. how services can best be implemented and
organized
• Inequalities in cancer control

65. LEADERSHIP ROLES
• Advocate for government funding for cancer research.
• Develop a research agenda for cancer prevention and control in the national research
agenda.
• Create dissemination channels for research on cancer such as annual cancer
symposiums.
• Work with other research institutions to develop strategic process for facilitating
cancer research.

66. RECOMMENDATION
• Develop an effective training program for awareness on male reproductive
cancers.(Awareness-campaign)
• Counselling and information sharing about screening for male cancers.
• At a minimum, screening for every man > 55 years of age at least once in a year.
• Advocacy- for male reproductive cancer services.

67. References
• Assessing national capacity for the prevention and control of noncommunicable
diseases: report of the 2019 global survey. Geneva: World Health Organization;
2020
• Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al. Global Cancer
Observatory: Cancer Today. Lyon: International Agency for Research on Cancer;
2020 (https://gco.iarc.fr/today, accessed February 2021).
• Msyamboza, K. P., Dzamalala, C., Mdokwe, C., Kamiza, S., Lemerani, M.,
Dzowela, T., & Kathyola, D. (2012). Burden of cancer in Malawi; common types,
incidence and trends: national population-based cancer registry. BMC research
notes, 5, 1-8.

68. References
• Fu, L., Tian, T., Yao, K., Chen, X. F., Luo, G., Gao, Y., Lin, Y. F., Wang, B., Sun, Y.,
Zheng, W., Li, P., Zhan, Y., Fairley, C. K., Grulich, A., & Zou, H. (2022). Global
Pattern and Trends in Penile Cancer Incidence: Population-Based Study. JMIR public
health and surveillance, 8(7), e34874. https://doi.org/10.2196/34874
• Rawla P. (2019). Epidemiology of Prostate Cancer. World journal of oncology, 10(2),
63–89. https://doi.org/10.14740/wjon1191