Response to Bosland

We thank Maarten C. Bosland, University of Illinois at Chicago, for further highlighting the importance of a concerted effort to address prostate cancer (PCa) presentation across Sub-Saharan Africa,1 which as pointed out in our Brief Communication,2 is shockingly scarce. As a retrospective study, the team was dependent either on hospital records (Kenya) or pathology records (South Africa), the latter allowing for further pathological observation for benign prostate hyperplasia (BPH) and/or prostatitis. While a much-needed snapshot across the last decade, with a notable deterioration of record-keeping the further we went back in time, both teams acknowledge that missing or unconfirmed pathological information cannot be ignored. However, as concluded, and in contrast to GLOBOCAN 2022 data,3 our results suggest an underestimation of PCa in East Africa, observing a 1.44-1.46-fold greater risk for International Society of Urological Pathology (ISUP) grade group 4/5 disease over Southern Africa.2 Notably, and at the request of Bosland, when we further break down the age and prostate-specific antigen (PSA) levels by ISUP grade group and country at presentation (Table 1), while observing a 2-year increased age at presentation between ISUP1 and ISUP5 in Black South Africans, in Kenya the converse was observed, where age at presentation decreased by 3 years between ISUP1 and ISUP5. The latter concurred with our original observation that age was not a confounder for aggressive disease at presentation (both ISUP and PSA) in our study (see original Figure 1D and E). Again, as previously highlighted by Bosland et al.,4 and observed with regard to the highly heterogeneous presentation of PSA levels across the regions represented in our study,2 African nations require an African centered solution, from screening guidelines to prevention, prognosis, and treatment, to tackle the significant PCa burden across the continent.