Strategies for Improving Access to Effective Prostate Cancer Medications (Abiraterone and Enzalutamide) in Low- and Middle-Income Countries (LMICs): A Survey Among Nigerian Health Professionals

Abstract

Introduction

The burden of prostate cancer (PCa) is disproportionately concentrated in low- and middle-income countries (LMICs). Abiraterone and enzalutamide have improved survival rates and quality of life for men with PCa. However, cost constraints limit access to these medications due to limited insurance coverage and out-of-pocket payments. The survey assessed the current practices and opinions of Nigerian clinical oncologists and urologists regarding the use of low dose abiraterone and enzalutamide for the management of metastatic PCa.

Methods

This survey consisted of twenty multiple-choice questions, distributed via Google Forms to urologists and oncologists in Nigeria from August to November 2024. It examined current practices, awareness of effective dose reduction strategies, and opinions on their cost-effectiveness. The collected data were entered into Microsoft Excel, and responses were presented using tables and charts.

Results

A total of 104 respondents completed the survey. Among them, 37 (36%) reported that 61%–80% of their patients initially presented with advanced PCa. Additionally, 55 respondents (53%) were unaware of studies and guidelines regarding low-dose abiraterone. Furthermore, 66% of clinicians indicated that fewer than 20% of their patients could afford abiraterone, and 91 (87.5%) noted that few could afford enzalutamide. Moreover, 92 (89%) respondents believed that low-dose abiraterone would improve compliance, while 76% felt that reducing the enzalutamide dose would also enhance compliance and decrease patient costs. Sixty percent (58%) of respondents were willing to switch to low-dose abiraterone.

Conclusion

The survey revealed limited awareness of landmark studies on dose-reduction strategies for abiraterone and enzalutamide. These strategies have the potential to enhance affordability and compliance in the management of advanced PCa in Nigeria.

Plain Language Summary

Prostate cancer is a major health issue for men in many low- and middle-income countries, including Nigeria. Two medications — abiraterone and enzalutamide — have been developed to help men with advanced prostate cancer live longer and feel better. Unfortunately, many patients in Nigeria cannot afford these treatments, as they often have to pay out of pocket, and health insurance coverage is limited. To better understand how Nigerian doctors manage this issue, we surveyed 104 urologists and cancer specialists. We asked them about their experiences treating men with advanced prostate cancer and their views on using lower doses of abiraterone and enzalutamide as a way to reduce costs. What we learned in our survey was; About 1 in 3 doctors said that most of their patients are first diagnosed when the cancer is already advanced. More than half of the doctors did not know about studies that support using lower doses of these medicines. Most doctors said less than 1 in 5 patients could afford abiraterone, and even fewer could afford enzalutamide. Almost 9 out of 10 doctors believed that using lower doses would help more patients stay on treatment and reduce costs. Over half of the doctors said they would be willing to use low-dose abiraterone. In summary, many Nigerian doctors are open to using lower doses of these important prostate cancer drugs to make treatment more affordable. However, there is a need to raise awareness about existing research that supports this approach. Making lower-dose treatment options more available could improve care for men with advanced prostate cancer in Nigeria.

Introduction

Prostate cancer (PCa) is a global health concern, contributing substantially to cancer-related morbidity and mortality. While precise etiology remains elusive, several risk factors have been identified, including advanced age, familial predisposition, and African ancestry. ¹ The burden of PCa is disproportionately concentrated in low- and middle-income countries (LMICs), particularly in Sub-Saharan African (SSA) countries like Nigeria. ² Nigeria is the most populous country in Africa, with a population exceeding 230 million. Disparities documented in people of African descent are attributed mainly to socioeconomic factors and genetic susceptibility. ³ Among malignancies in SSA, PCa exhibits the highest age-standardized incidence, mortality, and 5-year prevalence rates. ⁴

Cancer awareness in SSA remains limited, with restricted access to specialized oncological care. Emerging research suggests that PCa in men of SSA ancestry exhibits aggressive behavior, with an accelerated transition from latent to aggressive forms. ⁵ The burden of PCa in SSA may be underestimated due to several factors: inaccurate data since only 11% of Africa’s total population is covered by cancer registries, ⁶ limited availability of early diagnostic tools such as Prostate Specific Antigen (PSA) testing, insufficient access to digital rectal examination, inadequate biopsy services for differentiation between malignant and benign disease, and weak health management systems. These challenges underscore the urgent need for improved cancer surveillance, enhanced diagnostic capabilities, and strengthened healthcare infrastructure in SSA. ⁷

Metastatic Prostate Cancer (mPCa), classified into castration-sensitive (mCSPC) or metastatic hormone-sensitive prostate cancer (mHSPC), and castration-resistant (mCRPC), requires systemic treatments to overcome receptor pathways.^4,5 Abiraterone and Enzalutamide are pivotal drugs in the treatment of multiple stages of mPCa, ⁸ resulting in improvements in survival and quality of life compared to earlier treatments that focused solely on androgen deprivation therapy (ADT).^9,10 Despite the availability of these effective therapies, significant barriers to treatment in LMICs persist. In resource-constrained contexts, such as Nigeria, barriers including high out-of-pocket costs, limited access to novel agents, and deficiencies in oncology infrastructure —particularly diagnostic capacity —continue to hinder the effective treatment of the disease. These barriers not only limit the timely initiation of life-prolonging therapy but also exacerbate disparities in survival between high- and low-resource settings. Collectively, these challenges underscore the pressing need for treatment strategies that strike a balance between clinical efficacy, affordability, and feasibility.^11,12 In efforts to develop treatment strategies that balance clinical efficacy with affordability, studies have investigated lower-dose regimens. Evidence indicates that administering reduced doses with food can achieve pharmacokinetic exposure comparable to that of standard dosing. A study by Szmulewitz et al and other randomized clinical trials (RCTs)^13,14 reported such outcomes when 25% of the registered dose of abiraterone was administered after meals, compared to the full dose. Several retrospective studies and real-world analyses have evaluated the potential for these lower doses to make treatment more accessible and sustainable, as well as to improve global access, particularly in low-resource settings. ¹⁵

Several large randomized controlled trials (RCTs) have demonstrated that adding enzalutamide (160 mg/day) to ADT provides similar benefits to the addition of abiraterone to ADT.^10,15 Although these agents work by different mechanisms, they are essentially interchangeable in their ability to improve prostate cancer outcomes at every stage of the disease. Recent retrospective studies have explored the efficacy of reduced-dose enzalutamide in mPCa treatment, comparing low-dose (≤80 mg/day) to standard-dose (160 mg/day) enzalutamide and have demonstrated fewer adverse events. ¹⁶ These studies suggest that reduced-dose enzalutamide may offer comparable efficacy with fewer side effects, particularly in older patients. ¹⁶ While these dose reduction strategies offer opportunities that may improve affordability and accessibility, several critical concerns remain. It is essential to assess clinician awareness, confidence, and acceptability, as prescribing behaviors are significantly influenced by both the strength of evidence and perceived standards of care. We conducted a national survey to assess the awareness, current practices and opinions of Nigerian urologists and oncologists regarding the use of low-dose abiraterone and enzalutamide in mPCa.

Methods

Conforming to the STROBE guidelines for observational studies, ¹⁷ we conducted a cross-sectional survey. We employed a purposive sampling method to assess the current practices and opinions of Nigerian medical oncologists and urologists regarding the use of low-dose abiraterone and enzalutamide in men with metastatic prostate cancer (mPCa). Participants are prostate cancer specialists (oncologists and urologists) at various treatment centers located across Nigeria’s 6 geopolitical zones (Appendix 1). Participants were sourced from professional associations and conferences. Data were collected using a self-administered questionnaire on low-dose Abiraterone by Patel et al. ¹⁵ Our survey, consisting of 20 multiple-choice questions, was distributed via Google Forms from August to December 2024. To minimize the risk of bias arising from missing data, we set all questions as mandatory, ensuring that participants completed every field before submission. This study was exploratory; therefore, no formal sample size calculation was undertaken. Instead, recruitment was targeted at including as many eligible specialists as possible within the study period, to enhance optimal representation across the nation. The survey instrument evaluated: (i) Clinicians’ experiences with prostate cancer patients, including the proportion of patients presenting with advanced or metastatic disease, (ii) Clinical indications for abiraterone use, its affordability in the clinicians’ localities, and the estimated percentage of patients able to afford the medication, (iii) Clinicians’ perceptions regarding the potential benefits of lower dosages of abiraterone in improving patient compliance and reducing costs, as well as the challenges associated with its use, (iv) Awareness of studies that have investigated optimized dosing strategies with food or other approaches that maintain efficacy while minimizing costs and side effects, and (v) willingness to adopt such strategies in their practice. A parallel set of questions was posed regarding enzalutamide, allowing for a comprehensive understanding of clinicians’ experiences and opinions regarding both medications (The full questionnaire is in Appendix 2).

Responses were summarized using absolute frequencies and percentages. For clarity, we grouped some quantitative variables into categorical ranges. The distribution of responses was presented in bar charts, pie charts, and tables, which were generated based on the responses compiled from the Google Forms survey instrument. Only descriptive statistics were employed in this study.

Results

The survey results showed that most respondents, 61.5% (N = 64), were urologists, while 38.5% (N = 40) were oncologists. Responses were received from 50 prostate cancer treatment facilities, with the highest participation from the South-West region, specifically Lagos, Ogun, Ondo, Oyo, and Osun states (Table 1).

The survey revealed that most patients present with advanced or metastatic prostate cancer; 37 (36%) and 34 (33%) of respondents reported that 61%–80% and 41%–60% of their patients, respectively, presented first with advanced or metastatic PCa, emphasizing that late presentation is characteristic of PCa in SSA (Table 2). Awareness of dose de-escalation strategies for abiraterone remains limited. Only 40.4% of clinicians were familiar with the landmark study by Szmulewitz et al (2018), which demonstrated that 250 mg of abiraterone taken with a low-fat meal achieves similar pharmacokinetic and clinical outcomes as the standard 1000 mg dose administered on an empty stomach. Additionally, only 40% of clinicians know that the latest NCCN guidelines have endorsed a dose-reduction strategy for abiraterone to 250 mg with a low-fat breakfast as an alternative to abiraterone 1000 mg after overnight fasting (Table 2). Abiraterone is frequently prescribed by respondents (64%), using both generic and brand-name formulations, such as ZYTIGA (24%). The cost of generic abiraterone ranges from N150 000 ($95) to N250 000 ($150) per month for the full dose (1000 mg), while branded abiraterone (Zytiga) costs approximately N1 350 000 ($850) per month. The economic advantage of dose de-escalation is apparent, as 95% of clinicians agreed that reducing the abiraterone dose would significantly lower costs and enhance patient compliance (89%) (Table 2). Hence, a reduction of dose to 250 mg will reduce the monthly cost to about $20 for generics and $200 for branded (Zytiga).

Affordability remains a substantial barrier, with 66% of clinicians reporting that fewer than 20% of their patients can afford abiraterone. Most (94%) of patients must pay out of pocket, with minimal support from health insurance or government intervention programs (Figure 1). A substantial proportion of the respondents (58%) expressed willingness to switch from 1000 mg fasting to 250 mg with food, while another 26% would prescribe the lower dose for cost-constrained patients (Figure 2). The survey showed that 24% of clinicians prefer to prescribe branded drugs, 13% prefer generics, while 66% of the respondents prescribe both generic and branded (Zytiga). This highlights a growing acceptance of dose optimization to improve affordability and access (Table 2).

Most clinicians (91, 87.5%) reported that few patients could afford enzalutamide. However, a substantial proportion of them (76%) believed that reducing the enzalutamide dose from 160 mg/day to 80 mg/day would improve compliance, and 94% agreed that this strategy would lower costs. However, the clinical adoption of this approach remains limited, with only 45% expressing a willingness to switch and 37% prescribing the lower dose only for cost-constrained patients (Table 3). The cost of generic enzalutamide ranges from N350 000 ($220) to N450 000 ($280) per month, while the branded enzalutamide (Xtandi) costs approximately N1 650 000 ($ 1050) per month. Hence, a reduction of dose to 80 mg will reduce the monthly cost of enzalutamide to about $110 for generics and $525 for branded (Xtandi). Enzalutamide affordability presents a challenge, as 98% of clinicians reported that patients must pay out-of-pocket, and 88% indicated that fewer than 20% of their patients can afford the medication. Meanwhile, 16% of clinicians prefer to prescribe branded drugs, 33.3% prefer generics, and about half of the respondents prescribe both generic and branded (XTANDI) types of enzalutamide (50.5%) (Figure 3).

Discussion

The present survey results offer insights into the current perspectives of Nigerian oncologists and urologists on dose reduction strategies for men with mPCa. The findings highlight the interplay between clinical awareness, economic constraints, and the willingness to adopt cost-saving strategies, particularly in resource-limited settings such as Nigeria. Despite compelling evidence from Szmulewitz et al., ¹³ only a few of the surveyed clinicians were aware of the study demonstrating that 250 mg of abiraterone, taken with food, achieves pharmacokinetic and clinical outcomes similar to those of the standard 1000 mg fasting dose. This lack of awareness is concerning, as the study offers a simple alternative for reducing treatment costs and mitigating financial toxicity among patients. ¹³ Additionally, very few respondents were aware that the latest NCCN guidelines incorporated this dose-reduction strategy, further highlighting knowledge translation and implementation gaps. This aligns with the limited dissemination of knowledge on low-dose abiraterone strategies. ¹⁸

Our study’s findings on the lack of awareness stand in contrast to Patel et al, who reported that many oncologists in India were already familiar with, and in some cases had adopted, the low dose low-dose Abiraterone strategy. ¹⁵ Addressing this observed knowledge gap requires systems that go beyond guideline publication to strengthen physician education and the dissemination of evidence-based guidelines. Nigeria has platforms such as the Continuing Professional Development (CPD) framework, the Society of Oncology and Cancer Research of Nigeria (SOCRON), and the National Cancer Control Plan (NCCP), which emphasize oncology training and guideline dissemination.^19–21 However, these programs often lack disease-specific focus, consistent funding, and the mechanism to evaluate knowledge uptake and practical application. Adapting NCCN guidelines into CME modules on mPCa within NCCP rollouts, tied to measurable learning outcomes and CME credits, could enhance dissemination and clinician awareness. A substantial barrier to optimal prostate cancer management in Nigeria is the high cost of medications. Most clinicians also reported that few of their patients could afford abiraterone. This statistic aligns with broader concerns raised by The Lancet Commission on Prostate Cancer (2024) regarding access to advanced prostate cancer treatments in LMICs, ⁷ given that a substantial percentage of the surveyed clinicians recognize that reducing the abiraterone dose to 250 mg would dramatically lower costs, and dose reduction could offer a critical solution to address financial barriers and improve patient compliance. Similarly, financial constraints limit the use of enzalutamide, with more respondents indicating that few of their patients can afford it. Bromley et al (2024) have demonstrated that reducing enzalutamide to 80 mg/day from the standard 160 mg/day can maintain efficacy while reducing adverse effects and costs, particularly relevant for older patients or those with comorbidities. ²² We found that branded drugs in Nigeria cost 5 to 7 times more than generic medications. Utilizing generic brands, after a proper assessment of efficacy, could provide an additional strategy to address financial barriers through cost reduction, alongside dose reduction, and improve patient adherence. Globally, the generic oncology drugs market was valued at USD 26.9 billion in 2023 and is projected to grow at a 5.8% Compound annual growth rate (CAGR) from 2024 to 2032, attributed to the global rise in cancer cases.^23,24

Limited insurance coverage for lower-dose prescriptions may further hinder the adoption of this approach. Through the Cancer Health Fund, the Nigerian Institute for Cancer Research and Treatment (NICRAT) aims to align national cancer control efforts with global standards while addressing local challenges, such as late-stage diagnoses and treatment inequities. ²⁵ It is also well-positioned to address these issues through policy updates and training initiatives. Pharma-sponsored initiatives also exist to reduce treatment costs, such as Janssen’s Abiraterone and Astellas’s Enzalutamide assistance programs; however, these programs mainly target insured or pre-qualified patients, as well as local regulatory collaborations in a given country.^26,27 Specifically in Nigeria, the American Cancer Society-Clinton Health Access Initiative collaboration and Roche’s cost-sharing model with Nigeria’s NHIA have improved access to selected cancer medications, narrowing affordability gaps while reducing financial toxicity and addressing inequities in PCa care by promoting dose reduction as a cost-saving measure.^28,29 Unfortunately, these programs have limited coverage for advanced therapies, such as abiraterone and enzalutamide, highlighting the need for national strategies that improve the affordability of these medications.

Clinicians overwhelmingly support the notion that dose reduction could enhance patient adherence. Respondents agreed that lowering abiraterone from 1000 mg to 250 mg/day would improve compliance, and they also believed the same for enzalutamide, reducing it from 160 mg to 80 mg/day. This is consistent with real-world data, which demonstrated that a lower dose of abiraterone resulted in fewer treatment interruptions due to cost or side effects. ¹⁸ Similarly, improved adherence has been reported with lower-dose enzalutamide, particularly in patients who experienced adverse events with the standard dose. Unfortunately, the economic and clinical benefits of dose reduction are evident, but its practical adoption remains inconsistent. ²² The use of both branded and generic types of abiraterone and enzalutamide appears to be driven primarily by clinicians' beliefs about efficacy, rather than perceived cost differences. This is especially given that clinical equivalence between treatment responses in cancer treatment has been a prominent concern in these discussions. The lack of local guideline endorsements and physician education will also affect broader implementation.

Strengths and Limitations

This study explores the broad representation of clinicians across various geopolitical zones and healthcare institutions in Nigeria, thereby enhancing the generalizability of the findings. By capturing insights from both urologists and oncologists actively managing PCa, the study provides an understanding of current prescribing practices and prevailing attitudes towards dose de-escalation strategies. Furthermore, the study addresses a significant gap in the literature by examining the practical application of evidence-based dose-reduction strategies in a low-resource setting, which is particularly relevant given the economic constraints faced by patients in Nigeria. A weakness of the study is that it did not incorporate patient perspectives, which are crucial for a comprehensive understanding of the impact of cost, adherence, and overall treatment experience in the context of dosing, these will be explored in further studies. Additionally, the survey required stable internet access, potentially excluding clinicians from areas with poor internet connectivity.

Conclusion

The survey highlights the potential benefits of implementing dose reduction strategies in managing mPCa in Nigeria, by reducing the standard dose of abiraterone to a quarter (from 1000 mg to 250 mg) and standard dose of enzalutamide to half (from 160 mg to 80 mg), we may reduce the cost of these effective medication, putting it in a range many Nigerian patients can afford, hence improving accessibility, affordability and compliance. However, gaps remain in awareness, clinical adoption, and regulatory endorsement among Nigerian physicians. Addressing these gaps through clinician education, policy updates, and further real-world validation could facilitate greater uptake of cost-effective treatment strategies, ultimately improving outcomes for Nigerian patients with metastatic prostate cancer.

Supplemental Material

Supplemental Material - Strategies for Improving Access to Effective Prostate Cancer Medications (Abiraterone and Enzalutamide) in Low- and Middle-Income Countries (LMICs): A Survey Among Nigerian Health Professionals

Supplemental Material for Strategies for Improving Access to Effective Prostate Cancer Medications (Abiraterone and Enzalutamide) in Low- and Middle-Income Countries (LMICs): A Survey Among Nigerian Health Professionals by Omolara Fatiregun, Onyeanunam Ekeke, Egbuchilem Chisor-Wabali, John Raphael, Charles Okpani, Kufre Udoh, Okigbeye Danagogo, Oto-Obong Peters, Olusegun Biyi-Olutunde, Nwamaka Lasebikan, Temitope Olatunji, Omisanjo Olufunmilade, Ikuerowo Odunayo, Abolarinwa Abimbola, Basit Balogun, Boluwatife Borisade, Nicholas James, and Ian Tannock in Cancer Control