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Onyeanunam Ngozi Ekeke: I am from Port Harcourt, the oil city in West Nigeria, West Africa. Prostate cancer is the leading cancer in terms of incidence and mortality in Africa among men. The incidence is still rising due to improving diagnostic capabilities and also the actual rise in incidence. There is poverty, and as a result, poorly funded health infrastructure. The hallmark is late presentation and delayed diagnosis leading to poor outcomes. There is, therefore, the need to adopt strategies to improve diagnosis for better outcome.

So this will involve shortening the diagnostic interval, doing risk assessment, getting patients and physicians in a shared decision-making process for early detection. And then when you diagnose, you do the staging. There is lack of knowledge of prostate cancer among our men, and there is lack of accessible, affordable, and culturally responsible primary health care services. With the resultant patients presenting with advanced and terminal diseases, we see patients coming with fracture of the long bones and paraplegia as first presentation.

So patient education is crucial. If we raise the awareness about prostate cancer risk, it will lead to earlier presentation and diagnosis. We need to adopt community-based campaigns to help disseminate the information. So patient screening and early detection—I know that screening is controversial but research shows that screening is very beneficial to Blacks and Africans. Early detection is important, and we advocate shared decision-making. Screening of target groups will improve specificity and avoid overdetection.

Now, what we are looking at is developing a risk stratification model specific to Africans. And by the way, I'm talking more for sub-Saharan Africa except South Africa, because the North African countries—North African and the others—are slightly different. So I'm talking about sub-Saharan Africa.

So the person's age is important. They raise the family. PSA—here we are not talking about just PSA level, but all the PSA derivatives. And then yesterday we were told that DRE may not be so important, but it is very important in Africa. And we don't have a problem convincing people—I don't have that experience. We just explain and they adopt it. So we look at all the PSA derivatives, using them to make a diagnosis.

Now, another thing is that prostate cancer tends to occur earlier among Africans and also progresses more. So we advocate starting screening at the age of 40 years. And we don't have any study right now to say when to stop, so we adopt the universal 70-75 years of stopping. And of course, apart from those with family histories and those carrying mutations, we also consider age-specific thresholds in PSA. We advocate a one-year interval in testing.

So the second strategy is to increase access to biopsy services. Because a lack of biopsy services hinders accurate diagnosis, we need to promote training of health care workers to perform biopsies and interpret the results. And we advocate image-guided biopsies.

However, we have a few places now where we can have mpMRI. So where available, we advocate that they use them. But the common thing in Africa is the use of ultrasound-guided biopsies. And we prefer the transperineal approach so that it can reduce infection.

But this may sound shocking or primitive, but over 30% of diagnoses are done by finger- or digitally-guided biopsies. And the yield is high because most of them present late, so it's easier to get that. Immunohistochemistry services are available but limited. Now, there may be a need for repeat biopsies, and we have specific indications. We can also utilize biomarkers when available, as well as genetic testing where available. I will come back to that.

So imaging is important. It helps us in decision-making for biopsies and staging, and it will also guide biopsies. Where available, we prefer pre-biopsy MRI. Then it will help in staging and detection of metastasis. Currently, we have conventional imaging in most centers. For MRIs, we have some 1.5 Tesla.

And regarding bone scan machines, in a country as big as Nigeria, we have only two isotope bone scan machines. For the new generation imaging, as my colleague just said, about a year ago or thereabouts, we have a new PET CT scan. So we have it available—we advocate that it should be used.

But what we want to say is collaboration for limited resources. So the best way to help us is regionalization. For instance, for immunohistochemistry services, we have four centers that pool their resources so we can send the sample to that place. We also advocate telepathology so that we can share the slides with other centers.

And genetic testing—our cancer registry is problematic. So if we can regionalize it, which we have done, it can help. We need a multidisciplinary approach: the urologists, radiologists, pathologists, and oncologists developing guidelines specific for Africa to help improve the diagnostic pathway.

In conclusion, we need a comprehensive approach involving creating awareness, infrastructure development, training of the workforce, research and collaboration, and all this will lead to policy changes that will strengthen the capacity for early prostate cancer diagnosis to address this rising challenge. Thank you very much.