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Nicholas James: So we were able to take questions now. Everybody's stuck perfectly to time, so we have time for questions. We have one online question at the moment, which is-- when we talk about prostate cancer incidence mortality, and management in Pakistan, it's asked for what numbers and percentages. So I think that's a question we can't answer directly because we didn't look specifically at countries, but we did look at regions. And it's very clear that Pakistan will see the same trends as we've outlined. So the same issues apply.

So if there are no questions from the floor, one of the things that-- just coming back to the diagnostic pathway, and specifically you gave a very clear outline of diagnostic pathways in Nigeria. And it's obviously a huge country with a huge population. How variable is availability and access? At the one end, you're saying MRI, and the other end digital-- digitally-guided biopsy, for example.

Onyeanunam Ngozi Ekeke: MRI is still very limited in number. And so even where they have just installed the machines, they need to train people how to utilize that. But ultrasound-guided biopsies is commonly done. But also there are several centers that don't even have that. And because the patients come late-- so if you put your hand into the annals, you can actually guide and see a lesion and get it. So we know that the diagnostic-- there are challenges in terms of yield, but because the patients come very late, they are also able to detect up to 60%.

Omolara Aminat Fatiregun: I'll just say something to you. I think just to add to his comment, at least when you think about the diagnosis, like MRI, in places like Lagos State, it's about 20 million people. It used to be the economic capital of Nigeria. So we have quite a number of MRI machines in Lagos state. But IN other regions of Nigeria, we still have that disparity, like in Port Harcourt. He is from the South-South, right? They have the machine there because that's a core city.

But when you go to regions, there are still regions that don't have availability of this services. So it's a little bit skewed, just like I mentioned that you have the reach that are able to afford this treatment, and you have the poor that it's financially toxic for them to access services because it's out of pocket payment. Thank you.

Nicholas James: So questions.

Audience Member: Hi. Just wondering if you could help us prioritize a little bit. It seems like in countries like Nigeria, I mean, we need help with everything-- from screening, to initial treatments, to imaging, to management of advanced metastatic disease. If you were going to prioritize one or two areas to start, what would be the best way to bring something to change the outcomes in this setting. And I'm just curious what you think would be the best value to start.

Onyeanunam Ngozi Ekeke: I think the best value would be to reduce the diagnostic interval. First of all, if we increase the awareness and then early detection, it will help because now, we have started having a few patients coming early. We offer either radical radiotherapy or radical prostatectomy. For now, we do open a laparoscopic. We don't have robots yet.

But if we-- looking at the outcome-- so if we can improve the diagnosis early, it will help us. So if we can get more people to support increased awareness screening, it will help.

Audience Member: So just so I understand, if people were aware, would access to screening, to say PSA screening, be widely available, or is that something still that you don't have the health care system structure to do?

Onyeanunam Ngozi Ekeke: Yes. First of all, even the standardization of the PSA, because of loss of control, only in few well-established hospitals that you can, actually, utilize the PSA. There's a lot of variations. And many laboratories are not standardized. So you cannot even utilize the PSA results. So if we have well-established laboratories, where the PSAs can be done, it will help.

Audience Member: So starting with just a mechanism to broadly create access to PSA-- some kind of mobile labs or things like this. I'm just trying to understand where we could-- because it seems to me I agree with you. That's where we can make the biggest impact. It's just diagnosing people earlier.

Onyeanunam Ngozi Ekeke: Yes. And then if we can support-- even if it's ultrasound-guided biopsies to be widely available, it can help also in terms of diagnosis.

Audience Member: That's great. Thank you.

Nicholas James: So actually, we have-- so Fernando, just bringing in a minute. But we have four additional panel members. We were planning to have a separate panel discussion at the end, but I think it might be worthwhile having the additional members introduce themselves, who haven't spoken. So we can draw you into the Q&A as well. So I can't see who's sitting in which order, but maybe we should start nearest me and move away.

Fernando Maluf: So to answer your question, when you look in Brazil, the public versus private, the chance of someone in the public system get diagnosis early is three times less than in the public. Because in Brazil, PSA is opportunistic. It's not obligatory. So the patients are not informed. But when you look at the same patient, same stage, public versus private-- you have a database. You have it published yet.

But the mortality for localized disease, public versus private, is twice as more in the public. So we couldn't dig out the treatments. But in our opinion, many of the patients with localized disease-- the lucky patients with localized disease in the public system, probably, have been treated palliatively, not curative. So I think one of the works is screening to the high risk population because the country cannot afford screening for everybody because the problem is not the PSA. It's what to do with so many people getting the diagnosis of prostate cancer.

I mean, how they are going to be treated if no screening has been done. The delays in surgery and lack of radiation therapy is a big issue at this point. And secondly, how to optimize treatment, such as hypofractionation. Developing centers, high volume centers, to do the radical prostatectomy. Change the agonist-antagonist for orchiectomy. So made to optimize treatment.

So my major concern is the curative part of the disease. Of course, we're thinking about the patient with metastatic disease, but we don't have a viable treatment for the localized patients. And that for me is the biggest issue. And that's where probably we would invest more money to cure patients because one is curable. And second, it's much cheaper than patients who evolve to metastatic disease.

Nicholas James: And just to comment on the PSA testing thing-- so one of the things we tested in this [INAUDIBLE] project I've been running in London was a point of care machine. In the end, we decided it wasn't particularly useful in the context we were doing because we can turn around venous blood reliably within 24 hours anyway. But we did test the machine, and it was very accurate.

And it's the size of a desktop printer, and it functions on just straight mains electricity. So it's quite a practical solution for mobile testing that is very easy to roll out. So next question from the floor.

Audience Member: Well, so first of all, I want to congratulate the organizers for this panel. It's not trivial to see such a high level conference, a panel like this. So thank you for the opportunity to see that and for the panelists. It was amazing. And more-- well, I know Fernando's initiatives in Brazil and his initiative in providing and organizing the developing country consensus. It was a very important initiative.

And going in that line, what we feel normally in developing countries-- I'm also from Brazil-- is that it's not easy for us to publish our own data. So we tend to create our own papers. But after a short while, these papers tend to follow and try to improve their impact factors and act like developed world papers. So for instance, all this data that we have just seen-- impressive data from Africa, from Brazil, from China, from India.

It's hard to see this data published. So my question to the panelists, to the North American panelists, and to the South hemisphere panelists is how do you see opportunities to demonstrate this data? Not only good data, but also real world bad data that we see. And maybe we can work on that data to foresee opportunities to improve health care for underdeveloped or developing countries.

Nicholas James: Can we maybe ask you to comment on that?

Vedang Murthy: How to publish our data-- that's the question, isn't it? There's a lot of stuff happening. How do we publish it? I think to be fair-- I mean, 10 years back, I used to think that we really cannot publish-- they don't accept. They reject. They comes from India. They reject. I had that kind of a feeling internally.

But over the time, I realized that if you present it well, it is about packaging it. And we have to learn to do that. We don't package any of our thousands and thousands of patients that we see, so we must learn to do that. I think that's what I tell my residents also-- how you package it, how you sell it to the world is important. And I think our focus has to be there because the data is all there. How you sell it to the world is what I have learned over time. That would be my comment.

Nicholas James: Yeah. And I would say that have been particularly successful at doing it as well. So this is why I asked you, yeah.

Audience Member: Hi. So Thanks for this very, very interesting presentations today. I have a question, especially for Dr. Maluf and Dr. Murthy from India and Brazil. Because what I heard from you is that there is a big opportunity in your country to participate into clinical researches, both sides, I would say, because you have a very densely populated countries and on the other side the patients may also benefit.

My point is, all the limitations to the health systems that you presented us may also be applicable outside of the prostate cancer management. So for instance, when it's about safety reporting into clinical trials or for instance, management of comorbidities, don't you think that these may somehow impact the data of the clinical research? And how can the scientific community interpret the intrinsic limitations that you now explained as exist in your country's in clinical trials, especially with long term outcomes like overall survival?

Fernando Maluf: Yeah, I think it's a good question. Many of the trials that have been run in Brazil have been audited by FDA and by other agencies. So I think my feeling is, yes, physician education has to be continuous. There is room for improvement. But like Brazil and some places in Latin America, they are quite mature to participate in the trials and even leading it. So there are some trials that Brazil is leading, which didn't happen 10, 15 years ago.

If I mentioned that 10 or 15 years ago, people will call me crazy. But this is a reality. And I think one of the reasons for that is because there are many more trials than before, but the population did not increase that much. So now having Latin America as a continent with so many people and so many patients, now becomes an opportunity for patients, but also for the farmers to run the trials in the country. Again, because I don't think that the coexistence traditional countries are going to run the trial as quick as they are in the past because the number of the trucks and the number of these strategies have increased exponentially.

So I think it's a win-win opportunity. And I think in my guess, the researchers and you have many researchers from Brazil and Latin America, they are quite mature in their centers. And these centers that I mentioned that we created these new research units, yes, it's a process. Initially they are not going to do complicated phase III trials, but there are some easy and not that easy trials. So we are now featuring and connecting the feasibilities to the centers.

Audience Member: Thank you.

Nicholas James: So last question from this part of the thing. Paul Nguyen.

Paul Nguyen: Yeah, thanks. Thanks, Nick. And this is such a great panel, and I'd love to see all the convergence from the panelists here. And I do have a question for Stacy Loeb. But just before I do, I Nick, you had wanted the panelists on the left to introduce themselves. So I'll pause for a moment and let them introduce themselves before I ask my question.

Nicholas James: I did. Yes Thank you for Yeah, I just wanted to let the discussion run. So we have additional panelists down the far end who we've picked for various reasons. So I'll ask you to introduce yourselves just to say about your background, and then we'll let you ask your question. And we have online panelists as well who is unable to attend in person. But yeah.

Mouna Ayadi: Thank you so much. I'm really glad to be here. I'm Mouna Ayadi. I'm from Tunisia. For whom I don't know where is Tunisia, Tunisia is a little country in North Africa. So I will talk about Tunisia and what we have in Tunisia. In Tunisia, we have two sectors private sector and public sector. And really we don't have problem with diagnoses in prostate cancer since we have MRI, since we have biopsy, guided biopsy, since we have health professionals who do a good job. But what really we have problem with high cost medication. And we have late approval for this medication. This is mainly the problem in Tunisia.

Nicholas James: Yeah, thank you. I think James is next here.

James N'Dow: Hi. I'm James N'Dow, professor of urological surgery in Aberdeen. As you can probably tell, I wasn't born in Aberdeen. I was born in the Gambia, West Africa. And I've been there 38 years now. And I had the great privilege of working with Nick and others looking at the early detection, chairing that subgroup. I spent a number of years as chair of the EAU guidelines, and the past two years adjunct Secretary General in the EAU responsible for the education portfolio. Thank you.

Franco Cavalli: Well, Nick, I will take two minutes to explain why I'm here. I'm Franco Cavalli. I am not a prostate cancer specialist, and I am not here because I have built up the Cancer Institute of which now Silke is the director, but because of the World Oncology Forum. So I am enlarging a little bit the topic, but it is very similar in many tumors.

So the World Oncology Forum I created in for the European School of Oncology to assess regularly the situation in the global fight against cancer. In 2012, we met in Lugano to answer the question, are we winning the war against cancer. 100 worldwide experts we're here. and the answer was scientifically yes, globally no. We put together an appeal with 10 measures which should be implemented. We met very many times, and last time last September, where we tried to evaluate whether in the last 12 years, the worldwide situation has become better or worse or the same.

I mean, we are very concerned because just looking at the low and middle income countries, it is calculated that between 2020 and 2040, the mortality for cancer will increase by 100%. And looking just a few days time, more than one third of African countries do not have one single radiotherapy machine. 75% of breast cancer patients who need that do not get trastuzumab, and so on and so on.

So we came to the conclusion that there are a few very important things which we should do together. The most important one is that we have to convince the international political organizations to deal with the cancer problem. They have refused to do that till now, because this has to do with improving the health care situation. So G20 and G7, they refused up to now to do that. But we have to put a lot of pressure in order to convince them, because we need some resources to start tackling the most important issues.

We have calculated together with the World Bank somewhere between $15 billion a year, which is not a lot if you consider that last year $2 trillion were spent for weapons. And looking at the most. Well, WHO, you will hear, has launched now three big project in cervical cancer, breast cancer, and childhood cancer. They are very important. But there are bigger issues.

The most important point is to invest a lot in prevention and early diagnosis. Because even in the rich countries where we have somehow a decrease in the cancer mortality, this is more due to prevention and early diagnosis than to treatment. And we know how prevention and early diagnosis could be structures in the low and middle income countries. But we need to invest in that.
And we have to invest in treatable cancer, for instance, through having many more radiotherapeutic machines but to have also drugs. I mean, India has shown one of the ways with this global procurement, but there is a huge problem. We have put together the 10 most important issues. And one was to have the possibility to offer a new model in generating new drugs, which would generate a drugs which are useful but also accessible for the vast majority of the world population. And this has not improved, has gotten worse in the last 12 years.

But there are possibilities. One is the Indian possibility. The other one is that nations should use compulsory licensing to oblige. They can do that according to the international law. And they can get then a cheap, generic, cheap good generics, even if the drug is still under patent.

Nicholas James: So I'm just going to stop you just.

Franco Cavalli: Yeah, I'm just stopping. Yeah just stopping. But I think that it is our responsibility as a researcher and as physician to build up this pressure because cancer within 20 years will be the most important cause of death worldwide in all countries.

Nicholas James: Thank you. And I absolutely. You've covered loads and loads of points all in one go there. So just to do two more quick introductions. So we have one person online. But just to finish the row here first.

Raffaella Casolino: Good evening. Good afternoon, everyone. It's Rafaela Casalino, Medical Oncologist and Technical Officer with the cancer team at WHO headquarters in Geneva. And there is also my colleague, the technical lead for the cancer team online, Andre.

Nicholas James: So I can see Andre in front of me, but I don't see him behind me.

Raffaella Casolino: But he can speak also. Can we hear?

André Ilbawi: Yes, can you hear me?

Raffaella Casolino: Yes, perfect.

André Ilbawi: Wonderful, wonderful. Well, I'm very sorry to not be there in person for such an important discussion. I'm based in Jerusalem. And given the difficult situation here, I've been unable to travel. But I would just like to make a brief remark of appreciation to you, Nick, and to the organizers for putting prostate cancer so highly on the agenda. Because as you heard from Professor Cavalli, the initiatives we have started at the grassroots and the session today, the meeting you're having is a reflection of the grassroots activation that's happening in prostate cancer. I hope we can comment on where WHO can support. But first and foremost and most critically, congratulations.

Nicholas James: Thank you. So, Paul, Thank you for being so patient. I have one more question from the floor as well. But we'll take your question first, and then we'll go to the panel discussion, which we've kind of half had now.

Paul Nguyen: Super, thank you. And what a great panel. It's really an honor to have everyone here. So my question for Stacy is Stacy, you pointed out the value of social media, both in the developed countries and in the lower and middle income countries, but also pointed out this great danger of misinformation. So what are some of the strategies that can be used to counter this health misinformation that's out there in developing in low and middle income countries?

Stacy Loeb: That's a great question. And first and foremost, they have these expressions like dilution is the solution to pollution. So even what we're doing here at this conference with millions of impressions having scientific experts participate in dissemination of evidence based information is absolutely critical. So as health care providers getting involved in public media and also even giving information prescriptions to our patients. As you can see, if somebody just goes online and searches, the top things that come up are very likely to contain misinformation.

So I think we actually need to be proactive about telling people good sources of representative, understandable sustainable information and contributing to the content wherever we can. But I think we can't do this alone. And we do need buy in from health care, professional societies, governmental organizations, international organizations, and putting out high quality information.

Nicholas James: And actually, a related question from the floor is, we've traditionally gone to people like pharma companies to help us fund our research. I mean, should we be going to tech companies to help us fund communications strategies?

Stacy Loeb: I think it's absolutely critical, just like we have these partnerships for the development of new treatment strategies. And this whole topic just needs a lot more attention. In medical training, there's not enough attention to public facing communications. There's a brief period in medical training about patient physician communication, like in a one on one encounter, but not so much training on the media and how to present what we do to lay audiences. So I think all of that needs much more attention.

Nicholas James: So we have another question. We have two questions. I think Neeraj was first. And so for the whole panel, and we have a lot of experts here in all sorts of different things. So Neeraj first.

Neeraj Agarwal: Yeah, what a fantastic panel. Such a great learning experience for me. So well done thank, Stacy, Dr. Yay. Everybody has great points. So coming to the telemedicine, how do you manage side effects? So prescribing abiraterone low dose all sounds great. But I think managing side effects through telemedicine can be very challenging.

Inequalities exist everywhere. It exist where I practice. So what can I learn from you from the perspective of managing the side effects such as blood pressure, hypertension, hypokalemia of abiraterone? And this can be extrapolated to any treatment.

Vedang Murthy: And I can talk about radiotherapy. Hypertension is not one of the problems that we create. It's fairly simple. I think for prostate radiotherapy if we are talking. And we have developed this whole trial. This is especially for the trial patients. I mean, we were talking about how to make the data more robust coming from India and Brazil.

So there is this trial WhatsApp whole system that we have created and patients report in their toxicity, their CTCAE. We give them a little form photo. They take that, take a picture, and send it back. So that is one way to do it. We also collect quality of life on that. So that is a record for us. So that's how we do it in the trials. That is telemedicine, isn't it?

Neeraj Agarwal: Of course, you talked about National Cancer grid. I'm sure the primary care doctors who can learn from the oncologist in the big hospitals, right?

Vedang Murthy: Yes, I think that's a huge opportunity that basically the most important thing that NCG will do is get everybody on the same platform, so that information and resources can be shared.

Neeraj Agarwal: Yeah, thank you very much.

Nicholas James: So I have a question for Andre online. So we're very keen to facilitate more research in low and middle income countries in particular. And I'd be very keen to hear how we can work with organizations that the WHO, which is an organization I've never worked with before, in order to facilitate this. Because there's clear expertise, willingness. And we've got a big audience here in the room as well. And a lot of the audience, like Neeraj who just spoke, has links back into India. So whilst working in America, there's a huge amount of goodwill we can harness. How do you think we can do this?

André Ilbawi: Thanks, Nick. The timing for this question is very appropriate. And WHO, just to briefly reference, is an organization that has an agenda driven by governments. And for the overall health agenda, last year they put on a resolution on clinical trials and innovation. So there are significant work being done. And I'll pass the floor to Dr. Casolino shortly to have her comment on her specific work in cancer.

But we are now fostering regional networks in clinical trials. And cancer is one of the primary interests for this workstream because of its relevance to impact its agenda. And as we say it often for cancer, innovation is best achieved through collaboration. We heard already what clinical trials have been able to do in terms of advancing the science of cancer control. But it's also important to acknowledge the role that clinical trials can offer to build capacity. And that means, again to foster, partnerships between cancer centers in different countries and doing so in a subregional network.

So the potential to invest in clinical trials is perhaps the strongest instrument that many of the audience would be able to walk away from focused time and effort. In order to define the workstream, we spent some time understanding the landscape of cancer clinical trials. And I would like to acknowledge Dr. Casolino for her work to better understand what is the current state of clinical trials in cancer. So perhaps, Raphaela given your efforts, if you don't mind sharing with just a bit of what we've discovered and some of your thoughts on how we can foster the type of collaboration moving forward.

Raffaella Casolino: Thank you, Andre for the introduction. And as Dr. Ilbawi highlighted, the member states in 2022 passed a resolution on clinical trials, not just for cancer, but broader clinical trials. So recognizing the importance of research and to strengthen the clinical trials network, but also addressing the ethical issues related to clinical research.

Within this context, we are trying to address the specificities of cancer clinical trials. And to do that we started several activities. First of all, we started analyzing the clinical trials landscape, mapping what are the clinical trials around the world through a resource that is available and curated at WHO. And this resource is the international clinical trials registry platform, which includes 24 different international cancer databases.

We extracted more than 100,000 clinical trials, and we looked at characteristics, basically focusing on equity and inclusion, first of all. So where are the clinical trials conducted? What are the specificities on the different cancer types that are more included in clinical research? But I think that for this preliminary analysis, one of the key messages that we are getting is, of course, research is mainly focusing, has been mainly focusing in high income countries, while low and middle income countries as well have only a small, small proportion of clinical trials.

And these data are generate a question about the relevance of the research. Questions that we ask are the clinical research questions that we asked in high income countries relevant for low income countries? So the answer is not automatically yes. So we need to listen more to the local priorities.

We don't have to adopt the colonialistic approach and going to low income countries and countries say, we have this international clinical trials. We just want to include participation there. But we need to ask, what are the relevant priorities in your countries. What is the burden of what is most the cancer type that is impacting the most? But also what are the kind of questions from implementation research. I listened to we all listened to the interesting inputs from the colleagues from India about implementation research.

We need to focus more in implementation research. We need to better understand not just looking at new drugs, but to better understand how can we optimize already available and approved treatments, not just systemic treatments, but also radiotherapy? How can we improve the escalation in fractionated radiotherapy without compromising efficiency? So these are the key questions that we need to. Prioritize if we really want to improve our clinical research at a global level. Back to you, Andre.

André Ilbawi: Thanks, Raffaella . Please go ahead to her, Nick.

Nicholas James: I was going to say.

Omolara Aminat Fatiregun: OK. So thanks for that response. I just wanted to layer on that question. One of our panel questions, which says, how do we improve research and evidence practice? We've said so much about under-representation of men of African descent in clinical trials globally. So I want to direct this question to James. Could you comment on how do we increase the representation of men of African descent in clinical trials, especially pharma driven trials?

Because one of the challenges we have in Africa is that most pharmaceutical companies, they are largely set up for sales. So they don't focus on research. And I think if we see that whenever there's an interest from the high income country, it's easier to get them to put these men on the trials. So how do we increase this under-representation? I want to hear from you.

James N'Dow: Well that's obviously not easy. I think the first practical option is to do non-commercial trials. That may be one, which clearly involves a stronger political will of governments to invest in that area. But I think the challenge we have goes beyond that. I actually think that the quality of data from low and middle income countries is generally poor. The quality of data across the care pathway, right across all patients that are affected is poor. The registries we have is poor.

And I think the smart investment is actually to just do a very boring bit of research and start collecting data across the care pathway of everyone who's affected with prostate cancer, so that we know about the epidemiology, about the presentation, about the mortality, so that we have a baseline. At the moment, it's all a big mess, unfortunately.

Omolara Aminat Fatiregun: Yeah, I think most countries are still at that preliminary stage of advocacy, political advocacy to even let their government know that we need data. But on the flip side of-- actually, I mean, I always feel that when we build capacity in this area, it could serve as reverse innovation. For example, if there's a site in Nigeria, you know that all the patients you recruit from that site are going to be men of African descent. And we can see there's a lot of immigration across countries. We could use it as a hub for studying men of African descent.

And one of the lessons that I've learned, I mean, we've learned as oncologists in Africa is that whenever we have international collaborations, we build capacity. Because it's easy for you to say, oh, do this, do the research, do that, but you really don't have someone guiding you. And so most of the studies that we've collaborated in. Now we have the first breast cancer clinical trial ongoing in collaboration with University of Chicago. We are on the IRONMAN registry. And I tell you that there has been capacity development from there.

So the theory I've learned is different from the practical. So as we bring in studies like this, I think it's also a strategy to build capacity. And sometimes you have databases, registries, tools that are like REDCap. It's already available. It's widely used. But when you bring it into Africa, we learn. And there's capacity building around that. And that's why I'm actually passionate about bringing these collaborations in, yes.

Fernando Maluf: Just one quick comment. I just show that we are able to create a research units. So if you have the patients, if you have the medical doctors that are willing to do, if you have the basic infrastructure and a third party to hire the adequate people for this mission, plus implementing the process, it can be done. We have been done already. And these six centers, the first new six centers, they are running trials in hospitals that only provide medical assistance. So we are scaling up because it's possible. So if it's possible in Brazil, it's possible in Peru, in Mexico, in Africa. I don't think there is any difference between all of these places.

Nicholas James: Yeah. So Jason, you've been very patiently stood there, and they have behind you as well.

Jason Efstathiou: Absolutely fantastic panel. Maybe Neha and I should shout our questions together. I bet you there's some overlap. But radiotherapy is critical to comprehensive control, cancer control plan. And it's cost effective. And we know that access to quality radiation is limited in LMICs, especially perhaps sub-Saharan Africa. And yet it's a responsibility and investment that we need to prioritize.

It's a complex issue. It's not just getting machines, it's quality assurance. It's retention and development of human capital. And that's a major issue. That's a rising issue in the US as well. So what should we be doing as a global community? Radiation is involved in more than 50% of patient care. It's used in cure control and palliation. It's a major, major thing. What is being done and what should we be doing? Easy question.

Nicholas James: James, I think your hand was up first.

James N'Dow: Yeah, very happy to take on. I think if you look at least sub-Saharan Africa or the African continent as an exemplar, when you look at the Pan-african Urological Association, they're now really motivated to do something about this in terms of a strategy across the continent.

Let's remember Africa. We talk about it as one country. It's 54 countries, right. It's like you're talking about Albania versus France, very different in all these countries. So they all have different economic powers, different political systems, different GDPs, all sorts. But I think what they've come up with is pretty smart that they would look at building five hubs, North Africa, East, West, South and Central Africa, where they have a hub. And a hub and spoke where you have a hub where experts are not only in urology but in oncology, radiation oncology, in research, in epidemiology, and they train people.

I think building capacity. This cannot be a short gain. I think for LMICs, we have to accept that there are no quick fixes. We have to plan 10, 15 years ahead. We're going to accept that people are going to die between now and then. But we must do the right things from now, i.e. build capacity local. And collect data to show that this is where we are today. And as we improve, these are the improvements. These are the lessons learned. We cannot shortcut it. There are no shortcuts.

And I think we cannot just look at our specialties like surgeon and go let's focus on surgery. No, we should have a multidisciplinary approach from the beginning. Build capacity in surgery. Because if we're going to screen, means we're going to do a shift from advanced disease to more localized disease, and we need to be able to have capacity around surgery, radiation treatment, all sorts. And we need to do that together, not as a specialty, the surgeons and the oncologists doing different things.

Nicholas James: So before we come to Franco and Mouna , I'd be very interested in your thoughts on this as well, because working in North Africa, because we kind of obviously different issues potentially. So Frank?

Franco Cavalli: Yeah, I think that this is a problem which could be tackled because, I mean, we have the IAEA in Vienna, which is already the International Organization which can organize everything in that sense. And they just would need to have enough resources, for instance, to buy equipment for the and half of the countries in Africa, which do not have almost a single radiotherapeutic machine. And that can be coupled with telemedicine in the sense that teleplanning, for instance, is absolutely possible today.

So a lot of the problem of the human resources concerning radiotherapy in the poor countries can today be at least tackled using artificial intelligence and telemedicine. So we need the equipment. And that's not so expensive and could be solved if the international community would give to the Vienna agency enough resources and then telemedicine could help to manage that.

Omolara Aminat Fatiregun: And just to add to the telemedicine component. In Nigeria, and that's why I talked about international collaborations, the clinical trial we have in breast cancer, the plans are not approved until we have this MDT with specialists at Weill Cornell, who is on the team then. We also have private centers that have MDTs across board.

So it's telemedicine. You're sitting in your office. We have a question. And then we do the remote sharing. And you're able to see whatever we plan there before you go ahead, know the clinical history of the patient and move on to planning. So there is that component in we've started that in Nigeria. But I feel that I mean, like he said like James said that you have to plan ahead. It's a long term thing.

During my presentation, I talked about the National Cancer Control Plan being established in 2006. And fast forward all the way to 2024, it's been like a work in progress. So it's for us to then plan ahead. Long term planning. And we just keep moving the science forward.

Nicholas James: Yeah, fantastic. So Mouna, I'll maybe ask you to comment as well on these aspects in terms of telemedicine and distributing decision making and care and so Mouna. Yeah?

Mouna Ayadi: It's a little bit different in Tunisia. I've heard from my colleagues. In Tunisia, we don't use telemedicine for research. We use it to be in several clinical trials. Especially I was co-investigator in Brasilica, but it was in 2010, 2009. But now I really try to bring some clinical trials in Tunisia with Karim Fizazi with G2. But it's very difficult, especially when it's academic trial because we don't have the standard of care. So it's difficult to do three phase trial.

It was without success. But we never did this. We try again. We will try. Again to have many clinical trials. And for radiotherapy, we don't really have a problem with radiotherapy in Tunisia. And we deal with many African patients, Libyan patients, sub-Saharan patients and Tunisian patients, especially in the private sector. In the public sector, it's a little bit crowded, but it's OK. We can have access to radiotherapy, no problem. As I said, the real problem is the access to every high cost medication in Tunisia, such as Anti-PARP, Lu-PSMA and that's it.

Nicholas James: So we have about one minute left. So we have a really good question. I'm afraid we don't have any time.

Neha Vapiwala: So I get the distinction of keeping us all here longer on a Friday night, sorry. I just want to echo the applause to the organizers and to each of our panelists just for not just sharing your insights today, but the incredibly important work you're all doing. And thank you, Jason, also for the radiotherapy question.

So I can jump to my second question, which is. So each of you addressed in some way of all the various stages within the cancer care continuum, that entry point of patient awareness, patient education. But before they become patients, they are community members. They're our neighbors. They're family members. And I think if there's one thing social media has shown us, yes, it is the great unifier, but it also is great at creating silos and echo chambers.

And I wonder how again, with Dr. Loeb's work and each of you in your respective regions, many of which are countries with multiple different cultures within those countries and regional differences. Some of the community based research we've done at our institution has revealed a lot of community myths and misperceptions among, for example, Black and Latino men and women that we've done mixed methods research with in Philadelphia.

And by learning what those beliefs were, we were actually really quite surprised. Some things we expected, some things we really did not and are able to then have our messaging and our education start by focusing on those areas before they ever become patients. But in fact, that penetrates into the community is so important. So I'm wondering how each of you might see?

And maybe this is not a question to be answered today, but really just for discussion as we continue this conversation, how each of you in your countries, in your regions, within communities are going to address not just the basic prostate cancer education, but really getting at local like local? Each of you were talking global, but I mean local myths and misperceptions that are pervasive and that will prevent them from hearing the message that doctor Loeb and others are trying to get out there. And how do we leverage social media and these other ways to get those messages out there?

Nicholas James: I think this is probably a thing that we need to address over aperitivos outside. I mean, basically you're saying, think global, but start local. And I think that's very true. I think we have to wrap up. We're out of time. I'd like to thank the entire panel. I think we've had a fantastic discussion.

And I think what is very clear is that there are huge potential issues coming. And I think a lot of the issues are going to be outside the APCCC world, as described by Declan. And I think it's really a great that we've had this session today, and I think this should be an increasingly prominent feature of conferences on advanced prostate cancer, because if we want to address the whole problem, we have to address the whole world.