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Neal Shore: Well, hi everyone. I'm Neal Shore, the medical director of Carolina Urologic Research Center. It's an incredible pleasure to have with me two colleagues from Tanzania today. What everyone should know and understand are the discordances and discrepancies we see in low and middle-income countries, especially within Africa. And we're going to focus on some of the really pioneering research that's occurring at the Kilimanjaro Christian Cancer Research Institute. Recently, Dr. Nicholaus Ngowi and his mentor, Professor Blandina Mmbaga, who are pediatric epidemiology experts. And Dr. Ngowi is a urologist.

And they're focusing on prostate cancer education screening and the discrepancies that are the big challenge I think in Tanzania, but lessons that can be learned throughout Africa and other countries that are challenged. They are the proud recipients recently of a Prostate Cancer Foundation grant to do this education. So with that, let me turn it over to you, Nicholaus. It's a great pleasure to be with you and Blandina today. These are really the cornerstones of work that we all need to be focused on, whether you're in a developed or a developing country, because I'm fond of saying that when you get cancer stamped on your passport, no one cares what country you're from. You've got cancer, and you want to be treated, and you want to be treated compassionately, and you want to have access to good care. So let me stop with that and hand it over to you, Dr. Ngowi.

Nicholaus Ngowi: Thank you. Thank you so much for the nice introduction. I would like to share our research, which we recently conducted here in Kilimanjaro. So may I take this opportunity to share our research findings, which we conducted in Northern Tanzania, and the study is about prostate cancer knowledge and barriers to screening among men who are at risk of developing prostate cancer in Northern Tanzania. And this was a community-based study. So I, Dr. Ngowi, as introduced, I'm a urologist working with Kilimanjaro Christian Medical Center as a urologist, but also working with Kilimanjaro Clinical Research Institute. So together with me is Professor Blandina, who is the director of Kilimanjaro Clinical Research Institute, but also the PI of the project, and my mentor. So I'll be going through this outline, introduction, methods, results, summary, and lastly, take-home message.

So how did we come up with this idea? Through our daily activity, we observed that the majority of prostate cancer cases diagnosed at KCMC, where I'm based, they are presenting with either locally advanced disease or metastatic disease. And this actually contributed to the high mortality rate, which has been observed in the country, whereby prostate cancer was found to be among the common causes of mortality in men. So the only secret for a diagnosis is prostate cancer screening. And this actually helps to diagnose the disease early, early treatment, and actually ultimately at the end of the day, you reduce mortality. However, prostate cancer screening is surrounded by a number of barriers, including myths, some knowledge level barriers, but also misconceptions about the disease. So because of the advancement of the disease at presentation in our setup, we believe that our community, our at-risk men, don't screen for this disease and therefore present late.

So we actually conducted this study to try to assess the barriers facing the community, but also their knowledge level in terms of prostate cancer so that once we identify these barriers and measures are taken, then we can improve the screening. But also our end result is to reduce mortality. So having this idea in mind, we secured around 150K USD from Pfizer. And initially, we planned to use these funds to conduct this study in three regions of the northern zone, that is Kilimanjaro, Arusha, and Tanga. And in each region, we planned to select three districts. And in each district, we wanted to select one health facility where the data collection process was taking place. Fortunately, before we launched this study, we secured another 50K USD from CIRGO. And this actually helped us to expand this study now to the whole Kilimanjaro region.

That is to say to actually involve all the seven districts of the Kilimanjaro region. But also we managed to expand it to the Manyara region. This is another region which is also within the northern zone. And the reason for studying the whole Kilimanjaro region is because according to our local data, it shows that the majority of prostate cancer cases actually come from the Kilimanjaro region. So we wanted to know what is happening in this region. So as I said, our study was conducted in all regions of the northern zone, which are Kilimanjaro, Arusha, Tanga, and Manyara. And our study population was men who were aged 40 years and above. This was selected because it is believed that black people at the age of 40 years need to be screened because they're at risk of developing prostate cancer. So after we went through the ethical clearance processes, we managed to secure ethical clearance in May 2022, and the same month and year we actually launched the study and started the data collection.

So in the launching process, we involved key local leaders, including our regional medical officer, Mr. Kanga. We actually had our district medical officer, we had a team from KCMC, you can see Professor Blandina there, and the other team from KCMC. But also we had also important local leaders. And at the back there, you can see we have the study team. So on your right, you can see participants going through the consent process so that we can start collecting the data.
How did the participants reach the study site? These participants were informed about the study and the study site through various communication media. This included using social media groups like WhatsApp, using religious leaders through churches and mosques. But also we had loudspeakers going through the community, through the districts announcing the presence of this study and the area where participants were supposed to gather so that data collection process could take place.

So once participants reached the selected health facility within the districts, they were actually obtained consent and they were given the questionnaire to start filling up the questionnaire about the knowledge and the barriers they're facing, which makes them not screen for prostate cancer. Knowledge level was assessed using a Likert scale and scored as less than 50%, which means poor knowledge. And those who scored 50% and above were categorized as having good knowledge. And actually, we used 16 sets of questions to assess knowledge. So the good thing with this study is also that those who were willing to undergo prostate cancer screening using PSA, we actually gave them this service in the same setting. And the whole process of data collection took one week in each district and sometimes we ran two sites per week. And the whole duration, the total duration of the data collection took five months.

So in terms of the results, as I said, our participants were men who were aged 40 years and above, their mean age was 60 years and the majority of course were residing from the Kilimanjaro region. This is because of the reason I already said that in Kilimanjaro, we actually studied the whole region. That means all the seven districts, unlike the other regions where we selected only three districts. And the majority of participants had primary education only. And surprisingly, only 9.7% had ever screened for prostate cancer before participating in this activity.

Looking at the prostate cancer knowledge and barriers to screening, we found that only 20.4% had good knowledge of prostate cancer. And some of the determinants of prostate cancer screening were age, having healthcare insurance to cover the screening cost, but also those who were known to have comorbidities such as hypertension, they were found to have higher odds or chances of never screening for prostate cancer.

But most importantly, having prostate cancer knowledge in terms of risk factors, signs and symptoms, prostate cancer screening, and knowing somebody who had ever screened for prostate cancer was among the factors which were facilitators for prostate cancer screening. So when you look at the perceived barriers among participants, which made them not screen, the five most common barriers which were reported, were that they believed that prostate cancer is not a serious disease and some actually condemned the screening method, which is digital rectal examination, saying that it is an embarrassing and harmful procedure.
And some men reported to be healthy and therefore they thought there is no need to participate in the screening because of their health. And of course, some also mentioned about the cost implication that they were unable to afford the screening. To summarize our findings is that we found the majority of men who are at risk of developing prostate cancer in Northern Tanzania, they have poor knowledge of the disease. And most of the perceived barriers are related to misconceptions about the disease and the screening.

And the men who had prostate cancer knowledge actually had higher chances of ever screening for prostate cancer. So which means knowledge is a key for screening. So in terms of take-home message, we think that prostate cancer knowledge plays a key role in the uptake of prostate cancer screening to facilitate early diagnosis and reduce mortality among men. I would like to take also this opportunity to express our sincere appreciation to the Prostate Cancer Foundation for funding this activity, but also the government of Tanzania for their support, which they gave us to make this activity possible, but also KCMC, KCRI together with KCMU core for all the support which we received from them, which made the activity go smoothly and be successful. Thank you so much.

Neal Shore: Well, thank you. That was a wonderful review. As you stated at the very beginning very articulately, if we don't have adequate screening, then we see patients presenting with advanced disease metastatic cancer when we can no longer cure them. And of course, we've made great advances in multiple therapies for metastatic cancer, but we have accessibility issues in Tanzania.

Nicholaus Ngowi: Yeah.

Neal Shore: Early detection is our chance for cure, which is a truism across all solid tumors, breast, ovarian, cervical cancer, prostate cancer. So it's knowledge, and knowledge is power, power to do the right thing. So with this wonderful learning that you have, can you share with us what are your actions to move forward in improving knowledge and how can grants from PCF and other foundations, how can we fix this problem? I find it incredibly frustrating when I see these data that you present so nicely. It makes me sad because with the right knowledge, we could cure people and we can help their family members. This is what we oftentimes call the low-hanging fruit for success. So what are the next steps?

Nicholaus Ngowi: So actually we've started some sort of intervention where I've been involved in radio sessions to try to educate the community, give them the appropriate knowledge so that they can get rid of this misconception about prostate cancer and therefore they can participate in the screening. That's one.

But number two, we are thinking of applying for some sort of a grant to actually try to empower community health workers. We have community health workers in our areas, and these community health workers, one of their responsibilities is to educate the community in terms of the prevention of diseases. And one of the diseases is cancer, and prostate cancer is quite common. And therefore we wanted to educate them, give them appropriate education with regard to prostate cancer, and they can actually transfer this knowledge to the community to see if there will be any change by using these community health workers. This is something which I'm thinking of if it can bring a change.

Neal Shore: I really like that. We have to be so much more nimble and innovative in our approaches. Take advantage of telemedicine, telehealth opportunities. Everyone is seemingly connected. But one of the challenges that I've seen, Professor Mmbaga, is, and we saw this with HIV and we saw this with COVID, and we see this with cancer, is people mistrusting. They don't trust. So how do we find authentic and trusted sources now so that we can debunk barriers that say, oh, I can't get an examination or I'm so healthy and strong, there's no way I could potentially have cancer? How do we continue to find authentic, trusted sources of information?

Blandina Mmbaga: Yeah, thank you for this question. It is quite very important because we know that in most of the cases, especially chronic diseases, misconception plays a big role, especially in our societies where people could have signs of chronic disease, they know, but due to misconception, they could go maybe to look into local herbs and leading the delays. So awareness creation is quite very important. Like my fellow, Nicholaus has said, we have tried to use the media, but we saw during the screening study when we used the local leaders as well as church leaders in the mosque, it made people actually understand that something is going on. We never expected to have the number of people we received, especially the first day, where the team we had could not be able to screen. We had to shout for help from the hospital and added more nurses to come and help in screening and consenting because people flooded the site.

And it made us open the second site on the next day in the nearby health facilities to accommodate the number of people. So we learned that under knowledge or awareness of the service which is existing is also important. And one of the most important keys we learned, people flooded in because they got the brochure. They learned that we are going to see using blood and we are not going to screen using digital rectal. We'll do a blood test, but also we'll do an ultrasound test. And that is what made people come in and screen and got into it. The advantage of the screen, I saw that, for the first time the cancer care managed to get people in stage one because normally people are coming at late in metastatic cancer, but at least currently they have a cohort of a patient who came early for treatment and who could be able to be cured.

But the challenge we got is that people were screened from PSA and then were called for tru-cut biopsy and then those who were positive for prostate cancer were invited for treatment. But we got the challenge that okay, we can screen many, but access to care might be a challenge because the majority had no health insurance. Yeah. So at least to do the baseline investigations so that they could be transferred to chemotherapy. But the advantage of it, a number of patients knew that they had cancer, they were able to consult their children in other regions and went there for treatment. So it was all beneficial that they could be able to go and get the treatment or the children or relatives could know earlier and supported them rather than delaying and coming at the later stage. So for me, awareness and availability of screening is quite potential so that the service can be able to make people go into it and screen.

And what we learned also, which will come maybe in the next paper, which is in the pipeline, is when we learned about the high level of PSA and at least the cut-off, which we looked at, that it might help us even to think that, okay, everyone who is maybe above 20 who has to be highly suspicious, and started doing some wake-up and even counseling for a regular coming maybe for checkup and other things. So that's what I can say. So awareness and knowledge imparting is quite very important, but availability of services is key.

Neal Shore: Yeah. You make some fantastic points. Screening, absolutely, finding disease early so we can cure. But to your point, if there's no accessibility to radiation treatment, to excellent surgical opportunities, then that's even more frustrating. But I really applaud the two of you. This is fantastic work that you're doing. Congratulations on getting your award from PCF. I know Professor Mmbaga and I are working together with the Duke Global Health Institute and we need to continue to do these things. We live in a world now where people are very nationalistic and parochial political, but I think when you're a healthcare provider, you're a globalist because cancer knows no boundaries. It's that individual patient who's suffering and their family is suffering. So I think we're all globalists when it comes to being healthcare providers. So thank you so much for the great work that you're doing. I look forward to working with you in the future. Any final comments, Dr. Ngowi?

Blandina Mmbaga: Finally, we say that we do appreciate the support, which one can think is a small grant, but for us, it is huge and making an impact, and even an eye-opener for us. And even interest like Ngowi is now interested in becoming an actual urological oncology specialist. Having a person who is really dedicated to specializing in that as the first person is quite great for me as a mentor to make sure that I'm supporting him to reach that goal. He is really dedicated to taking care of patients with cancer.

And there is our starting point, and we hope that we are putting effort into different small grant applications, like he said, the knowledge and the awareness that the small grant he has submitted somewhere. But in the future, we're looking forward to him, possibly becoming one of the young investigators in prostate cancer so that he can actually provide more information, get more data, and compare with other countries and regions to see how best we can improve care and treatments for identifying cancer patients in our area.

Neal Shore: Yeah, that's fantastic. Well, great mentors develop great students who become wonderful, exceptional leaders. So, Dr. Ngowi, that is you. Any final thoughts?

Nicholaus Ngowi: Yeah, I think we really, really appreciate this opportunity. It was a golden chance for us to try to dig into prostate cancer and get to know more about this disease because, as a urologist, I see a lot of prostate cancer cases, about 100 cases per year. In my department, if you look at urological malignancies, prostate cancer is the leading one, and therefore there is a real need to look at this disease in detail.

So one of the areas which we think we need to look at in the future is the genomic analysis of prostate cancer, because this also has an impact on treatment. So in the future, we may also need to dig into it so that we can tackle the disease better. But also, as far as knowledge is concerned, one of the areas which we think might have some effect is providing prostate cancer knowledge to patients who are coming to the hospital for any kind of condition. So while they're in the waiting queue, somebody can be there and just talk about prostate cancer to these people in various clinics, not necessarily urology, but even in orthopedics, medical, surgical, everywhere, hoping that of course these people will change, but also they can disseminate this information to their neighbors and friends. Thank you so much.

Neal Shore: Professor Mmbaga and Dr. Ngowi, thank you, thank you very much for the great work that you're doing, and thank you for sharing that work with us today on this program. Greatly appreciated. Thank you.

Blandina Mmbaga: Thank you very much.