Charles Ryan: Hello, I'm very pleased today to be speaking Dr. Patrick Maison from the University of Cape Coast in Ghana. Doctor Maison is a urologist, and a lecturer at the university, he is the recipient of a 2021 PCF Pfizer Health Equity Challenge Award. Welcome, Doctor Maison, good to see you today.

Patrick Maison: Thank you, good to see you too.

Charles Ryan: We're going to start with a brief presentation about your award, and about your work, and then we'll have a conversation.

Patrick Maison: Thank you very much. As I was introduced, my name is Patrick Maison, and I'm a urologist Fellow of the West African College of Surgeons. The project we are working on is integrating orthodox and traditional prostate cancer care and treatment in Ghana.

So the study team comprises of researchers from the University of Cape Coast and then we collaborate with Precision Medicine for Aggressive Breast Cancer, and then the Henry Ford institute in Michigan, and with the Ghana Health Services.

So, as a background to the research that we are doing. In Ghana, prostate cancer is known to be the leading cause, or second leading cause of cancer deaths in men, and the incidence has since been rising from 2019. When we did epidemiologic studies, we found that most patients with prostate cancer present late, and because of that, there is a high mortality of prostate cancer in Ghana.

About 75% of our population are known to rely on indigenous traditional medicine, and so when they are ill, they will first report to their traditional medicine providers, who will keep them and treat them for some time, before they allow them to come to the hospital.

In my own institution, which is the Cape Coast Teaching Hospital, we find that about 70% of patients we diagnose with prostate cancer are seen with the cancer locally advanced, and about 25% of them already have very advanced disease at the time of diagnosis, or at the time of presentation. So, we hardly pick up patients with early prostate cancer. Again, we have found that more than half of these patients would have first been to their indigenous traditional medicine provider, and would have spent years with them, two years, three years, when they first noticed urinary difficulties with them. And when they realize that their symptoms are not getting any better, then they ask them to report to see us at the Cape Coast Teaching Hospital, by then, they would come in with advanced, or very metastatic diseases.

And so, the goal of this project is that we aim to reduce the deaths of prostate cancer in the men who come to us, or who have prostate cancer in Cape Coast by identifying all the barriers that contribute to late presentation of prostate cancer.

One of the things we want to do is that we want to partner the traditional medicine providers so that we will be able to pick up the patients when they first report to them at the early stage, and help to make the diagnosis and manage them, rather than permit the patients to stay with them for so long, and only wait for the patients to come when the cancer is so advanced and they cannot be helped much. And so, in doing this, we will be taking prostate biospecimen, and we hope that we can also use these specimen to create a bank which will be used for future genetic studies.

So, the methods will be to use questionnaires to interview the patients with prostate cancer who present to the herbal medicine providers, and then we will also interview these traditional medicine providers, and also interview ordinary hospital workers to find out their own perception about why patients prefer to go to the traditional medicine providers rather than come to see us first when they are sick with all forms of ailments.

And so for those patients that we find that traditional medicine providers with prostate diseases, we will first check their prostate-specific antigen, and for those who have high levels of prostate-specific antigens, we will do a prostate biopsy to confirm the diagnosis of prostate cancer. When that diagnosis is made, then we will educate the traditional medicine providers who were attending to them, and also educate the patients, get them to understand that not all difficulty with urination is from an ordinary enlargement of the disease, but sometimes there is cancer causing you to have problems with urination, and this cancer can be fatal. And so there is need to identify from the lot those who have difficulty to urinate due to cancer, and those who do not have it, and for that matter, help those who have cancer, so the cancer does not become advanced, and possibly lead to their death.

And so when this has gone on for some time, we hope to be able to partner these traditional medicine providers, and meet them periodically, maybe every three months we hold meetings with them to encourage them to refer patients who report to them early to see us, so we can rule out prostate cancer in those patients, and also help them with the management of all their patients so that in the end, they will not delay their patients with prostate cancer. So, this is partnership that we would like to form with these traditional medicine providers after they have understood what the challenge with prostate cancer diagnosis is, so that we can partner them, make the diagnosis early, an then help the patients appropriately.

And so work ongoing currently, as we speak, is that researchers have moved into the communities, they are interacting with the patients. We are also interacting with the traditional medicine providers, we are also interviewing some patients who come to hospital with prostate diseases to find out how long they were delayed in the traditional medicine providers, and see if they have cancers. And then we are also interacting with normal medical providers, or healthcare professionals, to find out from them their perceptions about why patients prefer to go to the traditional medicine provider, and not to us.

As we speak, we have also been able to, from some of these patients, take specimen for prostate-specific antigen test. Some of them are high, which is suggestive that they may have prostate cancer, and we are about getting them to come for prostate biopsy tests. And when the diagnosis of cancer is made, we will enroll them in the orthodox system, and provide the with care, so that we can at least address the cancer before it becomes very advanced and late for them to present to us, when we cannot do much to help then.

And so, here, you can see in the picture, researcher in the community interviewing a patient who has prostate disease, and is attending the local medicine, or herbal provider, herbalist in the community.

So, at the end of the study, we are hoping that we will be able to collaborate with about 50 traditional medicine providers, who, on average, should be able to recommend 100 patients every year who have prostate cancers. We are expecting that these numbers will actually go up, more then the 100 that we are talking about. But at least for now, we are expecting that the 50 traditional healers will be able to give us minimum of 100 patients with prostate cancer, who we will pick up in the early stage, and not in the late stage, when it is too late to help them.

Again, we will be able to educate the traditional healers, and even educate the patients so that we can break the barriers that lead to a delay in seeking care, especially when they have prostate diseases. And we also hope that we will be able to publish our findings in reputable journals, and maybe when we get the specimen in the future, we will be able to do genetic studies to understand the molecular disease of prostate cancer as it pertains to our populations.

So here are some references for our work. And I will say a very big thank you.

Charles Ryan: Thank you, and congratulations on receiving this award. It appears a very important opportunity in Ghana for caregivers to identify earlier stage prostate cancer, and hopefully to intervene, and prolong life and reduce complications over time in this population.

Couple of questions. For the traditional healers in Ghana, are they aware of prostate cancer as a common condition, or are they more focused on symptoms? And are they likely to say to man, "You may have prostate cancer, I will treat it," or are they more likely to say, "You have a prostate symptom, I will treat it," and they remain unclear about the diagnosis of the prostate cancer?

Patrick Maison: Thank you, Ryan, so all of them think that prostate diseases are just one thing, and they lead to urinary difficulty. And so they don't know that there can be a normal enlargement of the prostate, and there could also be cancer in the prostate.

Charles Ryan: I see.

Patrick Maison: And so that is the challenge we have with them. They manage their patients all in one, as though they all have a normal enlargement of the prostate. And so they never make anty effort at finding out whether someone has prostate cancer, or does not have it.

Charles Ryan: Sure. And I anticipate that you will get referrals for people who have non cancer, BPH, or other symptoms, other prostate enlargement symptoms, and of course what I guess you would hope would be that the many of your referrals are men who have noncancerous symptoms, so that you can follow them, and capture them, in a way, treat those symptoms, and perhaps follow them, should they develop prostate cancer later on. What are the standard... Are you only capturing men who have urinary symptoms, or will you be asking them to send you men with back pain, or other things that could be signs of metastatic diseases as well?

Patrick Maison: When we go into the communities now, we are asking about those who have urinary problems, and then we are also asking them about their patients in general. And so when we get any patients who has other symptoms of metastasis, as you said, severe low back pain, waist pain, who has maybe some weakness in the limbs, we include all these men. And so we are actually looking for any patients in the care of the traditional healer who is likely to have prostate cancer. We would even want to extend it to include those who go there for other forms of ailments, like hypertension, diabetes, et cetera. But for now, we think that it will be more accommodating if we say that we are only focusing on those who have urinary problems...problems that have got to do... Yes. Otherwise, they would then think that we are coming to take over the entire patient population.

Charles Ryan: And your plan is to include them in the care of the patient, even after a diagnosis, through shared, it's not really shared visits, but it's sharing information back and forth with them, and including them in the care, correct?

Patrick Maison: Yes. So exactly what we want to do. So, when we have been able to prove to the that we picked up maybe five patients from you, three of them had urinary problems, or had problems due to prostate cancer, the other three had just a normal enlargement of the prostate, and this cancer can kill. They understand that cancer is dangerous, everybody knows that cancer is dangerous. So, when we tell them this one one cancerous, then they will sit up. But when we have been able to do that, then we will show them that it is for these reasons that we would like to be involved when the patient comes in early, so that we will be able to find those who have cancer, and those who do not have it. And so because of that, we would like to collaborate with you, when you get these patients, involve us as early as possible. And so after we have educated them, we will be, as you said, meeting with them periodically, and we are hoping that these collaborations will work out.

In fact, the indications we are taking from them is that they are happy to collaborate with us. As we have assured the that we are not coming to take over their patients, they are now happy to collaborate with us, after the little interviews that we have done with them.

Charles Ryan: That was my next question, are you experiencing resistance from the traditional providers about your role in the care of men with urinary symptoms?

Patrick Maison: Yes, thank you, Ryan. So, when we were putting up this project, we were concerned that there was going to be a lot of resistance from these traditional medicine providers. But I think our approach has helped, because within the communities, we have what we call the CHPs zone, the community health provider zone, where there is always a nurse who knows almost everybody in the community, and knows about their ailments, they visit them at homes, and they know where these people go for treatment. So almost everybody in the community knows this nurse, and even the herbalist also knows them. And they have relations with the herbalist.

And so your approach has been to first go to the community health nurses, or the nurses in the CHPs zones, and they lead us to the patients, and to the herbalist. When the herbalists see us in the company of these nurses, they are very calm. They are comfortable. They understand that we are friends, and they are able to cooperate with us. I think that strategy has helped. Working through the nurses in the community who are already familiar with these patients and herbalists in the communities. And so they have welcomed us, much to our own surprise.

Charles Ryan: That is good, and does bode well for the success of your project. Well, Patrick, it's great talking to you, and I look forward to hearing reports of the outcomes that you're achieving. And I think it will be fascinating, either way, to look, if you have 100 men referred to you, what you will end up be seeing, because I suspect that in addition to some prostate cancer, you will identify some other conditions that your intervention could help in some of these individuals, including other types of cancers, I presume. So, congratulations on receiving this award. I look forward to the results, and look forward to further conversations with you.

Patrick Maison: Thank you very much, Ryan. I am very grateful to you and to the Prostate Cancer Foundation for their support. We are hoping for the best, and we know that our patients will benefit in the end. Thank you so much.

Charles Ryan: I'm sure they will. Thank you so much.

Patrick Maison: Thank you.