Charles Ryan: Hello. Today I'm talking to Dr. Musliu Tolani, who is a urologist and lecturer at the Ahmadu Bello University in Zaria, Nigeria. Dr. Tolani is one of the recipients of the Pfizer Global Health Equity Challenge Awards presented by the Prostate Cancer Foundation. Congratulations Dr. Tolani, and thank you for joining us.

Musliu Tolani: Thank you so much. I'm so glad to be here.

Charles Ryan: Well, we're glad to have you. We're really excited about the work you're doing on behalf of the Prostate Cancer Foundation and your community in Zaria, and we'd like you to tell us a little bit about it, and then we'll have a conversation about what you're finding.

Musliu Tolani: Yeah. Of course, I'm talking from Zaria, Northwest Nigeria. I mean, it's about three, four hours drive from Abuja. Just to start, our project is on the utilization of an implementation science approach to develop and evaluate a systems strengthening intervention for clinical localized prostate cancer management in a low/middle-income country in Sub-Saharan Africa. I'm the principal investigator, Musliu Tolani. I hold an MBBS degree as well as a postgraduate certificate in public health. I'm a fellow of the West African College of Surgeons and of the Medical College of Surgery. I have an amazing team, multi-institutional: Rebecca DeBoer from UCSF,  Ahmed Muhammed, Agbo Christian, and then Rufus Wale Ojewola from different institutions in Nigeria, and Ernie Kaninjing from the Georgia College & State University in the US.

As a background, we know that there's a disparity in the outcome of cancer care between low/middle-income countries, which Nigeria actually falls into, and developed world. I mean, if you look at it in terms of mortality, the mortality is quite high in this part of the world compared to high-income countries. The same can be said of the mortality to the incidental issue. But not just this. I mean, incidence of prostate cancer has been rising in Nigeria to create a forecast.

Now, there are a lot of challenges in the management that probably translates to this disparity in outcome. There are structural challenges and process challenges. And one of the ways we could look at low income settings is the delays are being talked about in diagnosis of prostate cancer and the treatment of prostate cancer. It translates to perhaps a lot of late presentations we see for this disease in low/middle-income countries, including Nigeria. I mean, treatment is also a problem. In an organization, there are a lot of non-uniformity in the treatment of prostate cancers probably because of non-contextual guidelines.

[inaudible 00:03:19] just recently introduced some harmonized guidelines, but I can say the adoption is something that still needs to be worked on. But again, there's also limited access to treatment options, and this also, our counsel look at this in the sense of access to clinical trials. Lost to follow up is quite common and then fragmentation of care during the follow up period of these patients. How can we make this better? I mean, there are gaps in identifying these barriers of care. There are also gaps in connecting it with an intervention. Most of the research is done in this country stops at research and not at tying to an intervention, not to make a change.

Another thing in designing an intervention that's patient centered, and then for these interventions to be successful would not want to look at it at just one level, want it to be broad based in order to facilitate it's working. The other thing is, of course, pilot and testing these interventions. And that's what we're trying to do in the project location of Nigeria.

So our first aim was to describe and identify predictors of the time to treatment initiation in a cohort of patients with clinical localized prostate cancer. This is a retrospective cohort study, and our study endpoints is time to treatment as well as clinical progression free survival of prostate cancer. Of course, we looked at a lot of qualitative metrics that are being used as a baseline to evaluate the intervention.

Next is our second aim which is based on a qualitative study to assess perceived facilitators and barriers of clinically localized prostate cancer and the adherence of the patients to treatment. Now, we are doing this with multiple stakeholders which we classify as providers of care. That includes a multidisciplinary team of urologists, clinical oncologists, radioncologists, oncology nurses, and then the patients with different experiences, as well as caregivers, some of whom are family of patients. Some are their relatives. Some are their neighbors, and some are social careworkers who form formal group of caregivers. And we are evaluating these based on the socio-ecological model of the individual level and interpersonal level as well as organizational level, not to look at these and then get an output which are analyzed using the framework method.

We're going to focus on aim three on the perspectives of the providers to develop and evaluate a multifaceted system strengthening intervention. We've seen a lot of gaps in protocols in multidisciplinary management in navigation of patients in coming out, investigations underway. So when we find these interventions which we are proposing using the data from objectives one and two based on implementation science approach that are systemic and science based so that whatever we develop can be replicated by a different setting. How I evaluate this, using implementation outcomes of their feasibility, the acceptability, as well as the appropriateness of the intervention. Thank you for much for this, I will take, continue discussions.

Charles Ryan: Thank you, Dr. Tolani, for that presentation. It's an ambitious project and mirrors what we're seeing in a number of the other similar projects in the Health Equity Challenge Award Program. What do you think are the greatest barriers to diagnosis of prostate cancer as well as the implementation of therapies? What's your grounding hypothesis as to what the barriers are?

Musliu Tolani: I mean, major extent, I think the barriers are related to patient awareness, then process challenges. Now, I will give an example of process challenges. Care is centralized in the traditional hospital setting in Nigeria. It means that for a patient to get diagnosed of prostate cancer, or even get screening with PSA for prostate cancer, he either has to go to a private setting or in hospital to get recommendation for it. There are actually community health workers in all of the local government of the country, but they are not adequately skilled to diagnose and appropriately refer patients for prostate cancer. And that perhaps underlies why we get a lot of late presentation of the disease. I talk about that, and I also talk about the awareness of such patients. I mean, a lot of patients feel prostate cancer as symptoms. Prostate cancer do have symptoms, but it sometimes comes very late.

And for us to pick prostate cancer, some patients need to be aware that regular testing with PSA needs to be done in our population which is actually of high risk of having prostate cancer in the first place. Those are part of the challenges. The system is complex, a lot of challenges, but one can only undulate in a systemic manner.

Charles Ryan: Excellent, and tell us a little bit about the team that you have. You have a number of names here, and how is the... You mentioned the word navigation, and I'm just wondering how are you processing, to use that word, individuals who come to your center for screening and other things. What is the breakdown of how the team is working on those?

Musliu Tolani: Okay, that's a study team. This team is an excellent and we are a local team who I have been working with for a while now. Prof. Ahmed Muhammed is a professor of urology at Ahmadu Bello University and we've been working together, he was my mentor, of course, for quite a long time. Agbo Christian Agbo is a colleague in Dalhatu Araf Specialist Hospital. He's also a urologist. We've actually been in communication and research for quite a while as collaborators, the same with Rufus Wale Ojewola is a senior lecturer and also urologist in University of Lagos. This team, not only because of research, but we come under the same umbrella, under the National Association of Urological surgeons in Nigeria and we'll communicate quite a lot and know the challenges and want to make an impact as part of those that will solve these challenges.

Of course, Dr. Rebecca DeBoer working at UCSF is a huge collaborator, a mentor on this project. She has expertise in the implementation science and she was quite instrumental in motivating and getting things to completion. Dr. Ernie Kaninjing works in the Georgia College & State University, and he has a huge expertise in qualitative research and also implementation science. Actually I think that in training done by [inaudible 00:11:19] center moderated by [inaudible 00:11:24] implementation science, and that also stimulated me. I mean, not just doing research or just publishing results, but to see how we can use this research to develop interventions and test it as a project.

Charles Ryan: Yeah, excellent, and what will you look at... What will your metrics... What are your own metrics for success of the project when you look back at this after it's been completed? How will you... What are the learnings or the outcomes that you expect and hope to see should this go exactly as you hope?

Musliu Tolani: Okay, I mean, the project, as I said, is ambitious. We are looking at three different objectives. For the first objective, I mean, we are trying to look at the barriers to care, looking at the predictors of kinds of treatment and that includes problems with documentation. Now we are trying to look at metrics such as the documentation of family history in patients folder to be able to know whether the documentation is complete or not. We are also trying to look at problems in the pathological processing. Our metrics here is for biopsy course they are taking for prostate biopsy, as well as the importance of things like Gleason Grade just to see how much of that we are doing to be able to know what gaps exist in that aspect. Of course, there are other qualitative metrics that are based on a publication Gloria Tao made on process outcomes for clinical localized prostate cancer which is our focus here. Then the metrics for the qualitative aspect is actually quite broad based. We are looking at it along the lines of infrastructure, interpersonal communication. We are looking at protocols. We are looking at just, I mean...

Then for the third objective, the indicators we are looking at, as I mentioned on the slides are how feasible are those things we are going to develop. And we are going to interview key informants and institutional leaders about this and how appropriate are they. Because this is very important if we have scale up which is our plan after this project, to scale this up and try it in a larger setting to see how well it's working, and to see whether it is scalable to other settings.

Charles Ryan: Very good. Will you be collecting tissue from positive biopsies you have from individuals? Will you be creating a tissue bank for further work on the pathology of these cases?

Musliu Tolani: Well that's not the focus of this work. I mean, the focus of this work is basically on identifying barriers, trying to get info on the patient, but of course, as I told you, we are planning on identifying, going to... one of our metrics is to identify some barriers in pathology so I think we will find tissue banking as an intervention. I mean, so those kind of things we are looking at.

Charles Ryan: Very good. And, well, we're very proud to help sponsor this project. I think proves to be very promising for our understanding of prostate cancer in Nigeria, and we look forward to talking to you down the road as you get more data to see what the results are and how we can work to build further questions and develop further answers on this condition. So I want to thank you very much for joining us today.

Musliu Tolani: I'm so glad to be here. Thank you very much.