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Charles Ryan: Hello, Chuck Ryan here. We're talking with the winners of the Pfizer Health Equity Challenge Awards that were awarded to the Prostate Cancer Foundation last year. And I'm very pleased today to talk to Dr. Pius Musau, who is a senior lecturer and senior consultant in urology at Moi University in the Eldoret College of Health Sciences in Eldoret, Kenya. Dr. Musau was the recipient of one of our awards and he's going to do a brief presentation on the work. And then we'll follow that with a brief conversation. Welcome Dr. Musau.

Pius Musau: Thank you very much, Dr. Ryan. And so this is a project that we looked at and decided to come up with a way of dealing with prostate cancer care in Western Kenya. And we wanted to check on the barriers to the care, establish some systems that can help in improving the care, including setting up satellite clinics which would be rapid access clinics. And then we evaluate the instituted measures so that we can see the impact and the outcome measures that we are going to see how much has changed since we started the project. So this is supposed to take 24 months and I'm the principal investigator, Dr. Pius Musau. Then I have three of my co-investigators: Dr. Edward Mugalo, Dr. Walter Akello, and Dr. Dennis Rono.

We understand that prostate cancer is one of the leading courses of malignancies in the males. And in Kenya, in particular, we have these numbers that are quite a significant portion with most of them coming late to the hospitals. In fact, the Moi Teaching and Referral Hospital, where we do the trainings and where much of the region...

Maybe I can briefly say that Kenya has 47 counties. And this project is aimed at covering the Western region of Kenya, including or involving eight counties out of the 47. And this is the portion of the people that will constitute almost half of the population of Kenya, because there are only two major hospitals in Kenya. The Moi Teaching and Referral Hospital I'm talking about, and then the Kenyatta National Hospital, which is in Nairobi. So this are separated by about 350 kilometers. And so the region that we are talking about is the Western part of the country that is going to benefit from this kind of endeavors and the general knowledge and the practice in this part of the country is known to be very poor among both the patients and the practitioners. And in fact, we have only five urologists who are all based in Eldoret.

So the rest of the region, the county referral hospitals do not have that kind of a setting who have the privilege of consultant urologists. And it's a situation where we have found that most of the patients are coming very late. In this hospital that we are talking about, I've never had to do, or there's never been any patient done a radical prostatectomy because of the delays and the kind of presentation they come with. And so out of this, we decided that this situation is not acceptable and it needed to be addressed. And that's how we now came up with this project.

The main objective was to look into improving the outcomes of care among the patients in this region, because besides they're presenting late, it becomes very frustrating to them in terms of their interventions and in terms of the outcomes. And it's also very, very discouraging to the consultants and the urologists in particular. And projects or the studies that I've done before, a number of them, in fact, over the past one decade, have revealed that most of the patients will come late because the referral system is either nonexistent or is not adhered to. Then the infrastructures, in terms of the setting of those hospitals, the facilities do not cater for those kind of people.

And so we thought that if we can come up with a way of reestablishing a referral system, sensitizing patients, getting even the healthcare workers to be informed and even trained on some of those procedures like PSA collection of the blood and took a biopsy for the prostate. And particularly getting the referral system working to ensure that these people who have now been sensitized can be catered for, taken care of early enough, and then referred very necessary for that we can end up with a change of how these patients present their common understanding, and even the common understanding of those who care for them. So that at the end of it all there's early detection, early referral and early interventions that are going in the long run to bring about a change in terms of the outcomes of care. That's what's the main objective.

As I had mentioned, this project is going to be in four phases. The first phase will be a retrospective study that will need to do some descriptive study that will audit the patient flow to the referral and identify possible reasons. We already have some of the ideas, but we want to concretize this information so that we'll be able to ascertain the key bottleneck and the challenges that these patients have, including their attitudes, including the care takers, how much of it is hindering their early presentation. That we'll now find in the first phase, the first three months.

Then the second phase, which is also another three months, it'll be to establish the satellite clinics in the catchment area; the eight counties. Their county referral centers are going to be our points of operation, where we'll be getting people to be trained, sensitize the patients, including sending emissaries into the villages so that they're all made aware of the situation that is obtaining, and now we can change and how we can make it easier. So we set up the satellite clinics and then subsequently the third phase will now be running all those clinics and collecting data on the initial presentations. And as time goes by, by the time we are finished with the setting of the clinics and the issue of the running of those clinics, we'll be able to gather data that will now be used as the pre-project time and the post-project time.

So that now the last phase, which is the fourth phase, will now be analyzing of this data and bringing forth the changes or the things that have now taken effect and how we can sustain this. Including the fact that we have thought that at the end of it all, when we have finished with this project, the clinics that have been set, the people we have trained, and the general systems that have changed in terms of reviving the moribund referral system, all those will now be handed over to the administrative centers, the county healthcare system to be incorporated into the routines. That now from the time that we have set in to the time we are exiting, those changes that will have taken place will have a way of being sustained subsequently in the years to come.

The expected outcomes will be increased prostate cancer awareness, early presentation, rapid access to the clinics, functional referral system, and improved overall outcomes of the care.

The sustainability, as I said, is that we are going to have these rapid access clinics and the people that we have trained who are now going to be part of this public hospital, including the administration, who are now going to be running these clinics as part of their healthcare in those regions. And so with that, we'll have attained the change from what obtains now to what we anticipate. We envisage a system that will now not only be helpful to the patient, but also beneficial to the healthcare, so that at the end of it all, we can get early detections and have better outcomes of these patients. Thank you.

Charles Ryan: Excellent. Well, that's a very ambitious and really fascinating project with an obvious benefit to the community. A couple of questions. When you talk about the rapid access clinics, are these going to be essentially in existing urology clinics, but creating an opportunity for somebody who looks like they have prostate cancer to be seen rapidly, or will you be establishing new entities, new offices?

Pius Musau: These clinics will be part of... You see, in every setting, in all these referral centers, what we would call the county referral centers, they have outpatient clinics, including the surgical outpatient clinic. So this is what we are going to hitch on to so that the rooms that are already available in place because the funding is minimal, the rooms that are going to be available are those that were being used for already existing surgical outpatient clinics.

Charles Ryan: I see.

Pius Musau: Then you train the people who have already been involved in the care of the surgical patients, but now with emphasis on the care of the patient with prostate cancer.

Charles Ryan: I see. I see.

Pius Musau: Yes.

Charles Ryan: You described that 80 to 90% of the new diagnoses are patients who have advanced disease. Are most of that 80 to 90% coming to a clinic because of a symptom that they have, whether it be urinary obstruction or perhaps pain for metastatic disease? In other words, it is symptom driven or are individuals coming in for primary care visits and being evaluated while they feel essentially well?

Pius Musau: Part of what we have found in the studies I was mentioning is that these patients, because they're in terms of the cultural consideration, they're much older than the people who are going to take care of them. And even culturally, among themselves, they will find it very difficult to share the information about their conditions. So by the time they're presenting, it's because they're already having metastatic disease or they're coming because there's been no obstruction that has been chronic over a period of time. So besides the obstruction of the urine, there is also the aspects of these are the comorbidities like hypertension and renal compromise. So we are seeing those kind of patients now by the time they finally present. We want to see how we can turn that around to ensure that now people are aware and they are more comfortable with sharing their problems among themselves and even among relatives and have the confidence to face their doctors who most of the times will not be their age mates. They're usually very young people in their 20s, in their 30s.

Charles Ryan: The doctors?

Pius Musau: Yes. And particularly if they're going to be ladies, these elderly men find it very difficult to even expose themselves to these people. So those are some of the things we need to change so that we can address the issue of why do they come late? And how can we turn it around to make it easier for them to present early?

Charles Ryan: Do men in Kenya, let's say at 50 years old who are generally healthy, do they go to a primary care physician for routine healthcare? It's a problem in the United States and we see the same thing where women are more likely to be going to primary care doctors for a whole variety of reasons, whereas men are less likely. Do you see that pattern as well in Kenya?

Pius Musau: Very much so. In fact, most likely, much more than in the US, because as I've said, there's a cultural aspect that makes them become very stoic. For a man, you're not supposed to be showing emotions about small things like how difficult you're finding urinating. So they will keep it to themselves.

The other thing is in terms of exposure, the education level is relatively very low among those people in that category of patients. And so they will not even have the means to even have a routine or even a healthcare, the kind of Medicare that is going to take care of them in a manner that they will be comfortable enough financially to find time to even visit without having symptoms. So the routine care, the routine medical checkups are very rare. They're the exception. Even among those who are educated, we find that men are not very keen on looking for problems. They would rather wait until it happens to them. And then now they can present.

Charles Ryan: That is perhaps a universal feature of maleness.

Pius Musau: So it is

Charles Ryan: You highlighted a problem. And then I think I heard you speak to a potential solution. The problem you indicated is that you have for a very large catchment area, only five urologists, but then you told me that the urologists tend to be in their 20s and 30s, the doctors frequently, which leads me to believe that perhaps there's a growth of interest in urology in the country, maybe I'm wrong. But can you tell me a little bit about the workforce that you have in the clinic, in terms of the availability of physicians to address what will likely be a growing population of patients who need care?

Pius Musau: Most of these patients will be seen by other kind of of healthcare workers other than doctors who are trained in urology. Those are the ones that I'm saying out in the periphery and even when they come to the main referral centers, they will be finding relatively younger people. But the urologists that we have in place, I think the youngest is in his 50s. So they can rhyme, they can talk, they can reason with those old men, but in terms of the general care of these patients, by the time they come to the urologists, they have already met these other younger people who are not trained in urology, but have at least had some exposure as medical officers, as clinical officers, as nurses with the long experience. So these are the people that I was alluding to as having younger ages that these people find difficult besides the culture of hiding those issues pertaining to the reproductive tract. And also the tendency to first of all, try the traditional medications and-

Charles Ryan: Sure.

Pius Musau: ... finally come back to the conventional medicine.

Charles Ryan: Sure. Okay. Well, one final question is as you approach your work and you launch the program, you outlined several goals that will be signs of success of the program. If you had to pick one measurable goal that you could say, "After three years, we've accomplished our goal because we've seen the following outcome." What would be your single most desired outcome? The particular goal that you would look at?

Pius Musau: I think the key one would be the flow, the general transition, the movement from the village to the nearby facilities. And then from both facilities down to the referral centers that can do something about the urological condition. So if we can have a rehabilitated referral system that is now almost moribund or nonexistent, then we will achieve much more by virtue of the sensitization that this referral will be able to put into these people so that they are aware of their condition and they need to seek early care. And then once they present there, they find people who are enlightened. And then these are the people now who will facilitate and make it easier so that the time of the symptoms to the time of interventions is cut by many, many folds. Because presently we see patients coming years after the condition started because they did not have that sensitization that they have. So if we can establish a referring system that has those points of contact that are enthusiastic about this care of prostate cancer, then that will be the greatest hallmark of the achievement of this project.

Charles Ryan: Sure. And you have a very ambitious goal to do essentially a handoff to your government health administration. I really like that notion because it suggests that we at the Prostate Cancer Foundation can help change the practice in your region, but your handoff to your government could affect the whole country. And of course, Kenya is a country with a very large population and a growing population. And so the results of your work could disseminate not only through the country, geographically, but through the time of the coming years. And that would be a tremendous legacy of your work. Is the government looking for a particular outcome before they decide they would adopt your methodology? Tell me a little bit about that partnership?

Pius Musau: You see, these counties have a devolved system and healthcare is part of those devolved functions. And if you engage these people without having even to think about the national government, if you can think about the county government with their governors that are going to have the capacity to initiate the care of these prostate cancer patients, because they are those executive committee members who are going to be part of their engagement. These are the people we'll be talking with. These are the people we are going to sell the idea that it is worthwhile to have these things done the way we have found is helpful. And the moment this takes root and they see the difference between now the Western region and the rest of the areas, then it definitely will be attractive enough. And we wouldn't mind being the initiators of change.

Charles Ryan: And we would be happy to be the supporters of the initiators of change.

Pius Musau: It would be nice.

Charles Ryan: So it's been a great pleasure speaking with you. As we wrap up our conversation, are there any other comments or words you would like to say for the listeners?

Pius Musau: Well, I think the thing that we decided to bring into the whole issue of the care of prostate cancer patients, is that if we can identify the challenges and come up with a way of resolving it, then we will be of great use, not just to our patients, but also to the practice because the things that were not being done will be able to be done. The radical prostatectomies that are not possible now because of the advanced disease that comes, will become part of our care. And routine becomes part of the general improved care of these patients, not just in the region, but hopefully beyond even in the country and in the East African region, because Kenya is actually the hub, the center of the rest of the East African region that is going to be looking forward to whatever changes that are beneficial to Kenya, to be absorbed by the other neighbors. So we are at a strategic position that can make a difference, not just in Kenya, but in the rest of the Eastern Africa.

Charles Ryan: Well, that's wonderful. And congratulations again on the receipt of this award. We look forward to hearing your progress and hearing you speak of it in person at one of our upcoming meetings and certainly important work for your region. And I think also safe to say for the country in general and perhaps other countries as well. So Pius Musau, great pleasure speaking with you today. You take care and thank you so much and congratulations.

Pius Musau: Thank you.