(UroToday.com) The 2024 American Urological Association (AUA) Annual Meeting held in San Antonio, TX was host to a bladder and upper tract transitional cell carcinoma podium session. Dr. Quoc-Dien Trinh delivered the Journal of Urology lecture discussing the significance of fostering prostate cancer awareness and resilience among men of color.
Mitigating racial disparities requires a three-step process:
- Detection: Access to care is a key factor contributing to racial disparities in prostate cancer outcomes
- Understanding: Men of color face significant barriers, including transportation challenges and mistrust, in receiving care
- Reduction: A community outreach clinic can help overcome these disparities in access to prostate cancer treatment
Dr. Trinh highlighted that racial and ethnic minorities experience worse outcomes and lower quality of care across a variety of diseases. Hispanics and Asians have narrowed the survival gap, but Blacks have not.
Access to care is critical for mitigating racial disparities. Improving access to care in all aspects can mitigate racial disparities in timely treatment receipt. This is exemplified by the fact that Black men are 27% more likely to die when accounting for demographics alone. Black men are 4% more likely to die when accounting for demographics + access to care (p=0.2). Black men are 8% less likely to die when accounting for demographics + access to care + cancer.1 As such, when accounting for access to care, treatment, and cancer characteristics, being Black was associated with improved overall survival in men with advanced prostate cancer.
We note that there are facility-level racial/ethnic variations in treatment rates of localized intermediate/high-risk prostate cancer patients. In a National Cancer Data Base (NCDB) analysis of 223,873 White and 59,262 Black men ≥40 years of age receiving care within the USA with biopsy confirmed localized intermediate/high-risk prostate cancer diagnosed between January 2004 and December 2013, Friedlander et al. demonstrated that White men were significantly more likely to receive definitive therapy in 39% of the treating facilities. Conversely, only one facility demonstrated significantly higher rates of definitive therapy in Black men.2
Overcoming inequities in access to health care and diminishing these disparities requires a total team effort. As illustrated below, the Massachusetts Department of Public Health Prostate Cancer Workgroup includes the following key players:
What is the current state of racial differences and geographic variability in prostate cancer care within Massachusetts? Currently, Black men are 22% less likely to receive definitive therapy for prostate cancer.
What aspects of access to care explain racial disparities in prostate cancer outcomes?
- Affordability: Ability to pay
- Availability: Human and material resources
- Acceptability: Comfort when receiving services
- Accommodation: Patient convenience
- Travel burden: Time and resources required to travel
Dr. Trinh highlighted their group’s comprehensive outreach program in the largest health system in New England focused on community engagement. This program aims to overcome access to care as a major driver of racial disparities in prostate cancer mortality.
How do we define community engagement in healthcare? Community engagement is important to support the clinical care of underserved communities, including low resourced neighborhoods and/or communities of color. Engagement approaches vary based on the setting and desired outcome and may include events, surveys, focus groups, and advisory boards. Level of involvement ranges from sharing information to empowering the community as shared decision-makers.
Building trust and trustworthiness in community partnerships is a critical component of the engagement process.
The MGB prostate cancer outreach clinic will serve as a catalyst to bring communities together through compassionate prostate cancer care. Its goal is to offer high-quality, accessible, and affordable prostate cancer care to minority men. An overview of this initiative is illustrated below:
The marketing strategy of this outreach clinic was co-developed in tandem with the MGB marketing and quality teams to bring patients into the MGB Prostate Cancer Outreach Clinic:
This clinic aimed to empower change by creating a patient advisory board that allowed patients to:
- Create new patient education materials
- Inform the location and timing of patient engagement events
- Serve as a sounding board for research proposals
The clinic workflow is summarized below. Once a referral was received, contact with community health workers was initiated to identify whether patients had compatible insurance policies. If they did, an appointment was scheduled at Brigham Women’s Hospital or Massachusetts General Hospital. If patients were deemed insurance incompatible, patient financial services were contacted to facilitate appropriate referral. There were 407 referrals and 1,316 appointments between February 2022 and February 2024. 17.7% of patients were referred by a third party (AdMeTech Foundation) or self-referred.
In order to optimize the workflow of the prostate cancer safety net, the following eligibility criteria were applied:
- Inclusion criteria:
- Confirmed elevated PSA >4 or >2 on finasteride or dutasteride
- Most recent PSA is elevated.
- Exclusion criteria:
- Recent urology visit
- History of prostate cancer
- Intervention not clinically indicated
- Closure criteria:
- PSA normalizes
- Prostate biopsy or MRI
- Intervention not clinically indicated
- Decision for watchful waiting
Patient education events were organized to facilitate effective outreach. The objective of these community outreach prostate cancer education events was to build trust in a non-threatening environment. The involved parties discussed shared decision-making principles for prostate cancer screening, treatment options, and side-effects. From a referral standpoint, community health workers were able to address care-related questions and follow up on requests for prospective patients.
He noted that since its inception, there have been 28 community events with five upcoming events in the next month alone.
What are the preliminary results? In the 2022–2023 fiscal years, there have been 407 referrals and 1,316 appointments made. 25% of patients with elevated PSA referrals were diagnosed with cancer. 110 procedures have been completed at MGB.
This outreach initiative has significantly reduced the proportion of unfollowed abnormal PSA values over the past two years, as summarized below:
Dr. Trinh noted that challenges in expanding outreach initiatives have included the following:
- Navigating insurance: Addressing challenges for out-of-network and uninsured patients
- Patient retention in MGB urology
- Overcoming language barriers
- Sustaining outreach: Maintaining engagement with stakeholders after initial contact
- Adapting to COVID-19: Adjusting to in-person restrictions and telehealth dynamics
What is the path to sustainable community engagement?
- Financial support: Diverse funding through UAR, departmental backing, grants, and philanthropy
- Workforce development: Strategies for recruiting and retaining medical staff and volunteers
- Collaborative outreach: Working with other institutions/systems to enhance service delivery
- Infrastructure growth: Expanding our physical presence to enhance
service delivery
Notably, the PCOC initiative has served as a ‘springboard’ for innovation, as evidenced by the research funding supporting the PCOC. Additionally, PCOC is increasingly being used as an enrollment site for clinical trials.
Dr. Trinh concluded his presentation by noting that outreach initiatives are key drivers of solution efforts to address social determinants and reduce care variability.
Presented by: Quoc-Dien Trinh, MD, Associate Professor of Surgery at Harvard Medical School, Section Chief of Urology at Brigham and Women's Faulkner Hospital, Boston, MA
Written by: Rashid Sayyid, MD, MSc – Society of Urologic Oncology (SUO) Clinical Fellow at The University of Toronto, @rksayyid on Twitter during the 2024 American Urological Association (AUA) Annual Meeting, San Antonio, TX, Fri, May 3 – Mon, May 6, 2024.
References:
- Krimphove MJ, Cole AP, Fletcher SA, et al. Evaluation of the contribution of demographics, access to health care, treatment, and tumor characteristics to racial differences in survival of advanced prostate cancer. Prostate Cancer Prostatic Dis. 2019;22(1): 125-36.
- Friedlander DF, Trinh Q, Krasnova A, et al. Racial Disparity in Delivering Definitive Therapy for Intermediate/High-risk Localized Prostate Cancer: The Impact of Facility Features and Socioeconomic Characteristics. Eur Urol. 2018;73(3): 445-51.