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Samuel Washington: Hi everyone, it's Dr. Samuel Washington with UroToday. Today I have the privilege of talking with Dr. Leanne Woods-Burnham, Assistant Professor, Co-Director of the community-based prostate cancer screening program at Morehouse School of Medicine. Thank you for taking the time to chat with us.

Leanne Woods-Burnham: Yeah, thanks so much for having me.

Samuel Washington: I wanted us to discuss what you went over about the impact of screening for prostate cancer for Black men within the United States. A topic which you discussed during the SUO conference most recently, and there's a lot that goes into that. We discussed a little bit about NCCN guidelines, AUA guidelines, and their emphasis on screening practices. Can you tell us a little bit about the impact of the task force recommendations on screening practices and outcomes that we've seen?

Leanne Woods-Burnham: Sure. So, it has been reported that after that guideline change in 2012, obviously, the detection of localized prostate cancer decreased. That's what we would expect. As we went back in time, we saw that there was an increase in the diagnosis of regional and distant metastasis, which was across the board. It doesn't matter what your race or ethnicity is; we saw that across the board. However, those rates still remain higher for Black men, and what we've seen in studies that we've done and just in conversations with different health systems, different clinicians, is that while screening rates are tending to go back up for other ethnicities between that age of 55 and 69 according to what the task force is saying. We're finding that it's not necessarily the case for Black men at the same rate, and then if you look at some other, you know, how you're saying NCCN and AUA, which would also be in line with American Cancer Society and what Prostate Cancer Foundation is saying these days as well.

Is that for Black men, especially for those who have a family history, they should be screened at age 45, or even 40 depending on how extensive that family history is, and we definitely know that that is not occurring at any sort of consistent basis across the nation. And so when that happens, then what we have seen is this steady increase in metastatic diagnosis in men, especially for Black men.

Samuel Washington: So that really brings up a lot of the barriers that Black men face, generally speaking, across the United States when it comes to screening. Can you speak a little bit about what those barriers are and what others may be?

Leanne Woods-Burnham: Yes. And so we've published before, and others have as well, that Black men report that some of their barriers are health insurance issues. It can be a matter of what are the physician's office hours as it pertains to their work schedule. A lot of men are not aware that they are at higher risk. We see that a lot, that a lot of Black men are not aware that they're at higher risk for prostate cancer than other groups. But the number one thing that comes across is when they are not recommended by their clinician to have a PSA test or prostate cancer screening in general. They're not going to do it, right? When they're going to the doctor and they'll say, "I went to the doctor and I got my annual, and here's what I got done: my blood pressure, my cholesterol, all of this." If the doctor did not talk to them about the pros and cons of prostate cancer screening given their race and their family history, then they don't necessarily know to advocate for themselves to have that done.

Samuel Washington: That's a really important finding when we think of the progress or the pathway from elevated PSA to discussions of screening and diagnosis. Urologists like myself, radiation oncologists, all of us who focus on prostate cancer, are kind of farther along on the diagnostic treatment pathway. So, when it comes to primary care doctor recommendations, what do you think are the biggest issues that are preventing broader screening?

Leanne Woods-Burnham: At the primary care level, when we talk to some that we collaborate with, what we hear is primary care physicians have a hard task where they have to be up-to-date on a lot more than one specific disease. And so sometimes, what the current recommendations are for patients who are high-risk populations might be in the fine print of a recommendation. Sometimes a PCP might not be aware of how that screening guideline might differ for a high-risk population. So that's the first thing. The other thing is, depending on what healthcare organization they are affiliated with, those institutions will have different recommendations for high-risk populations, and so obviously, PCPs are going to go along the lines of whatever institution they're affiliated with, and so there are a few different reasons. I don't think that it's too often that a primary care physician would just have an overall bias of, "I'm going to make it a point to not screen Black men when they come in the clinic." So it's multilayered. Not to say that that never happens, I just don't think that that's the overall tone of what's happening.

Samuel Washington: Yeah. I think there are a lot of structural issues related to that, that often we can't catch in our data registries or even some of our qualitative studies. Do you think there are opportunities for the community to fill in those gaps? Provide some information or screening opportunities for some of those men who may not have gotten it with the structural barriers that they're up against?

Leanne Woods-Burnham: Sure. There has been a focus by some over the last I would say decade, but it's growing now and it's really sort of a hot area of focus to provide community-based prostate cancer screening. So, I know for our team, we recognized this right around 2012 when the guidelines changed. And so we would form multidisciplinary teams of... It takes a clinical team, it takes public health experts, and it heavily relies on our community partners. Those are the most important players in the equation. What we would do is partner with our community network, and we would host health fairs. So, we would go to churches, festivals, parades, barbershops, or whatever, and offer free PSA testing and then most importantly provide that follow-up afterwards, which requires a commitment from the hospitals and clinics around you, the urologists around you for follow-up for men who have elevated PSA levels. So we did that in California. Our team did that, we were able to screen around 1,000 men, and now we kicked this off in Atlanta just the past few months at Morehouse School of Medicine.

And to date, I mean, because it's always changing, but as of today, we've screened over 600 men doing that, and so it's exciting for us to know. We see, when we screen the men, the percentage that is average of men who have elevated PSA and they just had no idea. Right? They might be coming to a church service, they might be participating in a festival, and we talk to them in casual conversation. They decide to get their blood drawn and get their PSA tested, and lo and behold, they have an elevated PSA that they didn't know about. We had a man this past weekend at an event that we did where his PSA levels were in the four hundreds and just had no idea. So, these sorts of stories really drive us in what we do, but there is more of a focus on it. So I know that the Prostate Cancer Foundation, for one, is an organization that is turning attention this way, which I'm extremely excited about. I know that ZERO Prostate Cancer has an initiative that's starting to focus on this as well.

And so, I'm excited for this sort of initiative to pop up in different parts of the nation as well.

Samuel Washington: And I think you touched upon this a little bit as well. There's the screening, the actual event, getting the blood test, and then the thing that I would argue is almost as crucial is that follow-up afterward. So what happens to that test result? Can you speak a little bit about your programs and how you built out that follow-up to make sure we're not losing all of these men who now have a test result that needs action or some discussion?

Leanne Woods-Burnham: Yes. So it's different per institution that you're at, but here at Morehouse School of Medicine, we have our own Morehouse Healthcare system. So we start there; we rely on our primary care physicians there in terms of the initial contact with these men who have elevated levels. But then we partner with urologists, we like to give our men different options depending on their insurance status. Some men don't have insurance, some men are underinsured, and so we partner with a few different institutions in the Atlanta area so that men can go where they feel comfortable, where it's tailored to them, closer maybe to where they live. So we don't just offer one clinical option.

Samuel Washington: Wow. I mean, that is incredibly comprehensive, which is amazing. Just in terms of making sure that those barriers, we talked about those structural barriers, aren't there preventing team access to urologic care, to specialty care after the test is done. Can you speak a little bit about you mentioned a little bit about the test results, the PSAs that you found. What kind of outcomes do you feel are most crucial as these screening events happen? What things are you looking at as mile markers to show this is having an impact?

Leanne Woods-Burnham: Oh, wow. So to me, it's more the family impact. We had one screening event where a man found out his results and then went home and then encouraged his brother to come back to the next event, and he also had elevated PSA levels. We know if we see 100 men at an event, that's really translating into a few hundred men as that spreads, and then we know it's affecting their sons down the line. Because now it's talked about in the family, and it's just something that's going to be passed on when it comes to the importance of it. So that sort of thing is really the most important, and I like to be able to detect elevated PSA at levels where it's not extremely high yet. We want to detect it when the cancer is curable, and so if we find those elevated PSA levels and men go, and they can do active surveillance or decide on a treatment plan that they want to do. We are literally changing their life, right? And so that's the goal really to try to detect it at that earlier stage.

And one other thing I was thinking about too is it's important as people think about implementing this at their institutions. I can't stress enough the importance of having a culturally sensitive team depending on what demographic or which population you're targeting. So when we were doing this out of LA, we would be cognizant: are we in a Hispanic or Latino population? Are we in a black community? And we are very careful to make sure that we have a culturally sensitive and, if we can, a culturally congruent team to go to those populations. Because I can tell you what, the community can sniff and sense when groups are doing this out of a benefit for themselves rather than for the community that they're offering it to, and so that is something that we've been able to bring to the plate, and so I challenge others to dig deep and make sure that they're covering all bases.

Samuel Washington: I think that's an actually important point that I wanted to ask you about. So when other areas, other institutions, other organizations say, "I want to do a screening event in name whatever county you want or whatever city," how important is it to start those partnerships early with community organizations, community leaders who are already there doing this work?

Leanne Woods-Burnham: Yes. So some partnerships that we have are 20, 30 years old. If we are doing a new partnership, which right now we have an initiative to expand into rural parts of the state of Georgia, we're just not going to jump on our mobile unit and drive down the 75 and just show up in a community. There are already clinics in place, there are already key community leaders, they already have great things going on. They know exactly what they want, they know exactly what they need. So we partner with them to see how we can best fit into what they have going on, and not every high-risk population is the same; there are geographical differences. So I know for me, I am an African-American from Ohio. When I went to California, I had to learn, okay, well, what is this going to look like if I'm going into a black community in LA? That's not the same as Ohio. And just because we were extremely successful in LA, when I came to Georgia, I had to take a step back and humble myself and say, listen, I know how to do the logistics.

I don't know how this population in Georgia is, and so I don't want to walk into a church or an event or something and not be speaking in a sensitive way, not dressed maybe as what's to be expected, not talking to the right people. Sometimes there are chains of command that have differences depending on what part of the country you're in. And so that is where I really rely on our community partners who are embedded in that community to really sit me down and school me, teach me, give me a class before we show up.

Samuel Washington: It's such a necessary step, especially when we go from national guidelines or recommendations to actually implementing them and needing to go hyperlocal to understand how this will actually play out. Well, thank you, Dr. Woods-Burnham, for taking the time to speak to us about this great learning opportunity and a guide for how we should approach this problem given the increased interest and energy focused on this now.

Leanne Woods-Burnham: Yeah. Thanks so much for highlighting this, and I'm so excited that people are focusing on this, and I'm just looking forward to the initiative to spread because it's very much needed.