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Ruchika Talwar: Hi, everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar. And today, I'm very excited to be joined by Dr. Labban and Dr. Trinh, who are two researchers and urologists at the Brigham affiliated with Harvard.

Dr. Labban is a urology resident, and Dr. Trinh, who needs no introduction, is a prolific urologic oncologist and researcher, as I mentioned, at the Brigham. So we're really excited to have them both here today. We're going to be discussing recent work that they have published, exploring the intersection of some barriers that our prostate cancer patients face, specifically as they relate to transportation services. So thank you both for taking the time to chat with us this evening. We really appreciate it.

Muhieddine Labban: Thank you.

Quoc-Dien Trinh: Thank you.

Muhieddine Labban: Good evening, everyone. Thank you for today, for the opportunity to present. I'm very excited today to share with you our recently published paper, titled “Overcoming Challenges in Prostate Cancer Care with Transportation Services.”

And just to highlight that a lot of the work that I'll be sharing today is based on several years of research with different faculty and collaborators. And it's really tied to Massachusetts, but I feel that our findings could be applied in other states as well.

Now, one of the seminal papers that I would like to highlight is Dr. Cole’s work with the Department of Public Health here in Massachusetts. And we found that Black men were 22% less likely to receive definitive therapy for prostate cancer. And as you can see on the right side of the map, there's some geographic disparities. And we were really thinking, what are the drivers of disparity in Massachusetts?

What's important to highlight here is that since 2006, there's almost universal access to health care in Massachusetts because of MassHealth, this extended version of Medicaid. And so we thought that affordability or coverage, insurance, and availability of care are not big issues. But what we didn't know are what other factors could be contributing to this disparity.

This is why we conducted a qualitative research in Massachusetts. And we invited four hospital systems. We conducted semi-structured interviews with stakeholders to really pinpoint major themes that could be contributing to this disparity. And this culminated in a paper that was recently published in Cancer, entitled “Qualitative approach to understanding the drivers of unequal receipt of definitive therapy for Black men with prostate cancer in Massachusetts.”

There are several themes that emerged out of this study, but the one that really struck me the most was that Black men are facing more challenges when it comes to transportation services. And when we were looking and discussing it with other people and stakeholders at those hospitals, those hospitals that have been historically serving wealthier and white populations are not necessarily serving a representative composition in terms of racial and ethnic makeup that is reflective of the community.

Black men are willing to face greater transportation challenges to seek care at other hospitals. And what we notice is that they gravitate towards something called “safety-net hospitals” because those hospitals have the infrastructure to deliver transportation services, navigators, translators. And what we didn't know is—those were basically based off of interviews and qualitative work. But I wanted to understand how big of a problem was it at a national level, and how big was it at a local level or a state level?

So the next step is I went to something called the National Household Travel Survey. And it basically computes all the travels someone has over a year. And what we found is that Black patients are three to four times more likely to use public transportation for one health care visit. And at the same time, when you look at the intersectionality between race and ethnicity and income, we found that Black patients with lower family incomes spend on average 80 minutes more for one health care commute when using public transportation. And that's huge.

How is it really reflective in Massachusetts? This is when I started doing further research. And although Boston and Massachusetts have the fifth largest transportation system in the country, in recent years, it has come under scrutiny not only because of the safety of the transportation services but also because of inequity. Historical redlining has really shaped the way transportation services are delivered, and they're not really equally delivered.

And this is one piece in The Boston Globe by the mayor of Somerville, Katjana Ballantyne, mentioning that we really must remake the Massachusetts transportation services. And other organizations such as LivableStreets were looking at the time disparity among bus commuters. And as you can see, Black commuters and Latinx commuters are spending 64 hours and 10 hours more yearly to get to their destinations.

Some would argue that MassHealth offers something called PT-1 forms or basically transportation services to and from health care facilities. But what's interesting is that even among the 1.5 million eligible beneficiaries, only 3% are using those services. And honestly, I don't know the reason why there is such a discrepancy between those eligible and those using those services.

And it's important to acknowledge that people like Governor Healey are working on providing funding for people across the Greater Boston Area. And I think Governor Healey put in $30 million in order to fund the commutes of people in the Greater Boston Area. But I think, still, some of the transportation challenges that our patients are facing are rural isolation, limited public transit, direct and indirect cost, and options for individuals with disabilities and mobility impairment.

We thought that we need to do something about it, honestly. And we thought to leverage our clinic, which is called the MGB Prostate Cancer Outreach Clinic. This clinic is dedicated to deliver high-quality, accessible, and affordable prostate cancer care to minority men. And it was founded by Dr. Trinh and Dr. Feldman at the Brigham and MGH, respectively. And we have dedicated health care workers who help men who are diagnosed with prostate cancer navigate that diagnosis and get the treatment they need. And we offer transportation services, translator services.

We thought that since we were already doing this work there, we might as well back it up with further science. And if we were able to demonstrate that rideshares to and from their home would be able to reduce loss to follow-up and promote completion of treatment, then we might be able to also influence policymakers to make it part of that standard delivery of care. And thankfully, last year, we got funded by the Department of Defense.

And as part of this multi-aimed project, we’ll be not only characterizing the geographical barriers each prostate cancer patient is facing, but we’ll also be piloting a rideshare program to demonstrate that our hypothesis would be that providing rideshare among patients who need it will eventually decrease loss to follow-up and ensure completion of care.

Finally, I would like to extend my gratitude to the AUA Summit, opening this opportunity to discuss those findings with our senators, Senator Warren and Senator Markey. And I would like to end this short presentation with a quote from our mayor of Somerville, Ms. Ballantyne. And here I quote, “What happens if our state doesn’t have a world-class system?” And here, I think she refers to the transportation system. “We not only risk economic stagnation, we also fail to meet our climate, health, racial justice, and housing equity goals. In Massachusetts, we have the talent pool to attract new jobs, but we risk our quality of life if we have a failed transportation system.” Thank you very much.

Ruchika Talwar: Thank you so much, Dr. Labban. There's so much to unpack there. And I want to start out by highlighting a couple of points that really stood out to me.

So first, you're providing an example of a state, of a local community that, frankly, is at an advantage here. You have a great infrastructure already, significantly, I'd say, higher resources devoted to public transportation than other states, such as the one I live in—Tennessee. We don't have a strong public transportation system. And so if you're emphasizing these disparities that we're seeing in these barriers, then that just tells me that this is a much bigger problem at a much larger scale than we are seeing in the literature particularly. So, first of all, congratulations on quantifying this to some extent and getting this conversation started. I think it's really important.

Now I'm curious, how do you have these conversations when you're talking about prostate cancer treatment options? If a patient is starting on their prostate cancer journey, Dr. Labban, do you recommend that we have some sort of screening tool that we use or information that we should be able to abstract from patients? We're busy in clinic. How do we even get the ball rolling on some of these discussions? What's your advice to the urologic community?

Muhieddine Labban: Definitely. And I think I can speak on behalf of the Prostate Cancer Outreach Clinic. And we do extend a lot of these screening tools to identify the social determinants of health. And we're able to flag patients who probably need more support when it comes to transportation, even like food vouchers or even when it comes to—because a lot of the prostate cancer treatment—let's take radiation therapy.

Patients have to show up 30 days consecutively to get their treatment. So if they cannot take time off, if they cannot have the child support, then it would be difficult for them to present to their appointments. So we try to identify those risk factors early on and provide the support as much as possible to those patients. And here, I think, Dr. Trinh, I don't know if you have any other things you'd like to highlight since you founded the clinic.

Quoc-Dien Trinh: Yeah, no, I agree with you. And I think the one key message is that you have to be really conscientious and actually devote resources to address these issues. An anecdote I can say is that a lot of hospitals—and I'm sure your hospital and mine—have very stringent policy on people who show up late. You show up 15 minutes late and your appointment is canceled, your treatment is canceled. Every patient is lined up in a very organized fashion. But if you adopt draconian measures here, the people who are the most marginalized are going to suffer the most. And I think that, in my own experience, I've learned to be a little bit more tolerant about such issues, trying to be very conscientious about equity, which is something that I'm passionate about.

Ruchika Talwar: Yeah, that's a great anecdote. And I think often the question, particularly from urologists who are in the community who may not have an infrastructure that can screen for things like social determinants of health, is, how do we even tackle this problem? I mean, I'm just trying to get through the day to make sure patients are getting the care they need. And particularly in access-strained communities, we don't have a good way to screen. So, Dr. Trinh, I'm curious, as you've established this clinic and as you've built some of these transportation support services, what are some lessons that you've learned that you think the broader urologic community can actually practically implement in their day to day as they see prostate cancer patients?

Quoc-Dien Trinh: Yeah, I think Dr. Labban mentioned some of them in his short presentation, but there's actually a lot of systems that are in place, whether it's volunteer or organized by the state, associated with MassHealth. And I'm sure every state has some variation of this. You just actually have to know these resources exist. And you can streamline it and provide these to patients.

And there are so many barriers to receiving care. We talked about affordability. We talked about the trust in the system. But there's probably a way to at least eliminate or mitigate the transportation part if you know what resources exist. And for example, like I said, I know which resources exist. But I think that it's important for clinics everywhere to know that there's at least, as far as I know, 10 volunteer organizations that provide free transportation for patients and all these vouchers that exist that are provided free of charge for certain populations.

Ruchika Talwar: Yeah, absolutely. Thanks for emphasizing that aspect of the presentation. I love what you call out, the fact that there are so many aspects of health care disparities that are really challenging for us to tackle. They're really complex, and they don't always have a simple fix. But I'm an optimist, and when I hear you say this is something that there actually is a fix for, and there are resources out there, that definitely energizes me. And I'm glad that we have the opportunity today to get the word out and get this conversation started.

I know that some of this work more broadly is funded by the DOD, as was mentioned. And so I'm really excited to, hopefully, bring you both back as work continues to be published from this overarching project. But today, I just wanted to thank you both for taking a few minutes to spread awareness about this really important issue.

Quoc-Dien Trinh: Thank you. Thanks for having us.

Muhieddine Labban: Thank you.

Ruchika Talwar: Awesome. Well, to our urologic community that tunes into UroToday, thanks again for joining us. I hope that this conversation gave you something to think about the next time that you potentially have identified a transportation barrier in one of your patients. I know it certainly has sparked a couple of ideas for me, but we appreciate you tuning in, and we'll see you next time.