What Mass General Brigham Is Doing to Combat Prostate Cancer Disparities Among Men of Color

During the Saturday morning plenary session at the American Urological Association (AUA) 2024 Annual Meeting, Quoc-Dien Trinh, MD, MBA, chief of urology at Brigham & Women's Faulkner Hospital, shed light on the pressing issue of prostate cancer disparities among men of color.

The Journal of Urology lecture, “Empowering Communities: Fostering Prostate Cancer Awareness and Resilience Among Men of Color,” delved into the web of factors contributing to these disparities and outlined innovative solutions addressing them.¹

Trinh underscored a critical point: while biology undoubtedly plays a role in prostate cancer outcomes, access to care is a key factor in racial disparities in outcomes. Drawing from extensive research, he highlighted the barriers faced by men of color, including transportation burdens and mistrust in receiving care at large academic centers. Despite advances in health care, the gap in prostate cancer outcomes between Black and White men persists, pointing to systemic issues beyond biological factors. While the survival gap has been slightly narrowed for Hispanic and Asian patients, that’s not the case for Black patients.

Care access is a key factor in racial disparities in prostate cancer outcomes | Image credit: Syda Productions – stock.adobe.com

Interestingly though, after accounting for factors such as access to care, treatment, and cancer characteristics, Black patients actually had more improved overall advanced prostate cancer survival compared with White patients in certain simulated circumstances.

“But the key word here is that these are simulated circumstances,” Trinh said. “These are not real-world factors.”

For instance, in a study published in 2018, data showed that 39% of health care facilities were inclined to treat White men more frequently than Black men for intermediate and high-risk prostate cancer, with only 1% doing the opposite.² These findings garnered the attention of the Massachusetts Department of Public Health Prostate Cancer Workgroup, which Trinh has been involved with for a decade, more recently serving as chair. Trinh explained how the committee serves as a platform for community engagement, bringing together clinicians, scientists, advocates, and various stakeholders to strategize on initiatives, studies, and community projects aimed at addressing these disparities. One such commissioned study revealed that Black men were 22% less likely to receive definitive therapy for intermediate or high-risk prostate cancer in Massachusetts compared with White men.³ Despite the state's extensive health insurance coverage, this study underscored that mere access to insurance doesn't ensure equitable care delivery.

Trinh then showed the audience the 1981 conceptual model by Penchansky and Thomas, which highlights 5 dimensions of access to care: affordability, availability, acceptability, accommodation, and travel burden.⁴ He also explained how the workgroup—funded by the American Cancer Society—conducted a stakeholder analysis across various health care facilities, engaging hospital executives, physicians, patients, and community centers. This analysis revealed themes of mistrust in large health care systems among minority communities and a recognition among hospital leaders of the need for improved population health strategies. To address access barriers contributing to racial disparities in prostate cancer mortality, the proposed solution involved operationalizing research findings into a comprehensive outreach program within the largest health care system in New England, with a strong focus on patient engagement and stewardship.

Community engagement in health care involves collaborating with communities to address key issues, particularly in underserved areas such as low-resource neighborhoods, communities of color, and rural regions. Trust plays a central role in community engagement and as part of an initiative to help foster this trust, a prostate cancer outreach clinic was established as a case study to bring communities together through prostate cancer care. Supported by the Unite Against Racism initiative, key components of this outreach program include the creation of a patient advisory board to collaborate on patient education materials and event planning, as well as the hiring of a full-time community health worker to navigate the complexities of prostate cancer care and ensure patient retention. The clinic’s main mission is to offer high-quality, accessible, affordable care to men from minority populations who have prostate cancer.

Patient education events have shown to be successful in this initiative, not only educating the public about prostate cancer but also rebuilding trust with communities of color. These events are held in various community settings, such as churches and local celebrations, and cover topics like men's health alongside discussions specifically on prostate cancer.

In 2022 and 2023, these efforts resulted in:

• 407 patient referrals
• 1316 new appointments
• 107 new patient referrals out of network
• 25% of patients with elevated prostate-specific antigen (PSA) receiving a prostate cancer diagnosis
• 110 procedures performed at Mass General Brigham

“We have to believe that a significant proportion of patients of these would maybe not have had that care if this effort didn't exist,” Trinh added.

Trinh also showed pride in Mass General Brigham’s prostate cancer safety net in collaboration with the Department of Patient Safety and Patient Quality. This initiative ensures that patients with elevated PSA levels receive necessary follow-up care—particularly focusing on men of color or those who may face language barriers—by regularly printing and sending a list of these patients to community health workers to help with the patient-provider reconnection and assistance with scheduling follow-up appointments in the urology clinic.

The safety net effectively reduced the number of patients with elevated PSAs who were unable to follow through on their care. While the effectiveness of the safety net has varied over time due to several factors, it has played a significant role in improving patient engagement. Challenges in outreach efforts—including navigating insurance, patient retention, and language barriers—have been compounded by the COVID-19 pandemic. Trinh emphasized the importance of adapting telehealth services to ensure accessibility for communities of color with varying levels of technological literacy, such as providing phone calls for those who cannot access or navigate video call platforms.

Regarding sustainability, financial support for the initiative is assured both institutionally and through strategic efforts to secure grants and philanthropic backing, exemplified by recent grants from the Department of Defense facilitating patient recruitment. Future directions include expanding the safety net beyond PSA monitoring to encompass all stages of prostate cancer care, particularly survivorship, and enhancing navigation and multidisciplinary clinic offerings to cater to marginalized populations.

The workgroup initiative also aims to address disparities in treatment access and outcomes, with plans for an enhanced navigation system and multidisciplinary clinic focused on marginalized populations, supported by philanthropic funding and organizational backing. Additionally, efforts are underway to broaden the outreach clinic's scope beyond prostate cancer, as seen by creating an access clinic at Brigham and Women's Faulkner Hospital for various diagnoses beyond PSA levels and prostate cancer.

Speaking to the audience in the AUA session, Trinh highlighted the wide variation in prostate cancer care, acknowledging the efforts of many of those in the room toward producing the evidence and guidelines to ensure consistent physician recommendations. He also applauded those working to reform policy through physician recommendations and talking to payers about reimbursement.

"But I also believe that some of us dedicate efforts to do community outreach because that's the only way we can mitigate the social and environmental disparities that we see across this country,” Trinh closed. “I also believe that we as physicians should be providing that stewardship, because it is probably not going to come from the payers, and certainly not from our governments.”

References

1. Trinh QD. Journal of Urology lecture: empowering communities: fostering prostate cancer awareness and resilience among men of color. Presented at: AUA 2024 Annual Meeting; May 3-6, 2024; San Antonio, TX. https://aua2021.app.swapcard.com/event/2024-annual-meeting-san-antonio/planning/UGxhbm5pbmdfMTczMDU5Ng==
2. Friedlander DF, Trinh QD, 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):445-451. doi:10.1016/j.eururo.2017.07.023
3. Cole AP, Herzog P, Iyer HS, et al. Racial differences in the treatment and outcomes for prostate cancer in Massachusetts. Cancer. 2021;127(15):2714-2723. doi:10.1002/cncr.33564
4. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19(2):127-140. doi:10.1097/00005650-198102000-00001