Novel Survey Identifies Targets to Reduce Racial Disparities in Prostate Cancer
By: Molly DeWitt-Foy, MD; Robert Abouassaly, MD | Posted on: 29 Jan 2021
African American men are more likely to suffer worse outcomes from prostate cancer. This group is more likely to be diagnosed with high grade prostate cancer, more likely to die from prostate cancer, less likely to undergo prostatectomy and less likely to receive appropriate definitive care for high risk disease. 1–5 In addition to poor clinical outcomes, African American men (AAM) have been shown to experience more decisional regret regarding prostate cancer treatment, a metric that is correlated with poor quality of life. 6
Though multiple studies have speculated as to the cause of these discrepancies, no definitive source or solution have been identified. We were curious about the origins of decisional regret (DR) in men treated for prostate cancer and wanted to focus in particular on the risk of DR in AAM. Using previously published data about DR, cancer beliefs and medical mistrust, we designed and internally validated a novel survey that we have titled the Prostate Cancer Beliefs Questionnaire (PCBQ). 7–10 This questionnaire includes 15 Likert scale and 1 multiple choice questions themed around medical mistrust, masculinity and cancer beliefs. The aim of this survey was to get a better understanding about what beliefs, concerns and cultural contexts contribute to a man's perspective on his prostate cancer care.
Using a database of men treated for localized prostate cancer at the Cleveland Clinic between 2010 and 2016, we constructed 2 cohorts, 1 made up of AAM and 1 made up of nonAAM. Groups were matched by age, time since treatment, Gleason sum score, prostate specific antigen at diagnosis and type of treatment. The PCBQ, along with the Decisional Regret Scale, the EPIC26 questionnaire and a demographics questionnaire, were distributed to 1,143 men. 20,21
Analysis was conducted using descriptive and comparative statistics as well as multivariable logistic regression. Just more than 1,000 surveys were delivered, of which 36% were returned. Differences in demographics were noted with the AAM group more likely to report lower annual income and lower rates of college graduation. No differences were noted in pretreatment erectile function or posttreatment urinary incontinence, bothersome urinary symptoms, bowel or hormonal symptoms.
We were able to demonstrate a correlation between race and regret with higher average DR scores among AAM even when adjusting for primary treatment, treatment age, time since treatment, reported comorbidities, income, sexual function and education. Significant differences were noted in PCBQ scores by race with AAM reporting more medical mistrust and greater concern about masculinity. Higher medical mistrust and masculinity scores predicted DR independent of race.
By identifying medical mistrust and masculinity as factors that contribute to posttreatment regret among AAM, the PCBQ offers a tool for providers caring for men with prostate cancer. When administered to a patient recently diagnosed with prostate cancer, the PCBQ may inform future conversations and shared decision making between provider and patient. It can also identify opportunities for education, as in our study many men believed that different sexual practices could increase a man's risk for prostate cancer, and not all men understood that AA race increases the risk of prostate cancer and that radiation can increase the risk of other subsequent malignancies. On a community level, our hope is that results of this survey can continue to identify targets for intervention. Going forward we plan to repeat this study in larger populations, in different geographic areas and among different minority groups.
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- Wei JT, Dunn RL, Sandler HM et al. A comprehensive comparison of health-related quality of life following contemporary therapies for localized prostate cancer. J Clin Oncol 2002; 20: 557.
- Diefenbach MA and Mohamed NE: Regret of treatment decision and its association with disease-specific quality of life following prostate cancer treatment. Cancer Invest 2007; 25: 449.