PROSTATE CANCER Approaching Rural-Urban Prostate Cancer Disparities Through Mixed-methods Research Design
By: Michael G. Stencel, DO, Charleston Area Medical Center, West Virginia; Benjamin J. Davies, MD, University of Pittsburgh Medical Center, Pennsylvania; Lindsay M. Sabik, PhD, University of Pittsburgh, Pennsylvania; Kimberly J. Rak, PhD, University of Pittsburgh, Pennsylvania; Bruce L. Jacobs, MD, University of Pittsburgh Medical Center, Pennsylvania | Posted on: 25 Oct 2023
Not all men with prostate cancer receive the same level of care. Addressing the chasm between the best and worst outcomes has been a major focus of disparities research for decades and has revealed underlying social determinants that are associated with prostate cancer outcomes. For example, Black men present with advanced or metastatic prostate cancer more often than White men, but when socioeconomic factors are controlled for, stage disparities are diminished.1 Likewise, underinsured men with prostate cancer tend to have higher stage and worse outcomes.2 Equally compelling, however, is the urban-rural divide among men with prostate cancer. Rural men are less likely to receive definitive care and have poorer outcomes compared to their urban counterparts.3,4 Identifying barriers to care and levers for improvement is essential for quality care delivery.
Urban-Rural Prostate Cancer Disparity
There are many potential reasons why men with prostate cancer living in rural locales tend to have worse outcomes compared to their urban equivalents, including increased travel distance, less robust preventive care, and treatment delays.3 Another major barrier is a lower per capita concentration of urologists in rural areas. Despite the existing underabundance, even fewer young urologists are choosing to practice in rural areas, which will exacerbate the rural urologist shortage in the future.5 Rural physicians face unique challenges when providing care. A recent study investigated barriers to rural health care by interviewing providers and identified cost, geographic dispersion, and provider shortages as the most significant barriers to providing care to rural residents.6 Despite a relatively small body of qualitative literature in prostate cancer, this study is an example of how qualitative research can yield fruitful data, especially when examining rural cancer disparities.
Relative Strengths of Quantitative and Qualitative Methods
The strengths of quantitative and qualitative methods complement each other well. Quantitative methods strengths include the ability to answer questions about rare diseases and effects of an intervention, and produce broadly generalizable, concrete data. The vast majority of existing literature utilizes some form of quantitative data from sources such as electronic health records, insurance claims, or cancer registry databases. Yet, quantitative data lack the depth of qualitative data and are limited by the rigidity of predetermined variables and numeric output. On the contrary, qualitative methods are not limited by these constraints and are well suited to characterize experiences, attitudes, and perspectives. Qualitative methods exist on a spectrum that may include large focus groups down to 1-on-1 semistructured interview, any of which is inherently nimble and allows latitude for the interviewee to provide unanticipated feedback, or interviewer to explore a response in greater detail. Qualitative approaches leverage open-ended questions to provide highly detailed information and opinions.
Applying Qualitative Methods to Address Rural Disparities
Qualitative methods applied to urban-rural disparities in prostate cancer might revolve around barriers to prostate cancer screening, treatment, or survivorship. They could be structured as focus groups or 1-on-1 interviews to discuss differences in perceptions between treatment options and concern for treatment side effects.7 During data gathering, the flexibility to explore interesting or unexpected themes as they emerge is a major strength of qualitative designs. For example, an ongoing qualitative study on the impact of rurality for men referred for prostate cancer at the University of Pittsburgh Medical Center has revealed travel distance and financial considerations as major themes, but also finds that barriers may be mitigated by reputation and referring provider recommendation. In this way, qualitative research can generate hypotheses.
Mixed Is Better
Imagine layering the strengths of quantitative data, along with the ability to assign context, perspective, and meaning. Incorporating both approaches, mixed methods provides a depth of understanding greater than either approach by itself. There are 3 basic approaches to mixed methods (see Figure)8: (1) exploratory sequential, where qualitative data are collected first, and then support quantitative approaches, (2) explanatory design, which begins with quantitative data that refine subsequent qualitative methods, and (3) convergent approach, where quantitative and qualitative approaches occur simultaneously. The research question should dictate the approach, but any approach will allow the investigator to pursue emerging and unanticipated questions and is inherently flexible, repeatable, or redirectable.
Virtually any research question can be addressed using mixed methods study design. For example, a group investigating treatment preferences for men with metastatic prostate cancer utilized an exploratory sequential design where small group sessions identified several themes that were then used to design a survey to explore treatment preferences within a larger cohort.9 Mixed methods design is uniquely suited to address urban-rural differences among men with prostate cancer because it not only can identify quantitative data, but also can incorporate valuable patient and provider perspectives. In this way, mixed methods can provide more robust data than either method alone. Despite the advantages of mixed methods, it requires expertise in both qualitative and quantitative methods, which likely has curbed more ubiquitous use. A best practice statement was issued in 2011 by the National Institutes of Health that underscored the importance of mixed methods to address future health problems and improve scientific power and quality of data.10 Disparities among men with prostate cancer, including urban-rural differences, remain an area ripe for the application of mixed methods.
Much is needed to bridge the gap between men who experience the best and worst outcomes. Blending qualitative and quantitative methods is an effective tool researchers should wield to combat pervasive prostate cancer disparities.
- Dess RT, Hartman HE, Mahal BA, et al. Association of Black race with prostate cancer–specific and other-cause mortality. JAMA Oncol. 2019;5(7):975.
- Mahal AR, Mahal BA, Nguyen PL, Yu JB. Prostate cancer outcomes for men aged younger than 65 years with Medicaid versus private insurance. Cancer. 2018;124(4):752-759.
- Maganty A, Sabik LM, Sun Z, et al. Under treatment of prostate cancer in rural locations. J Urol. 2020;203(1):108-114.
- Wang M, Wasserman E, Geyer N, et al. Spatial patterns in prostate cancer-specific mortality in Pennsylvania using Pennsylvania Cancer Registry data, 2004-2014. BMC Cancer. 2020;20(1):394.
- Loughlin KR. The confluence of the aging of the American population and the aging of the urological workforce: the Parmenides fallacy. Urol Pract. 2019;6(3):198-203.
- Maganty A, Byrnes ME, Hamm M, et al. Barriers to rural health care from the provider perspective. Rural Remote Health. 2023;23(2):7769.
- Tuckerman J, Kaufman J, Danchin M. How to use qualitative methods for health and health services research. J Paediatr Child Health. 2020;56(5):818-820.
- Creswell JW. A Concise Introduction to Mixed Methods Research. 1999. SAGE Publications Inc; 2015.
- Oswald LB, Schumacher FA, Gonzalez BD, Moses KA, Penson DF, Morgans AK. What do men with metastatic prostate cancer consider when making treatment decisions? A mixed-methods study. Patient Prefer Adherence. 2020;14:1949-1959.
- Creswell JW, Klassen AC, Plano Clark VL, Smith KC; Office of Behavioral and Social Sciences Research. Best Practices for Mixed Methods Research in the Health Sciences. National Institutes of Health; 2011. Accessed May 30, 2023. https://obssr.od.nih.gov/sites/obssr/files/Best_Practices_for_Mixed_Methods_Research.pdf