PROSTATE CANCER Challenges of Community Outreach With the Mass General Brigham Prostate Cancer Outreach Clinic
By: Katherine Merport, BA, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, Massachusetts General Hospital, Harvard Medical School, Boston; Genevieve Benoit, MPH, Massachusetts General Hospital, Harvard Medical School, Boston; Muhieddine Labban, MD, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; Adam S. Feldman, MD, MPH, Massachusetts General Hospital, Harvard Medical School, Boston; Quoc-Dien Trinh, MD, MBA, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts | Posted on: 19 Sep 2023
The Prostate Cancer Outreach Clinic (PCOC) was launched in March 2022, a mere 2 years after the emergence of COVID-19, and rather timely in the setting of health care redesign.1 As part of a pilot program funded by the Mass General Brigham United Against Racism initiative, the PCOC was operationalized with the goals of increasing access to high-quality prostate cancer screening and to champion prostate cancer awareness in the greater Boston area.2 To date, the PCOC has received close to 350 referrals and has treated more than half of these patients. Fifty percent of the patient population is composed of racial and ethnic minorities, thus decreasing disparities in prostate cancer outcomes across Massachusetts.
The clinic also aims to provide education on the prostate cancer care continuum for both clinicians and patients. This has been achieved through attending community outreach events. Having tabled at over 20 events in 18 months (see Figure), as well as presenting at community health centers and primary care clinics, the PCOC team has rendered much success in connecting with various communities and driving its mission, and conversely faced challenges given the target populations and landscape.
The complexity and expansive nature of our modern health care system often lends itself to structural barriers. To date, the team has identified 2 significant structural barriers that have become a primary focus: transportation and insurance.
A growing body of literature suggests that travel and transportation pose major hurdles to the receipt of prostate cancer care, especially for Black men.3,4 As prostate cancer care often requires many visits, whether for active surveillance or definitive treatment, transportation barriers create racial and ethnic disparities in prostate cancer outcomes, as well as a hesitancy for certain groups to obtain prostate cancer screening and care.3,4 To that end, the PCOC team has been awarded a grant by the Department of Defense to pilot a ride-share program for our patient population, which will provide free transportation for our patients while allowing the clinical team to focus on providing care for these men.
In addition to geospatial barriers, the PCOC team has encountered difficulties with insurance. While Massachusetts boasts near-universal insurance coverage for its residents, we have found that many of the insurance plans offered to the patients we hope to serve often do not cover services provided by some of the major academic institutions in the Boston area.5 Our team works hard to troubleshoot insurance barriers and streamline the prior-authorization process, but denials and network contracts are not always within our control. While our team has fruitful referral pathways with outside organizations, restrictive insurance contract practices pose challenges to truly equitable care access.
Funding and Personnel
PCOC operates on a set budget primarily sourced from grants. This allocation supports the employment of a community health worker and a part-time program coordinator. As it stands, the faculty and clinical support staff contribute their expertise without direct compensation from PCOC. Diversifying the team and enhancing stakeholder engagement has been somewhat constrained due to institutional governance policies. As the clinic experiences an increase in service demands and extends its community network, the limited staff and financial resources pose challenges to efficiently scale its service offerings. Furthermore, the continuity of funding on an annual basis is not absolute; articulating the need for sustained investment in community outreach is becoming an intricate task, as the fruition of significant results is typically long term.
Engaging Men in Care
Many attendees at community events are women. Some women are accompanied by male partners, though most attend with their children or other female friends or relatives. Focused almost exclusively on men’s health, we often receive less attention from health fair attendees. However, the women who do approach our table will often say that the men in their lives are unwilling to talk about their health, much less about something as sensitive as prostate cancer.
Creating a space that attracts men and encourages them to speak openly about their health is challenging. Including both Black and Latinx male volunteers, particularly those who have personal experience with prostate cancer, has been helpful to our team. We have found that our patients who connect with these volunteers are more likely to pursue prostate cancer screening and treatment, as they relate to volunteers of similar racial and ethnic backgrounds.
Moving forward, we hope to devise alternative strategies to engage men in their care. We also hope to connect with more groups who champion men’s health issues and to become one of those groups as well.
Gaining Community Trust
Many health care systems struggle with a stigma due to historic discrimination against minority populations; furthermore, the US has subjected marginalized groups to unethical practices and unjust access to high-quality care. This, in turn, creates a gross distrust in the health care system, leading to downstream challenges such as building rapport with the community members we aim to serve. One remedy we have identified is actively spending time in the community. Although this effort serves as an opportunity to bridge the gap, our services are still complicated by institutional barriers, leading to reaffirmation of the community’s beliefs that large academic health systems are not interested in helping, or simply cannot help, marginalized groups. To mitigate this, we have established connections with grassroots organizations that are deeply embedded in the community and can help serve patients. Unfortunately, some individuals are still hesitant to accept our services and trust in our mission as a positive force in health care.
As the PCOC enters its second year, the team is eager to evaluate progress by assessing current state challenges, build on our foundation of knowledge, and strategize next steps. It is our mission to continue to serve as many patients as possible by expanding outreach to many more individuals in need of prostate cancer care. We are grateful for the opportunities that have been awarded to our team, and we are excited to see what comes next.
Conflict of Interest Disclosures: QDT reports personal fees from Astellas, Bayer, and Janssen outside the submitted work and research funding from the American Cancer Society, and Pfizer Global Medical Grants. ASF reports personal fees from Olympus America and Urogen Pharma, outside the submitted work; stock ownership in Vessi Medical and Scentient, outside the submitted work; research funding from Convergent Genomics outside the submitted work.
- Benoit G, Labban M, Merport K, Trinh QD. DIVERSITY: the Mass General Brigham Prostate Cancer Outreach Clinic: tackling disparities by providing more equitable access to care. AUANews. 2022;27(12):40-41.
- Mass General Brigham. United Against Racism. Accessed June 30, 2023. https://www.massgeneralbrigham.org/who-we-are/united-against-racism
- Probst JC, Laditka SB, Wang JY, Johnson AO. Effects of residence and race on burden of travel for care: cross sectional analysis of the 2001 US National Household Travel Survey. BMC Health Serv Res. 2007;7(1):40.
- Wolfe MK, McDonald NC, Holmes GM. Transportation barriers to healthcare in the United States: findings from the national health interview survey, 1997-2017. Am J Public Health. 2020;110(6):815-822.
- An Act Providing Access to Affordable, Quality, Accountable Health Care, Chapter 58, Acts 2006, The 193rd General Court of the Commonwealth of Massachusetts. April 12, 2006. Accessed June 30, 2023. https://malegislature.gov/Laws/SessionLaws/Acts/2006/Chapter58