PROSTATE CANCER Improving Equity in Prostate Cancer Outcomes Through Patient-reported Outcome Measures
By: Mara Koelker, MD, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Jonathan Makanjuola, MD, King Edward VII Memorial Hospital, Bermuda Hospitals Board, Bermuda | Posted on: 19 Sep 2023
Racism and inequity are problems in the health system of the United States. With prostate cancer being a common disease affecting millions of men, physicians should engage in the current efforts to improve equity across prostate cancer care. Disparities in prostate cancer outcomes persist, particularly among marginalized and underserved populations.1 They can arise due to differences in access to health care, cultural background and health beliefs, socioeconomic factors, as well as systemic racism.2,3 This includes cultural, linguistic, or financial challenges that impact their prostate cancer experience.4,5 Additionally, demographic factors such as race and ethnicity, socioeconomic status, and the patient’s geographical location play an important role in the existing inequity in prostate cancer care.6 Furthermore, as shown in prior studies, racial disparities potentially lead to delayed cancer diagnosis, treatment, and supportive care after, for example, surgery or radiation.7 As discussed by Cole at al recently, strategies to address these disparities should include patient-reported outcome measures (PROMs) to capture patients’ experiences and preferences in order to improve prostate cancer outcomes for all men.8 PROMs offer an inexpensive tool in enhancing patient-centered care and promoting equity. They capture patients’ perceptions of their burden, functional status, symptoms, and overall quality of life.
In order to promote equity, PROM use should be considered in different settings. PROMs provide valuable information about patients’ impairment prior to treatment, quality of life, and possibly treatment preferences. When considering these outcomes, health care providers can individualize treatment plans and use PROMs as decision aids.9 Through this patient-centered approach disparities could be reduced in an early treatment stage. Additionally, PROMs allow for real-time identification of side effects and, in the next step, management of treatment-related symptoms and toxicities. In our own institutional analysis at Brigham and Women’s Hospital in Boston presented at AUA2023, we showed that non-Hispanic Black men had significantly lower quality-of-life scores at 3 and 6 months after their radical prostatectomy (P < .01) compared to their White counterparts.10 This difference was mostly driven by sexual and urinary function, even though surgery was performed by the same high-volume surgeons. In the long-term results, 12 and 24 months postsurgery, these differences were mitigated. Therefore, timely identification of side effects is especially important in populations that may face additional barriers to health care access. Additionally, PROMs could lead to a shared decision-making process between patients and their physicians, which is essential for equitable care. Collaborative approaches strengthen patient empowerment and reduce disparities in treatment decision-making.
Nevertheless, achieving equity in prostate cancer outcomes requires a multilevel approach that addresses the underlying disparities and ensures patient-centered care. To maximize the impact of PROMs, health care systems need to expand their utilization. Efforts should be made to ensure equitable access to patient-reported outcome (PRO) assessments for all patients, including those from marginalized communities. Further, physicians and researchers need to be trained in cultural sensitivity to interpret the results.
Large-scale analysis of PRO data can help identify patterns and trends in prostate cancer outcomes among different populations, shedding light on potential disparities. This knowledge can lead to targeted and individualized interventions and policy changes aimed at reducing inequities and improving overall prostate cancer care. This includes considering patient perspectives in clinical trials and decision-making processes. By incorporating these approaches, the development of new treatments and interventions can better align with their needs, preferences, and priorities.
Integrating PROMs into clinical practice allows health care providers to individualize treatments, assess side effects, and engage in a shared decision-making approach, all of which contribute to more patient-centered care. However, to fully leverage the benefits of PROs, there is a need for standardized assessment tools, analysis, and most importantly equitable access to patient-reported assessments. Collaborative efforts are essential in implementing these programs and addressing disparities in prostate cancer outcomes. By embracing PROMs in the existing structures, health care systems can make significant steps toward achieving equity in prostate cancer care and outcomes, ultimately improving the lives of men affected by prostate cancer.
- 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.
- Riviere P, Luterstein E, Kumar A, et al. Survival of African American and non-Hispanic White men with prostate cancer in an equal-access health care system. Cancer. 2020;126(8):1683-1690.
- DeWitt-Foy ME, Gam K, Modlin C, et al. Race, decisional regret and prostate cancer beliefs: identifying targets to reduce racial disparities in prostate cancer. J Urol. 2021;205(2):426-433.
- Kilbridge KL, Fraser G, Krahn M, et al. Lack of comprehension of common prostate cancer terms in an underserved population. J Clin Oncol. 2009;27(12):2015-2021.
- Imber BS, Varghese M, Ehdaie B, et al. Financial toxicity associated with treatment of localized prostate cancer. Nat Rev Urol. 2020;17(1):28-40.
- Fletcher SA, Marchese M, Cole AP, et al. Geographic distribution of racial differences in prostate cancer mortality. JAMA Netw Open. 2020;3(3):e201839.
- Krimphove MJ, Cole AP, Fletcher SA, et al. Evaluation of the contribution of demographics, access to health care, treatment, and tumor characteristics to racial differences in survival of advanced prostate cancer. Prostate Cancer Prostatic Dis. 2019;22(1):125-136.
- Cole AP, Koelker M, Makanjuola J, et al. Can PROMs improve racial equity in outcomes after prostatectomy?. Nat Rev Urol. 2023;20(3):125-126.
- Adsul P, Wray R, Spradling K, et al. Systematic review of decision aids for newly diagnosed patients with prostate cancer making treatment decisions. J Urol. 2015;194(5):1247-1252.
- Koelker M, Labban M, Frego N, et al. MP80-17 Racial differences in patient-reported outcomes among men treated with radical prostatectomy for prostate cancer. J Urol. 2023;209(Suppl 4):e1159.