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A Patient-Partnered Approach to Identifying Drivers and Barriers to PSA Screening of Black Americans
By: Jenney R. Lee, MA, Black and African-Descent Collaborative for Prostate Cancer Action (BACPAC), University of Washington, Seattle; Danté Morehead, MPH, Black and African-Descent Collaborative for Prostate Cancer Action (BACPAC), University of Washington, Seattle; Victor Tolbert, BA, Black and African-Descent Collaborative for Prostate Cancer Action (BACPAC), University of Washington, Seattle; Ben Young, AA, Black and African-Descent Collaborative for Prostate Cancer Action (BACPAC), University of Washington, Seattle; Yaw A. Nyame, MD, MS, MBA, Black and African-Descent Collaborative for Prostate Cancer Action (BACPAC), University of Washington, Seattle | Posted on: 30 Dec 2024
Over the last 50 years, Black prostate cancer patients have demonstrated a higher rate of cancer deaths compared to their peers.1 This more than twofold higher rate of cancer death represents the widest racial disparity in cancer death in the United States. In work presented at the AUA Annual Meeting this year, our team showed that excess death among Black Americans has accounted for 1.5 million years of potential life lost over the last 50 years.2 Despite this staggering loss of life, very few efforts currently exist to address the structural, social-environmental, health care, and biologic determinants of prostate cancer among Black Americans, especially at the national scale.1 In 2020, we formed the Black and African-Descent Collaborative for Prostate Cancer Action (BACPAC) to develop an infrastructure that would allow Black prostate cancer survivors to participate in prostate cancer research as engaged and informed team members. Using BACPAC, we have been able to train and engage over 20 prostate cancer survivors in health equity research to date. One of the first BACPAC projects aimed to understand the structural, social, health, and patient-level factors that facilitate and impede access to PSA screening for the early detection of prostate cancer among Black Americans (Figure).
We used a prospective, mixed methods study approach that included semistructured interviews with self-identified Black males in the Pacific Northwest and a survey of primary care providers and urologists in the Washington, Wyoming, Alaska, Montana, Idaho, and Oregon (WWAMIO) region regarding prostate cancer screening. A research team, including 3 community and prostate cancer advocates, was convened to facilitate the semistructured interviews. The team met on a bimonthly basis to facilitate the development of our interview guide and our interview enrollment strategy in the greater Puget Sound region of Washington State. Based on feedback from our community advisors, we built the capacity to conduct interviews with an interpreter if needed. All interviews were conducted by a younger Black male, who was a community health educator for the Black and African-descent population at the Fred Hutch Cancer Center. The interviews were recorded and transcribed to allow for analysis. Consensus coding and thematic analysis were used to analyze interviews using a health equity framework.
In collaboration with the Washington State Urology Society, we developed and disseminated an anonymous online survey to primary care providers and urologists in the WWAMIO region. The survey instrument was adapted from a German study3 evaluating prostate cancer screening beliefs and behaviors among primary care providers and urologists. The surveys were disseminated through the University of Washington’s Institute of Translation Health Sciences, the Washington State Medical Society, and the Washington and Oregon urological societies. All providers were sent anonymous online surveys via email using REDCap.
In total, 29 Black males from Washington State participated in our interviews. Thematic analysis found that barriers to PSA screening include the following: (1) primary care providers were the gatekeepers in accessing PSA testing, (2) primary care providers lacked knowledge about the increased prevalence, incidence, and mortality of prostate cancer among Black Americans, and (3) primary care providers may hold attitudes against the use of PSA testing. Interviewees also reported a lack of trusted primary care relationships as an obstacle to obtaining PSA testing.
We surveyed 32 urologists and 31 primary care providers from the WWAMIO region. While both groups reported high awareness of current US Preventive Services Task Force (USPSTF) guidelines, primary care providers (6.5%) were significantly less likely than urologists (70.0%) to believe in the value of PSA testing or the role of early detection in preventing prostate cancer–related deaths (Table). Primary care providers were also less likely to be familiar with the findings of the screening trials (PLCO and ERSPC) that serve as the evidence basis for screening guidelines.
Table. Provider Survey Responses
Urologists (n = 32) | PCPs (n = 31) | |
---|---|---|
Awareness of current screening guidelines (%) | ||
US Preventive Services Task Force | 93.8 | 96.7 |
AUA | 93.7 | 45.2 |
Guidelines that influence use of PSA testing for screening (%) | ||
US Preventive Services Task Force | 31.2 | 96.8 |
Other guidelines | 90.6 | 51.6 |
Early detection reduces cancer-related mortality (%) | ||
For all cancers | 84.3 | 83.9 |
For prostate cancer | 81.3 | 41.9 |
Beliefs about PSA testing (%) | ||
PSA is valuable | 96.9 | 48.4 |
PSA significantly reduces prostate cancer mortality | 70.0 | 6.5 |
Often/always discuss PSA testing (%) | ||
Patient with family history of prostate cancer | 90.6 | 80.6 |
Patient who is Black/African American | 87.5 | 61.3 |
Abbreviations: PCP, primary care provider. |
Our findings from the survey support interviewees’ perception that primary care providers may not value PSA testing for prostate cancer early detection. Our results also demonstrate that the USPSTF guidelines are likely the driver of primary care provider perspectives on the value of prostate cancer screening. Unfortunately, the current USPSTF guidelines do not provide any screening recommendations for high-risk populations such as Black Americans. The work conducted by BACPAC and our research team at the University of Washington has influenced thoughtful evidence synthesis to support shared decision-making among Black Americans.4,5 These evidence reviews were followed by the development of screening guideline recommendations for Black Americans by the Prostate Cancer Foundation.4 Additionally, our research team has ongoing patient-centered research projects with BACPAC to help develop tools to support awareness and informed decision-making around PSA screening for both Black patients and their primary care providers.
Acknowledgments
We thank John Masembe, Garrett Britt, Lars Neuenschwander, Kyle Schuppe, Richard Pelman, Debi Johnson, Sung Min Kim, Erika M. Wolff and John L. Gore, the Fred Hutch Office of Community Outreach and Engagement, the Washington State Urological Society, and the Washington State Medical Association for their support and collaboration in completing this work.
Funding/Support: This project was made possible in part by the Andy Hill Cancer Research Endowment (CARE) Fund (Award No. 2021-DR-01), the NCI SPORE (P50 CA097186), and the U.S. Department of Defense, Office of the Congressionally Directed Medical Research Programs under Grant No. W81XWH2110531.
- Nyame YA, Cooperberg MR, Cumberbatch MG, et al. Deconstructing, addressing, and eliminating racial and ethnic inequities in prostate cancer care. Eur Urol. 2022;82(4):341-351. doi:10.1016/j.eururo.2022.03.007
- Frimpong NA, Holt SK, Carson D, et al. Mp68-05 Excess death and potential life years lost among Black prostate cancer patients (1970-2020). J Urol. 2024;211(5S):e1109. doi:10.1097/01.JU.0001008744.60568.e8.05
- Kappen S, Jürgens V, Freitag MH, Winter A. Attitudes toward and use of prostate-specific antigen testing among urologists and general practitioners in Germany: a survey. Front Oncol. 2021;11:691197. doi:10.3389/fonc.2021.691197
- Garraway IP, Carlsson SV, Nyame YA, et al. Prostate cancer foundation screening guidelines for Black men in the United States. NEJM Evid. 2024;3(5):EVIDoa2300289. doi:10.1056/EVIDoa 2300289
- Kensler KH, Johnson R, Morley F, et al. Prostate cancer screening in African American men: a review of the evidence. J Natl Cancer Inst. 2024;116(1):34-52. doi:10.1093/jnci/djad193
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