CE / CME
Pharmacists: 1.00 contact hour (0.1 CEUs)
Nurses: 1.00 Nursing contact hour
Physicians: Maximum of 1.00 AMA PRA Category 1 Credit™
Released: August 16, 2023
Expiration: August 15, 2024
Disparities in Prostate Cancer Care
Alicia K. Morgans, MD, MPH:
Let us start with a brief discussion on disparities among patients with prostate cancer. Awareness and knowledge of disparities in prostate cancer care is a key to understanding how to improve our treatment of all patients with prostate cancer. The available data from clinical trials are suboptimal and lack appropriate representation of a large portion of the patient population in terms of the percentage at which they’re affected by prostate cancer. Dr. Schweizer, what is your perspective on the topic of disparities in equitable care for prostate cancer? What are some of the challenges that you see within our community?
Michael T. Schweizer, MD:
Black patients with prostate cancer are diagnosed at more advanced stages and with worse survival and oncologic outcomes across the board.1,2 The challenge is to find creative solutions to address these outcome gaps. At our institution and others, we are in the early stages of identifying ways to reach patients from diverse backgrounds and eliminate these disparities. Key barriers include simple things like transportation to and from centers of excellence, handling lost time at work to deal with cancer therapy, and ensuring access to adequate insurance coverage and affordable copays for incredibly expensive cancer therapies. These are all big societal issues that I think are hard to tackle from the standpoint of a physician or even from the standpoint of a cancer center itself. One way to start bridging this gap may be to invest in building more clinics in predominantly Black and other underserved communities.
David VanderWeele, MD, PhD:
I agree that addressing diversity and equity is a very difficult problem, and a significant part of the problem occurs before they reach an oncologist’s or urologist’s office; as you mentioned, Black patients are being diagnosed later, and present with more advanced disease. There is a group at Northwestern University that goes out into the community and talks about prostate cancer screening, raising awareness in creative ways. I do think there are ongoing disparities beyond being aware of the need for screening, and transportation is a big one. I work with a team to try to make sure that transportation is lined up for clinic appointments and keep my clinic running on schedule so that patients do not miss their ride back home or are late to work.
In terms of the expense of medications, it varies a bit by insurance; if the patient has no prescription coverage, it gets very difficult. For those with low income who can be on Medicaid, patient assistance programs do a decent job for many of the outpatient medications. Often, the people with some income but not nearly enough to pay what they are being charged are the ones who may fall through the cracks.
Alicia K. Morgans, MD, MPH:
This is also an area of focus being discussed at my institution, but I think that the actions that are needed are unclear, because we do not know what will work best. We know that we want to be present in underserved places, but just having a building there does not mean that people know when they are supposed to go, or that they have the insurance to get into the building and access the care. There are all kinds of social determinants of health and health literacy issues that we also have to overcome such as: “Well, prostate cancer doesn’t really kill anybody, so why do you need to go to the clinic?” and “what is a prostate, anyway?”
It is important to acknowledge that multiple clinical trials and Veterans Affairs data sets show that in settings with diminished barriers to access, our Black patients seem to have the same outcomes or better than our White patients. Thus, if we can overcome some of these barriers that start before diagnosis and extend through the journey of prostate cancer care, I think we can make a difference. We certainly need to make sure patients are getting enrolled into clinical trials in representative numbers to ensure that the findings are actually applicable to all of our patient populations.
ZERO Prostate Cancer Patient Survey
Alicia K. Morgans, MD, MPH:
ZERO Prostate Cancer, a nonprofit patient advocacy organization, surveyed individuals who are associated with the organization. There were 455 patients with metastatic prostate cancer who completed the survey, 87% of whom self-reported as White; 90% were 60 years of age or older. It is important to acknowledge that this was a very select group of patients, affiliated with ZERO, who received an email request and then had the means and interest to complete the online survey.
Among the issues they reported, <5% noted difficulty accessing care or finding transportation to care, which defines this as a patient population with few barriers to care, perhaps better healthcare access, better health literacy, better financial means, and fewer obligations.
One of the other things that came out of this particular survey was patient goals; approximately 47% said that their primary goal was prolonging life and 46% said their primary goal was maintaining quality of life. Dr. Schweizer, does that ring true with the population of patients that you see in your clinic, or do you feel that this statistic may also be skewed to a particular patient population?
Michael T. Schweizer, MD:
Prolonging life and maintaining quality of life go hand in hand for most patients I see. Although some patients will tell you that one or the other is more of a priority, I think improving both is the sweet spot in terms of an ideal therapy.
David VanderWeele, MD, PhD:
I agree that most people want to prolong a high quality of life, which is reflected in the survey numbers. The most surprising result to me was that <1% of respondents chose ‘maintaining sexual function’ as their primary goal.
Alicia K. Morgans, MD, MPH:
I usually think of this as a spectrum between expending every bit of energy and attacking the cancer with absolutely every treatment option vs the other end of the spectrum where maintaining quality of life at all costs is the primary goal. Most patients are somewhere in the middle and understanding where they are in that spectrum directs how I help them work through all these treatment choices, because different treatments may lean more in one direction or another along this spectrum. For example, first-line triplet therapy with ADT plus docetaxel plus an ARSI may have a greater negative impact on maintaining quality of life, at least initially, compared with ADT plus an ARSI, but triplet therapy may ultimately prolong life and lead to better quality of life in the long term; however, we do not yet have that data to confirm this.
ZERO Prostate Cancer Patient Survey and Biomarker Testing
Alicia K. Morgans, MD, MPH:
Biomarker testing is another potential disparity in care that should be acknowledged, similar to delivery of care. Among survey respondents with metastatic prostate cancer, 59% had discussed biomarker testing with their healthcare professional and 37% had discussed clinical trial enrollment. At present, biomarker testing (germline genetic testing, at a minimum) is recommended for all patients with metastatic prostate cancer.3 Dr. VanderWeele, were these numbers surprising to you at all?
David VanderWeele, MD, PhD:
I would say it is disappointingly low. Perhaps I should not be surprised; when we compare real world data with what we aspire to, we are often falling short of the mark.
Michael T. Schweizer, MD:
This figure is in line with what I probably see in the community, if not actually a bit higher. Although 60% of patients with prostate cancer undergoing genetic testing is pretty good by community standards, it is still woefully inadequate. This number should be 100% and I try to do that in my clinic.
David VanderWeele, MD, PhD:
Although the numbers may be improving, people would come to me after having exhausted all their options, and I always ask if they have done genetic testing. Often that answer is no, so I agree that in this scenario, the number is not surprising to me.
Alicia K. Morgans, MD, MPH:
Other than having all patients treated in academic medicine centers, what strategies do you have for how to increase screening numbers? Do you implement collaborations with your satellite and community practices within your systems?
Michael T. Schweizer, MD:
There are educational initiatives to emphasize the importance of screening, but there are challenges beyond that too. For example, I often see patients who had germline screening but never had tumor testing. In many cases we subsequently find actionable somatic mutations that directly affect the therapies available to a patient. In such a rapidly changing field, it is difficult for someone who is busy in clinic, seeing multiple tumor types, to keep up on all the latest in prostate cancer biomarker testing.
In addition to education on the importance of germline screening, it is crucial to eliminate barriers to getting the testing done. One initiative is the PROMISE project (prostatecancerpromise.org) spearheaded by Heather Cheng, MD, and Channing Paller, MD, with support from Advancing Cancer Treatment (ACT) and the Prostate Cancer Clinical Trials Consortium (PCCTC), which includes numerous internal projects involving web based consent for germline screening.
Alicia K. Morgans, MD, MPH:
I send a lot of patients to PROMISE because it offers free germline genetic testing for anybody with prostate cancer as long as they do not have leukemia, a bone marrow transplant history, or a couple of other minor exclusion factors.
Michael T. Schweizer, MD:
However, germline testing is only part of the puzzle, and I think obtaining somatic testing for everyone can be even more challenging because of the additional costs and barriers associated with procuring tissue for testing. It all comes down to educating payors on why sequencing is so important.
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