Overcoming Disparities in Prostate Cancer Beginning With Patients Insured by Medicaid

Strategies to overcome disparities in care are an essential need in prostate cancer based on projections made by the American Cancer Society for 2022, showing a 30% increase in cases and 2.4% increase in disease-related deaths. The Association of Community Cancer Centers has identified 4 cancer programs offering a range of approaches that can improve disparities in prostate cancer screening and treatment.¹

Among the programs highlighted by ACCC is The Ohio State University Comprehensive Cancer Center (OSUCCC), which recently proposed a new prostate cancer assessment program that follows patients from screening to diagnosis. The program involves increased screening for the at-risk population of patients. For referrals, the program requires physicians to hold the initial assessment within 14 days of prostate-specific antigen (PSA) screening, followed by a televisit with a coordinator or tracking down patients who do not show for their appointments. For diagnosis, the program requires secondary testing scheduled within 30 days, and options for the location and time of biopsies.²

The overarching goal of the program is to increase the Medicaid patient population referred for an abnormal PSA by 30% and to reduce the Medicaid no-show rate to 5% or less for patients with elevated PSA levels.

In an interview with Targeted Oncology™, Shawn Dason, MD, a urologic oncologist at OSUCCC, discussed existing disparities in prostate cancer, the impact of the COVID-19 pandemic on the issue, and achieving health equity for patients with prostate cancer in the future.

TARGETED ONCOLOGY: Can you talk about the COVID-19 pandemic and the decline of cancer screenings. How has this impacted prostate cancer?

Dason: That's been a huge aspect of prostate cancer screening. In the setting of the pandemic, I think everybody naturally kind of focuses on different priorities. And some of these things that are a little bit more insidious a little bit kind of more chronic, like cancer screenings, I think, took a bit of a backseat. As you know, nobody necessarily has active symptoms, or something that actively prompts them to go seek [screening]. And similarly, the healthcare system has been under more strain recently. This is firstly due to the fact that you have COVID itself, but then secondly, due to workforce shortages and other things like that. So, sometimes things like preventative health care measures can take a bit of a backseat.

Which disparities became more evident during the pandemic?

We know that within the sphere of prostate cancer, there are significant disparities with regards to screening and then subsequently access to care. I think 2 things are important to highlight. The first thing is that men of African American heritage are significantly more likely to both develop prostate cancer, and then subsequently to pass away from breast cancer. The second thing is that socioeconomic status, namely, that if a patient has Medicaid as their insurance status, there are also significantly more likely to have a delay in presentation, and then maybe some difficulties with access to health care. Subsequently, there may be difficulties with receiving important treatment to optimize success with respect to outcomes.

I think we kind of knew about those disparities, and accumulating research has demonstrated that these are ongoing and significant. The data on disparities and COVID in a separate sphere is also kind of accumulating that those with more difficult socioeconomic status and African American heritage, are also maybe feeling the brunt of some of the some of the lack of healthcare access issues that we see with COVID. And I think that be marrying the 2 concepts together, we can see that prostate cancer screening, prostate cancer diagnosis, and treatment are impacting certain groups more significantly than others. That is a huge aspect of understanding prostate cancer in 2022. And subsequently, targeting groups or areas for improvement with regards to achieving equity in that respect is important.

What are some key takeaways from your ACCC webinar presentation on overcoming disparities in prostate cancer?

For me, the first big thing is that, while frankly, there are disparities, and understanding that and knowledge in recognition of that is a key aspect in being a clinician that focuses on prostate cancer.We have discussed a couple of the things about race and ethnicity being a big aspect of this and how it afflicts certain groups more. Secondly, we discussed how access to the best screening, diagnosis and management is more difficult, depending on socioeconomic status, and how that maybe marries into race and ethnicity in the US.

The second takeaway is, I think that a lot of significant work is being done to overcome this, and that was really what the ACCC Congress was hoping to highlight. We were fortunate to have our program featured, but there was some excellent work from a number of places. What comes to mind is work from UCSF, Delaware, and Alabama. I recall seeing practice profiles on certain programs there, that were really focused and integrated into the community. The profiles showed how in their community, they could target disparities and attempt to reduce them, improve access to cancer care for prostate cancer, and make that an aspect of improving patient outcomes. So, I think the big thing was recognition of the disparities, and subsequently, highlighting certain strategies and practice patterns and plans to focus on.

Are there any call to actions that you have from the oncology community in relation to overcoming disparities?

I think the biggest thing is, and as a urologic oncologist, I think I focused a lot more on the earlier stages of prostate cancer, which I think is a good thing in a couple of ways. The first is that there's a lot of opportunity in that early stage to potentially cure prostate cancer. Or, if it is maybe a more indolent and less aggressive prostate cancer, there is a chance to follow it, and prevent overdiagnosis and overtreatment. So, the biggest call to action I would have is that PSA screening is a critical aspect of diagnosing prostate cancer in modern. There’s been a lot of back and forth over the last decade with regards to the benefits and the risks and harms of PSA screening. You know, 10 years ago, there was this kind of blanket understanding from public health authorities, based on a couple of studies that PSA screening was potentially more harmful than good. And in 10 years, we've understood significantly, that it is more beneficial than was once thought. And I think it's a pretty much standard amongst all kind of guideline bodies today to have at least a shared decision-making conversation with patients with respect to pursuing PSA screening.

So, I think if clinicians are not practicing that, my call to action would be to really consider PSA screening as a shared decision-making amongst at-risk men. That's probably the biggest single thing that we can do to reduce prostate cancer mortality in the in the US, at least right now. With the understanding of disparities in that respect, , that can be a good opportunity to improve access for groups that are maybe at risk, not just of prostate cancer, but also have reduced access to the best care.

_REFERENCES:

_{1. Practice Profiles: Overcoming Prostate Cancer Disparities in Care. ACCC website. Accessed April 7, 2022. https://bit.ly/3uiScPn}

_{2. Dason S. Improving access to prostate cancer screening, diagnosis and treatment in central Ohio Medicaid population. Presented at: Overcoming Prostate Cancer Disparities in Care: Effective Community Engagement Strategies. ACCC On Demand Webinar.}