Could Shared Decision Making Eliminate Racial and Ethnic Disparities in Prostate Cancer Screening?

The efficacy of prostate-specific antigen (PSA) screening in reducing prostate cancer (PCa) mortality remains a matter of debate. Nonetheless, some racial and ethnic minority groups—particularly Black and Hispanic men—are less likely to receive prostate cancer screening and treatment. This discrepancy, in turn, may contribute to racial and ethnic disparities in PCa outcomes, including higher mortality rates.

According to Alexander Putnam Cole, MD, a urologist in the Department of Urology at Brigham and Women’s Hospital, many prior studies have focused on the differences in PCa outcomes among various racial and ethnic groups. He is corresponding author of a new study published in the American Journal of Preventive Medicine that keys in on how clinicians might alleviate these disparities through shared decision making (SDM).

“We realize there are pros and cons to PSA screening, so the goal of SDM isn’t necessarily to get more men to do PSA screening,” Dr. Cole says. “The goal is to help patients become informed, incorporate their values and preferences into decision making, and work with physicians in deciding whether to pursue the test. And in doing so, we can also mitigate those disparities that exist.”

A Powerful Case for Employing Shared Decision Making

For the study, Dr. Cole and his colleagues reviewed responses to the PSA screening portions of the 2020 U.S.-based Behavioral Risk Factor Surveillance System survey. Since the survey does not cover the entire SDM process, the authors computed an estimated SDM variable to serve as a proxy for SDM.

The objectives of the study were to:

  • Identify any race- or ethnicity-based differences in self-reported PSA screening and estimated SDM use.
  • Assess the impact of estimated SDM on racial/ethnic disparities in self-reported PSA screening.

The study authors found a significant interaction between race/ethnicity and estimated SDM. Among survey respondents who did not report SDM, non-Hispanic Black and Hispanic men were much less likely than their non-Hispanic counterparts to receive PSA screening. Among respondents who did report SDM, however, no race- or ethnicity-based differences in PSA screening were discerned.

“These are two minority groups that are historically underserved and underrepresented,” Dr. Cole says. “But even with factors like poor access to care or language barriers, we see that if you’re doing shared decision making, the lower likelihood of PSA screening among non-Hispanic Black and Hispanic men disappears.”

Searching for Simple Fixes That Can Have a Major Impact

Dr. Cole notes that only about one-fifth of men in the survey who were eligible for PSA screening had SDM. This, despite the fact that American Urological Association guidelines advise clinicians to “engage in shared decision making with people for whom prostate cancer screening would be appropriate and proceed based on a person’s values and preferences.”

“Shared decision making about PSA screening is something we’re already supposed to be doing,” Dr. Cole says, “but it also has the added benefit of possibly making those racial and ethnic disparities in PSA screening go away.”

Furthermore, Dr. Cole adds, SDM is a simple, cost-effective solution. “There are a lot of ways you could try to get at this issue—build new health centers, expand insurance coverage, recruit more minority physicians,” he says. “This is a comparatively small tool, but one that could make a big difference.”

The research shows great promise, according to Kerry L. Kilbridge, MD, MSc, a medical oncologist at Dana-Farber Cancer Institute and expert in the field of disparities and racial equity. “These tantalizing results suggest that policy measures to support shared decision making may be a valuable tool in our efforts to mitigate the unequal toll that prostate cancer takes from Black men,” Dr. Kilbridge said. “Identifying shared decision making as a strategy to decrease health disparities represents meaningful progress in our search for solutions.”

In his ongoing research, Dr. Cole is focusing on practical steps to reduce racial disparities in PCa diagnosis and treatment. For example, he has received funding for studies looking at implementing ride sharing programs for patients and at improving access to MRIs and genetic testing in community health centers.

Dr. Cole and his colleague Quoc-Dien Trinh, MD, MBA, also led a study published in the Journal of Urology last year that found that disparities in PSA screening were eliminated in veterans who represent a population of men with near universal insurance coverage and access to an integrated health system through the U.S. Department of Veterans Affairs.

“There are a lot of possible factors at play here, from implicit biases to structural racism,” he says. “We’re trying to uncover what I’ll call ‘simple fixes’—potential levers we can use that give us the biggest bang for our buck. These are examples of those kinds of studies.”


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