Black men are disproportionately affected by prostate cancer, which is is the second leading cause of cancer death among men in the U.S., although mortality has dropped since the adoption of prostate-specific antigen (PSA) screening. Current guidelines recommend a shared decision-making approach to PSA screening between at-risk men and their healthcare providers.
Danil V. Makarov, MD, an associate professor of urology and population health and Joseph E. Ravenell, MD, an associate professor of population health and medicine, have initiated a randomized clinical trial to evaluate whether a community health worker (CHW)-led decision coaching model can be a feasible, low-cost intervention to improve patient decision-making for prostate cancer screening among Black male patients and their healthcare providers.
The trial is funded by the National Institute on Minority Health and Health Disparities and is done in partnership with Flatbush Family Health Clinic.
Pervasive Disparities
Physician Focus: Why are Black men disproportionately affected by prostate cancer?
Dr. Makarov: Prostate cancer comprises approximately one third of all new cancers in Black men, but the incidence rate is 70 percent higher for Black men compared with other groups, and mortality is 2-3 times higher relative to white men.
“Our hypothesis is that differences in PSA screening rates are a signficant contributer to racial disparity in outcomes.”
Danil V. Makarov, MD
Previous data have shown that low socioeconomic status is a predictor of poor prostate cancer outcomes, including mortality, but the Black/white disparity persists even when adjusting for other factors. Our hypothesis is that differences in PSA screening rates are a signficant contributer to racial disparity in outcomes.
CHWs Support Shared Decision-Making
Physician Focus: Can you explain shared decision-making in the context of PSA screening and your research?
Dr. Makarov: An informed decision-making, or shared decision-making approach, to PSA screening includes three critical steps: information exchange, deliberation, and ultimately a shared decision between the patient and healthcare provider. Most prostate cancer screening decisions do not meet the criteria for this as they lack a balanced discussion of decision consequences and preference clarification.
We believe that shared decision-making is very important especially for Black men, among whom the balance of risks and benefits is not definitively established, but likely favors screening.
Physician Focus: What is unique about a CHW-led intervention model?
Dr. Ravenell: The strength of the CHW model is derived from its roots of community organizing, social support, social networks, self-efficacy, and peer models.
In general, it’s an effective model in communities that need a culturally sensitive, contextualized approach to health promotion and intervention. Prior research, including work by our team at NYU Langone Health, suggests CHWs are effective in supporting cancer screening decisions in the Black community.
Testing the CHW-Led Intervention
Physician Focus: What are you hoping to learn from this trial and how does it work?
Dr. Makarov: Our study has four aims:
- To test whether a CHW-led decision coaching program affects decision quality, the decision-making process, patient-provider communication, and PSA utilization for Black men in the primary care setting;
- To assess whether a CHW-led decision coaching program improves provider experience with counseling Black men considering PSA screening;
- To determine the cost and budget impact of a CHW-led decision coaching program for PSA screening; and
- To assess participant attitudes, behaviors, and norms around PSA screening, and assess perceptions of the feasibility, acceptability, and sustainability of CHW-led decision coaching in the primary care setting.
The study is being conducted at a primary care clinic in Brooklyn. Participants in the intervention arm will receive a decision aid by mail and CHW-led decision coaching on PSA screening one hour before their appointment, while those in the control arm will receive the same decision aid by mail, but have a CHW-led discussion on cardiovascular dietary and lifestyle modification rather than PSA screening. The discussion of cardiovascular risk reduction serves as an attention control.
Physician Focus: What is the current status of the trial? Do you have any preliminary results?
Dr. Makarov: This trial is ongoing. Recruitment started in June 2019 and we are still accruing. The trial procedures are expected to be completed by the end of March 2023.
Physician Focus: What other equity and minority health initiatives are ongoing at NYU Langone Health?
Dr. Ravenell: We have a range of initiatives led or coordinated by our Institute for Excellence in Health Equity centered on the promotion of equity and health for all our patients.
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