Excess mortality due to prostate cancer among African American men is one of the most intractable cancer disparities. In the San Francisco Bay Area, incidence in this group is 40 percent higher and mortality is more than twice that for non-Hispanic White men. Research to increase early detection in this high risk group has stalled due to controversies surrounding the efficacy of the PSA test and even though the equivocal studies that tested the PSA did not include adequate samples of African American men. Resulting national guidelines emphasize shared decision-making (SDM) prior to PSA testing, a process to elucidate a patient's values and preferences and to foster his understanding of the limitations of the test. Because disproportionately more African American men have low literacy skills, it is not clear whether SDM is feasible or commonly practiced in settings where low-income men and/or those of low educational attainment access cancer screening such as health fairs and public health clinics. We propose first to ascertain current and best possible pre-screening SDM communication practices in these settings. Second, because the PSA debate is largely due to over-treatment of low-risk disease and since approximately 95 percent of PSA test results are normal, we will explore the feasibility of shifting the focus of SDM from screenin to pre-biopsy counseling for the 5 percent of men with elevated PSAs. For this community-based participatory and mixed methods study, our specific aims are: 1. To document current practices in shared decision-making for PSA testing where uninsured, low-income and/or low-literacy African American men obtain screening, and to explore the potential for effective SDM communication in these settings. a. conduct in-depth interviews with 20 clinicians, 20 staff, and 20 patients regarding SDM and screening to ascertain key concepts, barriers, and facilitators, and to inform survey questions; b. conduct observations of 200 men at community screenings to document SDM in these settings; c. measure PSA test and SDM practices, preferences and confidence regarding SDM, barriers to SDM, and tailoring by race/ethnicity and health literacy in a survey of 150 providers with practices of at least 10 percent African American patients. 2. To assess the feasibility of pre-biopsy counseling (PBC) for African American men with an elevated PSA by pilot testing a theory-based PBC protocol with 40 men with a recent abnormal test.
This study addresses one of the most intractable cancer disparities, the excess mortality due to prostate cancer experienced by African American men. Efforts to increase early detection in this population have stalled due to the controversies surround efficacy of the PSA test and concerns regarding over-treatment of early stage disease. Experts recommend that all men engage in informed decision-making (consideration of benefits, harms, risks and how these factors fit with individual values), usually in conversation with their doctor. Our study will assess the viability of this process in settings where low-income men obtain care, and the feasibility of decision-making prior to biopsy among men whose PSA test results are abnormal.
