Empowering Providers to Close Gaps in Prostate Cancer Care

Dr. Nicole Rochester:

Hello, I’m Dr. Nicole Rochester, and welcome to this Empowering Providers to Empower Patients podcast. In this inaugural episode, we are exploring prostate cancer care, a field where scientific innovation is advancing at an unprecedented pace, yet critical gaps remain in how evidence is translated into everyday practice. From overcoming outdated treatment paradigms to enhancing communication with patients and care partners, providers face the dual challenge of adopting new therapies while empowering patients to be active participants in their care. 

Today, we’re going to dig into strategies to close these gaps, spotlight disparities in care, and examine actionable approaches that make a real difference in patient outcomes. Joining me is Dr. Andrew Laccetti a medical oncologist at NYU Langone Hospital in Long Island, New York, and the Director of Quality for Hematology and Medical Oncology at Perlmutter Cancer Center. Dr. Laccetti brings extensive clinical expertise, a deep commitment to patient-centered care, and hands-on experience in implementing innovations that bridge the gap between research and practice. Dr. Laccetti thank you so much for joining us today.

Dr. Andrew Laccetti:

Well, thank you so much for the opportunity, and I’m very happy to be speaking with you today.

Dr. Nicole Rochester:

Well, I’m really looking forward to this conversation, but before we get into the medical knowledge and the research, I want to just start by asking, what brings you joy? You know, there are lots of challenges that we’re facing in our country and globally, and there are a lot of reasons to be sad or disappointed or frustrated or anxious, and one of the things that has grounded me is to really focus on centering joy. So, tell me something that’s brought you joy lately.

Dr. Andrew Laccetti:

So, I am a very fortunate individual in that I have three beautiful daughters and a wonderful wife. So, my wife and I actually welcomed our third daughter in July, so it’s been a very busy and exciting summer for us. So, the first thing that comes to mind are my little girls. My older daughter, the four-year-old, started pre-K today, so I couldn’t be prouder, and that’s my source of joy.

Dr. Nicole Rochester:

Oh, my gosh. Thank you for sharing that. I’m a girl mom. I have two daughters, so they bring me joy as well. Congratulations on the new addition to your family. That’s awesome.

Dr. Andrew Laccetti:

Thank you so much.

Dr. Nicole Rochester:

You’re welcome. So, let’s start by setting the stage. Can you speak, Dr. Laccetti to the current landscape in care for prostate cancer, and what do you see as the biggest challenges in translating the new evidence that we have into clinical practice?

Dr. Andrew Laccetti:

This is a great question and a great starting off point. I’m very fortunate to spend the bulk of my clinical and research effort on prostate cancer. Prostate cancer is the most common cancer affecting men in Western nations and has experienced a dramatic evolution and improvement in our practice standards over the last 10 to 15 years. With that said, advancement and improvement foster some challenges in incorporating up-to-date care across all practice venues, as well as coordinating care that’s becoming ever more complex. So, prostate cancer now, as a disease entity, incorporates multiple treatment modalities, surgical, radiation, medication-based therapies. This involves urologists, radiation oncologists, and medical oncologists like myself. So, the landscape is quite complex, yet rapidly evolving. So, that aspect creates challenges amongst all the medical providers involved.

Dr. Nicole Rochester:

Awesome. And how do things like practice inertia or limited awareness of some of these updates or access challenges affect whether patients even have an opportunity to benefit from these latest advances?

Dr. Andrew Laccetti:

Yeah, so I think I’ll take a step back and really lay out how things have shifted over the last 10 to 20 years. So, going back into the 2000s and even the early 2010s, men with advanced prostate cancer would routinely be given one drug, traditionally referred to as a Lupron or a variant of Lupron, drugs that lower testosterone. When I see patients in the clinic, my analogy is that testosterone is like the gasoline in the engine of the prostate cancer. So, we’ve developed various treatments that block or lower testosterone in an effort to control and in some scenarios cure patients. So, in the era preceding the evolution of some of our newer drugs, there was one injection that patients got, they moved forward until that injection stopped working. So, that’s a fairly straightforward and simple approach that many physicians grew up in and had set the stage for their understanding of advanced prostate cancer first-line therapy.

So, fast-forwarding over the last 10 to 20 years, we’ve developed multiple oral hormone-based therapies, as well as data to support the integration of chemotherapy earlier on in the treatment landscape. So, we’ve developed a system in which patients were starting with one drug alone in all scenarios to now we have half a dozen plus drugs that will be considered in various scenarios for patients, and it’s created a very complex, a very diverse, and a very personalized approach to each patient. So, options and advancement in care has optimized our ability to care for prostate cancer. Men are living longer and better than they ever have before, but allowing for a robust understanding and application of this complex treatment landscape is very challenging given the rapid evolution from a very simple strategy. So, to answer the question more succinctly, I think practice inertia being we all learn and know what we trained on is a challenge in an era of rapidly developing care, and it’s our responsibility and our ultimate goal to provide access to this evolved and personalized care to the best of our ability. 

Dr. Nicole Rochester:

Thank you so much for answering that, and like you said, we get used to knowing what we used to know, and there’s definitely a responsibility, frankly, on the part of the healthcare provider to stay up to date with these latest challenges, but we also know that unfortunately, even when we have addressed maybe practice inertia or limited awareness among the provider community, there are challenges that are disproportionately impact different communities. So, we know that in marginalized communities, as an example, there are often obstacles just related to screening for prostate cancer, and then if they are properly screened or diagnosed, often members of those communities don’t have access to novel therapies.

So, with that in mind, can you speak about how genitourinary cancers disproportionately impact certain populations and then also speak to some of the barriers that those populations face? biggest challenges in translating the new evidence that we have into clinical practice? 

Dr. Andrew Laccetti:

So, absolutely, and it’s a really, really important point that unfortunately, we see in the clinic quite regularly. So, genitourinary cancers in general, I’ll speak to that first. So, it’s like kidney, bladder, and prostate cancers. A fairly universal theme for cancers in general is that limited access to care, limited access to timely evaluation of symptoms, and limited access to screening practices all translate through to worse outcomes related to cancer. That may be a higher incidence of diagnosis, a higher incidence of diagnosis at later stages, and then once being diagnosed in this more advanced setting, less access to treatments. So, as mentioned, disadvantaged communities on a basis of socioeconomic status, in some scenarios race, can lead to lesser outcomes that associates with less access to care. So, I’ll speak more in depth on prostate cancer, which is unique in that we’ve realized and investigated at great length that outcomes as well as incidence levels are worse for the African-American population. Reasons for such are still not quite clear. There’s certainly some data to link into access to care, as well as some cultural differences that may be involved in trusting the healthcare system.

 And these barriers can, again, result in less screening, less access to timely, potentially curative therapies, or just some inherent personal resistance to trust medical teams. Beyond that, there may be a genetic component that we are starting to unveil where the types of prostate cancer that can occur in Black patients have a more treatment-resistant makeup. Now, that’s somewhat of a controversial and less well-established theory, but the likely reality is it’s probably a component of both. So, there’s a great initiative within the prostate cancer world to do our very best to overcome these disadvantages experienced in the African-American population in particular. We know from fairly robust literature that when we match patients that are Black and non-Black, when they have equal access to care, equal times to diagnosis, outcomes are the same. So, there’s great optimism in that by overcoming some of the disparities we see, hopefully some of the disadvantaged populations, particularly for prostate cancer, can achieve better outcomes. 

Dr. Nicole Rochester: 

Thank you so much, Dr. Laccetti And I really appreciate where you ended because, you know, unfortunately, even today in the medical community, there are some misconceptions about the sources and the causes of disparities. And so, I really appreciate you pointing out that when access is equalized, that we do see the same outcomes. So, with that in mind, what are some of the things that healthcare providers can do to reduce some of these barriers to access?  

Dr. Andrew Laccetti: 

So, I think acknowledgment is the first step, and it gains a lot to overcoming some of these issues. You know, simply in the clinic, asking patients more about who they are, what their home environment is like, are they experiencing financial toxicity, are they having transportation barriers, paying attention to some of the inherent root causes of disparate access to care is the first step to improving things. Now, certainly, you know, just identification of the problem doesn’t necessarily solve it, but it does allow us to loop in the resources that we may have at hand, whether it’s a social worker, a nurse navigator, access to community-based programs that can help with food insecurity or transportation.  So, you know, knowing what the problem is for the individual patient is the starting point.  I also think it’s important for all physicians to understand, you know, what their particular bias is and, you know, inherent beliefs are and blind spots are in this topic, because it’s not something that we ask ourselves enough, because in order to best serve our patients, we need to know about ourselves, we need to know about the assumptions we may make, sometimes right or wrong, and do our best to try and, you know, act accordingly and improve upon some of these maybe inherent biases.

You know, another kind of plug I’ll give, and it’s somewhat of a pet project for mine, is to not only ask ourselves, are patients getting access to our standards of care? It’s one thing for them to make it into the office, you know, have financial coverage for testing and treatment, but I think we need to be take things one step farther and ensure that we’re allowing for access to novel treatments, such as clinical trials. An initiative that I worked on in combination with the Prostate Health Education Network, which is a grassroots prostate health organization aimed to reduce disparities in prostate cancer, was to develop an education program targeted at African-American men to help educate on clinical trials and clinical research, how these aspects to care can allow for improved outcomes and a better alliance with the health care team. So again, somewhat of a personal agenda, but I think acknowledging not only how disparities and unequal access to care affects standard of care, but being thoughtful and mindful and proactive to extend initiatives to reduce disparities to access to clinical research.

Dr. Nicole Rochester: 

I really appreciate you sharing those very specific examples, Dr. Laccetti and thank you for the work that you’re doing in that area. It brings me to our next question, and it ties nicely because you spoke about mistrust, and we know that that’s very significant, particularly in the African-American community, well-earned, and part of that has to do with the lack of connection, some of these things you’re talking about, and just really getting to know our patients, and it also has to do with shared decision-making. We know that when individuals feel that they are being included in decisions around their care, when they feel that they have been heard, then that really improves shared decision-making and also improves adherence and outcomes. So how can providers better empower patients and their care partners to participate in treatment decisions?

Dr. Andrew Laccetti: 

Yeah, it’s a huge topic, an area that is critically important for all patients, but as mentioned, even more so for those in disadvantaged populations in particular, Black African American populations for which there’s been a very checkered history and past in American health care to unfortunately fuel that distrust. So, what the literature suggests is that although there are unique attitudes in this population, for the most part, African American patient populations are open and willing to engage in health care. In order to do that, though, there needs to be trust and a relationship that’s established. So, the first step and what I try and do in my personal experience is to really get to know individual patients beyond the clinical medicine, who they are, who’s in their life, what their priorities are. Inherent to that is really talking to your patients as if they’re a person, a human being, not just someone that you are engaged in clinical decision making with. Learn about them, share things about yourselves with them, and do your best to try and break down the barriers that are a more dogmatic and hierarchical doctor and patient relationship. A line I like to use really for all patients is ultimately you’re in the driver’s seat.

I’m here to counsel you and guide you towards decisions that help you achieve the goals that are important to you. And I think really empowering patients to have that ability is paramount. It’s certainly not easy. Each patient comes into their medical care in a different place. Health care literacy varies dramatically. Personal preferences on how engaged someone wants to be in decision making varies significantly. There are scenarios where other individuals rather than the patient are empowered to make decisions. So it takes time and it takes effort to learn all of those dynamics so that one can customize and be as aligned to the unique circumstances. So I think that that’s the start and it’s building trust. It’s understanding where cultural variations occur in this way come from and doing your best to really personalize your approach to the individual.

Dr. Nicole Rochester: 

Thank you, Dr. Laccetti I love, again, you always end with like the perfect summary, which is personalizing. You know, it’s easy, especially when we’re being rushed in and out of examination rooms, the providers rush, the patients are rushed. It’s easy to just kind of want to get straight to the point. But I really appreciate what you shared about really seeing that patient in front of you as a human and taking a few moments to really understand their circumstance and what they’re bringing to the table and their beliefs and their concerns. Well, as we wrap up, I want to talk about unlearning. Certainly as a physician myself, this is something that has been very prevalent is just as much as we learn in our training and even post-training, there are often things that we need to unlearn as practices become outdated. Can you share one example where this shift is needed specifically in the care of genitourinary cancer?

Dr. Andrew Laccetti: 

I can give a very blanket kind of tangential answer that the pace of care in genitourinary cancers is shifting so rapidly. You tangibly need to unlearn treatments and treatment models, and that is very important. But I think that that’s kind of an inherent challenge across all of medicine, and we learn to incorporate new literature and evolving practice standards as a part of our professional skill set. So although I think that’s something we can talk about, I don’t think it’s quite as interesting. So I will give an example that I think is more inherent to oncology, where there’s a lot one learns in medical school, really regardless of the specialty and in training, that’s a textbook approach. So I think that the example that comes to mind where that textbook approach may not really fit the real world is in this idea of patient empowerment and shared decision making. So the idealized relationship that one has with the patient and their family is that you’re outlining a menu of options with pros and cons, nuances to the delivery of care. You outline that menu. You help the patients kind of understand it, and then a patient makes a decision.

So I think that’s great, and there are certain patients that are able to thrive with that a la carte approach. But that’s not everybody. And I think in the contemporary world, this idea of paternalism is somewhat of a dirty word for guiding patients towards a recommended treatment. Now, there are some scenarios, though, where I think a physician taking a more active role in therapy selection is real. And I never appreciated it as a trainee. I really didn’t appreciate it as a junior attending, really. And my reflex was always to say, here’s your menu of options, make a decision. I’ve learned, and I guess unlearned, is that you need to understand the unique preferences and circumstances for the individual. There are patients that will come in, and this happens in my prostate cancer population quite regularly, which is older men who are of a different era, and they say, Doc, I don’t want to know. This is what I want. This is my priority. You make the decision for me.

And that took me aback the first handful of times that I had to do that. But I think that unlearning is understanding that patient empowerment can come in multiple ways, meeting the patient at the level that they’re at, learning their priorities, where they fall on this autonomy versus paternalism spectrum, and customizing and realizing that in certain circumstances, it’s okay to make an informed decision for your patient.

Dr. Nicole Rochester: 

Wow, that was phenomenal. Thank you so much for sharing your personal experiences. And really, again, this idea that we need to meet our patients where we are. So this has been an amazing conversation. Just to summarize for the listeners, the viewers, we talked about the current landscape of prostate cancer care and how it’s rapidly evolving. We talked about some of the barriers to access, specifically for marginalized and disadvantaged populations and how to overcome those barriers. We talked about the importance of shared decision making, and we talked about some of the unlearning that needs to happen. 

And ultimately, I would say the theme throughout this episode has really been about personalized care, about humanizing our patients and meeting them where they are. So that wraps up this episode. Thank you so much, Dr. Laccetti for sharing your insights. Thank you to those of you who have tuned in. We are proud to present this podcast as part of the Patient Empowerment Network’s EPEP initiative, helping providers empower their patients every step of the way. I’m Dr. Nicole Rochester, and until next time, take care and be well.