HCP Roundtable: Empowering Providers to Bridge Barriers in Prostate Cancer Care

Dr. Nicole Rochester:

Welcome to this Empowering Providers to Empower Patients EPEP program. I’m Dr. Nicole Rochester. EPEP is a Patient Empowerment Network program that serves as a secure space for healthcare providers to learn techniques for improving physician-patient communication and overcome practice barriers.

In this Healthcare Provider Roundtable, we are tackling overcoming barriers to equitable prostate cancer care. This is not just another conversation. Today we’re going to dive deep and walk away with actionable steps from two highly respected experts on the ground floor of research.

Today we’re going to explore barriers to timely access and uptake of newer treatments in prostate cancer care. We’re going to discuss how outdated practices or lack of healthcare provider awareness can unintentionally limit patient options. And the role of outcome expectancy and inertia in perpetuating practice gaps, as well as strategies for removing practice barriers and ensuring equitable access as innovation in cancer treatment accelerates.

Today, I’m honored to be joined by Dr. Stacey Loeb, a professor of urology and population health at NYU Langone Health and the Manhattan Veterans Affairs. Dr. Loeb is double board certified in both urology and lifestyle medicine, and her research focuses on prostate cancer screening, active surveillance, and the critical role of lifestyle factors in men’s health. She hosts the Men’s Health Show on SiriusXM, bringing prostate cancer education directly to patients and communities. Thank you so much for joining us today, Dr. Loeb.                                                              

Dr. Stacey Loeb:

Thank you very much for the invitation.

Dr. Nicole Rochester:

We’re also joined by Dr. Leanne Woods-Burnham, an assistant professor in the Department of Surgery at Morehouse School of Medicine. Dr. Woods Burnham’s groundbreaking research examines the biological determinants of prostate cancer disparities in Black men. Including her work on HER2 overexpression, and how psychosocial stress literally changes tumor biology. Dr. Woods-Burnham co-directs the Prostate Cancer Precision Prevention Program, bringing screening and education to underrepresented communities across Atlanta and rural Georgia. Thank you so much for joining us today, Dr. Burnham.

Dr. Leanne Woods-Burnham:

Thank you so much for having me today, Nicole.

Dr. Nicole Rochester:

So let’s get started by digging into practice barriers and inequities in access. We know that access barriers to cancer care exist across solid tumors, whether we’re talking about breast, colorectal, bladder, or prostate cancer. But many of these barriers are unique to specific diseases and the populations they disproportionately affect. For prostate cancer, which affects Black men 

Dr. Nicole Rochester:

So, Dr. Burnham, your research reveals that even our foundational research tools don’t represent diverse populations. Can you tell us how these upstream research gaps translate into downstream practice barriers? Like delayed adoption of therapies or limited guideline awareness, particularly in community oncology settings serving marginalized populations.

Dr. Leanne Woods-Burnham:

Yes, definitely. So, when we’re talking about the ability of research tools to represent diverse populations, we have to start with the facts that prostate cancer is driven, aggressiveness is driven by so many different factors, right? So, some of these factors are biological, and we know that there are genetic variants that are likely to lead certain populations to have more aggressive prostate cancer.

So when we’re talking about in the U.S., the highest risk population being men of West African ancestry, you really want to keep this in mind as you’re developing research tools and experimental models that are going to be inclusive. And so, part of that is recognizing that at the very beginning of the science. When you’re designing your experiments, when you’re designing your research studies and your clinical trials, that you make sure that you have biospecimens that are representative of all populations.

You want to make sure that whether you’re using cancer cell lines in the lab, that you have cancer cell lines that come from men of different disease stages of prostate cancer, different ancestral backgrounds included in that. Also, when you’re working with animal models or PDX models, and you’re receiving xenograph derived from patients that have various backgrounds, you want to make sure that men that are at worst risk for worse outcomes that those tissue samples are represented.

And so, a lot of times, unfortunately, what we notice is that these experimental designs don’t always include varied ancestral backgrounds in the design. But for those of us who do like to include them in the experimental design, some of these resources are limited for us, and so it’s really exciting for researchers today who are actively trying to expand diverse biospecimens that are available to scientists to be able to improve what we’re looking at at an earlier onset of the process, at the scientific process.

Because what we know is then when you’re then talking about drug development and designing therapeutics that we know can work well in all populations. What history has shown us is when we don’t take into account people of different backgrounds and how their ancestry can affect their treatment response, then sometimes we don’t see a uniform treatment response. So we see this whether we’re looking at blood thinner medications for Black people versus other people. We know this, in terms of some lung cancer treatments and how people of Asian ancestry respond different than people of other genetic ancestry. Those are just a few examples, but the reason it’s so important to start at the bench at being inclusive is because then that translates into our drug discovery.

And then as we go down, like, down the line, as we talk about clinical trial enrollment, and then standard of care treatment options in the clinic, of course, it’s always important to think about that as well. But the last point I want to make in response to this topic is it’s so important when you’re looking at the pipeline of the medical student to the resident, to the physician, to the postdoctoral fellow, to the academic faculty member who is designing some of these studies.

It’s important when you’re looking at a pipeline, is what we know, what studies have shown us, and what I know from personal experience, is that when you have family members who are affected, or when you come from a community that sees worse outcomes of disease more frequently than maybe some other communities, you have a personal drive, in addition to your academic prowess, but you have a personal drive to give back and to reach back, and a lot of people do that.

And so, that’s, to me, why the pipeline is so important, because if you have a pipeline that is representative of all populations, then when we go and get our MDs and our PhDs and our JDs and all of the degrees to help to progress health outcomes, then you have more of a fuller picture sitting at the table, at the decision-making tables, to help move the needle forward.

Dr. Nicole Rochester:

Thank you so much, Dr. Burnham. I feel like you just took us through such a great progression of how these upstream challenges lead to the downstream outcomes and the disparities and the inequities that we see clinically. So thank you so much for sharing that.

Dr. Loeb, you work across both the Veterans Affairs Systems and Academic Medical Centers. From your perspective, where does the breakdown happen between what we discover and who actually benefits from those discoveries?

Dr. Stacey Loeb:

Yes, this is a great question, and really, I think it’s at many different levels where the breakdown can occur. Systemic and societal factors, even piggybacking on what Dr. Burnham was talking about, we’ve looked at diversity of representation in online content about prostate cancer in general, and about prostate cancer clinical trials. And found, for example, limited representation of Black and Latinx individuals.

And these things actually do have downstream impact. For example, we found that among many Black males with prostate cancer, because they hadn’t seen any Black faces, some even thought they were at lower risk of prostate cancer, or perhaps that Black men don’t get prostate cancer. So, I think we need to think of these things very broadly, including even what people are exposed to when they look online about prostate cancer.

But then, you know, this leaky pipeline is something that occurs not just in prostate cancer, but really across the boards. You know, why does it take so many years for only a proportion of the great discoveries of research to get implemented in clinical practice?

You know, there can be barriers at the organizational level, the patient level, the physician level. For example, there are, you know, physicians have knowledge gaps and certain practice habits, so de-implementation of old pathways can actually be very challenging. And patients may or may not be interested in certain things, you know, we’ve done some studies on uptake of genetic testing for prostate cancer.

And, you know, some patients are very interested, but there’s also a lot of knowledge gaps among patients, or some just don’t really perceive the benefit to them. Perhaps they don’t have any children, or their children are already older and already have other cancers. So they feel like maybe it’s too late for it to benefit the family, so… You know, really, I think at every different step of the process and every level there can be barriers.  

Dr. Nicole Rochester:

Absolutely. Thank you for sharing that. Again, you know, we’re seeing how the upstream effects trickle all the way down. I was really intrigued to hear you say that some Black men don’t think they’re at risk for prostate cancer, and that just shows the importance of seeing yourself and that representation that both of you spoke about.

Let’s move to discussing access barriers to precision medicine. We now have combination therapies like PARP inhibitors and androgen receptor inhibitors that work specifically for patients with HRR gene mutations. But if patients aren’t even getting tested, they can’t access these therapies.

Dr. Loeb, your work examines who receives biomarker testing in practice. What are the barriers that you’ve seen to widespread genetic testing adoption? Especially in community oncology and underrepresented populations.

Dr. Stacey Loeb:

Yes, thank you. So, definitely a lot of barriers to genetic testing at every level. There’s definitely a lot of knowledge gaps among providers. There’s also difficulties with referrals, with, for example, a shortage of genetic counselors, but many non-genetic providers, such as urologists and oncologists, not feeling sufficiently well-versed to perform genetic testing on their own and to be able to provide the full counseling to their patients.

At the patient level, you know, there can be barriers in terms of the cost of testing and coverage. It does have some insurance implications which is concerning for some people. Also, varying levels of knowledge and interest in genetics. For example, there’s really a lack of awareness in the population about transmission between different family members, and specifically the links between prostate cancer with cancers in female family members is something that people really are not aware of.

And so it may not seem like it would be relevant to, for example, the daughter of a patient with prostate cancer, when in fact, this could very much be linked with the patient’s daughter’s risk of breast or ovarian cancer, as an example.

So, lots of different issues coming into play that we have to tackle in order to try to get this more widespread. So, this is something we’ve been working on. We’ve looked at different, you know, points in the pathway where there are barriers, for example, knowledge gaps for clinicians, and we created a podcast series, and challenges applying the guidelines to figure out who’s even eligible for testing, so we made the Helix app for providers to answer some questions about the patient and find out if they would qualify in the guidelines.

But, you know, not everybody knows their full family history. Some people are adopted, and there may be cultural taboos around sharing of disease information. And so, if you don’t qualify based on family history criteria, but you don’t know your full family history, that alone might prevent insurance coverage of testing for some patients. So, definitely a lot of challenges that we have to, you know, overcome in order to provide more equitable access to, you know, genetically-based clinical trials and precision therapeutics.

Dr. Nicole Rochester:

Thank you for sharing that, and for sharing the resources. You know, it’s one thing for us to talk about the challenges, and there are many, but to understand what you all are doing about it, and some of the resources that you provide is extremely helpful.

Dr. Burnham, you’re identifying genetic signatures that should inform treatment decisions. From your research perspective, what do you see as the gaps?

Dr. Leanne Woods-Burnham:

There are some gaps in the original study design, for sure. But one thing that Dr. Loeb pointed out briefly as well is it’s important for the patient to know how this can benefit them, and maybe if it’s not going to benefit them personally in that moment within those next few weeks, if they can know how it will affect their children and their grandchildren.

I have a study that I have open in a major public hospital in Georgia right now, and when we’re consenting patients and we’re recruiting them, there was one patient who looked at me and he said, you know, I understand this isn’t going to help me at all. He said, but my son is sitting right here, and if you’re telling me that what I’m doing now could help if he ever gets prostate cancer in the future, then just sign me up. You know, he literally said that, like, it was a textbook response.

So a lot of times when patients know that this can affect them, how it can affect them, or their loved ones, that goes a long way in closing some of those gaps. It’s really important to find the right clinical settings and clinical partners who are passionate about this topic as well. I’ve worked at a few institutions, and for me, you know, the institution makes a big difference in terms of who’s that patient population. What are those demographics look like in the first place in terms of what disease you’re looking at?

And so, the right setting is important, but also, I, you know, I’m a scientist, I’m not an MD, but I rely heavily on my MD medical oncology collaborators and urology collaborators, and I’m very particular about choosing those who are passionate about this, because it’s truly a multidisciplinary team science approach that helps studies to be successful.

But I just wanted to touch briefly, too, while we’re talking about genetic signatures and PARP inhibitors. I’m a co-investigator on a study right now that’s actually looking at the role of using a PARP inhibitor in men who don’t have these genetic mutations that you mentioned earlier. Just for the simple fact that we see… we know that when it comes to PARP and androgen receptors, there’s a relationship, there’s an interplay there, and we know that there are variance in androgen receptor due to different variants in genetic ancestry.

So, for example, when we look at trinucleotide repeats within the receptor, within the gene, we know that men who have shorter repeat links tend to be men who have West African ancestry and men who have longer repeat links are men who have Asian ancestry, and so that can affect your response to drugs that are targeting androgen receptor, but also in combination with PARP inhibitors. So, we’re, you know, the data remains to be seen. We’re still collecting that data now. But there are literally genetic reasons that we believe that certain genetic signatures can be targeted differently, and that’s what we call precision medicine and using a precision medicine approach in the clinic.

The goal is that every patient can have a drug treatment that’s tailored to them that will work best for them, no matter who they are.

Dr. Nicole Rochester:

Wow, what an amazing goal! That is incredible. Thank you for sharing that, and thank you for sharing the study, and also, the importance of, you know, whether you call it cultural sensitivity, cultural resonance, being culturally informed, but this idea of meeting patients where they are, and that gentleman wanting to participate because of his legacy, and because that would benefit his son. And those are the conversations that we need to have, so thank you for sharing that.

So, both of you have helped us to understand that testing is a challenge, but even when appropriate therapies exist, patients face real structural barriers, and you’ve talked about some of these. Insurance denials, prior authorization, as well as things like the lack of patient navigators. So, Dr. Loeb, from your population health perspective, what role can providers play in navigating these insurance and access barriers, particularly for underrepresented populations, and what are some things that you’ve seen work?

Dr. Stacey Loeb:

Well, I think patient navigation and social workers can be very helpful and compiling, you know, a set of resources, for example, of options, you know, where to be able to get medications less expensively. There are some apps and programs online that can help with that. So those are just some of the options, and, you know, I think we have to know how well we’re doing in terms of providing care, so I think one of the bedrocks for, you know, implementation is audit and feedback, you know, tracking how well we’re doing with our patients in order to see if there are any disparities or gaps that need to be addressed.

Dr. Nicole Rochester:

Yeah, they say you can’t change what you don’t measure, right? So that’s important. Thank you for lifting that up. Dr. Burnham, anything to add from your community outreach work with the Prostate Cancer Precision Prevention Program?

Dr. Leanne Woods-Burnham:

Yeah, so Dr. Loeb also touched on this briefly previously is, to me, a major barrier I see, which is so surprising, but she’s a thousand percent right, is how much… how many times men who are in high-risk populations do not even know that they are at higher risk. That happens, like, constantly. So that’s… that’s a major barrier where you… if you don’t even know that you’re at higher risk, you don’t know when you go into your doctor’s office to advocate for yourself, to find out even if you’re being screened, if you’re having the conversation about the pros and cons of prostate cancer screening.

Because we know, you know, guideline recommendations have fluctuated when it comes to that, but if you’re at a higher risk and you’re going into your doctor’s office, and you’re 45 years old with extensive family history, and your doctor’s saying, you know, you don’t meet the U.S. Preventive Services Task Force recommendation of age 55, so don’t… you’re fine. But you don’t know that you’re at higher risk and you have this family history, then the conversation kind of ends there, because who wants to get extra testing that your doctor’s telling you that you don’t need? Like, none of us want to do that.

So, that’s a major barrier that we see for sure. And what we know, I’ve published previously, is that over half of Black men specifically, this was a study coming out of New York City and also Southern California, over half of them, their doctors were not discussing the pros and cons of prostate cancer screening, so unfortunately, it’s up to the patient sometimes to really be able to advocate for themselves, so we really try to spread awareness so that men know that they can talk about this, that they can find out their own personal risk through a conversation with their physician, and decide if they want to do the PSA blood test or not.

Dr. Nicole Rochester:

That’s so important. That leads perfectly into our next topic, which is around communication and shared decision making. And literally, like you just said, Dr. Burnham, if the men don’t even know that they are at high risk, then it’s very difficult for them to advocate for themselves. It’s difficult for them to participate in shared decision making. It requires patients to truly understand their risk, understand their options.

So, Dr. Loeb, I’m gonna go back to you. Based on your comparative effectiveness research and active surveillance work, you study what actually matters to patients beyond just the survival numbers. When the quote-unquote best choice isn’t obvious, like choosing between active surveillance versus immediate treatment, how can providers better partner with their patients in making these decisions, and are there any communication strategies that you’ve seen that actually work?

Dr. Stacey Loeb:

Yes, this is a great question, and I loved this paper that was published that said there’s… that there’s more to life than death, so certainly survival is definitely not the only variable to consider, and there are always going to be a substantial number of impacts for quality of life, not only for the patient, but also for their partner and their family members. We’ve done a lot of work looking at the impact of prostate cancer on the quality of life of partners, and that is significant, too. So there’s a lot that goes in there.

In terms of communication strategies, the bedrock for shared decision making is preference elicitation. So it’s very important to ask patients and their families what matters most to you, and to explore these trade-offs with them. For example, maybe somebody prefers shorter survival time in favor of better quality of life, and others may not have that preference, and that can really help to guide what might be the best option for that particular patient and their family.

Dr. Nicole Rochester:

Thank you. Thank you for sharing that. Well, we want to talk about patient education in the context of community oncology, and I’m gonna go to you, Dr. Burnham, for this question.

Your work on HER2 overexpression and genetic variations in prostate cancer is cutting-edge research happening at an academic medical center, but we know the reality is that most prostate cancer care happens in community oncology settings. How do we bridge that gap, and what needs to happen to ensure that innovations like Ancestry-informed biological insights and some of the other amazing things that you’ve been talking about reach the community providers and their patients, particularly in marginalized communities?

Dr. Leanne Woods-Burnham:

So, this is gonna be, like, a personal anecdotal approach, because how I have to do it was… Literally move my family across the country. Because what happened was, when I started this HER2 journey a few years ago, and saw that there was this link between HER2 and West African genetic ancestry, and realizing the implications that that could have on the prostate cancer space and the ability to fast-track potential treatments due to, you know, repurposing of currently FDA-approved drugs, I knew that I wanted to be able to have the biggest impact and collect as much data as I could sooner rather than later.

And so, when the opportunity came for me to relocate to Atlanta, Georgia… Atlanta has the third worst incidence and mortality for Black men with prostate cancer in the nation, so it’s only behind Washington, D.C. and Detroit. And so, coming to Atlanta, I learned the landscape very quickly, because as you pointed out, you know, an academic setting is different than what’s actually reaching the patient, and so… and I work at an academic institution, for sure. So, I was very intentional my first 3 months, really, finding out what the clinical landscape looks like in Atlanta.

And so, was quick to form collaborations with comprehensive cancer centers, with public hospitals in the area, with some FQHCs. And so, as I would talk to them about what we were finding, and we put our heads together in regular meetings, I sort of built this team out that was gonna address this from multiple institutions at one time. Now, is that easy? Absolutely, no way it’s not, in any way, shape, or form, because you have to do all the legal agreements and confidentiality agreements and data transfer agreements and material transfer agreements and all of those things. So, we had to work to get that in place, which can take, you know, several months, even up to a year.

But once that was in place, then we were able to hit the ground running, because one thing… one comment I heard a nurse say at one of the hospitals that I was visiting, and, you know, I don’t want to knock her approach, because I was a new face coming in town to where she was working, but I heard her say, overheard her say, well, who does she think she is, and why can’t she do this over where she’s at? You know? And so that just… what it turned into was a conversation to say, this is what I’m doing. I chose your institution specifically because this is your patient population that can benefit the most. I want these patients to have access to this type of a treatment. They’re not necessarily always offered this type of thing in this certain clinical setting.

And furthermore, I dragged my husband and kids across the country to come here to make this happen, so please, work with me here! So, it ended up, by the end of that conversation, we were besties, and she wanted me to hire her on my team. So it worked itself out, right? But yeah, it takes a lot of networking and work, if you really have that goal of making sure the underserved populations are able to have access to it. I was very intentional in my approach to make that happen.

Dr. Nicole Rochester:

Wow, that’s a great story. Thank you for making it personal, and thank you for your commitment.

Dr. Loeb, your population health work examines who gets what care and where. And as a bilingual physician, you intimately understand the language barriers, something that we haven’t yet talked about today. What strategies work for patient education across language and cultural differences.

Dr. Stacey Loeb:

Thank you for the question. I think this remains a big challenge. We actually just published a study showing, you know, less online information available about prostate cancer genetics in Spanish, for example. So, just recognizing, you know, many… Even comprehensive cancer centers only have their information available in English. And that presents a lot of barriers.

Published studies have shown, for example, that non-English preferring patients are less likely to receive genetic testing for prostate cancer, so this would, of course, then affect eligibility for clinical trials, eligibility for precision therapeutics, not to mention downstream impact for cancer risk for the patient and their family members. So, I think there’s a lot of work to be done in making sure we have more informational materials available in other languages.

Back to what Dr. Burnham discussed earlier, the critical importance of diversifying the workforce and also having staff in clinical settings who speak other languages and from different cultures who can help to narrow that gap with the patients. Unfortunately, we’re in the midst of a study right now about genetic testing, and there is very highly variable experience with third-party translation services. You know, some are excellent, but sometimes the translator themselves are not as comfortable with complicated cancer terminology or genetic terminology, so that can present a barrier as well.

So, I think this is… this is definitely a work in progress to make sure that we’re able to provide the same high quality of care for our non-English preferring patients.

Dr. Nicole Rochester:

Absolutely, thank you. This is also important as we continue to strive to provide equitable care. You know, everyone deserves access to these groundbreaking therapies that you all have described.

This has been a riveting conversation. Thank you both for sharing your insights, for sharing your expertise with providers today, there’s so much that we could say, but in summary, you know, you all have shared how structural barriers and really the things that impact upstream, decisions about who gets tested and who is involved in clinical trials, and the discussions and the language that we even use to talk about clinical trials, and how the research that’s being done doesn’t always make it to the people who need it the most, and what we as healthcare providers can do to bridge those gaps. So, just thank you so much for everything that you have shared today.

And thank you to you all for tuning in. We’re proud to present this Healthcare Provider Roundtable as part of the Patient Empowerment Network’s EPEP Initiative. Empowering providers to empower patients, helping providers support their patients every step of the way. I’m Dr. Nicole Rochester, and until next time, take care, and be well.