A Study to Compare a CHW-Led Versus Physician-Led Intervention for Prostate Cancer Screening Decision-Making among Black Men

Introduction

Prostate cancer is the second leading cause of cancer deaths among men in the United States and harms Black men disproportionately. Most US men are uninformed about many key facts important to make an informed decision about prostate cancer. Most experts agree that it is important for men to learn about these problems as early as possible in their lifetime.

Objectives

To compare the effect of a community health worker (CHW)-led educational session with a physician-led educational session that counsels Black men about the risks and benefits of prostate-specific antigen (PSA) screening.

Methods

One hundred eighteen Black men recruited in 8 community-based settings attended a prostate cancer screening education session led by either a CHW or a physician. Participants completed surveys before and after the session to assess knowledge, decisional conflict, and perceptions about the intervention. Both arms used a decision aid that explains the benefits, risks, and controversies of PSA screening and decision coaching.

Results

There was no significant difference in decisional conflict change by group: 24.31 physician led versus 30.64 CHW led (P=.31). The CHW-led group showed significantly greater improvement on knowledge after intervention, change (SD): 2.6 (2.81) versus 5.1 (3.19), P<.001). However, those in the physician-led group were more likely to agree that the speaker knew a lot about PSA testing (P<.001) and were more likely to trust the speaker (P<.001).

Conclusions

CHW-led interventions can effectively assist Black men with complex health decision-making in community-based settings. This approach may improve prostate cancer knowledge and equally minimize decisional conflict compared with a physician-led intervention.

Development and Validation of a Deep-learning Model to Assist With Renal Cell Carcinoma Histopathologic Interpretation

OBJECTIVE

To develop and test the ability of a convolutional neural network (CNN) to accurately identify the presence of renal cell carcinoma (RCC) on histopathology specimens, as well as differentiate RCC histologic subtype and grade.

MATERIALS AND METHODS

Digital hematoxylin and eosin stained biopsy images were downloaded from The Cancer Genome Atlas. A CNN model was trained on 100 um2 samples of either normal (3000 samples) or RCC (12,168 samples) tissue samples from 42 patients. RCC specimens included clear cell, chromophobe, and papillary histiotypes, as well as tissue of Fuhrman grades 1 through 4. Model testing was performed on an additional held-out cohort of benign and RCC specimens. Model performance was assessed on the basis of diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

The CNN model achieved an overall accuracy of 99.1% in the testing cohort for distinguishing normal parenchyma from RCC (sensitivity 100%, specificity 97.1%). Accuracy for distinguishing between clear cell, papillary, and chromophobehistiotypes was 97.5%. Accuracy for predicting Fuhrman grade was 98.4%.

CONCLUSION

CNNs are able to rapidly and accurately identify the presence of RCC, distinguish RCC histologic subtypes, and identify tumor grade by analyzing histopathology specimens.

The State of Men's Health Services in the Veterans Health Administration

PURPOSE OF REVIEW

For many diseases that place a large burden on our health care system, men often have worse health outcomes than women. As the largest single provider of health care to men in the USA, the Veterans Health Administration (VA) has the potential to serve as leader in the delivery of improved men's health care to address these disparities.

RECENT FINDINGS

The VA system has made recent strides in improving benefits for aspects of men's health that are traditionally poorly covered, such as treatment for male factor infertility. Despite this, review of Quality Enhancement Research Initiatives (QUERIs) within the VA system reveals few efforts to integrate disparate areas of care into a holistic men's health program. Policies to unify currently disparate aspects of men's health care will ensure that the VA remains a progressive model for other health care systems in the USA.

Risk Stratification by Urinary Prostate Cancer Gene 3 Testing Before Magnetic Resonance Imaging-Ultrasound Fusion-targeted Prostate Biopsy Among Men With No History of Biopsy

OBJECTIVE

To determine whether a combination of prostate cancer gene 3 (PCA3) and magnetic resonance imaging (MRI) suspicion score (mSS) could further optimize detection of prostate cancer on MRI fusion-targeted biopsy (MRF-TB) among men with no history of biopsy.

MATERIALS AND METHODS

We included in this study 187 men presenting to our institution between June 2012 and August 2014 who underwent multiparametric MRI (mpMRI) and PCA3 before MRF-TB. Biopsy results, stratified by biopsy indication and PCA3 score, were recorded. Receiver operating characteristics curves and multivariable logistic regressions were used to model the association of PCA3 and mSS with cancer detection on MRF-TB.

RESULTS

PCA3 is associated with cancer detection on MRF-TB for men with no prior biopsies (area under the curve: 0.67, 95% confidence interval: 0.59-0.76). Using a cutoff of ≥35, PCA3 was associated with cancer risk among men with mSS 2-3 (P = .004), but not among those with mSS 4-5 (P = .340). The interaction of PCA3 and mSS demonstrated significantly higher discrimination for cancer than mSS alone (area under the curve: 0.83 vs 0.79, P = .0434).

CONCLUSION

Urinary PCA3 is associated with mSS and the detection of cancer on MRF-TB for men with no prior biopsies. PCA3 notably demonstrates a high negative predictive value among mSS 2-3. However, in the case of high-suspicion mpMRI, PCA3 is not associated with cancer detection on MRF-TB, adding little to cancer diagnosis. Further studies are needed to evaluate the utility of PCA3 in predicting cancer among men with normal mpMRI.

Abstract A15: How does doctor-patient communication about prostate cancer screening influence African-American patients' decisional conflict around screening decisions?

Background: Decisional conflict is the state of uncertainty about the course of action to take. The decisional conflict scale measures personal perceptions of uncertainty in choosing options. Because experts in the medical community disagree about whether men should get screened for prostate cancer, the decision to get screened is often less certain than that for other tests. In order to make the best decisions about prostate cancer screening, patients must be well-informed of both the risks and benefits of screening. In this study, we assessed whether talking to a doctor about risks and benefits was associated with decisional conflict.

Methods: A total of 86 African-American men recruited in community-based and faith-based settings completed a baseline survey as part of a prostate cancer education program. The survey incorporated a revised version of the Decisional Conflict Scale. Participants responded “yes”, “unsure” or “no”, and these were scored as 1, 2, and 3 respectively. Scores for each of 10 items were averaged to obtain a decisional conflict score. The survey also included demographic information, questions about participants' experiences with prostate cancer screening, questions about past communication with physicians about screening, knowledge about prostate cancer, and health practices. All responses were self-reported. After the survey, participants took part in an in-depth prostate cancer information session lead by a physician or a community health worker. For this study, analyses were limited to responses from the baseline survey.

Results: The demographics of this sample include African American males of mean age 57.8 (sd 12.4), the majority of whom have at least some college education (72.0%). Most participants completed prostate cancer screening in the past year (57.4%). Half of the men completed a PSA test in the past year (49.4%), and 41% completed DRE. The majority of participants had discussed prostate cancer screening with their doctors (75.6%), and had discussed the benefits of screening with their doctors (67.4%). However, less than half (44.2%) had discussed the risks of prostate cancer screening with their doctors, and even fewer had doctors who informed them that experts disagree about whether men should have a PSA test (26.7%). We found that decisional conflict was negatively associated with having a previous PSA test (β=-0.378, p=0.007), having a doctor who talked with the participant about the benefits of testing (β=-0.424, p=0.002), having a doctor who talked with the participant about the risks of participating (β=-0.392, p=0.001), and with having a doctor who informed them that experts disagree on the need for PSA testing (β=-0.601, p<0.001). No association was found between having a previous DRE and decisional conflict. All associations remained significant after adjusting for age and education.

Conclusions: Well-informed patients experience lower decisional conflict. While few participants discussed risks or the lack of consensus about whether men should be screened with their doctors, we found that discussing the risks and disagreement about testing, in addition to the benefits of testing, were significantly associated with having lower decisional conflict scores compared to those who had not had such conversations with their doctors. In addition, previous PSA testing was associated with lower decisional conflict. These results suggest that, to facilitate better decisions about this controversial topic among black men, doctors should consider more open discussion about prostate cancer screening, and that they include the risks, benefits, and controversies in their conversations with patients.

Citation Format: Michael Fenstermaker, Theodore Hickman, Heather Gold, Danil Makarov, Stacy Loeb, Helen Cole, Elizabeth Cahn, Joseph Ravenell. How does doctor-patient communication about prostate cancer screening influence African-American patients' decisional conflict around screening decisions? [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A15.

A Study of the Use, Knowledge, and Beliefs About Cigarettes and Alternative Tobacco Products Among Students at One U.S. Medical School

PURPOSE

In the United States, the prevalence of the use of alternative tobacco products (ATPs) (e.g., hookahs, e-cigarettes, cigars/cigarillos) has increased sharply. As future health care providers, medical students will play a critical role in health promotion and disease prevention. This study investigated medical students' use, knowledge, and beliefs about cigarettes and ATPs.

METHOD

In 2014, the authors surveyed all students enrolled at one medical school in New York City. The survey included questions about personal use of tobacco products, perceptions about the harms of ATPs and their role in disease causation, education about ATPs, and cessation training and practices related to ATPs and cigarettes. The authors compared results across medical school classes.

RESULTS

Of 720 students, 431 (59.9%) completed the survey. Of those, 64 (14.7%) were current users of tobacco or smoking products, including cigarettes (17; 3.9%), ATPs (21; 4.8%), or marijuana (39; 8.9%). Many believed that ATPs contributed less than cigarettes to various diseases. Respondents received less cessation training regarding ATPs than cigarettes (P < .0001). They felt less confident providing ATP cessation counseling than cigarette cessation counseling (P < .0001) and were less likely to report counseling patients on ATP cessation than cigarette cessation (46 [10.7%] versus 280 [64.8%], P < .0001).

CONCLUSIONS

A concerning percentage of surveyed medical students use tobacco products, including ATPs, and lack the knowledge, education, and cessation counseling skills to provide accurate information about them to patients. ATP education should be added to medical school curricula to address this gap.

Prebiopsy MRI and MRI-ultrasound Fusion-targeted Prostate Biopsy in Men With Previous Negative Biopsies: Impact on Repeat Biopsy Strategies

OBJECTIVE

To report outcomes of magnetic resonance imaging (MRI)-ultrasound fusion-targeted biopsy (MRF-TB) and 12-core systematic biopsy (SB) over a 26-month period in men with prior negative prostate biopsy.

MATERIALS AND METHODS

Between June 2012 and August 2014, 210 men presenting to our institution for prostate biopsy with ≥1 prior negative biopsy underwent multiparametric MRI followed by MRF-TB and SB and were entered into a prospective database. Clinical characteristics, maximum mpMRI suspicion scores (mSS), and biopsy results were queried from the database, and the detection rates of Gleason ≥7 prostate cancer (PCa) and overall PCa were compared between biopsy techniques using McNemar's test.

RESULTS

Forty seven (29%) of 161 men meeting inclusion criteria (mean age, 65 ± 8 years; mean prostate-specific antigen, 8.9 ± 8.9) were found to have PCa. MRF-TB and SB had overall cancer detection rates (CDRs) of 21.7% and 18.6% (P = .36), respectively, and CDR for Gleason score (GS) ≥7 disease of 14.9% and 9.3% (P = .02), respectively. Of 26 men with GS ≥7 disease, MRF-TB detected 24 (92.3%) whereas SB detected 15 (57.7%; P < .01). Using UCSF-CAPRA criteria, only 1 man was restratified from low risk to higher risk based on SB results compared to MRF-TB alone. Among men with mSS <4, 72% of detected cancers were low risk by UCSF-CAPRA criteria.

CONCLUSION

In men with previous negative biopsies and persistent suspicion of PCa, SB contributes little to the detection of GS ≥7 disease by MRF-TB, and avoidance of SB bears consideration. Based on the low likelihood of detecting GS ≥7 cancer and overall low-risk features of PCa in men with mSS <4, limiting biopsy to men with mSS ≥4 warrants further investigation.

Relationship Between Prebiopsy Multiparametric Magnetic Resonance Imaging (MRI), Biopsy Indication, and MRI-ultrasound Fusion-targeted Prostate Biopsy Outcomes

BACKGROUND

Increasing evidence supports the use of magnetic resonance imaging (MRI)-ultrasound fusion-targeted prostate biopsy (MRF-TB) to improve the detection of clinically significant prostate cancer (PCa) while limiting detection of indolent disease compared to systematic 12-core biopsy (SB).

OBJECTIVE

To compare MRF-TB and SB results and investigate the relationship between biopsy outcomes and prebiopsy MRI.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of a prospectively acquired cohort of men presenting for prostate biopsy over a 26-mo period. A total of 601 of 803 consecutively eligible men were included.

INTERVENTIONS

All men were offered prebiopsy MRI and assigned a maximum MRI suspicion score (mSS). Men with an MRI abnormality underwent combined MRF-TB and SB.

OUTCOMES

Detection rates for all PCa and high-grade PCa (Gleason score [GS] ≥7) were compared using the McNemar test.

RESULTS AND LIMITATIONS

MRF-TB detected fewer GS 6 PCas (75 vs 121; p<0.001) and more GS ≥7 PCas (158 vs 117; p<0.001) than SB. Higher mSS was associated with higher detection of GS ≥7 PCa (p<0.001) but was not correlated with detection of GS 6 PCa. Prediction of GS ≥7 disease by mSS varied according to biopsy history. Compared to SB, MRF-TB identified more GS ≥7 PCas in men with no prior biopsy (88 vs 72; p=0.012), in men with a prior negative biopsy (28 vs 16; p=0.010), and in men with a prior cancer diagnosis (42 vs 29; p=0.043). MRF-TB detected fewer GS 6 PCas in men with no prior biopsy (32 vs 60; p<0.001) and men with prior cancer (30 vs 46; p=0.034). Limitations include the retrospective design and the potential for selection bias given a referral population.

CONCLUSIONS

MRF-TB detects more high-grade PCas than SB while limiting detection of GS 6 PCa in men presenting for prostate biopsy. These findings suggest that prebiopsy multiparametric MRI and MRF-TB should be considered for all men undergoing prostate biopsy. In addition, mSS in conjunction with biopsy indications may ultimately help in identifying men at low risk of high-grade cancer for whom prostate biopsy may not be warranted.

PATIENT SUMMARY

We examined how magnetic resonance imaging (MRI)-targeted prostate biopsy compares to traditional systematic biopsy in detecting prostate cancer among men with suspicion of prostate cancer. We found that MRI-targeted biopsy detected more high-grade cancers than systematic biopsy, and that MRI performed before biopsy can predict the risk of high-grade cancer.

Long-term Satisfaction After Open Radical Prostatectomy

OBJECTIVE

To determine the association between baseline factors, post-treatment factors, and long-term satisfaction after radical prostatectomy (RP).

METHODS

Between January 2000 and March 2009, 1425 men who underwent RP by a single surgeon were enrolled in an institutional review board-approved, prospective, longitudinal outcomes study. Baseline characteristics and post-treatment functional and oncologic outcomes were captured through 2013. Patient survey responses from 875 (61.4%) of these men were used to evaluate satisfaction with treatment outcome and treatment decision.

RESULTS

Overall, 88.2% and 91.0% men were satisfied to very satisfied with treatment outcome and treatment decision, respectively. Baseline sexual function was associated with satisfaction with both treatment outcome (adjusted odds ratio [aOR] = 1.40; 95% confidence interval [CI], 1.01-1.93) and treatment decision (aOR = 1.47; 95% CI, 1.08-2.01). Among post-treatment factors, higher University of California, Los Angeles Prostate Cancer Sexual Function (aOR = 2.95; 95% CI, 2.06-4.22), University of California, Los Angeles Prostate Cancer Urinary Function (aOR = 2.38; 95% CI, 1.66-3.40), and lower urinary tract symptom scores (aOR = 1.91; 95% CI, 1.19-3.06) were predictors of satisfaction with outcome. Bother due to incontinence and sexual dysfunction, and perception of cure were independent predictors of both satisfaction with treatment outcome and treatment decision.

CONCLUSION

Nearly 90% of men are satisfied with both their treatment outcome and treatment decision after open RP. Improving long-term satisfaction after RP requires efforts to provide realistic expectations and improve functional outcomes.

Adverse psychosocial outcomes associated with drug use among US high school seniors: a comparison of alcohol and marijuana

OBJECTIVES

There is debate about whether marijuana (cannabis) use is more dangerous than alcohol use. Although difficult to make objective comparisons, research is needed to compare relative dangers in order to help inform preventive efforts and policy.

METHODS

Data were analyzed from a nationally representative sample of high school seniors in the Monitoring the Future study (2007-2011; Weighted n = 7437; modal age: 18) who reported lifetime use of alcohol or marijuana. Students were asked to indicate whether they experienced various adverse psychosocial outcomes resulting from use of each substance. We examined which outcomes were more prevalent for each substance.

RESULTS

Compared to alcohol use, marijuana use was more commonly reported to compromise relationships with teachers or supervisors, result in less energy or interest, and result in lower school or job performance. Compared to marijuana use, alcohol was more commonly reported to compromise relationships with friends and significant others; it was also reported to lead to more regret (particularly among females), and driving unsafely. Marijuana users were more likely to report no adverse outcomes. Females and white students were more likely to report various adverse outcomes and higher frequency use of each substance also increased occurrences of reported adverse outcomes.

CONCLUSIONS

Marijuana and alcohol are associated with unique adverse psychosocial outcomes. Outcomes differ by sex and race/ethnicity, and perception or experience of outcomes may also be related to legal status and associated stigma. Public health interventions may be more effective by focusing on harm reduction strategies for these drug-specific outcomes.