Reducing Health Disparities in Our Communities

Pastor Steve Raj and Nadine Barrett, Ph.D., director of the DCI Office of Health Equity and Disparities, have been working together for three years to increase men’s access to prostate cancer screening and care.Pastor Steve Raj and Nadine Barrett, Ph.D., director of the DCI Office of Health Equity and Disparities, have been working together for three years to increase men’s access to prostate cancer screening and care.Black men face an unfortunate paradox when it comes to prostate cancer. They are the group hit hardest by this common disease, yet they are less likely than other groups to receive screening or medical care for this disease.

The National Cancer Institute estimates that black men are 60 percent more likely than white men to develop prostate cancer. Black men also develop prostate cancer earlier than other ethnic groups and are more likely to develop aggressive, high-risk forms. This greater risk has not, however, translated to greater care.

“Black men face disparities at all levels when it comes to prostate cancer,” said Nadine Barrett, Ph.D., director of the DCI Office of Health Equity and Disparities. “They go undiagnosed more often than white men, and are typically diagnosed at later stages, when prostate cancer is more difficult to treat and treatment is less likely to be effective.”

In addition to having limited access to cancer screenings and care, black men face the same barriers to seeking care that all men do: lack of knowledge about prostate cancer, fear of treatments that could affect a sensitive area of the anatomy, and most recently, confusion about whether or not even medical experts believe screening is worthwhile.

Together, these factors create a grim reality. Each year, about 5,000 black men die of prostate cancer, more than twice the rate of any other ethnic group. Many of these deaths are preventable.

The Men’s Health Initiative (MHI), an annual event held by the DCI and partners, is aiming to reverse this trend and ensure all groups are educated and receive access to care. The MHI combines a weekend-long event featuring education, screening and medical care with months of outreach to “get the word out” about prostate cancer screening to men in the Triangle.

For men who do attend, the MHI is also pioneering a patient-centered approach that allows men to decide on the best course of action based on both their individual risk, as determined by the latest medical evidence, and their own personal preferences.

“Over the last several years there’s been increasing confusion about the role of prostate cancer screening, especially for African American men,” said Steven Patierno, Ph.D., DCI deputy director and a nationally recognized expert on cancer disparities.

Two men receive screenings and health information in Durham’s Lincoln Community Health Center during last year’s MHI event.Two men receive screenings and health information in Durham’s Lincoln Community Health Center during last year’s MHI event.The reasons for this confusion are easy to understand. Treating prostate cancer is not as straightforward as treating a sore throat or mending a broken leg. Prostate cancer is usually a slow-growing disease that can take many years or even decades to become life-threatening. Aggressive treatment may involve serious, life-altering consequences such as incontinence, erectile dysfunction or rectal injury.Read more

And as anyone who has had to wait for the results of a major medical test knows, the process of even screening for this disease can be a stressful, frightening experience. In the past, the diagnosis of cancer has pushed men to undergo expensive, invasive treatments in order to “cure” a disease that, in some, may have never developed into a health threat. Other men were left with the stress of a diagnosis without a clear answer about what to do next.

In 2012, concerns about the over-treatment and over-screening of prostate cancer led the U.S. Preventive Service Task Force to make a recommendation against screening in all men, concluding that, “many men are harmed as a result of prostate cancer screening, and few, if any, benefit.” This led to a public outcry, particularly among the high-risk African American community, who were underrepresented in the studies used to make this recommendation, and criticisms that this conclusion was based on incomplete data.

But since then, the medical community has come to the realization that not screening men for prostate cancer at all can be as harmful to men’s health as over-screening. Moreover, new information, gleaned from studies following the impact of screening for longer periods of time, indicate that prostate cancer screening, particularly in high-risk individuals is just as advantageous as breast cancer screening in women.

“In 2012, the pendulum swung out too far in the direction of under screening,” Dan George, M.D., director of Genitourinary Oncology at the DCI. “Now it’s started to swing back to center.”

“In the past couple of years there’s been a greater focus on the health benefits of screening, particularly for middle-aged African-American men, who are at greater risk for faster, more aggressive forms of prostate cancer. We’ve also made improvements in treatment of early stage, slow-growing cases of prostate cancer,” George said.

To help patients make the best decision, the DCI and partners formed a multi-disciplinary expert panel to develop a series of screening recommendations. These recommendations provide a tailored risk assessment based on a man’s age, ethnic background, family history and other risk factors. The panel included physicians and faculty from the DCI, the Division of Urology, the Departments of Radiation Oncology, and Primary Care and Community and Family Medicine.

“Men who attend the MHI will undergo a discussion with a physician that includes the pros and cons of prostate cancer screening in order to make an informed decision,” said Glenn Preminger, M.D., Chief of the Duke Division of Urologic Surgery, who helped develop the materials.

“During this process, patients learn about prostate cancer, what screening entails and what medical options are available,” Preminger said.

Afterward they they can choose whether to be screened for prostate cancer, as well as other conditions such as diabetes and high blood pressure. They also receive one-on-one counseling and written materials. Men with abnormal results also receive visits from outreach counselors from the Office of Health Equity and Disparities called patient navigators for help navigating the health system.”

Reducing disparities involves more than just making screening services available. It also involves letting them know that care is available in the first place—a task the Office of Health Equity and Disparities has been working on for the past three years.

“Raising awareness among men on the importance of prostate cancer — and getting them access to care — are two of the most important things we can do to address these lasting disparities in healthcare,” said Nadine Barrett.

To that end, the Office of Health Equity and Disparities has built relationships with Latino, Asian and African-American faith organizations throughout the Triangle to talk with parishioners about screening and make faith-based leaders advocates for screening and care.

Representatives of the Office of Health Equity also visit barbershops to talk to men about prostate cancer, as well as beauty salons in an effort to get women to talk to their fathers, brothers and significant others about prostate cancer.

Steve Raj is a senior pastor at Life International, a Durham-based church that has been working with the DCI over the past three years. “The partnership has been a real game changer and a phenomenal help for many of our people,” Raj said.

“Many of our parishioners them do not have medical benefits that afford them screening. Others may be covered, but they don’t know that they are eligible. The patient navigators have been a wonderful resource in getting them information and resources about cancer screenings as well as further help for our congregants who are cancer patients.”

Raj estimates that hundreds of his parishioners have been able to receive screenings each year since he started working with the DCI. He has also spoken with and prayed for the families of men who received a positive result.

“I have seen all kinds of things that God can do. Nevertheless you need to take care of the temple that he has given us. We encourage prayer, but we urge our members to take care of their bodies,” Raj said.

The Duke Cancer Institute recommends that health professionals inform men between the age of 40 and 70 years about the potential benefits and harms of prostate cancer screening. Screening discussions for older men (over 70) may be also appropriate based on life expectancy and overall health.

The Men’s Health Initiative will be held on Saturday, Sept. 20, from 8 a.m. to noon in the Lincoln Community Health Center in Durham, and Sunday, Sept. 21, from noon to 4 p.m. in Duke Clinics 2A/B. The event is free and open to members of the Duke family and the general public. For more information, or to receive a consultation with a patient navigator, call 919.684.0409 or visit

Screening for Prostate Cancer

In this illustration, a doctor performs a digital rectal examination (DRE), one of two screening tests for prostate cancer.In this illustration, a doctor performs a digital rectal examination (DRE), one of two screening tests for prostate cancer.Two screening tests for prostate cancer are available at the Men’s Health Initiative: the prostate specific antigen (PSA) blood test and the Digital Rectal Exam (DRE). The event will also feature tests for body mass index (BMI), hypertension and diabetes.

PSA tests are blood tests that measure the level of PSA, a protein produced by the prostate. During a DRE, a physician inserts a gloved finger into the rectum and examines the prostate for irregularities in size, shape and texture.

A positive result in either case indicates the possible presence of cancer in the prostate; a biopsy, where needles are inserted into the prostate to take small tissue samples, may then be performed to confirm that cancer exists. If cancer is present, a pathologist can determine how aggressive the cancer is and discuss treatment options. In this illustration, a doctor performs a digital rectal examination.