Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm your host, Melanie Cole, and today we're discussing the important topic of prostate cancer disparities among minority groups, particularly Black men. Joining us today is Dr. Adam Murphy. He's an Associate Professor of Urology and Preventive Medicine at Northwestern Medicine.

He's a renowned Urologist who's dedicated his career to studying and addressing these disparities. His groundbreaking research has led to the development of innovative strategies that bridge the gap and provide equitable healthcare to all patients. Dr. Murphy, I'm so glad to have you with us today. Can you please start by providing us a bit of an overview of the current state of prostate cancer disparities among minority populations and in particular Black men?

Adam Murphy, MD, MBA, MSCI: Well, first, thank you for having me, Melanie. I really appreciate the opportunity. Second, you ask a big question, but I would say that we're in a good time in prostate cancer disparities research in general, because, while there are disparities that are pretty well known in terms of both prostate cancer incidence, and in terms of prostate cancer mortality rates being higher amongst Black men; there are still lots of areas, because medicine is moving so fast, where there's just a delay in getting enough proof that the treatments that we have, that the biomarkers that we have, work as well or very, very similarly in minority groups. So that includes Black men, but of course, Asians, Hispanics, and other ethnic groups are kind of behind in terms of seeing some of the state of the art treatments, and biomarkers kind of be proven for their effectiveness in these other groups.

Melanie Cole, MS: This is so interesting and your work as I understand it, involves studying the performance of established nomograms for individuals with elevated cancer screening markers. What are some of the significant discoveries you've made in this area, Doctor, especially as it pertains to the patients of various races?

Adam Murphy, MD, MBA, MSCI: And so, validations of these nomograms, there've been lots of studies that have kind of tried to show that the tools that we use to predict risk, perform similarly across different racial groups and different populations even in the same racial groups. So, that work has been done for years and there's an early detection research network that lays out how these validations should be done in terms of reporting it, so that people can assess whether or not these tests are working well in different populations. Problem is that the guidelines that have been laid out only really focus on discrimination of how the tests work to separate people who have the cancer or disease of interest from those who don't. It doesn't do a good job of saying whether or not prediction that the tests or nomogram suggests is a risk for this patient is actually accurate across different racial and ethnic groups.

So let me say that a little clearer. What we're trying to make sure that we see for our patients is that the predictive probability of disease is similar to what you actually observe for people in that group. That's called calibration. And most tests, whether it be, temperature gauges or whether it be predicting prostate cancer risk, may have to be recalibrated for different populations at different times.

And we typically forget to do that work for prostate cancer biomarkers, and risk models. And so that comparison between predicted risk and observed risk needs to be done when there are populations that have either very much lower risk or much higher risk than in the general population. And then we're supposed to actually see if that model performs similarly in other populations that may either have higher risk or lower risk.

So for prostate cancer, that could be Asians or Alaskan Natives, or maybe even Hispanics, is a low risk group, and Blacks is a high risk group in this country, and so because of that difference in prevalence of prostate cancer and aggressive prostate cancer; these tools need to be validated for their calibration, that concords between the predicted risk that the test will say versus what you actually observe in the population.

Melanie Cole, MS: So, Dr. Murphy, one of your notable contributions is integrating advanced genomic testing into the decision making process in clinical care of minority patients, including those with lower healthcare literacy. So how has this approach changed the way we screen and provide guidance for these patients?

Adam Murphy, MD, MBA, MSCI: I hope that it's changed. I think people are more aware of the fact that these tools help physicians make decisions, and we kind of are comfortable with saying that as long as this test is quote unquote accurate in separating people with disease versus not disease, we tend to trust them, but we're giving probability data to doctors and to patients, and people have variable understanding of probability. I learned this in business school, but there's a professor named Richard Thaler who would always talk about how bad people are at predicting risk when it's anything that's different than less than 5%, greater than 95%, or 50%. So, anything in the middle is hard for people to make decisions based off of, and what my research has shown is that people, will respond differently based off of their health literacy to this risk.

So if you have high anxiety, for example, you're more likely to respond to predictions of bad things happening more aggressively with your cancer treatment choice. You may choose surgery or radiation when you could have been watched. And that's to do with patients' anxiety, not about the differences in their disease status. And so, I think I just am bringing awareness to the fact that these tests will affect people with low health literacy, and maybe even low numeracy, ability to understand numbers differently than it will a person who has pretty good health literacy.

And so I think it means that it's our job as providers to probably do a better job at improving people's health literacy. And while we don't necessarily have time to do that in our busy clinics, one way that I've come around to doing it is giving people a couple additional weeks to process information.

I'll give them some homework to read up about their prostate cancer, so that they can come back a little bit more informed to engage in a conversation about what this risk means, and to help them get over their anxiety and their trigger to treat their disease aggressively, when that may not be the best course of action.

Melanie Cole, MS: Well, I think anxiety does play such a big part in that shared decision making and considering the complex interplay and along these same lines of socioeconomic factors, healthcare access, cultural considerations, you just mentioned a few. So some of the challenges that you've encountered while addressing prostate cancer disparities, how you've navigated them, but I'd also like you to tell us, Dr. Murphy, strategies that you've found. You mentioned homework. You mentioned having them addressing this healthcare literacy. What are some strategies that are successful in reaching and engaging minority populations as a whole, specifically Black men in proactive cancer care?

Adam Murphy, MD, MBA, MSCI: I think to attack the second question first, what a strategy that I've used to try to deal with the health literacy and kind of health disparity gap, what I noticed, I'm African American. I look stereotypically African American. I'm from the south side of Chicago. I just happen to have degrees after college, including a medical degree. And so there are times that I get to pretend to not be a doctor or a prostate cancer researcher and just a regular African American guy. And I can tell you that the degree of health education that happens to Black men, is lower than average.

And I think it's because doctors get scared of having to take a lot of time to bring up people's health literacy. I've pretended to not be a doctor in other healthcare settings, and I'll tell you that they may do perfect healthcare to me, but they won't usually talk to me about the disease process.

They may not talk to me about what the medications that they're recommending for me or treatment plan actually is or what it does. And so, what I quickly realized is that health literacy is a long term problem for Black men in the health care system, starting in pediatric days. People don't really engage you in conversations about your health care or about what your different organs do.

And so, a lot of what I am doing in my clinic is I draw a lot of pictures of prostates and genitourinary tracts, to kind of give people a sense of the lay of the land. And so they get used to the terms that we're going to use, prostate, penis, urethra, seminal vesicle, whatever, biomarker. And then I can use that baseline that I've talked about from the time that I first meet them to then build slowly their fund of knowledge around prostate or prostate cancer related topics.

So that when I need to have a prostate cancer discussion after a prostate biopsy shows cancer, they're more able to understand what their NCTN risk group is and what the treatment options mean. So if I say a prostatectomy, removing the prostate and seminal vesicles will trigger this person to understand that the nerves for an erection are nearby and that the prostate acts as a dam to urine flow and may affect their ability to control their urine flow. So that pre-work I do when I first consult with patients, when I usually have insurance on my side to pay for an extra, you know, 15 to 30 minutes of time, and I'll give them homework assignments so that when we are seeing each other in subsequent times, they're more likely to be compliant with the regimens that I lay out for them, I've noticed, because most men will tell me that I've taught them more in that 30 minutes than they learned from 30 years or 20 years with their physicians.

Melanie Cole, MS: That is fascinating, Dr. Murphy. And I'd like you to just share briefly some examples of how your research and insights have led to changes in how researchers approach clinical trial recruitment for minority groups. And I imagine similarly to the access issues that Black women have when it comes to breast cancer. I'd like you to tell us about your clinical trial network that you built in Chicago and its impact on recruitment and health outcomes for minorities in the Chicago area.

Adam Murphy, MD, MBA, MSCI: So, this was an interesting issue. I was here in Northwestern, in my lab year, from 2008 to 2009, and I was trying to do this vitamin D and prostate cancer research study, and I needed to recruit several hundred men over a couple years. And it was clear to me that I couldn't do it just through Northwestern, who had about 15% African Americans in the clinic at that point.

And so we reached out to University of Chicago, as our first site. And so we actually got the research approved by the Institutional Review Board there first and Northwestern was second. And then we spread the study to include, Cook County Health next, and then eventually we spread it to Jesse Brown VA, and to University of Illinois at Chicago.

So we had five sites, and I started to do this clinical trial, which was really just an observational study, as a chief resident, I was running this, study, along with my time during lab year, getting it off the ground. And so we ended up getting a Department of Defense Physician Research Training Award.

That was my first grant. It was the first grant I'd ever written and I got it. So, every dog has his day maybe, but that launched my research career and it also connected me to the urologists and pathologists and eventually the radiologists at these other academic institutions.

And so we had this minority enriched group of sites, and we were able to leverage Northwestern's research infrastructure and clinical infrastructure to kind of manage this multi site study. And eventually I came to call this network the CHARM Network, which was Cancer Health Alliance for Research in Men. And, we just found people who were also interested in prostate cancer and were interested in increasing the enrollment of African American men, or answering important genetic or epidemiologic questions about prostate cancer. And that's kind of how the network was formed.

Melanie Cole, MS: Brilliant work, Dr. Murphy, and you recently published a paper in Urologic Oncology that discusses the development and piloting of an online workshop aimed at educating other urologists on this shared decision making in diverse populations for prostate cancer screening and treatment. Could you tell us about the objectives of this workshop and the key findings from this study?

Adam Murphy, MD, MBA, MSCI: The American Urological Association wanted to do a shared decision making course for urologists focused on prostate cancer and focused on diverse groups of men, particularly underrepresented groups in prostate cancer. And so they knew that I focused on African American prostate cancer disparities and they asked me to be the course developer for this. Caveat, I am not a shared decision making researcher. I am a general urologist that studies biomarkers and genetics in prostate cancer, and usually prostate cancer risk or prognosis.

And, I think the fact that I had to learn how to recruit Black men into studies, during clinical care gave them some confidence that I could do this. I felt really ill prepared to do a good job with this workshop because I did not know shared decision making kind of methodology. And so I reached out to people who did.

 Aisha Langford and Daniel Makarov, from NYU were the people I tapped for that shared decision making expertise. And then I picked other urologists who were good with the other ethnic groups that I may not have had as much familiarity with. So, we defined six groups of underrepresented people, beyond just African American men. And then we picked clinicians that really, either by just the demography of where they lived, or their own research or clinical interests, had a lot of expertise in the other ethnic or racial minority groups and actually, I should extend that. We also included sexual and gender minorities.

We included Asians, rural living folks, African Americans, Hispanics, and so we had a transgender female, we had an Asian male that also spoke a different language and a Hispanic male that spoke a different language to try and get at language barrier issues, at cultural issues. And while you can't be culturally competent, we did use some of the more common cultural trends to give people realistic scenarios. We came up with six cases as a group of 12 faculty members, including ten urologists, a medical oncologist, and then Aisha Langford, who was a shared decision making PhD researcher. And what we learned from that experience was, we could use people's expertise to develop real cases that urologists would accept as believable cases. And so that was one major target. Two, we wanted to be sensitive about how we stereotype these cases so that people wouldn't be offended or feel like this is the end all be all for the Black male or for the Asian male who speaks Chinese, for example, but to give a realistic scenario so that people can role play in person. And so we basically created a 90 minute workshop where two urologists or urology providers were paired together, and they would act as either a patient or the provider in the case.

And they were both scripted partially, and then they also would have to have the urologist take people through the shared decision making process with an acronym from the Agency for Healthcare Research Quality, AHRQ. They developed a SHARE acronym to teach people how to do shared decision making with an easy mnemonic.

And so we did that and it was attended only by 14 urologists, but the people who showed up really did say that they got valuable information from it. They got to role play. They thought that we accomplished our aims with it. And so what I learned from that was personally how to do a better job at doing shared decision making, not only in prostate cancer, but in other disease states.

Because you have to keep practicing it to become good at it. And I think that was the main lesson was that it's doable. Doesn't have to take a lot of time, but you do need to practice it. And you should practice it with things that you're very, very comfortable with knowledge wise, so that you can help build that patient's confidence in engaging with you in a conversation. And then you get more nuance to that skill and you get better over time.

Melanie Cole, MS: I read the study, Dr. Murphy, and it's just absolutely amazing and as providers did report that lack of comfort with that shared decision making and what an amazing workshop that is and as we get ready to wrap up and in your opinion, how can the medical community, healthcare professionals, especially other urologists and researchers help to reduce these disparities, improve prostate cancer outcomes for minority communities?

Looking ahead, I'd like you to give us a blueprint for some future directions, what you'd like to see happen, and how reaching out to the medical community, other healthcare providers, even through podcasts such as this, are really going to help to bridge that gap for those underserved communities so that we can better the numbers and better the outcomes, which I think is really the key message here.

Adam Murphy, MD, MBA, MSCI: Future directions for this is to essentially have others replicate this in other settings and expand it to other larger groups of urologists. I think that people just need to learn that in medical school, and be taught that skill during residency, so that it's something that the young can just kind of think of as natural to engage patients in that way. That's one future direction. I think the other thing is to get urologists more comfortable with it, in other arenas, other practice areas. Whether that be bladder cancer or pediatrics or female reconstruction, just having it in other settings so that people can understand how to apply those tools there.

I think that the interactive workshop style is helpful for people to practice and having it amongst peers makes it low pressure. So that's what I think for the future directions of that kind of work. In terms of what you can do in your clinic to do a better job with reducing disparities, I do think that as a field, we tend to be paternalistic and we tend to kind of educate patients very well into doing what we want them to do, because we've gone to medical school and we've gone to residency and training and worked. But there's some diseases, some treatments that are so quality of life affecting that the patient really needs to have some agency there where they can make some decisions, especially when the choices between treatment choices are not wildly different in their outcomes. I think patients should have agency in that, and we need to be able to allow them to engage in that process as well. So getting us to practice educating our patients about their disease, giving them homework assignments, slowing down their decisions, especially when you can have some time to make choices thoughtfully, is really an important thing to kind of institute.

I think the telehealth visit helps with that kind of a process so that you don't always have to bring them back in in person, but you can have another appointment where you get paid for the visit, but they have had some time to do some work to prepare them for that visit.

Melanie Cole, MS: What an informative episode and I applaud all the great work that you're doing. Dr. Murphy, this was so interesting. Thank you again for joining us. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/urology to get connected with one of our providers.

That concludes this episode of BetterEdge, a Northwestern Medicine podcast for physicians. Please always remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole. Thanks so much for joining us today.