Community-based interventions to improve prostate cancer screening and implications for black men: a scoping review

INTRODUCTION

Globally, prostate cancer remains a significant public health concern. In 2022, prostate cancer was the fourth most commonly diagnosed cancer, accounting for 7.3 per cent.¹ With increasing incidence and mortality rates, prostate cancer has huge and ever-increasing cost implications for healthcare systems.^2-5 In the UK, prostate cancer is the most common male cancer, with increasing incidence and prevalence rates. Between 2000 and 2021, its incidence increased from 109 per 100,000 person-years to 159 per 100,000 person-years, while the prevalence rate increased from 0.4% to 1.4%.⁶

Ethnicity is an important underlying risk factor for prostate cancer. Research findings have consistently shown that prostate cancer rates are substantially higher among black men compared to white men.^7-9 Lifetime risk of being diagnosed with prostate cancer is higher (1 in 4) among black men compared to 1 in 8 among white men.¹⁰ When it comes to mortality from prostate cancer, black men are also disproportionately affected.^9-12 Hence, prostate cancer is not only significant public health problem, but it is also glaringly a vital health disparity issue.

Apart from ethnicity, studies have explored modifiable lifestyle and environmental risk factors that could be associated with the risk of developing prostate cancer and related mortality. Among these are roles that metabolic syndrome might play in increasing risk, association between smoking, obesity and prostate cancer mortality and the beneficial effect of regular physical activity on disease progression.¹³ Systematic reviews with focus on LMICs identified higher fat intake, alcohol consumption, red meat intake and smoking as risk factors, while higher vegetable intake and tea consumption could lower risk.¹⁴ Despite these findings, risk reduction measures that are based on these modifiable factors have no definite role in approaches to prevention/early detection and treatment of prostate cancer.

It has been hoped that early detection of prostate cancer at a stage which is treatable and curable using PSA testing with or without DRE could potentially reduce disease-related mortality. However, this benefit has not been demonstrated in research findings.¹⁵ A recent systematic review concluded that prostate cancer screening using the PSA test could be associated with only a small reduction in disease-specific mortality, with no effect on overall mortality.¹⁶ Some argue that apart from not achieving a remarkable reduction in mortality, PSA testing could engender fainting episodes and overdiagnosis, as well as contribute to complications like bleeding, clot formation, infection and urinary symptoms attributable to subsequent diagnostic procedures.^15,17 DRE has been associated with pain or bleeding.¹⁵ Hence, PSA testing with or without DRE remains controversial, with no national screening programme for prostate cancer to drive early detection.

More recently, the US preventive services task force (USPSTF) reviewed evidence of benefits versus risks of PSA- based prostate cancer screening, with evidence that prostate cancer screening in men aged 55 to 69 years could prevent 1.3 deaths over 13 years per 1000 men screened and prevent 3 metastatic diseases per 1000 men screened. It also documented psychological problems associated with false positive results and physical complications due to treatment, with conclusions that overall, for men aged 55 to 69 years, there is a small net benefit of PSA-based testing. However, for men aged 70 years and above, there is no net benefit.¹⁸ Based on USTPSTF recommendations, men aged 55-69 years could decide on an individual basis to undergo PSA- based prostate cancer screening after considering the potential benefits versus risks.¹⁸ In the UK, asymptomatic men over the age of 45 years can request and be offered PSA tests during primary care consultations with their GP.¹⁹

Despite compelling evidence that black men bear a disproportionate burden of prostate cancer compared to their white counterparts, prostate screening remains far from the ideal among this population. Research shows that black men are less likely to utilise opportunities for PSA testing and therefore likely to present late with advanced symptoms of prostate cancer, consequently missing out on critical early intervention.²⁰ A US study cites low awareness of cancer, a lack of recognition of risks and benefits of screening as contributing factors to low participation in prostate cancer screening. The study also identified fear of the screening process, as well as a positive diagnosis and mistrust of the health system, as barriers to prostate cancer screening for black men.²¹

To improve the participation of black men in prostate cancer screening, innovative community-based interventions have been developed and implemented in different country settings. Such interventions have been the subject of systematic and non-systematic reviews. Lopez et al identified and reviewed three full-text articles published in peer-reviewed journals between 2017 and 2023 while Benedict et al reviewed 21 studies carried out between 2010 and 2021.^22,23 Our review complements these and provides additional information and insights, especially in the era of vast and ever-evolving opportunities provided by advanced internet technology, including artificial intelligence. Specifically, we aim to improve outcomes for prostate cancer for black men in the UK through promoting early detection of prostate cancer. Unlike the previous reviews, this review prioritises the content and context of the interventions, including design, recruitment strategies, community participation, the role of faith organisations, technology, and outcomes. The findings would help to develop and implement appropriate, suitable and innovative prostate cancer screening interventions at the community level for underserved and hard-to-reach men in the UK.

LITERATURE REVIEW

This review is narrative and employs a non-systematic purposive literature review methodology to identify and characterise community-based interventions for improving prostate cancer screening. Compared to systematic reviews, the strength of this methodology lies in its flexibility, which extends beyond the rigid framework of systematic reviews, offering the opportunity to explore far-reaching questions and pursue novel insights. On the contrary, while systematic reviews involve rigorous methods to identify and select articles, there is the risk of excluding potentially insightful studies which do not fit into the pre-defined criteria.²⁴

Using the search term “community-based interventions for prostate cancer screening” and related terms, three databases (PubMed NLM, CIHAHL, and PsycINFO) were purposively selected and searched for relevant literature published between January 2015 to December 2024. Studies were included if they were published between January 1, 2015, and December 31, 2024, and contained a well-defined community-based intervention to improve screening for prostate cancer. The included studies were also limited to those with a focus on adults and studies that had abstracts, full-texts, and references available. Review studies, systematic or not, and study protocols were excluded, as well as studies that were not published in English/focused mainly on prostate cancer.

OBSERVATIONS

Fifteen studies met the search criteria and were included in this review. Figure 1 is a flowchart illustrating the search process used to identify the included studies, while Table 1 lists the included studies.

As shown in Table 2, most of the interventions were conducted in the USA, with one each in the United Kingdom and Iran; most were within the context of non-experimental studies. The race of study participants, study design and intervention content are also as shown in Table 2.

COMMUNITY PARTICIPATION

In nine of 15 studies, focus group discussions helped to shape and develop the interventions; in four studies, the interventions took place in the context of pre-existing community-based participatory research programmes, with the community contributing to developing the intervention. In one of the studies, a steering group was set up to guide the development and implementation of the intervention.

Focus groups were used by Ba et al to help understand black men’s perspective of prostate cancer screening, perception of health messaging and how comfortable they were with technology, and ultimately contributed to the content and delivery of the intervention sessions.²⁵

Prior to intervention, Allen and her team conducted focus groups with African American men from community settings like churches and barbershops. The groups reviewed decision aids developed in previous studies, assessed communication preferences and responses to educational messages. The findings were used to develop and finalise the decision aids utilised for the intervention they delivered.²⁶

In Wray et al the intervention involved an academic-community partnership. Faculty, staff and students at an accredited public health school collaborated with a preexisting community organisation, the empowerment network [TEN], which was founded and led by prostate cancer survivors and served African Americans in the community. Within the collaboration, educational material was developed to improve knowledge of prostate cancer and promote prostate cancer screening. The intervention was implemented within this collaboration.²⁷ Frencher et al enlisted the support of barbershops for their intervention, using such shops as recruitment and intervention centres.²⁸

THE ROLE OF FAITH-BASED GROUPS

In several of the interventions, faith-based groups, especially the church, played significant roles in facilitating participation, including the recruitment of participants, the training of session facilitators/navigators, or serving as sites for the intervention.^26,27,29-34 Focus groups with community clergy and lay leaders helped to provide input on the clarity, legibility and cultural appropriateness of the intervention materials, while the church helped with participant recruitment and served as the venue for the sessions in the educational intervention implemented by Sandiford and D'Erico.³²

LEVERAGING TECHNOLOGY TO IMPROVE PROSTATE CANCER SCREENING AT THE COMMUNITY LEVEL

Ba et al utilised TriNetX to identify eligible participants for their intervention. TriNetX is a network of electronic medical records and clinical data archives, from which electronic medical records can be accessed.²⁵ Study Finder, a platform that is designed to match study volunteers to research opportunities, was also utilised for recruiting participants. Furthermore, for this intervention, data capture was web-based using the research electronic data capture (REDCap) application; study participants received a link which granted them access to complete the study-related demographic survey and questionnaire. The educational intervention was virtually carried out using the Avaya 20250 IP Softphone.²⁵

In another computer-based intervention, a computer-based decision aid was developed and used as an educational intervention. Named iDecide, it contains evidence-based information regarding prostate cancer anatomy, risk factors, symptoms and screening recommendations. There is added information on the effectiveness and controversies associated with prostate cancer screening, including the role of shared decision making. Study participants were invited to utilise the decision aid and subsequently followed up to the review their behaviours with regard to the prostate cancer screening.³⁵

Allen et al developed and implemented a web-based interactive decision aid, prostate cancer screening preparation [PCSPrep] for African American men. It contains a 5-minute video talk show hosted by a couple of actors who posed as African American doctors; a “learn more” section which gives more in-depth information about prostate cancer risks; a “decide now” section which highlights decision-making steps, and the Ottawa decision support framework [ODSF]. In the fourth and final step, “next steps”, participants receive information about how to communicate their preferences and concerns regarding prostate screening to a provider.²⁶

HEALTH EDUCATION WITH OR WITHOUT DECISION AID TOOLS

Some of the interventions were prepared and delivered in the form of decision aids, designed to support participants to make informed prostate cancer screening decisions by providing specific details about the disease, personalised risk assessment, procedure for the tests, possible test outcomes and treatment options.^26,29,35 The iDecide and PCSPrep, are notable examples.^26,35 However, in the majority of the reviewed literature, general health education was utilised, to provide general knowledge about prostate cancer screening.^{27,33,34,36-38} In a couple of studies, decision aid tools were embedded in the educational materials used.^30,32

PROSTATE CANCER SCREENING DURING COMMUNITY-BASED INTERVENTIONS

In addition to educational content and or decision aids, some of the reviewed interventions also included PSA testing with or without DRE on site or on referral, as shown in Table 2. McAllister and co-authors described their intervention, which involves a ‘drop-in’ clinic where participants had discussions with a clinical nurse specialist on risk factors for prostate cancer and were subsequently offered PSA/DRE. The intervention received support from the local community with advertising and branding, which involved working with a cycling group and getting airtime on radio programmes.³⁹ Prostate screening by PSA testing and or DRE was also available on site or by referral, or scheduling in four other interventions.^27,30,31,33

OUTCOME OF INTERVENTIONS

Overall, the authors reported positive outcomes of their interventions. Improved or enhanced knowledge was globally reported in all the reviewed interventions. There has been improved understanding of the benefits and risks of prostate cancer screening.²⁵

When it comes to decision-making, decisional conflict [uncertainty when choosing between two decisions associated with risks] was lowered after intervention, as well as reduced anxiety about screening with increased self-efficacy-the ability to make an informed decision about prostate cancer screening.^26,27,29,30

There were reports of a behaviour change as well. Post intervention, participants scheduled informational sessions with study urologists, most went on to be screened, or decided to be screened, and PSA/DRE were performed in the majority of men.^25,31,35,36 Mozalem et al reported increased PSA testing in the intervention group 3 months after intervention; the vast majority of participants preferred to be screened.^26,38 In the MacAllister model of intervention, fourteen participants were detected to have PSA results that were high for age, of which nine were later confirmed to have prostate cancer.³⁹

DISCUSSION

Our review findings suggests that community-level interventions to promote and enhance prostate cancer screening remain relevant in today’s world, more so in contemporary British society. Ethnic population projections have shown that the British society continues to diversify with an increasing population of black and minority ethnic groups.⁴⁰ This amplifies existing health disparities generally and specifically for prostate cancer and its early detection.

Only one of the included studies was undertaken in the UK, while the majority [13/15] were US -based studies, a finding corroborated in previous reviews.^22,23,39 While the interventions described in North American literature are relevant and could be replicable in other country settings like the UK, important contextual differences exist that cannot be overlooked. For example, healthcare-seeking behaviour in the US could be different from the United Kingdom due to disparate health funding systems.²⁴ Notably, faith-based organisations in North America do have long and well-documented experience in health promotion among blacks and underserved communities.⁴¹ Hence, it remains important to innovate context-specific, homegrown interventions that may yield more positive outcomes in terms of helping black people [and other underserved ethnic minority groups] in their decision-making process for prostate cancer screening. This is especially significant for black men who bear the disease burden but hardly show up for screening interventions.^20,42

In the absence of national prostate screening programmes, men have to make informed decisions to be screened for prostate cancer. Barriers to such decision-making among black include lack of knowledge, perceived benefits and risks of testing.²⁰ To overcome these barriers, community-level work needs to be done with black men to help them deal with decisional conflicts, overcome their anxiety and improve self-efficacy. There have been past and present efforts like the PROCAN-B, but more needs to be done.⁴³ The only UK-based intervention included in this review was primarily designed to provide ready and available screening for participants carrying out ‘a discussion’ with the clinical nurse specialist who ran the centre. However, it lacks the essentials of a robust assessment and documentation of decision-making, whether informed or shared.³⁹ In another intervention carried out in South-East England, not included in our review as it did not meet our inclusion criteria, 312 study participants, including men and family members, received ‘awareness’ about prostate cancer screening, and 12 black men were followed up. This intervention also failed to delve into decisional conflicts associated with prostate screening, hence limiting important generalisable lessons.⁴⁴

Most of the reviewed studies utilised community-based participatory research approaches to facilitate their interventions. They employed Focus Groups to shape and fine-tune interventions, working effectively with community-based organisations and faith-based groups to good effect.^26,27,32,34 This is particularly relevant when it comes to black men in the UK, as most live in underserved areas, which could be hard to reach and lack access to clear information about risks and benefits, as well as treatment options that could make a difference to decision-making.^45,46 While the findings of the review help us to understand experience with such community-level efforts, especially in the US, it also gives insight into opportunities in the UK. For black men in the UK, a bottom-up approach would be ideal, working with men in their bubbles, understanding their perspectives, fears, motivations and facilitators of their decision-making for availing themselves to be tested.

One interesting finding in the review is the role of faith-based organisations [FBO] in the intervention efforts. In particular, the church was active in mobilising members, training trainers, and providing platforms for interventions.^32,33 The capacity of FBOs to manage health promotion activities is well established.^47,48 In the UK, congregants of the various faiths are mostly constituted by immigrants, especially blacks. This presents a significant opportunity to partner with and collaborate with such organisations to reach men. The role of social media has been suggested by some authors, contemporary as this may sound, it should only be supplementary, as the effectiveness of this is yet to be established.²³

Also of interest is the increasing role of technology, serving as a platform for participant recruitment, implementing interventions or following up participants. The iDecide and PCSPrep probably give us a glimpse of what the future of decision aids might look like, especially in the era of artificial intelligence [AI].^26,35 While such could be developed and deployed for use by black men in the UK, the role of the end users in conceptualising and developing them cannot be overemphasised.

When it comes to outcomes of the various interventions reviewed, they were encouraging, whether within experimental or non-experimental designs. For example, in RCTs, Carlson et al reported significant improvement in prostate cancer screening and lowered decisional conflicts. Holt et al also demonstrated significant increased knowledge about prostate cancer and decision-making stage.^30,34 Based on these, it can be deduced that carefully planned community-level interventions can potentially improve screening rates among black men and contribute to reducing morbidity and mortality from the disease.

A weakness of this review is its non-systematic nature and the subjectivity associated with study selection. However, a non-systematic review of this nature still finds its place in literature reviews, especially when the agenda is to address multiple research questions.⁴⁹ The findings unravel the extent of the unfinished work concerning prostate cancer screening among black men and could help to chart the way forward to the design of rewarding community-based interventions.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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