While North Carolina has some of the nation’s worst rates of prostate cancer among black men, it also has some of the country’s best intellectual resources to fight the disease.
UNC-Chapel Hill has the nation’s second-ranked school of public health, and researchers there and at the UNC Lineberger Comprehensive Cancer Center have been studying the racial disparity in prostate cancer rates for more than 10 years. The cancer centers at Duke, Wake Forest University and Carolinas Medical Center in Charlotte are some of the nation’s best, and among them have several hundred cancer doctors and researchers.
These centers are working with huge collections of data that can reveal patterns in where, who and how cancer strikes. And they have started working with smaller hospitals to raise their standard of cancer care, which helps reduce mortality rates.
Vidant Health is a nonprofit system that serves 29 counties in Eastern North Carolina, running facilities that include a major hospital in Greenville and smaller ones in places such as Windsor. Its service area includes some of the poorest counties in the state, and poorer often means sicker. Vidant broke ground in March on its own cancer center in Greenville.
The state also has a fresh and elaborate blueprint aimed at preventing and curbing key cancers called the Comprehensive Cancer Control Plan, and prostate cancer is among the diseases that the plan targets.
But while the facilities and research may be strong, something else is missing: enough money to mount a major fight against the disease in black men.
While the N.C. Comprehensive Cancer Control Plan targets prostate cancer, it doesn’t have significant funding to fight it. And while major research is underway on why the cancer attacks black men differently, there’s no research to show whether screening is effective in reducing their mortality from the disease.
Dr. Paul Godley, an associate dean at the UNC School of Medicine and one of the nation’s foremost experts on prostate cancer disparities, says that doctors need a serious study to figure out the effects of prostate cancer screening on black men, not just whites, like major previous studies.
How could North Carolina tackle the spread of prostate cancer in black men? Experts suggest five possible approaches:
1. More screening
One way to specifically target prostate cancer among uninsured or underinsured men, who are more likely to be African-American, is to create a program similar to one that the state administers for low-income women, called the Breast and Cervical Cancer Control Program.
It pays for breast and cervical cancer screening, and when those cancers are diagnosed, it can enroll the women in Medicaid for the duration of their treatment.
“Being able to have programs like that that can address cancer screening in general, and prostate cancer in particular, could make a huge difference in addressing the gap by making it accessible and helping connect directly to Medicaid and other insurance options,” said Nadine Barrett, who runs Duke’s Office of Health Equity. It targets cancer disparities in the Durham area and sponsors outreach efforts in black communities and an annual screening event for prostate cancer and other men’s health issues.
“It would be great for us to think of expanding it from not only breast (cancer) to also other types of cancer like colon and prostate. This would help those falling through the cracks, those who miss out because of lack of expansion, but also those who qualify for ACA but can’t afford even that insurance,” she said.
State officials said there’s nothing that prevents a program from paying for prostate screening, but that because of the federal laws and funding behind the breast and cervical programs, a similar prostate program would have to be separate and totally paid for by the state.
Nearly 14,000 women were screened for breast cancer, and 5,000 for cervical cancer under the program last year. That took $2.4 million from the Centers for Disease Control and Prevention and $1.5 million from the state. Of those, 636 received the Medicaid-paid treatment.
There are models for starting similar programs for prostate cancer. New York, for example, has such a program, though it doesn’t pay for screening because of the controversial guidelines announced by a federal advisory panel in 2011 that recommended against the blood test used in the screenings, saying it led to more harm than good. It started a breast and cervical cancer program like North Carolina’s in 2002, then added prostate and colorectal cancer to that five years later.
In 2014, 67 men with prostate cancer were treated at a total cost of $1.15 million, according to a statement from the New York health department.
New Jersey, meanwhile, has a program that pays for education, outreach, case management and screenings not just for breast, cervical and colon cancer, but prostate cancer as well.
2. Medicaid for more people
The idea of expanding Medicaid to more low-income people in North Carolina could scarcely be more divisive.
But health care experts believe people will see a doctor more regularly if they have health insurance. They say expanding Medicaid could help reduce a host of disparities, save substantial numbers of lives and reduce treatment costs by preventing disease and catching it earlier.
Medicaid expansion under the Affordable Care Act – Obamacare – has been blocked in North Carolina, as it has in many states led by conservative lawmakers.
In the original plan for the ACA, states would have been required to expand Medicaid to cover working adults making up to 138 percent of the federal poverty level. People earning more than that are eligible for federal subsidies to help pay for their health insurance.
The U.S. Supreme Court, though, ruled that states couldn’t be forced to expand Medicaid. More than two dozen states decided to anyway. But here and in other states that chose not to expand the coverage, people who make between 100 and 138 percent of poverty level fall in what’s often called as the “Medicaid gap” – not qualifying for subsidies under the ACA because they were initially expected to be on Medicaid, but earning too much to get Medicaid under current rules.
In North Carolina, an estimated 300,000 to 500,000 people would gain health insurance if Medicaid were expanded. That includes tens of thousands of men who suddenly would be able to afford health care.
That should have already happened, said Dr. Peter Watson, an oncologist in Kinston who frequently treats black prostate cancer patients.
“That’s the working poor, and so it would help a variety of illnesses, and I also have to say that I think it’s a fairness issue, and I’m a Republican,” he said. “I’m shocked we didn’t do that, because to me those are the people who are never going to be able to afford any kind of health insurance because they have to eat and pay their electricity bill.”
But the chances of expansion are slim at best.
Gov. Pat McCrory has suggested it might be an option, but Republican leaders in the legislature, which would have to approve an expansion, say they’re against the idea, with some saying any talk of expansion is premature until after a decision in a pending U.S. Supreme Court case that could have a major impact on Obamacare.
Senate President Phil Berger said earlier this year he saw no good reason to expand, and House Speaker Tim Moore said he fears that if the state took on more Medicaid patients the federal government could back out of its commitment to pay all of the cost at first and then nearly all in later years.
3. A personal guide
A state cancer advisory group is pondering another program that could help: patient “navigators,” or case managers, to help guide low-income patients through the forest of appointments and funding sources they face after diagnosis.
Steven Patierno, deputy director of the Duke Cancer Institute, who does research on the genetics of the disease in black men and on cancer disparities, led an experimental program to establish a network of such managers for low-income breast cancer patients in Washington, D.C. That city is one of eight places that were part of a national, five-year, $25 million experiment by the National Cancer Institute that began in 2005.
The program has not only improved health care but saved the participating hospitals so much money by doing things such as reducing the rates of missed appointments that nearly all of them kept the case managers even after they had to begin paying the salaries themselves, Patierno said.
On a small scale, case managers are being used in Durham as part of Duke’s Office of Health Equity and Disparities. Small numbers of them also have recently been put in place around the state for other types of health care needs.
McCrory appointed Patierno to the state’s advisory committee on cancer coordination and control last year. That committee is charged with recommending how to implement the state’s cancer blueprint.
Members of the committee, Patierno said, are keenly interested in reaching the state’s underserved communities and are considering how a statewide system of case managers for cancer patients could be put into place and funded.
They envision these case managers as also being health educators, he said. It’s too early to say exactly how such a network would function, but one option is to put them in the county health departments.
4. More targeted research
Another critical part of the fight against prostate cancer is figuring out how it may work differently in black men and why it’s more likely to be aggressive. Researchers at UNC and Duke, including Patierno, have been working on that and other aspects of the disparity for years.
UNC researchers including Godley, working in a massive joint project with scientists in Louisiana, made several crucial discoveries about the health care and biological parts of the mysterious disparity and built an important repository of data on a group of black patients in North Carolina and Louisiana.
Patierno’s lab is among those at both universities that are starting to uncover more about the biology of the disease in black men.
“We have some really, really exciting results coming out,” he said. “We have identified some of those molecular pathways that are driving the aggressiveness of prostate cancer in African-Americans.”
Pushing more money at prostate cancer, at least if it were spent wisely, would surely help close the gap. But expensive fixes aimed at prostate cancer alone may not be the best use of always-scarce public health funding.
It’s a killer, but one reason the disparity doesn’t get more attention is that it’s hardly the biggest. Diabetes, lung cancer and heart disease, for example, are more deadly for African-Americans. And fixes for prostate cancer are less precise, in part because accurate screening is difficult.
5: More effective outreach
Even a little more funding for local health departments for outreach efforts such as health education could help with colorectal screening, prostate education and more.
The health departments, which are widely regarded by public health experts as underfunded and overstretched, have traditionally concentrated mostly on the health of women and children.
Lisa Harrison, health director for Granville and Vance counties and president this year of the N.C. Public Health Association, said there are proven, if not perfect, methods of reaching African-American men. Often, however, these interventions, such as training African-American barbers and ministers in black churches to act as lay health advisers, spring up and then die off when a grant vanishes or a researcher moves on.
“So little money goes into the health education part of it,” she said. “We need to make a good connection, and it takes a minimum standard, and we should as a state determine what is a minimum standard that would do this in every county.”
Few people know more about public health in Eastern North Carolina than Jerry Parks, health director of Albemarle Regional Health Services, a district health department serving seven counties in the northeast corner of the state, including Bertie.
The county health departments across the state always have tight funding. They haven’t had the money to do much outreach, though for prostate cancer there are cost-effective models, such as systematic approaches to working with black churches and barber shops.
But public health agencies of all kinds struggle for enough resources to even do the basic local-level work to fight threats such as diabetes, let alone prostate cancer, he said.
“We kind of cobble together little grants here and there to do what we can,” Parks said. “And prostate cancer, I absolutely guarantee you if you put a little money in it, we could have an effect. And it wouldn’t take much money.”
Sunday: ‘It’s an epidemic’
Monday: Obstacles to care
Today: What can be done?
About the series
This series of stories was produced with support from the Dennis A. Hunt Fund for Health Journalism, a program of the USC Annenberg School of Journalism’s California Endowment Health Journalism Fellowships.
About the reporter
Jay Price, who joined The News & Observer in 1996, recently covered medical issues. He also reported extensively on the military, having been assigned to Iraq and Afghanistan four times each. Price is now with North Carolina Public Radio WUNC. He can be reached at 919-812-8551.