Barriers to Prostate Cancer Screening

Prostate Cancer: A Man’s Dilemma

• Afzal Hussain

Prostate cancer is the most common cancer in Canadian men. In 2013, the Canadian Cancer Society estimated that 23,600 men will be diagnosed with cancer; a further 3,900 will die from the disease in Canada (Canadian Cancer Society, 2014). The prostate is part of the male reproductive system; it surrounds the urethra (tube that carries urine and semen through the penis). Prostate Cancer Canada (2014) states, “Prostate cancer is a disease where some prostate cells have lost normal control of growth and division. They no longer function as healthy cells (Prostate Cancer Canada).

Potential barriers to screening includes socioeconomic status, lack of health care, culture, and false experiences of medical treatments. These barriers and other misunderstandings of the causes of prostate cancer impede the process for early screening further delaying early diagnosis and treatment. This paper explores socioeconomic status, race, fear, and sexual function as perceived barriers to prostate screening; it also identifies strategies that promote successful screening and eventual recovery. Canadian Cancer Society in their statistical report of 2013 reports, “Prostate cancer is rarely found in men younger than 50, most of the deaths associated with prostate cancer are found in men older than 75 years. Canadian males are more likely to develop prostate cancer, with 1 in 7 males expected to be diagnosed with prostate cancer in their lifetime. On average, 65 Canadian men will be diagnosed with prostate cancer every day. On average, 11 Canadian men will die of prostate cancer every day. (CCS)

Socioeconomic Status

Better survival is a testimony to the advances in research and treatment, but improving survival and reducing prostate cancer diagnosis is more resourceful to a better quality of life. Treatments and technological advancements in diagnosis and medications have transformed survival rates in cancer tremendously. Despite the overall improvement in survivorship in prostate cancer patients, socioeconomic inequalities in survival of prostate cancer patients remains a constant challenge in healthcare. Most men diagnoses with prostate cancer are at high risk, mainly because of their low socioeconomic status, unemployment, lack of education and inability to afford health care services. The Institute of Medicine (IOM) report, Care without Coverage: Too Little, Too late states that, “People without health insurance often go without appropriate care. For example, the uninsured more often go without cancer screening tests, delaying diagnosis and leading to premature death. ” (Institute of Medicine [IOM], 2002)

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In Canada, a fragment of the population lives on social assistance and cannot afford quality health care services, these “disadvantaged people” faces many health challenges and are at high risk for health issues. Residents faced with these challenges find it harder to have prostate cancer screenings despite doing their best to facilitate socioeconomic changes in their life. Fortunately, in Canada, Non-Governmental Organizations (NGO) provide prostate screening to low income citizens who cannot afford the screening. One such organization in Calgary, Prostate Cancer Centre has been a model of excellence in this service to the community.

However, in Alberta, Quebec, and British Columbia, prostate screenings is not medically covered by provincial health plans. Therefore, men persuing screening will have to pay out of his pocket or will incur charges through his health plan. Crawford (2010) in her online news article states, “The PSA test has been used as a widespread screening tool since the mid-1990s, but has been dogged by controversy. While seven provinces pay any man to get tested, B.C., Alberta and Quebec do not, unless there are risk factors such as a family history of the disease (Crawford, 2010). This clearly shows the partial distribution in persuing health care services within Canada. Jamuir, Robinson & Shavers (2008) found that, “ Underinsurance is of particular concern for racial/ethnic minorities, who are more likely than others to report having difficulties paying medical bills despite having medical insurance coverage16 and it may contribute to the lower rates of cancer screening observed for these groups.(p. 843).

Patients having the privilege of an extended private insurance coverage feel a sense of economic security. The real question is what is the case with the ordinary person without any coverage? Someone with a minimal wage and/or without coverage may feel the pangs of hopelessness, neglect, and long-term suffering.

This disadvantage stems from differences in the receipt of treatment and access to high-quality healthcare treatment presented with low economic status. Furthermore, considering the imbalance between economic classes in regards to access to prostate screening, it is viable to suggest a level playing field where screening should be available to all men, despite their income status or health care coverage especially considering the Canadian Cancer Society reports on new instances of the disease annually. Also reducing the cost/payments for screening will be a significant boost for uninsured patients, because patients can express greater satisfaction of having the screening done despite having a low-income status. Another important strategy is to make sure that an all-accessible approach towards this screening, where men can afford the screening despite not having enough income or insurance coverage, in doing so having the satisfaction of economic security.

Race

In their research titled “Racial/Ethnic Disparities in Survival among Men Diagnosed with Prostate Cancer White, Coker, Du, Eggleston & Williams (2011) found that, “Racial/ethnic disparities in prostate cancer survival have also been documented in the literature, and can be attributed to differences in socioeconomic status (p. 1080). In Canada, race is also a key risk factor for prostate cancer; it is prevalent in people of (Black African or Black Caribbean descent) who are at increased risk compared to white Canadians due to their genetic disposition, family history of prostate cancer, or age. Brooks (2013) states,” Black men are 60% more likely than white men to be diagnosed with prostate cancer during their lifetime, and is more than twice as likely to die from the disease. ” (Brooks, 2013). Furthermore, besides ethnicity and age, numerous other factors contribute to prostate cancer.

Canadian blacks are also higher risk due to the prevalence of comorbidities and heavy smoking or alcohol intake. These risk factors are common in Caribbean culture where people tend to take their health and lifestyle habits less seriously compared to North American culture. Despite the largest improvement in medication and technology Blacks remains a high risk of prostate cancer and is twice, more likely to be affected and die from the disease compared to whites. Having support groups plays a significant role in times of stress, especially when faced with a disease like prostate cancer. Establishing family networks and religious beliefs will offer a strong support base, especially when the patient is making health-related decisions that will establish his future life. Oster, Hedestig, Johansson, Klingstedt & Lindh (2012) states, “ Conversational group support can help men to realize that it is normal to experience mixed emotions including sadness, anger, or despair over losses caused by the disease, and such interventions have shown improvements in anxiety, depression, men’s abilities to cope with the situation, and their quality of life.” (p.332)

Fear. Many patients are afraid of prostate cancer screenings. With the increased amount of prostate cancer, patients diagnosed each year; countless men are still avoiding screening tests because it makes them uncomfortable with the results. This emotional and defensive action stems from the lack of independent knowledge patients have about the screening and the cancer itself. Presenting fear towards prostate screening changes the overall attitude towards treatment. This fear could provide a negative response to treatment. By expressing elevated levels of fear, a patient will be denied access to treatment and further delayed interventions, which may evolve into an advanced stage of the cancer.

Furthermore, a patient presenting minimal levels of fear will be motivated to peruse screening, leading to an eventual diagnosis. Male patients are also hesitant to take screenings for prostate cancer due to many misconceptions, many believe the cause of their disease is due to sexual promiscuity or sexual orientation, sexually transmitted diseases (STD) and unhealthy lifestyle attributed to alcohol and smoking. Consedine, Adjei, Ramirez & McKiernan (2008) found in their research, “ The high incidence and mortality rates for prostate cancer among African American and other men of African descent may be expected to be reflected in elevated anxieties surrounding prostate cancer and the associated screening in these men. African Americans report greater fear of prostate cancer and screening, particularly for the Digital Rectal Examination (DRE). When applying these findings to advance nurse practitioners’ practices, it can be said that men in the high-risk groups must first be educated on the risks of prostate cancer (p. 1631).

In preparing a patient for prostate screening, it is wise for the nurse to engage in careful planning and use best nursing practice while encouraging the patient to participate in screening thus eradicating some of his fear. Education on the risk of prostate cancer should be distributed among high-risk group. Patients in this group need to understand the implications of non-screening. One good nursing approach is the application of “change talk”, an important concept of motivational interviewing; the nurse will carefully implement strong concepts on why the patient should be screened, carefully supported with strong evidence of the clinical benefits. Apodaca, Magill, Longabaugh, Jackson& Monti (2013) state, “more change talk predicted better outcomes, whereas more sustain talk predicted poorer outcomes” (P.35). Another important strategy to improve accordance to screening is through programs/ advertisements, which opens awareness of prostate cancer about the general male public over 50 years of age. Proper media coverage will enhance the importance of the disease, the causative agents, and the importance of screening for a wider public.

It will also help patients to self-reflect on their lifestyle and make progression towards health interventions. Himelboim, and Han (2014), in their research on Community Structure and Information Sources in Breast and Prostate Cancer Social Networks found that, “ the past decade has witnessed a phenomenal growth in the use of the Internet—especially social media—in health care and management. From the user side, this means more opportunities to connect with others, obtain needed health information from available sources, and potentially benefit from that information (p. 211)

Sexual Function. Prostate cancer will have an effect on the sex life of many prostate cancer patients. Most men affected by prostate cancer will develop erectile dysfunction after diagnosis. Men will also lose interest in sex and will have difficulty maintaining an erectile penis or performing penetrative sex. Beck, Robinson, & Carlson (2013) found in their research that, “ Sexual dysfunction is the most significant long lasting effect of prostate cancer (PrCa) treatment, despite the many medical treatments for erectile dysfunction, many couples report that they are dissatisfied with their sexual relationship and eventually cease sexual relations altogether. (p. 1637). Because one of the risk factors of prostate cancer is age, it is important to point out that many patients because of impotence may have already contacted symptoms of erectile dysfunction prior to developing prostate cancer.

Treatment also plays an important role in the outcome of sexual functioning in patients, if patients are tolerable and react to the proper treatment regimen, the likelihood of sexual dysfunction will be minimized, and sexual urge will remain normal and intact. The stage of cancer also identifies the outcome of sexual functioning and the ability to deal with sensual life post surgery. Early screening can help a patient to identify possible malignant cancerous cells; it also can be helpful in managing impotency. Sex after diagnosis can be dreadful for various partners, especially when sexual desires may be minimal or much diminished. It may also dampen any chances for future families wanting to have kids in the distant future. A patient with impotence may consider sexual counselling by a sexologist to diminish any fears of sex. Chung & Brock (2013) in their research states, “Sexual function remains an important issue in many men, who often continue to be interested in sex after prostate cancer treatment. It has been shown that the impact of sexual dysfunction is greater than the impact of urinary incontinence and over 70% of men felt their quality of life was adversely affected following cancer diagnosis and treatment ” (p. 103). Participation in prostate cancer support groups helps patients to better be educated on sexual life after prostate cancer, just as support groups are helpful to eradicate the fear on early screenings, these groups will prepare patients on the trials of sexual intimacy after recovery, also providing coping mechanism for sexual dysfunction. Another strategy to cast away fears of sexual dysfunction is to promote sexual preferences amongst partners, which may bring a sense of satisfaction to both partners.

Conclusion

Prostate cancer patients continue to suffer from many dilemmas. Patients are continually faced with barriers to cancer care, which impede screening and treatment. Socioeconomic status, race, fear, and sexual function are all contributory factors in a patient dilemma when intrigued with tribulation of prostate cancer. Despite all the technological advancements, prostate cancer remains high in Black African or Black Caribbean descent compared to white males in Canada. Decision-making process when considering prostate cancer screening is influenced greatly by socioeconomic status, race, fear, and sexual dysfunction. These beliefs often result in a lower rate of compliance of prostate screenings. By establishing strategies to promote care for patients, the said barriers can be eradicated making treatment and recovery possible. Support groups, non-governmental organizations, media, and better insurance coverage for low-income families can all be used to effectively promote successful prostate screenings thus eradicating social inequality, racial and sexual barriers and increasing compliance through educating prostate patients’ ways to address these barriers. Effective strategies will help to decrease morbidity and mortality of prostate cancer in Canada.

References

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