Ethnic variation in the use of primary care among men with symptoms suggestive of prostate cancer: a multimethods

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1 Ethnic variation in the use of primary care among men with symptoms suggestive of prostate cancer: a multimethods study Tanimola Martins, William Hamilton, Fiona Walter. And I was also lucky actually, because my practice for many years, a very good practice, was being an all-female practice. And I think I'm perhaps of an age and the type which finds it quite difficult to speak about these kind of problems with a woman doctor. So I was particularly keen to see a male doctor. White, 72 years; Degree She said by this diabetic something you must be noticing that your erectile something... and I said, yes, THANK YOU!!...How do I go about it? Because she was a woman I wouldn t know whether if I mention it to her, she would think otherwise. She will misinterpret me. Because the thing came from her, I was able to open up. Black, 67 years; Degree.I don't think I would... not that I wouldn't want to take it [a prostate biopsy]... because he told me that he... he... he's not... he's not, err, not that he created a fear in me, but it's such that he doesn't want us to get to that. So, all I'm going to tell them is the... the improvement. Except if I m not sincere to myself, at least Black, 60 years; Degree 1

2 Background Ethnic minorities have a higher incidence, and poorer outcomes, for some cancers when compared with the white majority Over 30% higher disease-specific mortality Ethnic differences in prostate cancer mortality may be related to a number of factors including: Routine Prostate Specific Antigen (PSA) screening - if screening works Tumour characteristics - fast growing vs. slow growing tumour Diagnostic delay Background Diagnostic delay: Patient and Primary care delay Black men were more likely than White men to be referred by the emergency department (odds ratio 1.66, 95% CI: ) or another hospital team (odds ratio 1.67, 95% CI: ). 2

3 Aim and methodology Aim: To determine whether there are ethnic differences in the use of primary care in men with urinary symptoms. Specifically, to examine ethnic differences in: Patient interval - period between symptoms onset and medical help-seeking Urinary symptoms - hesitancy, frequency, nocturia, urgency, urgency + dribbling, incontinence, haematuria, erectile dysfunction, unusual weight loss and fatigue. Number of consultations before PSA and DRE offer Acceptance and performance of PSA and DRE Methods : Survey men from London (and surrounding areas) with recent episode of lower urinary tract symptoms. Face-to-face interviews 30 participants Assessment of primary care records - selected patients Participants characteristics by ethnic groups (April 2016 Feb 2017) All participants (N= 126) White N=93 Black N=21 Asian N=11 Age Median (range) 68 (43-95) 69.5 (43-95) 60.5 (49-85) 63 (43-86) Employment status Employed Unemployed Retired Sick/disabled Other Highest education level Degree/diploma/equivalent A level/gsce/o level Other/none Live alone Yes No Smoking Status Current Ex-smoker Never Co-morbidity Preliminary results 46 (37%) 4 (3%) 70 (55%) 4 (3%) 2 (2%) 78 (62%) 23 (18%) 24 (19) 33 (27%) 91 (73%) 26 (21%) 43 (34%) 56 (45%) 30 (33%) 2 (2%) 58 (62%) 3 (3%) 0 55 (59%) 18 (19%) 20 (22%) 22 (24%) 69 (76%) 15 (16%) 37 (40%) 40 (44%) 12 (57%) 1 (5%) 7 (33%) 1 (5%) 0 15 (72%) 3 (14%) 3 (14%) 8 (38%) 13 (62%) 4 (19%) 4 (19%) 13 (62%) 4 (36%) 1 (9%) 5 (46%) 0 (0%) 1 (9%) 8 (73%) 2 (18%) 1 (9%) 2 (18%) 9 (82%) 7 (64%) 1 (9%) 3 (27%) 66 (53%) 45 (48%) 13 (65%) 7 (64%) 3

4 0 Percent Symptom by ethnic groups Preliminary results Participants (N= 126) White N=93 Black N=21 Asian N=11 Table 1 - First symptom to prompt health care attendance Hesitancy 19 (15%) 11 (12%) 3 (14%) 4 (36) Frequency 23 (18%) 17 (18) 6 (29%) 0 Urgency 8 (6%) 7 (8%) 1 (5%) 0 Urgency + Dribbling... Nocturia 20 (16%) 17 (18%) 1 (5%) 2 (18%) Incontinence 4 (3%) Haematuria 16 (13%) 14 (15%) 0 2 (18%) Erectile dysfunction 12 (10%) 9 (10%) 3 (14%) 0 Other * 22 (18%) 14 (15%) 5 (24%) 3 (27%) Table 2 - Subsequent symptoms Hesitancy 46 (37%) 33 (36%) 6 (29%) 6 (55%) Frequency 67 (53%) 51 (55%) 8 (38%) 7 (64%) Urgency 57 (45%) 42 (45%) 9 (43%) 5 (46%) Urgency + Dribble 52 (41%) 37 (40%) 10 (48%) 4 (36%) Nocturia 83 (66%) 64 (69%) 11 (52%) 7 (64%) Incontinence 62 (49%) 45 (48%) 9 (43%) 8 (73%) Haematuria 29 (23%) 22 (24%) 4 (19%) 3 (27%) Erectile dysfunction 77 (61%) 55 (59%) 14 (67%) 7 (63%) * Tiredness, spasm, haematospermia, back pain, weak flow, blood from back passage, paruresis etc. Isolated symptom: 21 (16%) Two symptoms: 22 (18%) Three symptoms: 17 (14%) Four or more 66 (52%) Preliminary results Patient interval - first symptom to prompt healthcare attendance Patient interval for first symptom Number of days 4

5 Preliminary results Patients interval by ethnicity - first symptom to prompt healthcare attendance Patient interval for first symptom/s by ethnicity Number of days Ethnicity = White Ethnicity = Black Ethnicity = Asian Preliminary results Patients interval by ethnicity Subsequent symptoms Symptom (N= 126) All White Black Asian Median IQR n Median IQR n Median IQR n Median IQR n Hesitancy Frequency Urgency Urgency+dribble Nocturia Incontinence Haematuria Erectile dysfunction

6 Preliminary results Ethnic variation in patient interval - first symptom White Black Asian Unadjusted HR (95% CI) P-value Adjusted HR* (95% CI) P-value ( ) ( ) ( ) ( ) 0.03 HR hazard ratio; IQR Interquartile range; *Proportional hazards Cox model adjusted for age, smoking status and haematuria No difference in the offer and acceptance of DRE and PSA by ethnic groups, despite the clues in qualitative work.and that's when we had the female doctor, who just said, oh, it could be just muscular and see how you get on, and then if not come back again. Oh, can I do a finger test? That's when I refused her. That was the female doctor. Black male, 60 years; Diploma... I remember he said, oh, could do a prostate test. Yeah. And I was a bit embarrassed because he said, you know, they go through the rectum, you know, trying with the finger and... I said, no, it's okay Black male, 60 years; Diploma 6

7 Summary Black men have poorer outcomes of prostate cancer compared to men of other ethnic groups Inequalities in prostate cancer outcomes may be related various factors in the time before or after primary care presentation Initial findings point towards post-presentational factors more than pre-presentational Acknowledgements South West Peninsular Clinical Research Network South London Clinical Research Network North West London Clinical Research Network North Thames Clinical Research Network Dr Katie Mills Dr Gary Abel Policy Research Unit (PRU) - Funding 7

8 Reporting of other symptoms All participants All White Black Asian Other symptom Hesitancy 46 (37%) 39 (87%) 29 (91%) 4 (67%) 5 (83%) Frequency 67 (53%) 52 (79%) 40 (80%) 7 (88%) 4 (57%) Urgency 57 (45%) 37 (67%) 29 (71%) 4 (50%) 3 (60%) Urgency + Dribbling 52 (41%) 30 (59%) 22 (60%) 5 (56%) 2 (50%) Nocturia 83 (66%) 61 (76%) 52 (83%) 5 (50%) 3 (50%) Incontinence 62 (49%) 34(71%) 27 (75%) 3 (43%) 4 (80%) Haematuria 29 (23%) 23 (85%) 16 (80%) 4 (100%) 3 (100%) Erectile dysfunction 77 (61%) 47 (64%) 35 (66%) 8 (62%) 3 (43%) Hesitancy Frequency Urgency Urgency + Dribbling Nocturia Incontinence Haematuria Erectile dysfunction All White Black Asian 8