Comparing Prostate Cancer Treatment Decision Making in a Resource-rich and a Resource-poor Environment: A Tale of two Hospitals

Objective: Black men with prostate cancer are diagnosed later, have poorer treatment outcomes, and higher mortality from the disease than all other racial groups. While existing literature has explored differences in the treatment decision making process between black and white men with localized prostate cancer, little is known about how environmental factors may affect the treatment decision process for men with clinically significant disease for whom treatment improves survival. The aim of this study was to compare and contrast the treatment decision process, from both patients' and treating physicians' perspectives, in a resource-rich and a resource-poor hospital.

Methods: Qualitative interviews and focus groups were conducted with patients and their treating physicians from two urban hospitals. Patients were identified through retrospective review of pathology and tumor registries; their charts abstracted to ascertain treatments. Treating physicians were identified and contacted to discuss the treatment decision process. Physicians were also asked to discuss patients who did not receive definitive treatment. Transcripts were analyzed deductively using themes from the Health Belief Model, and inductively to explore emergent themes.

Results: Overall, patients and physicians discussed similar factors that influenced the decision making process at both hospitals. However, a few important differences were found: providers at the resource-poor hospital discussed cost as a barrier, highlighted having limited treatment options for their patients, and noted issues with follow-up as external factors affecting treatment decisions. Patients at the resource-poor hospital expressed greater fear and anxiety, and less self-efficacy and motivation in comparison to patients treated at the hospital with greater resources. Importantly, patients at both hospitals described significant trust in their physician, yet only at the resource-poor hospital did patients suggest that they lacked knowledge regarding treatment side-effects, despite physicians at both hospitals describing their attempt to disclose all side-effects.

Conclusion: These findings identify both medical-system factors, and practice-level factors that can help guide the development of interventions to reduce prostate cancer treatment disparities.