Black Men and Prostate Cancer with Nicholas Shungu, M.D.

Black men are twice as likely to die from prostate cancer compared to men of any other race. In this episode of Advance with MUSC Health, Nicholas Shungu, M.D., a family medicine physician at MUSC Health, talks about some of the reasons for this disparity and what can be done to better educate patients and their families about the importance of prostate cancer screenings.

"Even though Black men are more than two times more likely to die from prostate cancer, they are less likely in this country and in South Carolina to receive PSA prostate cancer screening. We also know, unfortunately, through some pretty large Medicare studies, that once Black men are diagnosed with prostate cancer, they have been less likely to receive standard of care treatments that can potentially be lifesaving. I think access and treatment is really important."
- Nicholas Shungu, M.D.

Topics covered in this show

• Shungu first became interested in the topic of prostate cancer disparities as a resident when his own father was diagnosed with prostate cancer. It was then he started focusing on studying the literature around prostate cancer and became aware of the significant disparities, especially facing Black men and prostate cancer incidence and mortality.
• He says largest study about prostate cancer screening comes from Europe and it did not include Black men. He says the largest study to date in the United States didn't include enough Black men to make conclusions about prostate cancer screening.
• Shungu says it is important that both patients and providers have prostate cancer screening on their radar, especially if they are Black men or if they're treating Black men.
• He says it is important men know they can do a PSA blood test to check their prostate cancer risk instead of a physical exam, which is a sensitive exam and one many men avoid.
• Some other misconceptions about prostate cancer that could prevent some men from screening include the persisting idea that most prostate cancers are not deadly, that doctors check the prostate during other procedures such as a colonoscopy (the prostate is not examined during a colonoscopy).
• Shungu would like to improve information on social media about prostate cancer risk and screenings for Black men. He recently published a study that found the overall quality of information on such videos on YouTube was poor.

Read the show transcript below

Erin Spain [00:00:04] Welcome to Advance with MUSC Health, I'm your host, Erin Spain. This show's the mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Prostate cancer is the second leading cause of cancer-related death for men in the United States. However, there is one group of men affected by prostate cancer at a more aggressive rate. Black men are twice as likely to die from prostate cancer compared to men of any other race. Dr. Nicholas Shungu, a family medicine physician at MUSC Health, is here to discuss this problem and some solutions that could help more Black men get screened for prostate cancer earlier and more often. Welcome to the show.

Nicholas Shungu, M.D., MPH [00:00:51] Thank you. I'm glad to be here.

Erin Spain [00:00:52] You are a family physician. Tell me about your work and your specific interest and prostate cancer and Black men and prostate cancer.

Nicholas Shungu, M.D., MPH [00:01:01] Sure. So, I am a family medicine physician at MUSC, and although I am involved in research and teaching, I always want the majority of what I do to be based in clinical care. And my questions to be driven by clinical care. So, prostate cancer is something that clinically, unfortunately, I do see men who go through prostate cancer and screening for prostate cancer is certainly something that it is in my purview and that I am talking with men about a lot as a primary care clinician. I think how I got interested in prostate cancer, specifically when I was a medical student, my father was diagnosed with prostate cancer. So, I started paying a lot more attention to what was going on in the world of the prostate cancer and the literature around prostate cancer, and became aware of the significant disparities, especially facing Black men and prostate cancer incidence and mortality. And I can remember distinctly as a resident in 2012, when the United States Preventive Services Task Force made guidelines that recommended against routine PSA screening for prostate cancer and feeling like we were totally discounting the epidemiology and the information that we had available about Black men and how much it does impact Black men. And so that has just been an interest of mine because of my own family experience and then thinking about the ways that it would impact both members of my family and then folks who I care about. And thankfully, that has translated into kind of a melding of my clinical work and some research projects I've been excited to be part of now that I'm on faculty at MUSC.

Erin Spain [00:02:36] Well, tell me about that. What do we know? What are some of the reasons why Black men are more likely to die from prostate cancer than men of other races?

Nicholas Shungu, M.D., MPH [00:02:45] So, a really good question. I think the answers are multifactorial. I think probably the easiest thing to think about is differential access to both screening and treatment. And we know, unfortunately, even though Black men are more than two times more likely to die from prostate cancer, they are less likely in this country and in South Carolina to receive PSA prostate cancer screening. We also know, unfortunately, through some pretty large Medicare studies, that once Black men are diagnosed with prostate cancer, they have been less likely to receive standard of care treatments that can potentially be lifesaving. I think access and treatment is really important. And there's been some really empowering work done out of the VA that has shown that in a system like the VA, where men should have equal access to both screening and treatment that we see those prostate cancer mortality disparities disappear. So that makes me feel like screening and treatment probably are the largest drivers of prostate cancer differences. We do know that life influences play a role. We don't clearly understand those, but we do know that environmental factors diet exercise levels do play into prostate cancer risk. We also do know that genetics plays a small role in that. I think we have focused a lot on genetics in the past, and what current studies show is that maybe five to 10 percent of prostate cancers are identified as genetically inherited. So, there is a component of that, but I think we're learning more and more that it is probably differential life experiences, differential exposures, differential experiences to stress that are driving some of these incident's disparities.

Erin Spain [00:04:32] Why is it so important to talk about this and to get this information out about these disparities?

Nicholas Shungu, M.D., MPH [00:04:39] I think it's really important for a couple of reasons. One is that prostate cancer in general is really common. So, one in 41 men in this country will die from prostate cancer. One in 25 Black men in this country will die from prostate cancer, which is a large number when we're thinking about just the sort of patients who I see in the clinic and what could potentially kill them, one in 25 Black men. It's pretty significant proportion. What is really difficult in the world of prostate cancer is the studies that guide our understanding of screening are essentially all white men. So are the best study that we know on prostate cancer screening comes out of Europe, where race was not even reported in the study, and the largest study to date in the United States didn't include sufficient numbers of Black men to really make conclusions about prostate cancer screening. And so, we take the results of those studies, and we apply them to a population of Black men that we know is higher risk in terms of being diagnosed with prostate cancer and dying from prostate cancer. What that unfortunately has led to, and especially talking about the 2012 USPSTF guidelines as we move into a space where we just were not talking about prostate cancer screening at all with men, including Black men who were high risk. And so, I think it's really important that both patients and providers have prostate cancer screening on their radar and have prostate cancer screening on their radar, especially at the tips of their tongue if they are Black men or if they're treating Black men.

Erin Spain [00:06:09] And family members could also help play a role in this. Isn't that right with sort of prodding folks along to go get the screening?

Nicholas Shungu, M.D., MPH [00:06:17] Absolutely. I cannot tell you enough in my own clinical practice how I see patients who come in at the prodding of very significant other or a family member or to talk about something and especially something that can be personal and sensitive to talk about, like prostate or prostate cancer. I also just in some of the focus group research work we have done, we've found the importance that significant referent individuals, so whether that be a significant other, whether that be a brother, an uncle, a father, a cousin, a close friend, the role that those folks play in our lives, in the way that we think about our health and our risk. So absolutely those folks play a huge role.

Erin Spain [00:06:57] So, aside from sort of the confusion that's out there around screening, there are some commonly held misperceptions about prostate cancer. Tell me about some of those misconceptions. Some people think everyone's going to get prostate cancer eventually at a certain age, so it's really not that deadly. I mean, tell me about some of the things that are set out there that you'd like to clear up.

Nicholas Shungu, M.D., MPH [00:07:19] Prostate cancer is it can be a confusing cancer in that a lot of cancers that we think about like colon cancer, for example, if you have a colon cancer and that goes undiagnosed over time, that will cause impacts and that will be potentially fatal and usually is fatal if it's not treated. Prostate cancer is confusing because there is a subset of prostate cancers, and that's about 30 to 40 percent in our best estimation from the literature that can be harmless and sit like a barnacle on a rock. And I think that that has gained a lot of traction and understanding that is based absolutely in epidemiology and science. But that has been one of the reasons that screening guidelines have moved away from screening and started talking about the risks and benefits because there is a real and substantial number of prostate cancers that are potentially harmless. What that doesn't capture is that there really are prostate cancers that can be aggressive and harmful. And as I mentioned, I mean, in this country, even not Black men and all men, one in 41 men in this country will die from prostate cancer, which is a high number, which means there certainly are aggressive prostate cancers that are out there. And so, I think the first misconception is that prostate cancer can be potentially harmless. There are two types of prostate cancer that are less harmful. There are certainly aggressive forms as well. So, I think that's misconception number one. I think some of the work that we've done in our studies as well. One of the interesting things that some of our focus group research has gone into is confusion between getting a colonoscopy, which is a procedure that looks for colon cancer and prostate cancer screening and numerous men, both within research studies that have been conducting but also in my own clinical practice, think they have been screened for prostate cancer because they've completed a colonoscopy. And so, I think it is incumbent as us, as clinicians to make sure we are educating our patients that if they've had colon cancer screening, that tells us nothing about the prostate and prostate cancer. And I think thirdly, there are some reluctance to go through prostate cancer screening because historically clinicians have done digital rectal examinations, which is an examination where a finger is placed in the rectum to feel for the prostate. And that is the only way physically that we can examine the prostate. There are some men who are really averse to getting that exam done. It is a sensitive exam and one that is not super comfortable. And prostate cancer can be screened for in blood work without having that examination done as well. But what some of our focus group work has found is that men did not want to bring up prostate cancer screening because they didn't want to have that examination, and they didn't know that there were other ways to screen for.

Erin Spain [00:10:00] Prostate cancer, you've been really looking into this issue specifically of how Black men are getting their information about prostate cancer screenings. You just published a study on this topic looking specifically at social media YouTube videos. Tell me what you found. Tell me about the study and what you found.

Nicholas Shungu, M.D., MPH [00:10:18] Right, so, it was kind of a fun study to look into and to go about. And I think probably the impetus from it is I know that so much of my own patients’ lives and information they get comes from outside of the doctor's office. And for every man who I see as a patient in the office, I know there are five or six other men who just aren't even coming in, who are also getting information from other sources. And so, a group of us wanted to look at the quality of information available on YouTube. And so, what we basically did is we had, and we chose YouTube as a platform because it is the most widely used social media platform among Black men. And we did not use Facebook because just the algorithms and Facebook are way too complicated for us to figure out what a any individual man would be seeing with a search on there. And so, what we did is we put in a search term a prostate cancer screening in Black men, and we pulled up the first 50 videos and we did that on multiple computers and make sure we were getting the same set of videos and then use a set of criteria in terms of the quality of the information and the usability of the information to make decisions on that have been validated in previous studies. And just went through those videos and graded them using those criteria to see what the quality of information was available for Black men looking for prostate cancer screening information on YouTube.

Erin Spain [00:11:43] And unfortunately, they didn't all get very good grades. Tell me about the quality of these videos that came up.

Nicholas Shungu, M.D., MPH [00:11:49] Unfortunately, you're correct that the overall quality of information on the videos was poor. A lot of the videos did not bring up the disparities that we've already been talking about, and some of the videos just had frank misinformation. And that is because, for better or worse, YouTube is a platform that is used to promote information no matter where it comes from. There is information on there that is medically legitimate and comes from scientific sources, and there is information there that is not. And YouTube is not currently in the business of sorting through that. And so, you can get great information on YouTube. But what we found in this study is you can also get some pretty serious misinformation as well.

Erin Spain [00:12:31] So there's an opportunity here, though, to kind of crack this code and create high quality videos that could float to the top. How do you see that happening?

Nicholas Shungu, M.D., MPH [00:12:43] I think there are kind of multiple ways to do that. I think one there need to be probably the production of videos that are up to date with information that are culturally relevant to populations who are we are trying to reach and then obviously that are seen and are viewed. And so, I think one is a production of the videos. And then, you know, YouTube works through streams and algorithms that the more videos and likes that videos get, the more that they are able to be seen by other individuals. So, I think no one would be creating that video that we feel, or other folks feel would be really meaningful and then getting folks to look at it, sharing it widely, using current pathways that we have, whether that be institutional here at USC or even the niche in the past has worked to promote videos that they have felt like we're educational for men. So, I think some of the tools and the groundwork already exists. I think it is creating the videos and then making sure it's plugged in to those avenues so that people actually see it.

Erin Spain [00:13:46] You know, here in South Carolina, there's a statistic that is a little troubling that South Carolina's incidence and mortality rates for prostate cancer are higher the national rates. Now do you see this in the folks that come to MUSC Health and what's happening to change that statistic here in South Carolina?

Nicholas Shungu, M.D., MPH [00:14:04] I absolutely, and I can't compare it to other states, necessarily. I have practiced in other states. I do certainly see prostate cancer in my own practice and in the patients who I'm treating, so it is very real and tangible. And I think that there are a number of things and really good opportunities in terms of how we close that gap. I think one again is the work to educate clinicians on bringing up screening. And we did an interesting study where we looked at academic family medicine clinicians and what their current screening practices were. And just only slightly above 50 percent of those clinicians are bringing up prostate cancer screening with Black men as part of routine care. So, we have a lot of work to do, and this is a national survey, so it's not specific to South Carolina, but we have a lot of work to do just in terms of putting this on the radar of clinicians. I will say just in terms of locally being part of team. Who are working on this, this is now on the radar of primary care clinicians here at MUSC who have been helpful in terms of recruiting patients for studies and helping out with studies. So, I think here locally, we are already doing that work. I think that a lot of the work that needs to be done happens outside of clinic walls. And just like we talked about influencers and family members, certainly religious organizations and churches are huge areas where information is and can be disseminated. And so, there is great outreach work that's happening out of Hollings, for example, led by Dr. Marbella Ford that is doing outreach through churches and religious organizations to educate folks and men, especially about cancer and cancer risk. So, I think it has to be a multi-pronged attack. But I think the good news is we are aware of the disparities here in South Carolina, and a lot of good folks are on board with trying to figure out how we best address them.

Erin Spain [00:15:55] Is there anything else that you want to add there that we didn't get to, or do you think is important to add?

Nicholas Shungu, M.D., MPH [00:16:01] I think that it is important to know that current screening guidelines for prostate cancer. And this is now uniform among the USPSTF, which I had mentioned in 2012, recommended against routine prostate cancer screening. In 2018, they modified their recommendation to say that every man should make an informed decision about prostate cancer screening after considering the benefits and risks of screening that is now in line with American Cancer Society, who also recommends informed decision making as well as the American Urological Association. I think one of the things that makes prostate cancer screening a little bit more challenging is that there isn't this universal recommendation that says, hey, when you hit a certain age that you need to go and get a PSA done, the guideline societies recommend when you hit a certain age, you should have a conversation with your clinician about it. What that means and what our studies have shown is that that doesn't happen for men who are not entering the clinic. And even among men who are entering the clinic, that is not being done as part of routine care for a lot of men who enter the clinic. So, I do think that it should be something especially for Black men. And I should say there are not separate screening recommendations for Black men. And it's really unfortunate because the group is the highest risk of dying from prostate cancer. We know the least about in terms of screening. What guidelines do say is that we may start having this risk benefit conversation earlier in Black men. So, for example, American Cancer Society says we should start having this conversation at age 50, but in Black men, we should start having it at age 45. So, there's some nuances in terms of when you might start having the conversation. But part of the reason that prostate cancer, I think disparities continue to exist is that physicians could practice within the scope of of standard of care and not order a PSA for somebody. And that wouldn't be looked on as inappropriate because the guidelines say men could make a decision not to screen. And so, I think it's really important, especially for patients to bring this up with their clinicians to say, hey, I've heard about prostate cancer screening. Can we have a conversation about it? Or, hey, I know as a Black man, I'm at two times a risk of dying from prostate cancer than other men in the United States. When I'm worried about their risk and I want to talk about it, I think it's really important for folks to understand that this isn't a universal, sweeping recommendation to be screened. And that's the reason that screening doesn't happen at levels that it probably needs to in order to reduce some of the disparities.

Erin Spain [00:18:34] What do you do to optimize your health and live well?

Nicholas Shungu, M.D., MPH [00:18:38] I like being a glass half full person, so I mean, you use the word optimized. I think it's easy in this day and age to get down about things and to to look at prostate cancer disparities and the feel disheartened. But I always look at those things as opportunities and kind of look at things as a glass half full person. I do think that spirituality is important for myself and a lot of my patients, so I think my faith also is really important for my health. And then taking time to spend time with my family. I have two young kids and a wonderful wife who's also a clinician. And so, we are juggling and balancing and always trying to find that balance, but always hitting reset and making sure that we have time to spend together as a family that is family time. And then finally, lastly, the importance of exercise. I mean, I can just in my own life when I make time to exercise, I feel so much better. I know that is great for my health, but I also just in terms of my own mental health, feel so much better when I exercise. And so that's something I preach to my patients. But it's also something that I incorporate as much as I can into my own life and health.

Erin Spain [00:19:46] Well, thank you so much for coming on the show today to talk about this, and I hope that we get to see some of these new videos in the future.

Nicholas Shungu, M.D., MPH [00:19:54] I hope so, too. Thank you so much for having me.

Erin Spain [00:20:01] For more information on this podcast, check out advance.muschealth.org.