Date Published: March 7, 2019
Publisher: Public Library of Science
Author(s): Ashwini Kannan, Maggie Kirkman, Rasa Ruseckaite, Sue M. Evans, Mieke Van Hemelrijck.
Previous research in Victoria, Australia, found differences in prostate cancer outcomes in regional and metropolitan areas. This investigation of undiagnosed men in regional areas and a metropolitan area of South Australia sought their perspectives on prostate cancer. Our aim was to learn whether men who had not been diagnosed could shed light on why men outside metropolitan areas tended to have poorer outcomes than metropolitan men. Our goal was to build on evidence contributing to improving outcomes in prostate cancer care. Semi-structured interviews were designed to elicit explanation and meaning. 15 men (10 metropolitan, 5 regional) not diagnosed with prostate cancer were recruited through widely-distributed flyers in medical and community settings. Interviews were recorded and transcribed; transcripts were analysed thematically. Five main themes were identified, four of which were prompted by the questions: Addressing prostate health, Experiences with and expectations of GPs, Differences in care between regional and metropolitan areas, and Achieving early diagnosis. The fifth theme arose spontaneously: Australian masculinity. Men identified as problematic the limited availability of GPs in regional areas, the lack of consistency in approaches to prostate cancer detection, and men’s reluctance to seek medical care. Community-level strategies appear to be valued to encourage men to address prostate health. Maintaining and extending a systemic approach to prostate care may improve outcomes for men in Australia.
In 2011, the Victorian Cancer Registry (VCR) reported that men diagnosed with prostate cancer in one regional integrated cancer service (RICS) in Victoria, Australia, had a 7% lower 5-year age-standardised survival rate than in a metropolitan region (93% vs 86%, p<0.001) . In order to investigate the identified disparity between the RICS and other regions of Victoria, data from men diagnosed with prostate cancer retrieved from the VCR and the Prostate Cancer Outcome Registry-Victoria (PCOR-Vic) were analysed . Clinical, sociodemographic and quality of life differences between men diagnosed with prostate cancer in the RICS were compared with other Victorian regions. It was found that men in the RICS were more likely to be diagnosed with more advanced prostate cancer and to have poorer outcomes than metropolitan men. Further qualitative inquiry of men with and without prostate cancer and of GPs identified challenges associated with living in regional areas, including limited access to health services, GPs, and specialists; limited understanding of prostate cancer; and regional men’s reluctance to consult their GPs (who were often well known in the community) about sensitive matters such as prostate cancer, with concomitant digital rectal examinations . Differences between metropolitan and rural men’s health are not confined to Australia, a topic we have discussed elsewhere . GPs requested more consistent guidelines, noting, for example, that the Royal Australian College of General Practitioners (RACGP) discouraged screening unless men requested it and the National Health and Medical Research Council recommended screening for men at average and high risk [4, 5]. Fifteen men (10 from metropolitan Adelaide, 5 from regional South Australia) were recruited from May to July 2017. The characteristics of these men are shown in Table 1. Despite seeking recruitment from rural and remote areas, there were no volunteers. It was not possible to establish how many men saw the invitation to participate but did not volunteer; no volunteers dropped out of the research. Interviews lasted on average 22 minutes (range 10–27) and no repeat interviews were required. Metropolitan men learnt about the research from Gumtree  (7) and Rotary Clubs (3); regional men learnt from Men’s Sheds (3) and word-of-mouth (2). The men were aged 40–75 years (mean 53), with the regional men older on average (61) than the metropolitan men (49); their ages were reflected in employment status, with 7 metropolitan men and 2 regional men in paid employment. All but two of the metropolitan men and one of the regional men were in a relationship. All but two men (both metropolitan) identified as Anglo-Australian; four men who were born overseas had lived in South Australia for over 20 years. Apparent socio-economic status and employment were diverse. The main findings of the paper were that men had a low perceived risk of being diagnosed with prostate cancer particularly due to the absence of symptoms; heterogeneity in men’s understanding of prostate cancer in all aspects including anatomy, symptoms and current trends in Australia; identifying with or resisting the discourse of masculinity influenced men’s approach to addressing prostate health; and men generally were not proactive in monitoring their prostate health unless they had family or friends with a history of being diagnosed with prostate cancer, or they had professional insights to health. Both prospects of over- and under-diagnosis pose a conundrum on the appropriate means of approaching prostate health. As opposed to encouraging or discouraging prostate checks, a focus on informed decision-making is required. With the current dependence on case-finding of prostate cancer, results of this study identifying factors preventing men from addressing prostate health, and existing literature documenting challenges of inaccessibility to care and poorer outcomes upon diagnosis for men in regional areas,  a systematic approach is required to improve prognosis for the future generation of Australian men. Source: http://doi.org/10.1371/journal.pone.0211539