April 22, 2024 – In Miami’s Little Haiti neighborhood, a fleet of four RVs regularly pop up in parking lots at churches, libraries and other locations. Sometimes known as “man vans,” these mobile screening units offer prostate cancer screenings and education as a way to reach patients who lack solid access to health care.
The idea to reach out to men to encourage them to get recommended cancer screenings and education began in 2018 in Miami, sponsored by the University of Miami’s Sylvester Comprehensive Cancer Center. Prostate cancer was added about 6 months ago and so far about 400 men have been screened. A similar program launched in New York City in 2022 through Mount Sinai Tisch Cancer Center, while countries from England to Brazil to Uganda have also experimented with ways to bring screening to the people.
In Miami, the vans, it turns out, are an ideal approach to doing a test that can sometimes lead to more harm than good. That’s because the question of whether a man should be screened for prostate cancer is a complex one. And men who have a higher risk of dangerous types of prostate cancer are the least likely to get tested. The vans, and the community health workers onboard, are trying to find them.
Who Should Get Screened?
Efforts to increase screening are important as a prominent medical journal this month predicted prostate cancer cases worldwide will surge by millions. In what seemed like an undersized recommended response, the authors suggested that these mobile screening units, sometimes called “man vans,” could help slow the estimated rise in prostate cancer cases, which are projected to double by 2040.
The new report in the journal The Lancet said Black men should be targeted for a simple blood screen called a PSA test starting at age 45, and other populations could be targeted from ages 50 to 69. The testing needs to be done along with education and outreach programs, the authors wrote, but they also said these types of mobile screenings are a possible tool for more and more communities with limited access to health care.
Report co-author and University of Miami associate professor Brandon Mahal, MD, noted that Black men have double the risk of getting prostate cancer, compared to the general population. Among the men at high risk for prostate cancer, he said, are those who:
- Self-identify as Black, particularly those of West African ancestry
- Are from a family with a history of prostate cancer
- Are from a family with a history of breast or ovarian cancer
- Have a genetic risk factor called a BRCA mutation
A simple blood test is the first step toward detecting the disease in its early stages, when it’s most treatable. Called a PSA test, the analysis looks for a protein called prostate-specific antigen that can be produced by both cancerous and non-cancerous tissue in the prostate, which is a gland that plays a role in men’s hormonal, reproductive, and urinary functions.
The problem is that the PSA test alone can’t always tell the types of prostate cancer that are very dangerous from the types that men perhaps can live with their entire lives and never have any problems. And once people hear the word “cancer,” they often will pursue treatment that some experts say isn’t necessary and carries risks such as impotence and infertility.
A paper published last year in a prominent British medical journal concluded that PSA testing “remains highly controversial because it is unclear whether the benefits of reduced prostate cancer mortality offset the harms of overdiagnosis and overtreatment.”
“Do not get a PSA test, and do not get a biopsy, unless you are comfortable hearing you have cancer and not treating it,” said Andrew Vickers, PhD, lead author of the British paper and a biostatistician at Memorial Sloan Kettering Cancer Center in New York City.
That’s because many doctors will recommend approaches such as active surveillance, observation, or watchful waiting for prostate cancers that aren’t causing symptoms, are small and haven’t spread outside the prostate, and are likely to grow very slowly.
The current PSA testing recommendation in the U.S. is for men ages 55 to 69 years old to talk to their doctor about the benefits and risks of getting a PSA test. But Mahal and his co-authors of the new recommendations in The Lancet argue that it is worthwhile to strongly recommend screening for high-risk groups like Black men.
“These men are the least likely to receive PSA screening, and most likely that is because of poorer access to health care, less access to primary care services that may provide screenings, or less access to primary care providers who understand that there may be a higher risk in that population,” said Mahal.
He called the current recommendation in the U.S. “not a very strong statement,” noting that a string of changes to it in recent years may be tough for primary care providers to keep up with. The website for the task force that makes the recommendations says that more changes are being considered, including perhaps changes based on age, race, ethnicity, or family history.
“Recommendations about cancer screenings are made around population benefits, not individuals,” explained Erin Kobetz, PhD, MPH, a professor of medicine and public health sciences at the University of Miami. “It’s a strategy for public health management, so sometimes these recommendations shift because yes, there may be benefits doing a certain test for a high-risk individual or a certain group of high-risk individuals, but endorsing it for all individuals within a certain age range may create more problems than the solution is intended to solve. The PSA is one of them.”
Current figures suggest that 1 in 8 men in the U.S. will get prostate cancer, which is the second-leading cause of cancer deaths in men, behind lung cancer.
The potential changes being considered by the influential U.S. Preventive Services Task Force signal that once again, the task force may be seeking to strike a more refined balance between the harms and potential life-saving outcomes of PSA testing.
Precision Medicine Meets PSA Screening
A cancer screening on one of the mobile units in Miami is typically just a walk-up visit. The vehicles are meant to attract attention and are brightly decorated by a famous Miami artist. The artwork can be a conversation starter in itself.
The mobile cancer education and screening vehicles operated by the University of Miami’s Sylvester Comprehensive Cancer Center are called “Game Changer Vehicles,” or GCVs. The community health worker teams speak English, Haitian Creole, and Spanish. Team members typically come from the same communities they serve, and all have a quality of being a natural helper.
“They know how to have conversations around a sensitive topic like cancer in a way that is mindful of sociocultural [customs], and they do education that speaks to the risks and benefits of screening,” said Kobetz, associate director for community outreach and engagement at the University of Miami’s Sylvester Comprehensive Cancer Center.
The mobile teams use a popular electronic health record system called EPIC, except the their version was custom-designed for this nontraditional health care setting in an RV. Using an the electronic health record allows patients to access their information from a mobile phone app and provides a way to message their health care team. The specially designed version for the Game Changer Vehicles streamlines the process of setting someone up in the record system, which is notoriously time-consuming in the medical field.
“One of the things we know is that appointments can become an unnecessary barrier, so we register people on the spot,” Kobetz said.
The health care workers spend most of their week in the RVs working in communities, but they also spend another 1 or 2 days per week calling patients with test results, or, if they can’t reach them, mailing certified letters or going to their homes to discuss results. They sometimes even go with patients to follow-up visits.
Men screened for prostate cancer are also invited to take part in a research project by Mahal that will examine the role of genetics, the environment, and individual lifestyle factors like diet and exercise.
“One of the strengths of looking at such a complex disease like prostate cancer in a diverse city like Miami is there are many different exposures and that can help us understand what drives the risk of this complicated disease,” he said.
Worldwide, the medical field is working to achieve what it calls precision medicine, such as making treatments for the specific traits of one person’s disease or even personalized vaccines. The Game Changer Vehicles are precision-medicine-meets-community-health. It’s a one-person-at-a-time approach.
“There’s always going to be cynics and critics,” Kobetz said. “We approach this from the perspective that we’re not only providing screening, but we’re educating and hopefully changing social and structural barriers to cancer prevention more broadly.”
Kobetz isn’t sure their work will be able to change overall cancer rates, but “I think that we have seen over time that showing up and being part of communities changes the way that they perceive health and health-related research and, ultimately, that’s critical for moving the dial on healthy equity.”
