5 ways to fight prostate cancer

1. MORE SCREENING

2. MEDICAID FOR MORE PEOPLE

The idea of expanding Medicaid to more low-income people in North Carolina could scarcely be more divisive.

But health care experts believe people will see a doctor more regularly if they have health insurance. They say expanding Medicaid could help reduce a host of disparities, save substantial numbers of lives and reduce treatment costs by preventing disease and catching it earlier.

Medicaid expansion under the Affordable Care Act – Obamacare – has been blocked in North Carolina, as it has in many states led by conservative lawmakers.

In the original plan for the ACA, states would have been required to expand Medicaid to cover working adults making up to 138 percent of the federal poverty level. People earning more than that are eligible for federal subsidies to help pay for their health insurance.

The U.S. Supreme Court, though, ruled that states couldn’t be forced to expand Medicaid. More than two dozen states decided to anyway. But here and in other states that chose not to expand the coverage, people who make between 100 and 138 percent of poverty level fall in what’s often called as the “Medicaid gap” – not qualifying for subsidies under the ACA because they were initially expected to be on Medicaid, but earning too much to get Medicaid under current rules.

In North Carolina, an estimated 300,000 to 500,000 people would gain health insurance if Medicaid were expanded. That includes tens of thousands of men who suddenly would be able to afford health care.

That should have already happened, said Dr. Peter Watson, an oncologist in Kinston who frequently treats black prostate cancer patients.

“That’s the working poor, and so it would help a variety of illnesses, and I also have to say that I think it’s a fairness issue, and I’m a Republican,” he said. “I’m shocked we didn’t do that, because to me those are the people who are never going to be able to afford any kind of health insurance because they have to eat and pay their electricity bill.”

Gov. Pat McCrory has suggested it might be an option, but Republican leaders in the legislature, which would have to approve an expansion, say they’re against the idea, with some saying any talk of expansion is premature until after a decision in a pending U.S. Supreme Court case that could have a major impact on Obamacare.

Senate President Phil Berger said earlier this year he saw no good reason to expand, and House Speaker Tim Moore said he fears that if the state took on more Medicaid patients the federal government could back out of its commitment to pay all of the cost at first and then nearly all in later years.

A state cancer advisory group is pondering another program that could help: patient “navigators,” or case managers, to help guide low-income patients through the forest of appointments and funding sources they face after diagnosis.

Steven Patierno, deputy director of the Duke Cancer Institute, who does research on the genetics of the disease in black men and on cancer disparities, led an experimental program to establish a network of such managers for low-income breast cancer patients in Washington, D.C. That city is one of eight places that were part of a national, five-year, $25 million experiment by the National Cancer Institute that began in 2005.

The program has not only improved health care but saved the participating hospitals so much money by doing things such as reducing the rates of missed appointments that nearly all of them kept the case managers even after they had to begin paying the salaries themselves, Patierno said.

On a small scale, case managers are being used in Durham as part of Duke’s Office of Health Equity and Disparities. Small numbers of them also have recently been put in place around the state for other types of health care needs.

McCrory appointed Patierno to the state’s advisory committee on cancer coordination and control last year. That committee is charged with recommending how to implement the state’s cancer blueprint.

Members of the committee, Patierno said, are keenly interested in reaching the state’s underserved communities and are considering how a statewide system of case managers for cancer patients could be put into place and funded.

They envision these case managers as also being health educators, he said. It’s too early to say exactly how such a network would function, but one option is to put them in the county health departments.

Another critical part of the fight against prostate cancer is figuring out how it may work differently in black men and why it’s more likely to be aggressive. Researchers at UNC and Duke, including Patierno, have been working on that and other aspects of the disparity for years.

UNC researchers including Godley, working in a massive joint project with scientists in Louisiana, made several crucial discoveries about the health care and biological parts of the mysterious disparity and built an important repository of data on a group of black patients in North Carolina and Louisiana.

Patierno’s lab is among those at both universities that are starting to uncover more about the biology of the disease in black men.

“We have some really, really exciting results coming out,” he said. “We have identified some of those molecular pathways that are driving the aggressiveness of prostate cancer in African-Americans.”

Pushing more money at prostate cancer, at least if it were spent wisely, would surely help close the gap. But expensive fixes aimed at prostate cancer alone may not be the best use of always-scarce public health funding.

It’s a killer, but one reason the disparity doesn’t get more attention is that it’s hardly the biggest. Diabetes, lung cancer and heart disease, for example, are more deadly for African-Americans. And fixes for prostate cancer are less precise, in part because accurate screening is difficult.

Even a little more funding for local health departments for outreach efforts such as health education could help with colorectal screening, prostate education and more.

The health departments, which are widely regarded by public health experts as underfunded and overstretched, have traditionally concentrated mostly on the health of women and children.

Lisa Harrison, health director for Granville and Vance counties and president this year of the N.C. Public Health Association, said there are proven, if not perfect, methods of reaching African-American men. Often, however, these interventions, such as training African-American barbers and ministers in black churches to act as lay health advisers, spring up and then die off when a grant vanishes or a researcher moves on.

“So little money goes into the health education part of it,” she said. “We need to make a good connection, and it takes a minimum standard, and we should as a state determine what is a minimum standard that would do this in every county.”

Few people know more about public health in Eastern North Carolina than Jerry Parks, health director of Albemarle Regional Health Services, a district health department serving seven counties in the northeast corner of the state, including Bertie.

The county health departments across the state always have tight funding. They haven’t had the money to do much outreach, though for prostate cancer there are cost-effective models, such as systematic approaches to working with black churches and barber shops.

But public health agencies of all kinds struggle for enough resources to even do the basic local-level work to fight threats such as diabetes, let alone prostate cancer, he said.

“We kind of cobble together little grants here and there to do what we can,” Parks said. “And prostate cancer, I absolutely guarantee you if you put a little money in it, we could have an effect. And it wouldn’t take much money.”