Academy of Oncology Nurse & Patient Navigators
With former President Joe Biden’s prostate cancer diagnosis being thrust onto the world’s stage, it is imperative that we use this as a teachable opportunity to educate people about the disease—and to highlight how oncology navigators make a difference in prostate cancer care.
It is the most common cancer among men in the United States after skin cancer. With 1 in 8 men being diagnosed with prostate cancer during their lifetime, the odds are many people will encounter someone with the disease.1 It has an interesting, varied presentation, with many men unaware they have the disease since they do not experience any symptoms, or it can aggressively appear and grow into tissues near the prostate, spread to nearby lymph nodes or other body organs. Men with prostate cancer who do not experience symptoms may live for many years, whereas prostate cancer becomes life-threatening if it spreads.
Prostate cancer has several risk factors. It is a disease of older men, with 6 in 10 prostate cancers are found in men older than 65 years but is rarely diagnosed in men younger than 40.2 It is more common in African American men and Caribbean men of African ancestry compared with other racial groups, primarily due to a complex interplay of genetic, environmental, and socioeconomic factors.3
Most prostate cancers occur in men without a family history of the disease, but it appears to run in some families, especially with earlier diagnosed cases. It is common for a healthcare provider to review a family history since having a father or brother with prostate cancer more than doubles a man’s risk of developing this disease, and the risk increases with multiple family members and earlier diagnosis.
Studies continue to look at obesity, diet, smoking, chemical exposure inflammation, and sexually transmitted diseases, but no solid conclusions can be reached at this time. To support this view, an alternative to biopsy in patients with an elevated prostate-specific antigen (PSA) level is the use of serum- or urine-based biomarkers that increase specificity of screening.
If a man experiences symptoms that can cause concern for prostate cancer, a healthcare professional should be contacted immediately. The common symptoms are4
With screening, there has been a long-standing and ongoing controversy concerning the PSA test and its potential for overdiagnosis and overtreatment. On one side of the argument, PSA tests can detect cancers that would not have progressed to a life-threatening stage, leading to unnecessary treatments and their associated side effects. PSA levels can be elevated by noncancerous conditions, such as benign prostatic hyperplasia and prostatitis, leading to false-positive tests. During the diagnostic phase, prostate biopsies can cause bleeding and infection. During treatment for prostate cancer, the patient can experience impotence, incontinence, and other complications that affect quality of life.
On the other side of this debate, the PSA test can detect prostate cancer early, potentially allowing for timely treatment and improving outcomes. Some studies suggest that PSA screening may reduce the risk of dying of prostate cancer, and early detection and treatment can lead to improved quality of life for some men.
To support the PSA view in the evolution of cancer screening, an alternative to biopsy in patients with an elevated PSA level is the use of serum- or urine-based biomarkers that increase specificity of screening; another alternative is multiparametric MRI.5 With the evolution of cancer screening comes expense and debatable insurance coverage!
Even the national guidelines and recommendations do not take a definitive stand on screening. The US Preventive Services Task Force currently recommends that men aged 55 to 69 years should discuss the benefits and risks of PSA screening with their doctor and make an informed decision.6
The American Urological Association recommends that men aged 55 to 70 years who are at high risk for prostate cancer (eg, family history) should consider PSA screening. Clinicians may personalize the re-screening interval or decide to discontinue screening based on patient preference, age, PSA level, prostate cancer risk, life expectancy, and general health.7
The American Cancer Society recommends that men aged 50 and older with average risk and are expected to live at least 10 more years should discuss PSA screening with their doctor.8
Since this is a shared decision between the healthcare provider and patient, general health and life expectancy are foundational points in continuing screening beyond the recommended suggestions. Medicare and many private insurance plans cover PSA tests for men over 50 as part of prostate cancer screening. While some policies may limit coverage for routine screening in men over 70, coverage is typically still available for medically necessary tests and for individuals with a life expectancy of at least 10 years. Coverage may depend on clear education about symptoms. Also, consider the question of how devastated one would be if screening stopped and then a cancer were diagnosed.
There are many treatments for prostate cancer, including surgery, radiation, ablative treatment, immunotherapy, and/or hormone therapy. This arsenal will grow in the future. A difficult decision for patients with cancers that tend to grow very slowly is the option of active surveillance or observation. This is sometimes called watchful waiting. This may not be an impediment in men who are older or have other serious health problems, but with someone who is highly active and in general good health, the concept of waiting to see if the cancer grows can be stressful, knowing they have “cancer” in their body. Urology or prostate oncology navigators are foundational in providing clear, transparent education for the patient (and caregiver) to make the best decision for their care.
Prostate oncology navigators, also known as patient navigators, play a crucial role in helping men with prostate cancer navigate the complex healthcare system. These navigators, nurses, social workers, or patient navigators, provide support and guidance throughout the diagnostic process by proactive management of patient- and system-related barriers.9 They function as a liaison between the patient and the healthcare team, ensuring the patient receives timely and appropriate care.
Navigators offer clear and concise information about prostate cancer, its stages, and treatment options, helping patients understand their diagnosis and treatment plan. They provide emotional support and address any questions or concerns patients may have about their diagnosis, treatment, or recovery. With the focus on the family as well, they connect patients and their families with resources such as financial assistance, support groups, and other community resources.
One study showed that patients seen by a navigator were substantially more likely to receive genomic testing (high-risk follow-up), and due to the trusting nature of the relationship, Back patients experienced a 6-fold increase if they were seen by a navigator.10 Normally, this population has very low genetic testing rates.
Over the past several years, former President Biden and the Biden Cancer Moonshot actively supported oncology patient navigation services. This support included ensuring that navigation services can be reimbursed through Medicare and private health insurers and expanding access to these services for millions of Americans. With such dedication to all navigators, may he find one to lead him and Jill through this journey of care and palliation.
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