Originally published on Cancer Doc in Evolution; reprinted with permission.
Even though I can’t defeat Father Time or my inherent genetic predisposition, I still enjoy my visits to the barbershop, no matter how far the time between them continues to stretch out. I have formed a bond and routine with my barber where I can simply sit in the chair and he can work his magic without even asking what I like. Although there is little chance to ruin what little is left, the inherent trust I have in him is surprising for someone like me with a type-A personality. We fill the time catching up, connecting about our families, politics, weather, and our thoughts on how Cleveland can bring home its next sports championship. We end each visit with a smile and firm handshake and put a date on the calendar in 4 (now, more like 6) weeks when I can escape from my stressful life and share 30 minutes with a good friend.
It’s not an enormous leap from thinking about my barber to thinking about my own work. I imagine how I can replicate this experience (someplace we visit routinely, enjoy visiting, and feel an inherent trust in the services provided) to improve the detection of cancer and the treatment of my patients. What if we could enable venues outside the hospital or clinic to be conduits to improve adherence and monitoring of cancer screenings and treatments? A recent paradigm-shifting study in the New England Journal of Medicine1 has shed some light on how we could transform this from concept to reality.
The study enlisted and trained barbers at barbershops in predominantly African-American neighborhoods to measure the blood pressure of their customers to identify those with elevated blood pressure (hypertension). Those with hypertension were randomly assigned to one of two groups. The first group, led by the trained barbers, focused on diet, exercise, and encouragement to follow up with their primary doctor. In the second group, the barbers encouraged follow-up with uniquely trained pharmacists (working in consultation with doctors) embedded in the barbershops, who then closely monitored customers with hypertension, adjusted meds, and met with them on a regular basis. After a 6-month follow-up, both groups had drops in blood pressure; however, the specialist-pharmacist group had a larger and statistically significant mean reduction in blood pressure. Also, in this group, 63% of patients reached a blood pressure under the national benchmark of 130/80, versus only 12% in the other arm. Lowering blood pressure can directly prevent cardiovascular complications which remain the leading cause of death in the United States.
I truly believe this study could transform the way we approach cancer care around the world. Global screenings for cancers (i.e. breast, colon, cervical) are clearly not meeting our hoped-for targets. Studies have also demonstrated that there are clear disparities in screening rates associated with racial/ethnic identity and socioeconomic status. We also can’t ignore the trust issue when it comes to doctors, and how a perceived lack of trust can lead to lower adherence to screening guidelines. The barbershop study could translate to better adherence by taking screening out of the hospital and into places where there is already a sense of community and connection. Here in Cleveland, I have seen firsthand successful attempts at empowering local community centers with health care providers (through organizations like Medwish and the Cleveland Clinic Minority Men’s Health Center) to enable people to get screening who otherwise would not traditionally get screened. Whether truly this impacts detection and outcomes remains to be seen, but we can’t accept the current standard of care. We need to embrace community centers and join forces with community leaders. They can actually conduct screenings, as we saw in the study, but more importantly they can be advocates for screening and early detection to their community members.
I also believe this innovative approach could have applications for patients who are undergoing active treatment for cancer. Part of what made the study a success was providing access to care (pharmacists) in community settings that patients were already frequenting on a regular basis. Patients are routinely being seen every 3 to 4 weeks in our offices, but we need to capture more patient-related outcomes that occur in between visits. We also need to clearly address the changing landscape of cancer treatments, particularly with the increasing availability of oral regimens, which stretch office visits out even further, and the uncertainty of whether patients are adherent to these regimens. Giving our patients easily accessible tools and resources so they can capture and relay symptoms, adherence, and side effects to providers will not only empower patients in their care, it could also potentially improve outcomes. We are just beginning to scratch the surface on patient engagement, yet I am encouraged by the success of such innovative projects as the Metastatic Breast Cancer Project and the Ironman Registry (capturing clinical and tumor samples from patients with advanced breast and prostate cancer at their convenience in a real-time manner as they undergo treatment). They offer a path to better understand responses and even to develop new approaches that involve researchers working hand in hand with patients at the comfort of their home.
This revolutionary study, in my eyes, has the potential to disrupt the way we approach patient care. Providing access to patients has to go beyond the traditional hospital and clinic setting. Enlisting the community centers and leaders in which people trust and earning their trust as expert health care providers is an invaluable combination that can improve adherence to cancer screening and treatment. Patients are more in touch than ever and we need to use their enthusiasm and their strength as active partners in their care and in driving new technologies and innovations. I can envision a future in which I thank my barber for a great cut and for referring a patient to be diagnosed for an early-stage cancer that can be potentially cured.
- Victor RG, Lynch K, Li N, et al. A cluster-randomized trial of blood-pressure reduction in black barbershops. N Engl J Med. 2018;378:1291-301.