African-American (AA) men with clinically localized prostate cancer (PCa) continue to receive definitive treatment less often than white and Asian men, a new study finds. Undertreatment of Hispanic patients is another worrisome trend.
“Persistent disparities in treatment for AA and emerging disparities in Hispanic men, regardless of stage at presentation, likely represent a significant predictor of higher mortality in underserved populations,” Kelvin A. Moses, MD, PhD, of Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, and colleagues concluded in Urology.
Their analysis of 327,636 patients diagnosed with localized PCa 2004 to 2011 from the SEER-17 (Surveillance, Epidemiology and End Results) database revealed that AA and Hispanic patients were 27% and 5% less likely, respectively, to receive any treatment (radical prostatectomy, external beam radiation therapy, brachytherapy, or cryotherapy) than white patients.
Disparities similarly emerged when investigators examined patients by D’Amico Risk classification (with and without questionable PSA values): AA patients had significantly lower odds of definitive treatment than similar white patients by 19%, 26%, and 38% in the low, medium, and high-risk categories, respectively. By Gleason score alone, AA men with Gleason 7 or 8–10 cancer were undertreated compared with white men with even lower risk disease (Gleason 6 or below).
Disparities appeared in other ways. Younger men typically receive PCa treatment in greater numbers than older men, yet AA patients, who were diagnosed at earlier ages, were still less likely to receive treatment. The researchers also investigated whether geographic location played a role. A racial disparity existed in US regions with a population greater than 12,000. Dr Moses and colleagues believe socioeconomics only partly explain the lack of access to specialty care. Neither PCa overtreatment in whites nor a higher comorbidity in blacks seemed likely.
Hispanic men with intermediate- or high-risk disease were 11% and 21% less likely, respectively, to be treated than white men with similar risks. Asian patients were as likely as white patients to be treated for their cancers, although they were diagnosed at older ages and presented with more advanced disease.
Dr Moses and colleagues suggested policy changes, patient education, and workforce diversification to address the disparities. On a clinical front, “…the plethora of data showing that AA men experience improved outcomes with surgery is clearly not being imparted to patients, implicating a potential lack of physician communication with patients regarding shared decision-making and discussion of benefits/risks of various treatment modalities.” Ash K. Tewari, MD, and colleagues reported in The Journal of Urology (177:911-915) that cancer-specific survival with non-definitive treatment was 7.8 years, while it was more than 14 years for radical prostatectomy and radiation therapy, they noted.
In accompanying editorial, Christopher P. Filson, MD, MS, remarked that the current study did not consider differences in insurance coverage and access to care, such as observed at the Veterans Administration. Noting that Dr Moses’ team call for an action plan “to eradicate the seemingly obstinate inequalities related to prostate cancer care based on patient race, Dr Filson pointed out that this already was set in motion with the passage in 2012 of the Affordable Care Act (ACA).
“It remains to be seen how racial disparities related to prostate cancer care will change in the post-ACA environment over the long-term,” Dr Filson wrote. “Nonetheless, I remain optimistic that the ACA will have made a significant dent in these tenacious discrepancies in the access to—and quality of—prostate cancer care among persons of color.”
1. 1. Moses KA, Orom H, Brasel A, Gaddy J, and Underwood W. Racial/Ethnic Disparity in Treatment for Prostate Cancer: Does Cancer Severity Matter. Urol. doi: 10.1016/j.urology.2016.07.045. [accepted manuscript].
2. Filson CP. Editorial Comment. Urol. [accepted manuscript].