Do racial disparities exist in the use of prostate cancer screening and detection tools in veterans?

Survival Outcomes by Race and Ethnicity in Veterans With Nonmetastatic Castration-Resistant Prostate Cancer

Importance

Racial and ethnic disparities in prostate cancer are poorly understood. A given disparity-related factor may affect outcomes differently at each point along the highly variable trajectory of the disease.

Objective

To examine clinical outcomes by race and ethnicity in patients with nonmetastatic castration-resistant prostate cancer (nmCRPC) within the US Veterans Health Administration.

Design, Setting, and Participants

A retrospective, observational cohort study using electronic health care records (January 1, 2006, to December 31, 2021) in a nationwide equal-access health care system was conducted. Mean (SD) follow-up time was 4.3 (3.3) years. Patients included in the analysis were diagnosed with prostate cancer from January 1, 2006, to December 30, 2020, that progressed to nmCRPC defined by (1) increasing prostate-specific antigen levels, (2) ongoing androgen deprivation, and (3) no evidence of metastatic disease. Patients with metastatic disease or death within the landmark period (3 months after the first nmCRPC evidence) were excluded.

Main Outcomes and Measures

The primary outcome was time from the landmark period to death or metastasis; the secondary outcome was overall survival. A multivariate Cox proportional hazards model, Kaplan-Meier estimates, and adjusted survival curves were used to evaluate outcome differences by race and ethnicity.

Results

Of 12 992 patients in the cohort, 826 patients identified as Hispanic (6%), 3671 as non-Hispanic Black (28%; henceforth Black), 7323 as non-Hispanic White (56%; henceforth White), and 1172 of other race and ethnicity (9%; henceforth other, including American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, unknown by patient, and patient declined to answer). Median time elapsed from nmCRPC to metastasis or death was 5.96 (95% CI, 5.58-6.34) years for Black patients, 5.62 (95% CI, 5.11-6.67) years for Hispanic patients, 4.11 (95% CI, 3.96-4.25) years for White patients, and 3.59 (95% CI, 3.23-3.97) years for other patients. Median unadjusted overall survival was 6.26 (95% CI, 6.03-6.46) years among all patients, 8.36 (95% CI, 8.0-8.8) years for Black patients, 8.56 (95% CI, 7.3-9.7) years for Hispanic patients, 5.48 (95% CI, 5.2-5.7) years for White patients, and 4.48 (95% CI, 4.1-5.0) years for other patients.

Conclusions and Relevance

The findings of this cohort study of patients with nmCRPC suggest that differences in outcomes by race and ethnicity exist; in addition, Black and Hispanic men may have considerably improved outcomes when treated in an equal-access setting.

Racial and Ethnic Variation in PSA Testing and Prostate Cancer Incidence Following the 2012 USPSTF Recommendation

BACKGROUND

The 2012 US Preventive Services Task Force recommendation against routine prostate-specific antigen (PSA) testing led to a decrease in prostate cancer screening, but the heterogeneity of its impact by race and ethnicity remains unclear.

METHODS

The proportion of 40- to 74-year-old men who self-reported receiving a routine PSA test in the past year was estimated in the Behavioral Risk Factor Surveillance System (2012-2018). Odds ratios (ORs) of undergoing screening by race and ethnicity were estimated, adjusting for healthcare-related factors. Prostate cancer incidence rates and rate ratios (IRRs) by race and ethnicity were estimated using Surveillance, Epidemiology, and End Results registry data (2004-2017).

RESULTS

PSA testing frequencies were 32.3% (95% confidence interval [CI] = 31.7% to 32.8%) among non-Hispanic White (NHW), 30.3% (95% CI = 28.3% to 32.3%) among non-Hispanic Black (NHB), 21.8% (95% CI = 19.9% to 23.7%) among Hispanic, and 17.7% (95% CI = 14.1% to 21.3%) among Asian and Pacific Islander men in 2012. The absolute screening frequency declined by 9.5% from 2012 to 2018, with a larger decline among NHB (11.6%) than NHW men (9.3%). The relative annual decrease was greater among NHB (OR = 0.86, 95% CI = 0.84 to 0.88) than NHW men (OR = 0.89, 95% CI = 0.89 to 0.90; Pheterogeneity = .005), driven by a larger decline among NHB men ages 40-54 years. The NHB to NHW IRR for total prostate cancer increased from 1.73 (95% CI = 1.69 to 1.76) in 2011 to 1.87 (95% CI = 1.83 to 1.92) in 2012 and has remained elevated, driven by differences in localized tumor incidence. Metastatic disease incidence is rising across all racial and ethnic groups.

CONCLUSIONS

The frequency of prostate cancer screening varies by race and ethnicity, and there was a modestly steeper decline in PSA testing among younger NHB men relative to NHW men since 2012. The NHB to NHW IRR for localized prostate cancer modestly increased following 2012.

Prostate Cancer Disparities by Race and Ethnicity: From Nucleotide to Neighborhood

Prostate cancer (CaP) incidence, morbidity, and mortality rates vary substantially by race and ethnicity, with African American men experiencing among the highest CaP rates in the world. The causes of these disparities are multifactorial and complex, and likely involve differences in access to screening and treatment, exposure to CaP risk factors, variation in genomic susceptibility, and other biological factors. To date, the proportion of CaP that can be explained by environmental exposures is small and differences in the role factors play by race or ethnicity is poorly understood. In the absence of additional data, it is likely that environmental factors do not contribute greatly to CaP disparities. In contrast, CaP has one of the highest heritabilities of all major cancers and many CaP susceptibility genes have been identified. Some CaP loci, including the risk loci found at chromosome 8q24, have consistent effects in all racial/ethnic groups studied to date. However, replication of many susceptibility loci across race or ethnicity remains limited. It is likely that inequities in health care access strongly influences CaP disparities. CaP is a disease with a complex multifactorial etiology, and therefore any approach attempting to address racial/ethnic disparities in CaP must consider the many sources that influence risk, outcomes, and disparities.

African American Participation in Oncology Clinical Trials--Focus on Prostate Cancer: Implications, Barriers, and Potential Solutions

In the United States, the incidence and mortality rates of many cancers, especially prostate cancer, are disproportionately high among African American men compared with Caucasian men. Recently, mortality rates for prostate cancer have declined more rapidly in African American versus Caucasian men, but prostate cancer is still the most common cancer and the second leading cause of cancer deaths in African American men in the United States. Compared with Caucasian men, prostate cancer occurs at younger ages, has a higher stage at diagnosis, and is more likely to progress after definitive treatments in African American men. Reasons for racial discrepancies in cancer are multifactorial and potentially include socioeconomic, cultural, nutritional, and biologic elements. In addition to improving access to novel therapies, clinical trial participation is essential to adequately establish the risks and benefits of treatments in African American populations. Considering the disproportionately high mortality rates noted in these groups, our understanding of the natural history and responses to therapies is limited. This review will explore African American underrepresentation in clinical trials with a focus on prostate cancer, and potentially effective strategies to engage African American communities in prostate cancer research. Solutions targeting physicians, investigators, the community, and health care systems are identified. Improvement of African American participation in prostate cancer clinical trials will benefit all stakeholders.

Determinants of Prostate Specific Antigen Screening among Black Men in the United States in the Contemporary Era

PURPOSE

Although black men represent a high risk population for prostate specific antigen screening for prostate cancer, recommendations in black men are unclear. To our knowledge the resultant effect of conflicting recommendations and disparities in access to care on prostate specific antigen screening in black men is unknown.

MATERIALS AND METHODS

We compared the rate of self-reported prostate specific antigen screening in black men relative to that in nonHispanic white men. The BRFSS (Behavioral Risk Factor Surveillance System) 2012 data set was used to identify asymptomatic men 40 to 99 years old who reported undergoing prostate specific antigen screening in the last 12 months. Age, education, income, residence location, marital status, health insurance, regular access to a health care provider and a health care provider recommendation to undergo screening were extracted. Subgroup analyses by race and age were performed using complex samples logistic regression models to assess the odds of undergoing prostate specific antigen screening.

RESULTS

In 2012 there were 122,309 survey respondents (weighted estimate 54.5 million) in the study population, of whom 29% of black and 32% of nonHispanic white men reported undergoing prostate specific antigen screening. Younger black males had higher rates and odds of screening than nonHispanic white men of a similar age (ages 45 to 49, 50 to 54 and 55 to 59 years OR 1.66, 1.58 and 1.36, respectively). Among black men only a higher education level (graduates vs nongraduates OR 2.12), regular access to a health care provider (OR 2.05) and a health care provider recommendation for screening (OR 8.43) were independently associated with prostate specific antigen screening.

CONCLUSIONS

Despite long-standing disparities in health care access black males 45 to 60 years old have a higher rate and probability of prostate specific antigen screening than nonHispanic white men. Among black men educational attainment had a more pronounced association. In contrast the association with health care provider recommendations was less pronounced relative to that in nonHispanic white men. Future research may shed more light on the gamut of factors that influence the decision making process for prostate specific antigen testing.

Earlier prostate-specific antigen testing in African American men--Clinical support for the recommendation

BACKGROUND

To determine whether prostate-specific antigen (PSA) testing in African American veterans (AAVs) aged 40 to 54 years is associated with high-risk prostate cancer characteristics compared with AAVs aged 55 to 70 years or white veterans (WVs) aged 40 to 54 years.

METHODS

A total of 231,174 healthy veterans aged 40 to 70 years without clinical evidence of prostate cancer underwent PSA testing between October 1, 2000, and September 30, 2007. Clinicopathologic tumor characteristics were available for 1,044/1,059 AAVs and 1,006/1,971 age-matched WVs diagnosed with prostate cancer after a PSA level>4 ng/ml triggered prostate biopsy. Tumor characteristics of AAVs aged 40 to 54 years were compared with AAVs 55 to 70 years, WVs 40 to 54 years, and WVs 55 to 70 years.

RESULTS

Of PSA-tested veterans aged 40 to 54 years diagnosed with prostate cancer, there were no racial differences in prebiopsy PSA levels, prostate cancer grade, or clinical stage at diagnosis. AAVs aged 40 to 54 years were more likely to have ≥ 3 positive cores (P = 0.0229) and were less likely to be active surveillance candidates (P = 0.0340) compared with similarly aged WVs. AAVs aged 55 to 70 years were more likely to have high-grade (P = 0.0204) and higher clinical stage (P = 0.0195) prostate cancer than AAVs aged 40 to 54 years.

CONCLUSIONS

This large national cohort study suggests that PSA testing at an earlier age for African American men may allow diagnosis of lower risk prostate cancer, potentially reducing disparate outcomes between AAVs and WVs.

Racial disparities in cancer care in the Veterans Affairs health care system and the role of site of care

OBJECTIVES

We assessed cancer care disparities within the Veterans Affairs (VA) health care system and whether between-hospital differences explained disparities.

METHODS

We linked VA cancer registry data with VA and Medicare administrative data and examined 20 cancer-related quality measures among Black and White veterans diagnosed with colorectal (n = 12,897), lung (n = 25,608), or prostate (n = 38,202) cancer from 2001 to 2004. We used logistic regression to assess racial disparities for each measure and hospital fixed-effects models to determine whether disparities were attributable to between- or within-hospital differences.

RESULTS

Compared with Whites, Blacks had lower rates of early-stage colon cancer diagnosis (adjusted odds ratio [AOR] = 0.80; 95% confidence interval [CI] = 0.72, 0.90), curative surgery for stage I, II, or III rectal cancer (AOR = 0.57; 95% CI = 0.41, 0.78), 3-year survival for colon cancer (AOR = 0.75; 95% CI = 0.62, 0.89) and rectal cancer (AOR = 0.61; 95% CI = 0.42, 0.87), curative surgery for early-stage lung cancer (AOR = 0.50; 95% CI = 0.41, 0.60), 3-dimensional conformal or intensity-modulated radiation (3-D CRT/IMRT; AOR = 0.53; 95% CI = 0.47, 0.59), and potent antiemetics for highly emetogenic chemotherapy (AOR = 0.87; 95% CI = 0.78, 0.98). Adjustment for hospital fixed-effects minimally influenced racial gaps except for 3-D CRT/IMRT (AOR = 0.75; 95% CI = 0.65, 0.87) and potent antiemetics (AOR = 0.95; 95% CI = 0.82, 1.10).

CONCLUSIONS

Disparities in VA cancer care were observed for 7 of 20 measures and were primarily attributable to within-hospital differences.

Impact of race in a predominantly African-American population of patients with low/intermediate risk prostate cancer undergoing radical prostatectomy within an equal access care institution

PURPOSE

To study the impact of race in an equal access care institution with a predominantly African-American (AA) population.

METHODS

We retrospectively reviewed data from 222 men with low risk (LR) or intermediate risk (IR) prostate cancer who underwent radical prostatectomy at the New York Harbor VA between 2003 and 2011. Biochemical relapse, distant control, and prostate cancer-specific survival were analyzed using the Kaplan-Meier method and compared using the log-rank test. Univariate and multivariate Cox regression modeling was performed to determine the impact of covariates on biochemical outcome.

RESULTS

Most patients (65.3 %) were AA. The median follow-up was 58 months, and 89.6 % of patients were followed for a minimum of 2 years after their surgery. Analyzing the whole cohort, the biochemical control was improved in Caucasian patients compared with AA (90.2 vs. 75.4 %, p = 0.008). On subgroup analysis, for IR disease, this difference was no longer significant, 80.5 % for Caucasians versus 69.8 % for AA (p = 0.36). However, for LR disease, the 5-year biochemical control remained significantly improved for Caucasians compared with AA, with a 5-year biochemical control of 97.6 versus 81.7 %, p = 0.006. On multivariate analysis, AA race was a significant predictor for biochemical recurrence (HR 2.69, 95 % CI 1.27-5.65, p = 0.009). There were no differences between the two groups regarding distant control (p = 0.14) or prostate cancer-specific survival (p = 0.29).

CONCLUSIONS

In this predominant AA population with equal access to medical care, AA race is an independent predictor of biochemical recurrence after prostatectomy in men with LR or IR prostate cancer.

Prostate cancer screening

Universal screening for prostate cancer (Pca) using prostate-specific antigen-based testing is not recommended, as the potential harms of screening (overdiagnosis and overtreatment) outweigh potential benefits. The case for Pca screening requires a paradigm shift, which emphasizes the risks of screening over the risks of undetected cancer. Physicians are encouraged to use shared decision making with patients who express an interest in Pca screening, taking into account both the patient's screening preferences and individual risk profile. New models of care informed by the Patient Protection and Affordable Care Act are intended to assist clinicians in providing recommended preventive services.

Variation in prostate cancer detection rates in a statewide quality improvement collaborative

PURPOSE

There remains significant controversy surrounding the optimal criteria for recommending prostate biopsy. To examine this issue further urologists in MUSIC assessed statewide prostate biopsy practice patterns and variation in prostate cancer detection.

MATERIALS AND METHODS

MUSIC is a statewide, physician led collaborative designed to improve prostate cancer care. From March 2012 through June 2013 at 17 MUSIC practices standardized clinical and pathological data were collected on a total of 3,015 men undergoing first-time prostate biopsy. We examined pathological biopsy outcomes according to patient characteristics and across MUSIC practices.

RESULTS

The average cancer detection rate was 52% with significant variability across MUSIC practices (range 43% to 70%, p<0.0001). Of all patients biopsied 27% were older than 69 years, ranging from 19% to 36% at individual practices. Men with prostate specific antigen less than 4 ng/ml comprised an average of 26% of the study population (range 10% to 37%). The detection rate in patients older than 69 years ranged from 42% to 86% at individual practices (p=0.0008). In the 793 patients with prostate specific antigen less than 4 ng/ml the cancer detection rate ranged from 22% to 58% across individual practices (p=0.0065). The predicted probability of cancer detection varied significantly across MUSIC practices even after adjusting for patient age, prostate specific antigen, prostate size, family history and digital rectal examination findings (p<0.0001).

CONCLUSIONS

While overall detection rates are higher than previously reported, the cancer yield of prostate biopsy varies widely across urology practices in Michigan. These data serve as a foundation for our efforts to understand and improve patient selection for prostate biopsy.