Black Men 97% Less Likely Than White Men to Receive Prostatectomy During COVID-19 Pandemic

Adrien Bernstein, MD

During the height of the COVID-19 pandemic, Black patients were significantly less likely to undergo prostate cancer surgery compared with White patients, highlighting potential systemic inequities in care across medical specialties, and providing further rationale to recognize and the unintended diversion in cancer care due to the pandemic, according to data published in JAMA Oncology.¹

Results from the study showed that during the pandemic, just 1.3% (n = 1/76) of Black patients underwent prostatectomy vs 25.9% (n = 50/193) of White patients. However, in Black and White patients examined the year prior to the pandemic, prostatectomy rates among the 2 groups were nearly equal, at 17.7% (n = 17/96) and 19.1% (n = 54/282), respectively. As such, the odds ratio for the likelihood of undergoing surgery during the pandemic vs prior to the pandemic was 0.06 (95% CI, 0.01-0.35; P = .002) for Black patients and 1.41 (95% CI, 0.81-2.44; P = .23).

Moreover, the largest changes in surgical volume experienced by cancer surgery sites were in those caring for a greater proportion of Black patients.

“Prior to the pandemic, there was no difference in the rate of surgery for Black and White patients diagnosed with prostate cancer,” said lead study author Adrien Bernstein, MD, a urologic oncology fellow at Fox Chase Cancer Center. “During the pandemic, however, Black men were 97% less likely than White men to undergo a prostatectomy.”

At the height of the COVID-19 pandemic, nonemergency oncology care was often deferred to optimize resources and keep patients safe. However, with these necessary changes came the concerns of widening disparities in care that already existed, specifically in oncology. For example, Black patients are 20% more likely to die from cancer-specific mortality compared with White patients. Furthermore, Black men are more likely than White men to receive a diagnosis of advanced prostate cancer and to die from the disease.

Moreover, recent studies have shown that when cancer care is equitable—with increased access to care, standardized resources, and more inclusive clinical trials—differences in cancer-related mortality are diminished, providing evidence that biological factors are not the sole reason for worse outcomes among Black patients.

Because the racial implications of the changes in health care practices during the pandemic are unknown among patients with cancer, investigators sought to examine the association of the pandemic on prostatectomy for Black and White patients.

In this multicenter, regional, collaborative, retrospective study, 2 cohorts of patients with untreated, nonmetastatic prostate cancer were examined. The first cohort included 269 patients examined during the COVID-19 pandemic (from March 2020 to May 2020). The second cohort included 378 patients examined prior to the pandemic (from March 2019 to May 2019). Patients included in the analysis were those who had received a diagnosis of prostate cancer within 1 year of the study period and who had not undergone any prior treatment. Races and ethnicities beyond Black and White were not included in order to minimize heterogeneity.

The primary end point of the study was the difference in surgical management between Black and White patients.

Among Black patients in the cohort examined during the COVID-19 pandemic, 43.4% were 60 to 69 years old, 38.2% were younger than 60 years old, and 17.9% were 70 to 70 years old. Additionally, 84.2% of patients had at least 1 risk factor for COVID-19, 38.2% were obese, and 80.3% had clinical T stage I disease. Moreover, the median prostate-specific antigen level among these patients was 8.8 ng/mL (range, 5.3-15.2).

Of the White patients in the cohort examined during the COVID-19 pandemic, 46.1% were 60 to 69 years old, 26.4% were 70 to 70 years old, and 24.4% were younger than 60 years old. Additionally, 89.2% of patients had at least 1 risk factor for COVID-19, 46.1% were obese, and 79.8% had clinical T stage I disease. Moreover, the median prostate-specific antigen level among these patients was 7.2 ng/mL (range, 5.1-11.1).

Additional data showed that after May 15, 2020, the date the lockdown ended according to investigators, prostate surgery rates were once again even, at 25.0% (n = 19/76) for Black patients and 28.0% (n = 54/193) for White patients. Moreover, Black patients were 94% less likely to undergo surgery during the pandemic vs prior to the pandemic, and 97% less likely to undergo surgery compared with White patients during the lockdown. The likelihood for undergoing surgery was not significantly different for White patients before and during the pandemic.

“If you look at the prostate cancer literature, there is an unfortunate signal that Black patients do worse than White patients when it comes to prostate cancer outcomes,” said Andres F. Correa, MD, study coauthor and assistant professor for the Department of Surgical Oncology at Fox Chase. “Historically there has been interest in exploring possible genetic links that may explain the difference in outcomes between Black and white patients. Recent reports, however, have demonstrated that when you provide equal care, those differences go away.”

Reference

1. Bernstein AN, Talwar R, Handorf E, et al. Assessment of prostate cancer treatment among Black and White patients during the COVID-19 pandemic. JAMA Oncol. 2021;e212755. doi:10.1001/jamaoncol.2021.2755