Treatment Underuse in Prostate Cancer Rare, Disproportionately Affects Black Men

Nina A. Bickell, MD

Nina A. Bickell, MD

An analysis of racial disparities in prostate cancer treatment found that treatment underuse is rare, but when it does occur, it is almost exclusively in black men.

Of 359 black and 282 white men included in the study, only 25 (4%) experienced treatment underuse but 23 (92%) of these were black. Most (78%) cases of underuse were due to system failures, where treatment was recommended but not received. All men with treatment underuse due to system failures were black.

“We found low rates of treatment underuse among men with clinically significant prostate cancer receiving care at an academic referral center or a municipal hospital,” first author Nina A. Bickell, MD, co-director, Icahn School of Medicine at Mount Sinai’s Center for Health Equity & Community Engaged Research, and coinvestigators wrote.

“The vast majority of underuse was due to system failures, which affected only black men, regardless of institution. These failures occurred despite the presence of integrated EMRs and HIT capabilities to create gap reports in these organizations. Hospitals need to harness their EMRs to track cancer care and intervene when there are care gaps. Doing so has tremendous potential to improve cancer care and to reduce disparities in health outcomes.”

Black men have the highest rates of prostate cancer incidence and mortality in the United States. Black men are 2.4 times more likely than white men to die as a result of prostate cancer, they are younger at diagnosis, more likely to have poorly differentiated tumors, and less likely to undergo surgery.

Generally, those disparities in survival have been attributed to socioeconomic factors and nonsurgical treatment, as well as to quality of care, rather than greater burden of comorbidities among black patients.

However, previous studies have shown that outcomes were similar between surgical and nonsurgical treatment of clinically localized prostate cancer and there are conflicting findings regarding racial differences in prostate cancer treatment receipt.

To identify hospital treatment rates, racial differences in treatments, and reasons for such differences, the research team looked at patients treated at an academic hospital and a municipal hospital serving the Harlem community in New York City. The goal was to assess possible racial differences in quality of care and explore reasons for differences in care received.

Bickell et al identified men with clinically significant, locally advanced prostate cancer (Gleason score ≥7) who could benefit from treatment and reviewed their records to assess care received. They then interviewed the treating physicians of men who experienced treatment underuse to identify possible reasons for underuse and potential interventions to improve outcomes.

Investigators identified all patients with Gleason score 7 to 10 treated at the academic tertiary referral center from 2007 to 2012 (n = 350 black; n = 1454 white) and at the municipal hospital from 2006 to 2013 (n = 135 black; n = 5 white).

Investigators retained all black patients and randomly selected Gleason score—matched white patients within 10-year age groups (<60, 60-69, 70-79, ≥80 years; n = 282) treated at the academic site. The total final cohort was 641 patients.

Surgery was the most common primary treatment but, white men were more likely than black men to undergo surgery (91% vs 69%; P <.001). Radiotherapy was more common among black men (21% vs 7%; P <.001).

All patients who experienced underuse were recommended for a treatment that was not received. Most of those incidents (77%) were classified as system failures—cases in which treatment was recommended and the patient did not refuse treatment, but treatment did not ensue. These men were lost to follow-up. The remaining 23% of underuse cases were due to patient refusal or financial barriers, half of which occurred at the academic hospital.

System failures affected black men exclusively (16 of 16) and were more likely to occur among men treated in the municipal hospital (14 of 16). Most system failures occurred as men underwent work-ups to rule out metastasis or to assess functional status and ability to undergo active treatment. Of those who experienced system failures, 38% continued receiving medical care at the same hospital.

A multivariate conditional logistic model found that underuse was not associated with black race (OR, 3.9; 95% CI, 0.8-36.5), age, poor life expectancy, or comorbidity. Investigators found that commercial insurance protected against underuse (OR, 0.09; 95% CI, 0.03-0.30) and intermediate D’Amico cancer risk (OR, 3.6; 95% CI, 1.3-9.8) increased the risk for treatment underuse. A race-insurance interaction was not significant and was not included in the final model.

“Most concerning is the concentration of system failures among black men, the group with the highest mortality from prostate cancer. Men treated at both the municipal and academic hospitals experienced system failures that potentially could have been avoided had the institutions used their EMRs to identify these gaps,” Bickell et al wrote.

“Both institutions had EMRs that contained gap report and best practice alert capabilities, yet neither facility used these capabilities to assess and ensure cancer care quality. The fact that several men continued to receive their medical care at these institutions reinforces critical missed opportunities to improve cancer care and potentially reduce racial disparities in cancer outcomes.”

Bickell NA, Lin JJ, Abramson SR, et al. Racial disparities in clinically significant prostate cancer treatment: The potential health information technology offers [published online ahead of print December 1, 2017]. J Oncol Pract. doi: 10.1200/JOP.2017.025957.