Black men are disproportionately affected by prostate cancer (PCa), with earlier presentation, more aggressive disease, and higher mortality rates versus White men. Furthermore, Black men have less ...access to PCa treatment and experience longer delays between diagnosis and treatment. In this review, the authors discuss the factors contributing to racial disparities and present solutions to improve access to care and increase clinical trial participation among Black men with PCa. Racial disparities observed among Black men with PCa are multifaceted, evolving from institutional racism. Cultural factors include generalized mistrust of the health care system, poor physician‐patient communication, lack of information on PCa and treatment options, fear of PCa diagnosis, and perceived societal stigma of the disease. In the United States, geographic trends in racial disparities have been observed. Economic factors, e.g., cost of care, recovery time, and cancer debt, play an important role in racial disparities observed in PCa treatment and outcomes. Racial diversity is often lacking in genomic and precision medicine studies. Black men are largely underrepresented in key phase 3 PCa trials and may be less willing to enroll in clinical trials due to lack of awareness, lack of diversity in clinical trial research teams, and bias of health care providers to recommend clinical research. The authors propose solutions to address these factors that include educating clinicians and institutions on the barriers Black men experience, increasing the diversity of health care providers and clinical research teams, and empowering Black men to be involved in their treatment, which are keys to creating equity for Black men with PCa.
Lay summary
Prostate cancer negatively affects Black men more than men of other races.
The history of segregation and mistreatment in the health care system may contribute to mistrust among Black men.
Outcomes are worse for Black men because they are less likely to be screened or to receive treatment for prostate cancer.
Black men also are unlikely to participate in clinical research, making it difficult for investigators to understand how Black men are affected by prostate cancer.
Suggestions for addressing these differences include teaching physicians and nurses about the issues Black men experience getting treatment and improving how Black men get information on prostate cancer.
Racial disparities seen within prostate cancer diagnosis, treatment, and outcomes are multifaceted and evolve from institutional racism. The disparities can be addressed by educating physicians about the barriers faced by Black men receiving health care, identifying the best practices for conveying information on treatments and clinical trials, and increasing diversity among health care professionals.
Cancer disparities among black patients in the United States have been well described for decades. Medical society now has the responsibility of implementing practice‐changing protocols and ...encouraging effective legislation that will eliminate these disparities.
Patient–physician communication, both verbal and nonverbal, can be negatively impacted by discordant dyads. Improvement in nonverbal cues and recognition of implicit biases may help mitigate ...suboptimal outcomes due to poor communication.
Objective To determine if there are variations in the receipt of treatment based on race and disease severity. Treatment variations in men with prostate cancer (PCa) among the various racial groups ...in the United States exist, which may be a source of potential disparity in outcome. Methods Utilizing Surveillance, Epidemiology and End Results 17, we identified 327,636 men diagnosed with PCa from 2004 to 2011. Logistic regression analysis was performed to determine the association of receiving definitive treatment and race in the context of disease severity. Results African American (AA) and Hispanic men were less likely to receive treatment compared to White men (odds ratio OR 0.73, 95% confidence interval CI 0.71, 0.75, and OR 0.95, 95% CI 0.92, 0.98, respectively). AA men had significantly lower OR of receiving definitive treatment within each D'Amico risk classification compared to White men, with decreasing odds of treatment for each increase in risk category (low-risk OR 0.81, 95% CI 0.78, 0.85; intermediate-risk OR 0.74, 95% CI 0.71, 0.77; and high-risk OR 0.62, 95% CI 0.58, 0.66). Hispanic men with intermediate-risk (OR 0.89, 95% CI 0.84, 0.94) or high-risk (OR 0.79, 95% CI 0.72, 0.85) disease had lower odds of receiving treatment compared to White men. Asian men had similar or greater odds of receiving treatment compared to White men within any Gleason or D'Amico classification. Conclusion There is a significant disparity in the receipt of treatment for PCa among AA and Hispanic men compared to White men. The variations in receipt of treatment reveal an area of opportunity to develop risk-stratified approaches to treatment regardless of ethnic identity, which may address the poorer PCa-related outcomes in these populations.
Patients eligible for Medicare Part D low-income subsidy have lower cost-sharing for both IV and oral cancer therapies. We evaluated associations between low-income subsidy and treatment choice, ...treatment initiation, and overall survival in patients with metastatic prostate cancer.
We identified men aged 66 years and older diagnosed with stage IV prostate cancer between 2010 and 2017 included in the Surveillance, Epidemiology, and End Results-Medicare linked data set. Using linear probability models, we evaluated the impact of low-income subsidy on type of first supplementary treatment (oral vs IV) among patients who received nonandrogen deprivation therapy supplementary systemic therapy, and initiation of any nonandrogen deprivation therapy supplementary systemic therapy. Overall survival was estimated with Kaplan-Meier curves.
Of the 5,929 patients included, 1,766 (30%) had low-income subsidy. On multivariable analysis, those with low-income subsidy were more likely to receive oral as opposed to IV treatments compared to patients without low-income subsidy (probability difference: 17%, 95% CI 12, 22). However, patients with low-income subsidy were less likely to initiate any nonandrogen deprivation therapy supplementary systemic therapy (oral or IV) compared to those without low-income subsidy (probability difference: 7.9%, 95% CI 4.8-11). Additionally, patients with low-income subsidy experienced worse overall survival than those without low-income subsidy (
< .001).
While low-income subsidy was associated with increased use of more expensive oral therapies in men with metastatic prostate cancer, barriers to accessing these treatments still exist. These findings stress the importance of continued efforts to improve health care access to low-income individuals.
Abstract Objective African-American (AA) men have excess mortality from prostate cancer compared with White men, which has remained unchanged over several decades. The purpose of this study is to ...determine if race/ethnicity is an independent predictor of receipt of any definitive treatment vs. watchful waiting/active surveillance (WW/AS). Methods and materials Men diagnosed with prostate cancer from 2004 to 2011 were identified from the Surveillance, Epidemiology, and End-Results program. Multinomial logistic regression analysis was performed to determine the relative risk ratio (RRR) of receipt of radical prostatectomy (RP), external beam radiation therapy (RT), brachytherapy, cryotherapy, or combination therapy vs. WW/AS. Results Compared with White men, AA men were significantly less likely to receive RP (RRR = 0.53, P <0.001), brachytherapy (RRR = 0.72, P <0.001), cryotherapy (RRR = 0.84, P = 0.001), and combination therapy (RRR = 0.70, P <0.001), and more likely to receive RT (RRR = 1.03, P = 0.041) vs. AS/WW. Hispanic men were significantly less likely to receive RP (RRR = 0.84, P <0.001) and brachytherapy (RRR = 0.77, P <0.001), and more likely to receive RT (RRR = 1.08, P <0.001), and cryotherapy (RRR = 1.19, P = 0.005) vs. AS/WW compared with White men. Conclusions The disparate risk of receiving definitive treatment among AA and Hispanic men represents a significant public health issue that requires efforts to improve physician education, increase cultural competency, and ensure equitable access.
Background
Previous studies have demonstrated an association between a diagnosis of cancer and the risk of suicide; however, they failed to account for psychiatric care before a cancer diagnosis, ...which may confound this relationship. The objective of this study was to assess the effect of a cancer diagnosis on the risk of suicide, accounting for prediagnosis psychiatric care utilization.
Methods
All adult residents of Ontario, Canada who were diagnosed with cancer (1 of prostate, breast, colorectal, melanoma, lung, bladder, endometrial, thyroid, kidney, or oral cancer) between 1997 and 2014 were identified. Noncancer controls were matched 4:1 based on sociodemographics, including a psychiatric utilization gradient (PUG) score (with 0 indicating none; 1, outpatient; 2, emergency department; and 3, hospital admission). A marginal, cause‐specific hazard model was used to assess the effect of cancer on the risk of suicidal death.
Results
Among 676,470 patients with cancer and 2,152,682 matched noncancer controls, there were 8.2 and 11.4 suicides per 1000 person‐years of follow‐up, respectively. Patients with cancer had an overall higher risk of suicidal death compared with matched patients without cancer (hazard ratio, 1.34; 95% CI, 1.22‐1.48). This effect was pronounced in the first 50 months after cancer diagnosis (hazard ratio, 1.60; 95% CI, 1.42‐1.81); patients with cancer did not demonstrate an increased risk thereafter. Among individuals with a PUG score 0 or 1, those with cancer were significantly more likely to die of suicide compared with controls. There was no difference in suicide risk between patients with cancer and controls for those who had a PUG score of 2 or 3.
Conclusions
A cancer diagnosis is associated with increased risk of death from suicide compared with the general population even after accounting for precancer diagnosis psychiatric care utilization. The specific factors underlying the observed associations remain to be elucidated.
In this study of 676,470 patients diagnosed with cancer (1 of prostate, breast, colorectal, melanoma, lung, bladder, endometrial, thyroid, kidney, or oral cancer) in Ontario, Canada, who are hard matched to 2,152,682 noncancer controls, a cancer diagnosis is associated with a significant increase in the risk of suicidal death. These results are consistent after accounting for prediagnosis utilization of psychiatric care.
PURPOSE Men diagnosed with prostate cancer have multiple options available for treatment. Previous reports have indicated a trend of differing modalities of treatment chosen by African American and ...white men. We investigated the role of ethnicity in primary treatment choice and how this affected overall and cancer-specific mortality. METHODS By utilizing data abstracted from Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), patients were compared by ethnicity, primary treatment, number of comorbidities, risk level according to modified D'Amico criteria, age, highest educational level attained, type of insurance, treatment facility, and perception of general health. Multinomial logistic regression analysis was performed to determine the effect of the tested variables on primary treatment and mortality. Results African American men were more likely to receive nonsurgical therapy than white men with equivalent disease characteristics. Whites were 48% less likely than African Americans to receive androgen deprivation therapy (ADT) compared with surgery (P = .02) and were 25% less likely than African Americans to receive radiation therapy compared with surgery (P = .08). Whites with low-risk disease were 71% less likely to receive ADT than African American men with similar disease (P = .01). Adjusted overall and prostate cancer-specific mortality were not significantly different between whites and African Americans (hazard ratios, 0.73 and 0.37, respectively). Risk level, type of treatment, and type of insurance had the strongest effects on risk of mortality. CONCLUSION There is a statistically significant difference in primary treatment for prostate cancer between African American and white men with similar risk profiles. Additional research on the influence of patient/physician education and perception and the role that socioeconomic factors play in mortality from prostate cancer may be areas of focus for public health initiatives.
Among patients with cancer, prior research suggests that patients with mental illness may have reduced survival. The objective was to assess the impact of psychiatric utilisation (PU) prior to cancer ...diagnosis on survival outcomes.
All residents of Ontario diagnosed with one of the top 10 malignancies (1997-2014) were included. The primary exposure was psychiatric utilisation gradient (PUG) score in 5 years prior to cancer: 0: none, 1: outpatient, 2: emergency department, 3: hospital admission. A multivariable, cause-specific hazard model was used to assess the effect of PUG score on cancer-specific mortality (CSM), and a Cox proportional hazard model for effect on all-cause mortality (ACM).
A toal of 676,125 patients were included: 359,465 (53.2%) with PUG 0, 304,559 (45.0%) PUG 1, 7901 (1.2%) PUG 2, and 4200 (0.6%) PUG 3. Increasing PUG score was independently associated with worse CSM, with an effect gradient across the intensity of pre-diagnosis PU (vs PUG 0): PUG 1 h 1.05 (95% CI 1.04-1.06), PUG 2 h 1.36 (95% CI 1.30-1.42), and PUG 3 h 1.73 (95% CI 1.63-1.84). Increasing PUG score was also associated with worse ACM.
Pre-cancer diagnosis PU is independently associated with worse CSM and ACM following diagnosis among patients with solid organ malignancies.
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