Initiatives to Improve Access to Care and their Effect on Reducing Racial Disparities in Prostate Cancer Outcomes - Editorial

Black men face a pandemic of prostate cancer risk and lethality which will still be present long after COVID passes. As compared to White men, Black American men have a high risk of presenting with aggressive and metastatic disease and suffer a 2.4 fold higher risk of prostate cancer-specific mortality, and a nearly 10-fold higher risk of death from prostate cancer as compared to Asian American men. This disparity in outcomes is present in both rural and urban regions1 in the United States and some of the highest global regions of prostate cancer mortality are in Africa and the Caribbean. This racial disparity may be linked to differences in biology2,3, access to care4, differences in treatment receipt, comorbidities, differences in risks and exposures, and differences in screening and early detection. 

In light of this observed disparity, Krimphove and colleagues5 from Harvard analyzed the National Cancer Database for all men with metastatic or locally advanced prostate cancer between 2004-10 and compared outcomes by race. Overall, Black men were more likely to have metastatic disease in this cohort as compared to locally advanced disease, were less likely to receive surgery or radiation, were more likely to be uninsured, were more likely to be treated locally, and to have not completed a high school education.

After adjusting for demographics and health status/comorbidities, Black men had a nearly 30% worse survival (HR 1.27 95% CI 1.2-1.34) as compared to similar White men with metastatic/locally advanced prostate cancer. Interestingly, in a simulation where differential weighting was applied to cohorts to balance access to care this mortality difference disappears (HR 1.04 95% CI 0.97-1.12), and the authors thus calculated that 85% of the excess mortality risk was explainable by access-related factors and only 5% from tumor-specific factors.

This work aligns with others4 suggesting that in populations where access to care is similar such as the VA health system or within specific clinical trial settings, prostate cancer outcomes by race are similar. In men with metastatic prostate cancer, studies have documented better survival in Black men when treated with immunotherapy6, taxane chemotherapy7, and novel AR inhibitors.8,9 These data suggest that efforts to reduce barriers to screening, early detection, and curative treatments may substantially reduce this mortality disparity in the United States. The NCCN and AUA, as well as recently revised USPSTF recommendations, may help, but establishing community and primary care buy-in for informed decision making in the clinic, universal health care access, and promoting patient navigation in health care systems should have the largest impact.

Written by: Andrew J. Armstrong, MD, ScM, FACP, Professor of Medicine, Surgery, Pharmacology and Cancer Biology, Director of Research, the Duke Cancer Institute Center for Prostate and Urologic Cancers, Divisions of Medical Oncology and Urology, Duke University, Durham, North Carolina

References:

1. Fletcher, Sean A., Maya Marchese, Alexander P. Cole, Brandon A. Mahal, David F. Friedlander, Marieke Krimphove, Kerry L. Kilbridge et al. "Geographic Distribution of Racial Differences in Prostate Cancer Mortality." JAMA network open 3, no. 3 (2020): e201839-e201839.

2. Wang, Bi-Dar, Kristin Ceniccola, SuJin Hwang, Ramez Andrawis, Anelia Horvath, Jennifer A. Freedman, Jacqueline Olender et al. "Alternative splicing promotes tumour aggressiveness and drug resistance in African American prostate cancer." Nature communications 8 (2017): 15921.

3. Huang, Franklin W., Juan Miguel Mosquera, Andrea Garofalo, Coyin Oh, Maria Baco, Ali Amin-Mansour, Bokang Rabasha et al. "Exome sequencing of African-American prostate cancer reveals loss-of-function ERF mutations." Cancer discovery 7, no. 9 (2017): 973-983.

4. Dess, Robert T., Holly E. Hartman, Brandon A. Mahal, Payal D. Soni, William C. Jackson, Matthew R. Cooperberg, Christopher L. Amling et al. "Association of black race with prostate cancer–specific and other-cause mortality." JAMA oncology 5, no. 7 (2019): 975-983.

5. Krimphove, Marieke J., Alexander P. Cole, Sean A. Fletcher, Sabrina S. Harmouch, Sebastian Berg, Stuart R. Lipsitz, Maxine Sun et al. "Evaluation of the contribution of demographics, access to health care, treatment, and tumor characteristics to racial differences in survival of advanced prostate cancer." Prostate cancer and prostatic diseases 22, no. 1 (2019): 125-136.

6. Sartor, Oliver, Andrew J. Armstrong, Chiledum Ahaghotu, David G. McLeod, Matthew R. Cooperberg, David F. Penson, Philip W. Kantoff et al. "Survival of African-American and Caucasian men after sipuleucel-T immunotherapy: outcomes from the PROCEED registry." Prostate Cancer and Prostatic Diseases (2020): 1-10.

7. Halabi, Susan, Sandipan Dutta, Catherine M. Tangen, Mark Rosenthal, Daniel P. Petrylak, Ian M. Thompson Jr, Kim N. Chi et al. "Overall survival of black and white men with metastatic castration-resistant prostate cancer treated with docetaxel." Journal of Clinical Oncology 37, no. 5 (2019): 403.

8. George, Daniel J., Elisabeth I. Heath, A. Oliver Sartor, Guru Sonpavde, William R. Berry, Patrick Healy, Carolyn Winters et al. "Abi Race: a prospective, multicenter study of black (B) and white (W) patients (pts) with metastatic castrate resistant prostate cancer (mCRPC) treated with abiraterone acetate and prednisone (AAP)." (2018): LBA5009-LBA5009.

9. McNamara, Megan Ann, Daniel J. George, Krishnan Ramaswamy, Stanislav Lechpammer, Jack Mardekian, Neil M. Schultz, Li Wang, Onur Baser, Ahong Huang, and Stephen J. Freedland. "Overall survival by race in chemotherapy-naïve metastatic castration-resistant prostate cancer (mCRPC) patients treated with abiraterone acetate or enzalutamide." (2019): 212-212.

Read the Full-Text Article: Evaluation of the Contribution of Demographics, Access to Health Care, Treatment, and Tumor Characteristics to Racial Differences in Survival of Advanced Prostate Cancer 

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