For decades, clinicians and researchers alike have been aware of major racial disparities in prostate cancer. Black men in the United States present more often, with higher PSA values, at younger ages, and are more likely to die from prostate cancer than their White counterparts. Within this framework of indisputable facts, there is a lot of discussion to what factors lead to these racial disparities. Is it genetics? Is it social determinants of health? Is it attitudes to the health system due to mistrust from many past horrible failed experiments (i.e. Tuskegee)?
Is it lifestyle differences? Is it all access to care? Recent data from the Veterans Affairs Health System have suggested that when given equal access, outcomes among Black and White men can be similar. While this certainly supports the importance of access to care, this does not mean Black and White men present with equal rates of prostate cancer indicating residual disparities that cannot be explained by access alone. However, as we move forward with newer technologies (MRI, genomics, next generation imaging), whether Black patients truly have equal access to these advances is unknown.
To address whether Black prostate cancer patients have equal access to MRI for diagnosing prostate cancer, Hoge and colleagues reviewed the records of 619 men (182 Black and 437 White) who presented with a suspicion of prostate cancer and underwent a prostate biopsy between January 2014 and December 2018 at a single academic institution in Cincinnati, Ohio, USA. Consistent with many studies, the Black men were younger but had higher PSA values. Within their cohort, 226 men (43%) underwent MRI-guided fusion biopsy. When analyzed by race, Black men were 68% less likely to undergo fusion biopsy (p<0.001). When stratified by first time biopsy and men with a prior negative biopsy, Black men were less likely to undergo fusion in both subsets, but this only reached significance in the first time biopsy (64% lower risk, p<0.001) and not in the repeat biopsies (49% lower risk, p=0.18). Thus, the authors found, regardless of the setting (initial vs. repeat biopsy), Black men were much less likely have a fusion biopsy.
There are two simple interpretations of these results. 1. Black men had equally undergone MRI but were more likely to be negative and such a fusion biopsy was not possible. 2. Black men had fewer MRIs. Given the higher rates of prostate cancer overall, it seems unlikely that a 64% lower risk of MRI in first time biopsies is due to more often having negative MRIs. Thus, I strongly believe we can conclude that Black men were having fewer MRIs.
Understanding why, at least in this report from a single academic medical center, Black men are having fewer MRIs is crucial. We have made major advances in our diagnosis and management of prostate cancer over the past 20 years. We now have new tools to diagnose localized (MRI) and advanced disease (next generation imaging). We now have new treatments for advanced prostate cancer that can extend survival by over a year (chemotherapy, novel hormonal agents, etc.). We even have data that in advanced prostate cancer, Black men have better survival when treated with new life prolonging agents. However, if these advances are used preferentially in White men, prostate cancer disparities will only widen. Thus, this paper should be a wake-up call to ensure that new practice changing advances are used equally – not just for White men. Ultimately, whether results from other centers including equal access settings would show similar results, remains to be seen. Finally, if confirmed in the future, more research is needed to understand why Black men have less access to newer technologies such as MRI and whether this applies to other newer technologies (genomic tests, next generation imaging, etc.).
In summary, we have entered a new era in prostate cancer that holds the promise to use technology to minimize health disparities. However, if the technologies are used in a disparate fashion, not only will this not reduce health disparities, but will increase them. As such, understanding the rationale behind such disparate access to care if crucial and most importantly how to eliminate such barriers moving forward.
Written by: Stephen J. Freedland, MD, Director of the Center for Integrated Research in Cancer and Lifestyle and co-director of the Cancer Genetics and Prevention Program and Associate Director for Faculty Development at the Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute.
Hoge C, Verma S, Lama D.J, et al. Racial disparity in the utilization of multiparametric MRI–ultrasound fusion biopsy for the detection of prostate cancer. Prostate Cancer and Prostatic Diseases volume 23, pages 567–572(2020)
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