Evaluation of Social Determinants of Health and Prostate Cancer Outcomes Among Black and White Patients: A Systematic Review and Meta-analysis - Beyond the Abstract

Immense resources have been dedicated to identifying innate biological differences between Black and White men that could explain the disparities in prostate cancer with the results being equivocal at best. Prostate cancer, the most commonly diagnosed solid organ cancer in men, represents perhaps the greatest disparity in outcomes in oncology.1 Few studies, if any, have attempted to evaluate the association between prostate cancer outcomes and social determinants of health (SDOH). The Department of Health and Human Services (HHS) defines SDOH as "the conditions in the environments where people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks".2 With the historical and continued oppression of Black people that transcends income and educational level, evaluating the association between SDOH and disparities in healthcare outcomes is crucial to determine initiatives to mitigate these continued inequities.

This systematic review and meta-analysis of publications comparing prostate cancer outcomes between Black and White men in the US was performed, focusing on prostate-cancer specific mortality (PCSM) and overall survival (OS) endpoints. Using SDOH definitions from the department of HHS, a scoring system was derived to evaluate the incorporation of SDOH in the analysis conducted in each study. All included manuscripts were categorized as low, intermediate, or high based on the incorporation of SDOH variables. A total of 1,019,908 patients were accounted for in the 47 papers included in the final analysis, with a median follow-up of 66.0 months.

Among the studies that did a poor job of incorporating SDOH into the analysis, Black men had higher PCSM (HR 1.29; 95% CI 1.17-1.41, p < 0.001). Conversely, in those studies with a high SDOH score, Black men had significantly lower PCSM (HR 0.86, 95% CI 0.77-0.96, p = 0.02). Studies with a high SDOH score also reported no significant difference between Black and White men when evaluating the OS endpoint (HR 0.94, 95% CI 0.85-1.04, p = 0.23). Finally, this study found that multiple manuscripts were published despite having a high degree of data missing (ex., missing T stage in 46.8% of studies), and of those studies with missing data, over 40% of published studies did not report how the missing data were handled in the analysis.

This meta-analysis spurs a greater call to action to the research community to see racism—rather than race— as one of the many drivers of disparities in disease-specific outcomes. SDOH disparities disproportionally impact Black populations in America; however, the effects of racism are infrequently acknowledged in prostate cancer literature.3,4 Future research should incorporate SDOH variables into models to evaluate the biological impact of societal inequities on our patients. Assessment of social factors should be standardized in patient encounters and electronic medical records to mitigate missing registry data. Investigation into other cancers and medical conditions can also improve understanding of the interplay of SDOH with health outcomes and advance cancer health equity. Failure to implement change will continue the vicious trend of poorer outcomes for our most underserved and disadvantaged populations.

Written by: Helen Sun, MD,1 Maheetha Bharadwaj,2 & Randy Vince, MD1

  1. Department of Urology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH
  2. Department of Urology, University of Washington, Seattle, WA

  1. US Department of Health and Human Services. Surveillance, Epidemiology, and End Results (SEER) Program, SEER*Stat Database. National Cancer Institute, DCCPS, Surveillance Research Program. Accessed December 5, 2022. www.seer.cancer.gov
  2. Centers for Disease Control and Prevention. Social Determinants of Health at CDC. Published online December 8, 2022. Accessed March 1, 2023. https://www.cdc.gov/about/sdoh/index.html
  3. Vince R, Spratt DE. Drivers of racial disparities in prostate cancer trial enrollment. Prostate Cancer Prostatic Dis. 2021;24(4):946-947. doi:10.1038/s41391-021-00427-z
  4. Vince RA, Eyrich NW, Mahal BA, Stensland K, Schaeffer EM, Spratt DE. Reporting of Racial Health Disparities Research: Are We Making Progress? JCO. 2022;40(1):8-11. doi:10.1200/JCO.21.01780
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