Prostate Cancer Treatment Among Black and White Patients During the COVID-19 Pandemic, Journal Club - Christopher Wallis & Zachary Klaassen
August 30, 2022
Christopher J.D. Wallis, MD, Ph.D., Assistant Professor in the Division of Urology at the University of Toronto.
Zachary Klaassen, MD, MSc, Urologic Oncologist, Assistant Professor Surgery/Urology at the Medical College of Georgia at Augusta University, Georgia Cancer Center
Christopher Wallis: Hello, and thank you for joining us for this UroToday Journal Club. Today, we're discussing a paper entitled Assessment of Prostate Cancer Treatment Among Black and White Patients During the COVID-19 Pandemic. I'm Chris Wallace, an assistant professor in the Division of Urology at the University of Toronto. With me today is Zach Klaassen, an assistant professor in the Division of Urology at the Medical College of Georgia. This is a citation for this recent publication, JAMA Oncology, led by Dr. Bernstein and Dr. Correa.
Most will know, and it's hard to overstate the impact of COVID-19 over the past year and a half, as of January 20th, 2020, only four countries had been affected, but very rapidly, by the end of March, nearly the entire world was affected. As a result of the COVID-19 pandemic, we had substantial changes in cancer related patient encounters. This is US data, but it's similarly been found in other jurisdictions and in a variety of different healthcare contexts. And so we see that in March and April, there's a rapid decline in nearly all cancer types in terms of patient encounters, both overall and particularly concerningly in new incident patient encounters.
And so this is similar data that we see in the pediatric world and in the UK, which finds a very similar effect. When we see this, we look not just for new patient encounters, but for the relatively associated procedures, and so this is changes in screening procedures, and then now in prostatectomies as relevant to prostate cancer. So we see rapid declines, and these are sustained over a number of months following the initial pandemic.
However, the pandemic did not affect all equally, particularly in the US. As you can see here, non-white populations, particularly black, were more heavily affected, and so there's higher rates of cases, hospitalizations, and deaths compared to white populations. This led to the aim and hypothesis underpinning this analysis, which was to evaluate the association between the COVID-19 pandemic and prostate cancer surgery rates among black and white men in a multi-institutional cohort.
So to do this, the authors relied on the Pennsylvania Urologic Regional Collaborative. This is a prospective collaboration of 11 urology practices in Pennsylvania and New Jersey, which includes more than 127 doctors. This is a nice cross-section in that it includes both academic and private practices as well as urban and rural locations. And for this analysis, the authors examined patients with non-metastatic prostate cancer who had complete PSA and T-stage information. To allow for complete analysis, those who were lost to follow-up were excluded. The authors defined two periods in which patients could be accrued. That would be prior to the pandemic, which was March to May, 2019, as well as the pandemic lockdown period, which was March to May, 2020.
The primary outcome was to assess the difference in surgical management of patients who were previously untreated for non-metastatic prostate cancer. The primary exposure was self-identified race, and the authors examined black versus white. There were a number of covariates used to account for potential differences in confounding, and these included patient level and practice level factors. At the patient level, co-morbidities including age, obesity, a history of myocardial infarction or peripheral vascular disease, as well as a history of diabetes or chronic pulm disease were examined. Other risk factors for severe COVID as defined by the CDC were included as well as prostate cancer factors, including PSA and biopsy-based Gleason grade group. At the practice level, demographic characteristics and overall change in surgical procedures were accounted for.
The authors used descriptive analysis to examine differences in baseline characteristics and then used univariable and multivariable logistic regression modeling to test the association between baseline characteristics and surgical treatment among both black and white men. They then used multivariable logistic regression models with an interaction between the year and race to test for effect modification, examining three specific comparisons. First, they looked at rates of prostate cancer treatment among black men before versus during the pandemic. They then looked at treatment rates in white men both before and then during the pandemic. Then they compared between black and white men during the pandemic. Now I'm going to pass it over to Zach to walk us through the results.
Zach Klaassen: Thanks, Chris. So looking at the cohort design of this trial, there was 3,797 patients diagnosed with prostate cancer between January 2013 and November 2020. Among these, there was 3,466 that were non-metastatic. Then looking specifically at the time periods for this study, in the pandemic lockdown between March 16th and May 15th, 2020, there was 269 patients, and in the pre-pandemic period between March 11th and May 10th, 2019, there was 378 patients.
So this is the demographic and clinical characteristics for patients with untreated non-metastatic prostate cancer during the lockdown period of the pandemic. They've stratified this by black and white patients, as you can see here. There was no difference in age of the patient, with the most common age being 60 to 69 for both groups. There was no difference in COVID severity risk factors between the two groups. And there was no difference in the obesity rate between these two groups, although white patients were more obese at 46.1% compared to 38.2% of black patients. Similarly, no difference in cardiovascular disease, type 1 diabetes, chronic pulmonary disease, or high-risk prostate cancer.
We can see here that at PSA level at the time of biopsy, there was a higher PSA for black men and median 8.8 PSA compared to 7.2 for white men. There was no difference in clinical T-stage of disease, about 80% were clinical T-stage one. No difference in biopsy Gleason grade group. There was a difference in the MRI during the workup. 70% of patients that were white had an MRI compared to 40% of patients that were black. In terms of the prostatectomy during lockdown, you can see here, this is a drastic change, 25.9% of white men had a prostatectomy during the lockdown compared to only 1.3% of black patients. To put this into context, during the reopening period there was no difference between race at 25% of black men having a prostatectomy compared to 28% of white men. And looking at the prostatectomy pre-lockdown, 17.7% of black men had a prostatectomy and 19.1% of white men did. So certainly a discrepancy, a large discrepancy during the lockdown period, which we'll discuss in the coming slides.
This is the univariable logistic regression analysis for predictors of surgery during the COVID-19 lockdown, and I've highlighted the analysis of interest here. So looking at by race, in 2019, with black as the reference, the odds of getting a prostatectomy in 2019 for white men was no different than black men with an odds ratio of 1.1 and a confidence interval of 0.6 to 2.0. However, in 2020, you can see there's a huge difference. The odds ratio is 26.2 for white men with a reference, excuse me, a 95% confidence interval of 3.6 to 193.6.
This table looks at the adjusted odds of prostatectomy during the 2020 COVID lockdown. You can see that there was no difference based on age, certainly not unexpectedly high-risk prostate cancer was more likely to have a prostatectomy during the lockdown with an odds ratio of 3.76 and 95% confidence interval of 1.93 to 7.32. However, if we look at race, white men had an odds ratio of 30.48 compared to black men for odds of undergoing prostatectomy with a 95% confidence interval, 3.84 to 241.95.
This looks at the association between race and prostate surgery with effect modification during or prior to the COVID-19 pandemic. And so looking at the top analysis, this is white men during the pandemic versus prior to the pandemic, statistically insignificant odds ratio of 1.41 and the 95% confidence interval of 0.81 to 2.44. When we look at black men during the pandemic versus prior to the pandemic, odds ratio of 0.06 and 95% confidence interval 0.01 to 0.35. So 94% decreased odds of having a prostatectomy during the pandemic versus prior. Finally, looking at the bottom of this table, black men versus white men during the pandemic, 0.03 odds ratio with a hugely significant 95% confidence interval. So we certainly see that even as adjusted analyses, black men during the pandemic versus prior, as well as black men versus white men during the pandemic, significantly decreased odds of having a prostatectomy.
This final figure looks at the association of the COVID-19 lockdown by prostatectomy volume, stratified by the hospitals that were included in this study. The shutdown is this light blue, black patients are in this medium shade of blue, and white patients are in the dark blue. We can see that in Hospital A, 2019, they had essentially majority of the patients were white. And we see that this translates to really no change in Hospital A for white patients getting a prostatectomy in 2020 compared to 2019, but we see a reduction in the black patients undergoing prostatectomy.
Hospital B, we see majority of patients in 2019 having a prostatectomy were white with essentially no black patients and increasing the percentage of white patients having a prostatectomy in 2020. Looking at Hospital C, a similar sort of trend as Hospital A. Hospital D really did not perform hardly any prostatectomies during the shutdown, but the ones that they did were essentially white patients. And similarly in Hospital E, essentially no prostatectomies being performed during the pandemic of 2020.
So several discussion points from this study. This data showed a 90.9% lower rate of prostatectomy among black patients compared with 17.4% lower rate of prostatectomies among white patients during the COVID-19 pandemic. During the initial lockdown period, black patients experienced 94% lower odds of undergoing prostatectomy while white patients experienced essentially no changes in their likelihood of surgery. So one could postulate that patients may have been diverted to outpatient procedures, such as radiotherapy, as a potential reason for the decrease in surgical volume, but in a separate analysis, the authors found no concurrent increase in radiotherapy use.
So several slides for conclusions and summary points from this important study. This study demonstrated an association between surgical management of patients with prostate cancer during the COVID-19 pandemic and race. At the institutional level, each site tailored its approach to prostate cancer management and balanced the needs of its own community, given that prostate cancer, specifically intermediate risk prostate cancer, can typically be delayed in management. At the system level, facilities with greater reductions in surgery cared for more patients from racial minority communities, which was associated with a decrease in treatment of black prostate cancer patients.
This trend likely provides a window into the intrinsic biases present within our healthcare system, which is likely unfolding across all disciplines in medicine. The lessons from this study should help us recognize and offset the implications of our pandemic related decisions by prioritizing care in the underserved communities and to avoid reversing decades of effort that have worked to narrow racial and ethnic gaps in medical care. As COVID-19 cases continue to periodically surge, particularly with the new variants, these findings should eliminate the systemic biases within well-intentioned guidelines and act to guide future policies. Thank you very much, and we hope you enjoyed this UroToday Journal Club.