Racial inequalities in prostate cancer treatment among Medicare beneficiaries

From Dr. Yaw Nyame, Fred Hutch Public Health Sciences Division and the University of Washington

Racial disparities in the US extend to the quality of cancer treatment. These racial inequities are highlighted in the case of localized prostate cancer. Early stage prostate cancer has a fairly high overall survival when diagnosed early and treated properly. Alarmingly, “Black men are over twice as likely to die from prostate cancer compared to their peers. This is largely driven by the impact of structural and social determinants of health including systemic racism. We wanted to evaluate how these factors could impact the quality of care Black men receive with regards to prostate cancer,” explained Dr. Yaw Nyame, a surgeon at the University of Washington (UW) and faculty in the Fred Hutch Public Health Sciences Division. Although disparities in treatment and outcome have been well described in prostate cancer literature, few studies have sought to understand how and why structural and social factors drive prostate cancer disparities. Dr. Nyame and his mentors’ (Drs. John Gore and Ruth Etzioni) findings, which highlight the differences in prostate cancer treatment across races, were recently published in Cancer.

As a surgeon-scientist at UW/Fred Hutch, Dr. Nyame specializes in the treatment of prostate, bladder, kidney and testicular cancers. He explains, “My research practice is focused on using patient-centered and community-partnered research methods to drive equitable care and outcomes among Black men with prostate cancer.” In their recent publication, Nyame et al. examined Medicare beneficiaries receiving prostate cancer treatment and analyzed available patient data in the Surveillance, Epidemiology and End Results cancer registry data linked to Medicare claims (SEER-Medicare) to perform a retrospective study. The researchers first characterized the demographics of their study population which included over 31,000 individuals where men were classified as White, Black, Hispanic or ‘other’. Black men represented 6.7% of men in this study and were of lower socioeconomic status (i.e., having a lower annual income), with a lower percentage of men from this population having received a college education compared to White males included in this study. Black men were younger at the time of diagnosis and had a longer time between diagnosis and surgery, despite generally having higher prostate-specific antigen (PSA) levels, a prognostic biomarker that is used in prostate cancer screenings.

The researchers next asked whether there were differences in the quality of cancer care received between different races and evaluated this at the surgeon and treatment facility level. To estimate treatment quality, the investigators used surgical volume as a surrogate. Various studies have demonstrated that radical prostatectomy volume, or the number of surgeries that remove the prostate for treatment of cancer, is a strong measure of quality as determined by patient outcomes and mortality. This correlation is true for other surgeries as well, not just for prostate cancer. Likewise, surgeons and facilities with lower volumes have been associated with lower rates of board certification and less access to cancer-specific clinical resources, respectively. When the researchers asked if men of different races received care from facilities or surgeons with low or high-volume, they found a lower percentage of Black men received care from facilities with high-volumes and were less likely to receive care from a surgeon in the top volume percentile compared with other races. In line with these findings, Black men were less likely to receive care at a National Cancer Institute-designated Comprehensive Cancer Center (like Fred Hutch) and more likely to be treated at a minority-serving hospital. Furthermore, White men were more likely to travel outside of their hospital service area, while Black men were more likely to be treated at local hospitals that were also larger in size. In this cohort being analyzed, 33% and 20% of Black men were treated by a surgeon or facility in the top 10th percentile of volume respectively, compared with 43% and 32% of white men.

Surgery by volume across races.
Surgery by volume across races. Image provided by Dr. Yaw Nyame.

How do these different treatment facilities and race play into the overall health outcomes of Black prostate cancer patients? Nyame et al. sought to answer this question by evaluating whether any of these factors were associated with an increase in mortality. Here, the researchers found that Black race in addition to treatment at or by low volume facilities or surgeons was associated with an increased risk of death from all causes. Even after adjusting for surgeon or facility volume, Black race remained associated with a higher risk of mortality. However, when the research team compared Black men treated at low volume facilities with Black men treated at higher volume facilities, the researchers found an increased risk of death due to prostate cancer only for those treated at low volume facilities. Receiving care from surgeons and facilities with lower volumes was associated with a staggering 61% increased risk of death from prostate cancer among Black men. Dr. Nyame says this finding was unexpected and “was true despite shorter follow-up.  It is unclear what drives this finding, but I think it is a reflection of the resource poor environments in which some of this care is delivered, which may limit access to valuable diagnostic tests and novel therapies among patients diagnosed and treated at these safety-net facilities.”

This research emphasizes the striking inequality in the quality of cancer care received by Black individuals. It also highlights the dire need to develop interventions that ensure accessible care across races. “Prostate cancer is a heterogeneous cancer and it is challenging to perform all the required testing and analyses to navigate the wide range of treatment options,” Nyame remarks. As to what changes could be easily implemented to improve prostate cancer treatment, Nyame adds “I think improving the quality of information available to patients to aide decision making and encouraging/facilitating second opinions are two important changes to consider.” This work also reflects the impact of factors such as structural racism, public policy and social determinants on care delivery. Recognizing the factors that drive this inequity is an important step in developing interventions to create parity in the delivery of high-quality prostate cancer care to Black men. Nyame exclaims, “Our hope is to bring the results of this study to our community partners at BACPAC (Black & African-Descent Collaborative for Prostate Cancer ACtion) to better understand how we can help Black men access higher quality care when they are diagnosed with prostate cancer. We rely heavily on our community partnerships to drive new areas of scientific work and intervention design, testing, and implementation.” In addition to his work with BACPAC, Dr. Nyame states that moving forward, “We are using this work and other projects we are completing as pilot data for a community-partnered project to help drive Black men towards high quality treatment when they are diagnosed with significant localized prostate cancers.”

This work was supported by the Department of Defense and National Cancer Institute Specialized Programs of Research Excellence.

UW/Fred Hutch Cancer Consortium members Yaw Nyame, Ruth Etzioni and John Gore contributed to this work.

Nyame YA, Holt SK, Etzioni RD, Gore JL. Racial inequities in the quality of surgical care among Medicare beneficiaries with localized prostate cancer. Cancer. 2023 Feb 13. doi: 10.1002/cncr.34681. Epub ahead of print. PMID: 36776124.