The Impact of African American Race on Patterns of Care and Outcome in Prostate Cancer

Abstract

Objectives: We evaluated whether African Americans (AA) with intermediate to high-risk prostate cancer receive similar treatment as white patients and whether any observed disparities are persistent with time, across age groups, or by insurance status. Methods: We used the Surveillance, Epidemiology, and End Results (SEER) database to identify 128,189 men with localized intermediate to high-risk prostate cancer (PSA >= 10 or Gleason >= 7 or T stage >= T2b) diagnosed from 2004 – 2010. We used multivariable logistic regression analyses to determine the impact of race on the receipt of definitive treatment and Fine-Gray competing risks regression to determine the impact of race on cancer mortality. Results: After adjusting for treatment, demographics, and prognostic factors, AA men had a higher risk of prostate-cancer specific mortality (AHR 1.12; 95% CI 1.01 – 1.25; P = 0.03). AA men were significantly less likely to receive curative-intent treatment than white men (Adjusted Odds Ratio [AOR] 0.82; 95% CI 0.79 – 0.86; P < 0.001). There was no evidence of this disparity narrowing over time (Pinteraction 2010 vs. 2004 = 0.490). Disparities in the receipt of treatment between AA and white men were significantly larger in high-risk (AOR 0.60; 95% CI 0.56 – 0.64; P < 0.001) than in intermediate-risk disease (AOR 0.92; 95% CI 0.88 – 0.97; P = 0.04), (Pinteraction < 0.001). The adjusted odds of receiving definitive treatment for AA vs. white men was 0.67 (95% CI 0.62 – 0.73; P <0.001) among men age <70, but was 0.60 (95% CI 0.55 – 0.66; P <0.001) among men age >=70, suggesting increased racial disparity in the receipt of definitive treatment among older men (Pinteraction = 0.01). Among uninsured men, the adjusted OR for definitive treatment for AA vs. white was 0.38 (95% CI 0.27 – 0.54; P < 0.001), but among insured men, the adjusted OR was 0.62 (95% CI 0.57 – 0.66; P<0.001), (Pinteraction = 0.01). Conclusions: AA men with high-risk prostate cancer were significantly less likely to receive potentially life-saving definitive treatment when compared to white men. This disparity is worse in high-risk disease and among men age >=70, and is not improving over time. Having health insurance was associated with a reduction in this racial treatment disparity, suggesting that expansion of health insurance coverage may help reduce racial disparities in the management of aggressive prostate cancer. Factors underlying these treatment disparities should be urgently studied, as they are potentially correctable contributors to excess prostate cancer mortality among AA patients.