Racial differences in outcomes, costs of care in older men with prostate cancer

Older black men with localized prostate cancer were more likely to have poorer quality care, incur higher costs and have worse postoperative outcomes than white men but that did not translate to worse overall or cancer-specific survival, according to an article published online by JAMA Oncology.

Prostate cancer is a frequently diagnosed cancer among men in the United States with an estimated 233,000 new cases in 2014. The treatment of prostate cancer is driven, in part, by the severity of disease at presentation. Definitive therapy for localized prostate cancer with the intention of curing it is radical prostatectomy (RP, removal of the prostate gland), radiotherapy or a combination thereof.

Quoc-Dien Trinh, M.D., of Brigham and Women's Hospital, Harvard Medical School, Boston, and coauthors looked at the effect of race on quality of care and survival of men receiving RP for localized prostate cancer. They used data from the Surveillance, Epidemiology and End Results (SEER)-Medicare database for 26,482 men 65 or older with localized prostate cancer who underwent radical prostatectomy: 2,020 black men (7.6 percent) and 24,462 non-Hispanic white men (92.4 percent).

While the authors found no difference in cancer-specific or overall death between black and white men with localized prostate cancer, the authors note several other findings:

• 59.4 percent of black men underwent RP within 90 days vs. 69.5 percent of white men.
• Black men had a seven-day treatment delay compared with white men in the top 50 percent of patients.
• Black men were less likely to undergo lymph node dissection.
• Black men were more likely to have postoperative visits to the emergency department or be readmitted to the hospital compared with white men.
• The top 50 percent of black patients had higher incremental annual costs for surgery, spending $1,185 more compared to white patients.

Limitations to the study include that it was comprised only of Medicare enrollees 65 or older and the authors acknowledge that most men being treated with RP are younger and have private health insurance, so the findings may not be generalizable to the general population of men having RP.

"We provide robust evidence for the existence of a substantial difference in the quality of surgical care of PCa (localized prostate cancer) in blacks. Because the unfavorable quality of care did not translate into worse overall and cancer-specific survival in our sample, the commonly perceived detrimental survival in black patients with PCa may be the sequelae of barriers and selection bias in definitive treatment. Public and professional awareness needs to be raised to address these concerning issues and identify their underlying causes," the authors conclude.

In a related commentary, Otis W. Brawley, M.D., M.A.C.P., of the American Cancer Society and Emory University, Atlanta, writes: "The black patients in this study have insurance and access to care and were deemed healthy enough for surgery, but there was still a disparity in quality of that care. ... This study documents clear evidence that quality of care differs by race. ... Race is an important sociopolitical categorization as quality of care differs. The reason is debatable. Is it racism on the part of physicians? I personally doubt it. My hypothesis is that a higher proportion of black men have physicians who do not routinely perform radical prostatectomies and a higher proportion of blacks are treated at hospitals that have a low volume of prostate surgery. It is widely established that physicians and hospitals that have high volumes of radical prostatectomy have better outcomes. ... It is my belief that quality health care is a basic human right. While many blacks get superb health care, being black in America means one is less likely to receive quality care and more likely to have a bad outcome. Schmid and colleagues show this in localized prostate cancer, and it is likely true for other diseases."