Within urologic oncology, equitable access to care and treatment remains a goal toward which the healthcare system must strive. Urology, also known as the “Gold Journal”, has released a 2-volume series of articles focused on diversity, equity, and inclusion in urology. Volume 2 contains several important articles investigating the role of diversity, equity, and inclusion in the context of prostate cancer care. In this edition of GU Oncology Now, we review these articles and summarize their key findings and relevance to prostate cancer care.
It is estimated that prostate cancer will be diagnosed in nearly 268,000 men in 2022, and a large number of these men (~34,500) will experience mortality from the disease.1 In the United States, prostate cancer-related mortality is the third most common cause of cancer-related death in men.2 Prostate cancer affects men of African American descent more frequently than those of European or Hispanic ancestry, and it is diagnosed in African Americans at earlier ages.3
Despite observational analyses demonstrating that African American men with prostate cancer have worse outcomes, several studies have shown that when these patients receive appropriate timely care, their risk of prostate cancer-specific mortality is equivalent to that in other racial groups. For example, in a Veterans Affairs hospital system analysis, Paller et al demonstrated that when patients received the same timely care for a given stage of prostate cancer, prostate cancer-specific mortality in African Americans men was equivalent to that for non-African Americans.4
Esdaille et al conducted a narrative review of access to clinical trials and precision oncology in prostate cancer care for African American men in the United States.5 They explain that clinical trials for prostate cancer are the cornerstone of finding effective treatments, yet African American men remain underrepresented in prostate cancer clinical trials. As an example, in another publication, these authors cited that only 9% of the patients were African American in the famous CHAARTED study investigating the role of docetaxel and androgen-deprivation therapy in metastatic prostate cancer.6
Barriers to enrollment in clinical trials include preexisting medical conditions, limited insurance coverage, and awareness of clinical trials. The authors explain that many clinical trials inadvertently exclude African American men due to exclusion criteria for comorbidities. A second reversible risk factor they identified was the underrepresentation of African American investigators in the clinical trial space. They explain that this underrepresentation results in decreased referral patterns and screening of patients for clinical trials. They advocate for diversifying the clinical investigator workforce to help alleviate this issue of underrepresentation.
Biomarkers are another area of potential inequity. The authors explain that several prominent diagnostic markers, including Prolaris® and Oncotype DX®, have come into widespread use in precision oncology care; however, the studies exploring their function and utility are conducted primarily in White populations. This raises the question of whether these biomarkers perform similarly in African Americans. To help address these disparities, the authors advocate for further validation studies. For example, they explain that the 4Kscore® test, which is commonly used before prostate biopsy in the setting of elevated prostate-specific antigen (PSA) or an abnormal digital rectal exam, was validated in African American men in 2018 and led to coverage by Medicare in 2019.
The authors also recommend further investment and research into understanding the prostate cancer tumor microenvironment in African Americans. As one approach to alleviating some of these concerns, they recommend increasing funding to minority-focused institutions as recruitment sites for clinical trials and using focused enrollment techniques to facilitate higher levels of African American representation in clinical trials.
In their review article, Vince et al examined disparities in the prostate cancer screening pathway for African American men.7 They explain that African Americans less frequently undergo routine screening for prostate cancer compared with other racial/ethnic groups. To elaborate on this point, they explained that several large screening trials, including the Prostate, Lung, Colorectal and Ovarian (PLCO) trial, the European Randomized study of Screening for Prostate Cancer (ERSPC), and the Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP)which together represent nearly 750,000 patientsincluded only 3,375 African Americans in their study population.
The authors explain that delays in diagnosis often result in higher PSA levels and tumor volumes at the time of eventual diagnosis. Access to care also remains a widespread problem. The authors note that African American men are more likely than other men to lack health insurance, which consequently leads to delays in treatment. They highlight an analysis of nearly 140,000 patients with localized prostate cancer which found that uninsured patients were significantly more likely to receive definitive prostate cancer therapy. Such issues may contribute to the disparities in prostate cancer-specific outcomes.8 The authors explain that although there is no biological basis for more aggressive prostate cancer in African Americans that would explain worse clinical outcomes, prostate cancer-specific mortality rates remain higher in this population. They advocate for further resources to be allocated to validating and exploring the etiology of this disparity.
In regard to the relation between prostate cancer and sexual orientation, Wilcox Vanden Berg et al sought to identify trends in prostate cancer screening in the gay and bisexual male community.9 To provide a rationale for the investigation, the authors explain that several studies have demonstrated health disparities among sexual minorities (gay, bisexual, transgender) and that prostate cancer screening in this population remains underdefined. Moreover, they cite that only 1.8% of National Institutes of Health-funded sexual and gender minority research was dedicated to issues in oncology.
Data for the study were obtained from the National Health Interview Survey (NHIS). The authors included data from 22,825 patients of whom 2.5% identified as gay or bisexual. They reported that gay men were more likely to be screened for prostate cancer compared with bisexual or straight men. Gay men were also screened at younger ages. In their discussion, the authors note that while the drivers behind this trend remain unclear, some theories include enhanced physician-patient relationships in this population, owing to HIV education campaigns and greater awareness of prostate cancer because they have male partners. Interestingly, the results showed that bisexual men did not have the same benefit as gay men in regard to prostate cancer screening.
The authors suggest that these populations may be more likely to lack of health insurance coverage and suffer from psychological stress. They advocate for further research to focus on the etiology of earlier screening in this population compared with the heterosexual male population. The overall takeaway from these articles, and several other exceptional reports, is that health disparities and equitable access to prostate cancer care remain significant issues in the United States. It is hoped that increasing awareness through funding of research projects that focus on underserved populations will yield improvements in care for these patients.
Akhil Abraham Saji, MD is a urology resident at New York Medical College / Westchester Medical Center. His interests include urology education and machine learning applications in urologic care. He is a founding and current member of the EMPIRE Urology New York AUA section team.