Investigating Racial Disparities in MRI-Fusion Biopsy Utilization in the Assessment of Prostate Cancer

It has been well-documented that, compared with their White counterparts, African American men have higher rates of prostate cancer (PCa) diagnoses, often present with more progressive disease at the time of initial diagnosis,¹ and are at a greater consequent risk for death. Moreover, numerous studies have confirmed that the more aggressive disease seen in African American men is largely attributable to socioeconomic inequality, including reduced access to advanced care.^2,3

Studies of Black patients whose access to care is equal to that of White patients report that their PCa outcomes are improved.⁴ This effect is likely due to advances in early detection and optimal early definitive management of PCa.

There have been critical and significant changes to the early detection and diagnosis of prostate cancer over the past few years. Among the most significant has been the adaptation and utilization of to improve the detection of clinically significant prostate cancer.⁵ This was confirmed in the seminal PRECISION trial published in 2018.⁶

Unfortunately, despite its clinical advantage and recognition and recommendation by major organizational guidelines,⁷ there is concern that African American men are less likely to receive MRI-guided biopsy than their White counterparts.⁸ However, it is not clear if this outcome can be attributed only to race or if it is correlated with other demographic factors such as socioeconomic status.

In a recent article in Urology, Roebuck et al reported lower MRI utilization in African American men compared with White men even when correcting for demographic and clinical factors.⁹ Their findings highlight an important and potentially actionable area to improve health equality, which would lead to improved outcomes for patients with prostate cancer.

Findings Among Prostate Cancer Patients

The retrospective investigation studied men at a single center who had received either a standard prostate biopsy or an MRI within the 6 months prior to biopsy. Demographic and clinical data were also collected. Between January 2018 and June 2020, 931 patients were enrolled in the study; 295 participants were Black, 561 were White, and 32% underwent MRI-guided biopsy.

There were significant differences seen in demographic, socioeconomic, and clinical factors (including age, insurance status, previous positive biopsy, and marital status) between patients who underwent MRI before biopsy and those who did not. Of patients with significant poverty, only 25% underwent MRI prior to biopsy. Before biopsy, only 18% (n=53) of Black patients received an MRI compared with 41% (n=228) of White patients.

Although not clinically significant, failure to receive an MRI before biopsy was also associated with lower income, lower education, and higher rates of unemployment. No significant findings were correlated with prostate-specific antigen status, prostate volume, family history of PCa, or digital rectal exam findings.

Of the patients who received an MRI, insurance status was significantly correlated with time between obtaining the MRI and undergoing biopsy. There was no association between time to biopsy and age, marital status, previous history of PCa, or degree of poverty. The researchers then accounted for the potential of the relationship and associations between socioeconomic and other demographic variables, and they found that Black men still were 54% less likely to receive MRI before biopsy when compared with White men.

The authors’ findings revealed an assessment of racial inequity when accounting for confounding variables and illustrate a significant disparity in the optimal detection of PCa. Black men were over 50% less likely to receive an MRI before biopsy even when adjusting for covariates. Previous research has found that equal access to care (e.g., through the US Department of Veterans Affairs) plays a critical role in reducing differences in the treatment of PCa,¹⁰ implying that actionable steps may be taken to improve equity in the early detection of PCa.

Limitations of the study included its retrospective single-center design and lack of assessment of PCa outcomes. Additionally, it is important to consider that correlation is not necessarily causation; there may be other confounding factors that were not addressed in this study.

The Importance of Access to MRI-Fusion Prostate Biopsy

Future clinical studies should continue to delve into the underlying etiology of prostate cancer—as well as factors that influence racial disparities in early detection, initial management, and long-term outcomes for patients—with an understanding of the disparities in the current healthcare system and an eye toward ways to improve access and health equity for all patients.

Patel and Gupta published a comment on this report alongside the initial study. They began by appreciating that the racial disparities in healthcare apply to many aspects of oncology. Indeed, several studies examining large databases have shown similar trends in bladder cancer, and previous studies have addressed the reduced likelihood for African American patients to undergo fusion biopsy when compared with White men.

They emphasized the Roebuck study’s importance in showing a continued race-related healthcare disparity when adjusting for multiple covariates, stating, “The findings that MRI biopsy use differs by race, independent of socioeconomic or clinical factors, is concerning.” MRI biopsy has become an important component of care that should be available to all patients. Read more about the disparities in prostate cancer therapies for African American men.

David Ambinder, MD is a urology resident at New York Medical College / Westchester Medical Center. His interests include surgical education, GU oncology and advancements in technology in urology. A significant portion of his research has been focused on litigation in urology. 

 

References

1. Moses KA, Orom H, Brasel A, Gaddy J, Underwood W 3rd. Racial/ethnic disparity in treatment for prostate cancer: does cancer severity matter? 2017;99:76-83. doi: 10.1016/j.urology.2016.07.045
2. Dess RT, Hartman HE, Mahal BA, et al. Association of black race with prostate cancer-specific and other-cause mortality. JAMA Oncol. 2019;5(7):975-983. doi: 10.1001/jamaoncol.2019.0826
3. Lu CD, Adeyemi O, Anderson WE, et al. Racial disparities in prostate specific antigen screening and referral to urology in a large, integrated health care system: a retrospective cohort study. J Urol. 2021;206(2):270-278. doi: 10.1097/JU0000000000001763
4. Riviere P, Luterstein E, Kumar A, et al. Survival of African American and non-Hispanic white men with prostate cancer in an equal-access health care system. 2020;126(8):1683-1690. doi: 10.1002/cncr.32666
5. Schoots IG, Roobol MJ, Nieboer D, Bangma CH, Steyerberg EW, Hunink MG. Magnetic resonance imaging-targeted biopsy may enhance the diagnostic accuracy of significant prostate cancer detection compared to standard transrectal ultrasound-guided biopsy: a systematic review and meta-analysis. Eur Urol. 2015;68(3):438-50. doi: 10.1016/j.eururo.2014.11.037
6. Kasivisvanathan V, Rannikko AS, Borghi M, et al; for the PRECISION Study Group Collaborators. MRI-targeted or standard biopsy for prostate-cancer diagnosis. N Engl J Med. 2018;378(19):1767-1777. doi: 10.1056/NEJMoa1801993
7. National Comprehensive Cancer Network®. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Prostate Cancer Early Detection. Version 1.2022. February 16, 2022. https://www.nccn.org/professionals/physician_gls/pdf/prostate_detection.pdf. Accessed April 18, 2022.
8. Hoge C, Verma S, Lama DJ, et al. Racial disparity in the utilization of multiparametric MRI-ultrasound fusion biopsy for the detection of prostate cancer. Prostate Cancer Prostatic Dis. 2020;23(4):567-572. doi: 10.1038/s41391-020-0223-5
9. Roebuck E, Sha W, Lu CD, et al. Racial and socioeconomic disparities in MRI-fusion biopsy utilization to assess for prostate cancer. [Online ahead of print.] 2022:S0090-4295(21)01201-2. doi: 10.1016/j.urology.2021.11.040
10. Optenberg SA, Thompson IM, Friedrichs P, Wojcik B, Stein CR, Kramer B. Race, treatment, and long-term survival from prostate cancer in an equal-access medical care delivery system. 1995;274(20):1599-1605.