BOSTON Imagine you’re a 70-year-old black man with prostate cancer. Here’s what a new study reveals about your outlook:
You’re far more likely to get worse medical care than your white counterparts, including more time waiting for your surgery and more emergency room visits and hospital readmissions after surgery. You’ll also likely spend more money on your care. Oddly, though, that inferior care won’t necessarily translate into a worse chance of survival.
The study, published online by JAMA Oncology, specifically looked at a group of men on Medicare with localized prostate cancer. The standard of care for such patients involves either removal of the prostate gland (called a radical prostatectomy or RP), radiation therapy, a combination of the two, or active surveillance (close followup of patients).
Prostate cancer is one of the most frequently diagnosed cancers among men in the U.S., with estimates of about 220,800 new cases in 2015 and approximately 27,540 deaths.
Researchers analyzed data from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER)-Medicare database for 26,482 men 65 or older with localized prostate cancer who underwent radical prostatectomy. The patients included 2,020 black men (7.6 percent) and 24,462 non-Hispanic white men (92.4 percent).
Some key 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.
I asked the study’s lead researcher, Quoc-Dien Trinh, M.D., of Brigham and Women’s Hospital in Boston and Harvard Medical School, to further explain the findings. Here, edited, is our conversation:
Rachel Zimmerman: What are the most extreme examples of disparities you found between black men and white men treated for prostate cancer?
Quoc-Dien Trinh: Blacks were 35 percent less likely to undergo surgery with 3 months of diagnosis; Blacks were 45-48 percent more likely to require a visit to the emergency department after surgery; Blacks were 28 percent more likely to be readmitted after surgery; Blacks were 24 percent less likely to undergo a lymph node dissection at prostatectomy.
How do you account for these dramatic differences in care?
It is possible that blacks are not receiving their care at the best institutions and/or with the best providers.
In the article, I provide reasons why this cannot explain all of the differences, but we did show, in a previous article, that blacks often do not receive care at the best hospitals (those that perform the most surgeries, designated cancer centers, etc). That could explain why they are experiencing more delays, less lymph node removals, more readmissions.
In addition, some of it may be due to unmeasured confounders [for instance, the existence of other diseases patients may have or other factors not captured in the data, like their body mass index or smoking history]. We try to account for what is available in the Medicare data, but sometimes there is more to it. Indeed, severity of disease is poorly captured in administrative claims. Take this for an example: someone labelled as diabetic in Medicare claims can be a well-controlled patient taking a single drug, exercising frequently and eating well, whereas another diabetic can be severely affected with major complications to the heart, kidneys and blood vessels. Yet, claims data will label these two individuals as simply ‘diabetic.’
Also, there may be biological differences to explain the disparities. The pelvic anatomy of blacks is slightly different (more narrow, etc.). As a result, one may believe that they are at a higher risk of bleeding complications at surgery. This could lead to more emergency room visits, readmissions, costs, etc. Personally, I don’t think this can account for the differences, but it is a hypothesis.
How do you explain the comparable mortality even with the inferior care for black patients? Does this call into question this surgery?
Some of the metrics that were examined for quality of care would presumably affect the patient short-term quality of life after surgery, but not necessarily in the long run. For example, more emergency room visits are certainly not desirable, but it should not affect long-term survival after surgery. Although blacks experience a longer wait time before surgery, no study has clearly shown that it affects long-term cure rates.
A possible interpretation of our findings is that the biological differences in tumor aggressiveness among blacks may have been exaggerated, and that the perceived gap in survival is a result of lack of access or cultural perceptions with regard to surgical care, or other factors that differentiate who makes it to the operating table.
Finally, I’m not sure I agree that these findings call into question the surgery. A randomized trial from Scandinavia (SPCG-4) showed that surgery is superior to watchful waiting in men younger than 75 years with a life expectancy of more than 10 years. In the same dataset as the JAMA Oncology study, we also found that Medicare beneficiaries with a life expectancy of 10 years or more benefited from surgery, regardless of disease stage.
What’s the overall takeaway from this research?
Of course, there’s the access to care issue, but also, for me, the comparable survival is also important. For all that we’ve been saying about this population, when it comes to the older black men who go to the operating table and have insurance, their survival is comparable. That raises questions about all we’ve thought about African-Americans with prostate cancer.
There is no doubt that in general there is a gap in survival between blacks and whites with prostate cancer (that’s among all patients, with or without insurance, with or without metastatic disease, treated or not treated). In fact, that gap is widening. However, in Medicare beneficiaries who undergo prostatectomy, there was no difference.
So, what is different about this subgroup compared to the population studied in the paper which showed a gap?
1. We only studied patients with health insurance (we know that Blacks are underinsured compared to whites)
2. We only studied patients over 65
3. We only included patients with non-metastatic disease (blacks often present later, probably due to less access to care)
4. We only studied patients who underwent surgery (there is much data to suggest that Blacks are under-treated for prostate cancer)
Thus, when the conditions above are met, there are no difference in survival between the groups. My interpretation is that the access to care/access to treatment problem may be more important than any biological difference in disease aggressiveness between blacks and whites.
What should black patients, in particular, be aware of and how can these patients optimize their care?
This is a controversial question (given all the discussion about prostate cancer screening). As a minimum, I would say, once diagnosed with prostate cancer, they need to know their options, seek treatment when recommended, seek care at specialized centers/providers with expertise to deliver quality care.
How do we fix this problem?
Acknowledging the problem is the first step. Spreading the knowledge to the community is key to reducing these differences and providing better care for all, equally.
Accompanying the study is an opinion piece written by Dr. Otis Brawley, chief medical officer of the American Cancer Society, in he which speaks more generally about the racial disparities in health care that go far beyond any specific disease. Brawley writes:
Many of the lessons of this study are applicable to medical care of the American population in general and not just the care of men with prostate cancer.
In this population-based study, black men undergoing radical prostatectomy as definitive treatment tended to have longer waits for surgery, were less likely to undergo lymph node dissection, and were more likely to experience postoperative complications, have subsequent emergency department visits and readmission to hospital. In short, the study shows that black men were less likely to get high-quality care compared with white men….
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. In colon cancer, it has been shown that poor patients treated at low-volume hospitals are less likely to receive adequate colonic lymph node dissection.
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. This is an ethical issue. This is an issue of social injustice and a very unsettling point.