Despite great strides in prostate cancer treatment over the past several years, racial disparities in care persist, according to new data presented during the 2021 Annual Meeting of the American Urological Association (AUA). Three studies highlighting this topic were presented during a virtual press session, which was moderated by Brian McNeil, MD, AUA spokesperson and Associate Dean for Clinical Affairs in the College of Medicine at SUNY Downstate Health Sciences University.
Brian McNeil, MD
Racial Disparities in the Utilization of New Therapies for Advanced Prostate Cancer
Black and Hispanic men have a high burden of prostate cancer mortality. In 2010, the U.S. Food and Drug Administration (FDA) approved a new immunotherapy agent—sipuleucel-T—for treating metastatic castration-resistant prostate cancer.
In this first study presented during the briefing, researchers analyzed annual trends of men with metastatic castration-resistant prostate cancer treated with chemotherapy or immunotherapy between 2010 and 2015 using National Cancer Database data; they compared utilization by demographic and clinical features (Abstract PD34-03). A multivariate analysis was then performed to determine predictors of receiving immunotherapy vs chemotherapy.
Of the 1,238 patients included as part of the study, 63% were White, with private insurance.
Overall, there was increased utilization of immunotherapy from 2010 to 2013, followed by a decrease in 2015. Simultaneously, there was a decrease in utilization of chemotherapy from 2010 to 2013. The increased use of immunotherapy was predominately seen in White men and not seen in Black or Hispanic men. Chemotherapy seemed to be used more often in a comprehensive community cancer program.
The study authors concluded: “FDA approval of sipuleucel-T in 2010 for metastatic castration-resistant prostate cancer led to increased utilization of immunotherapy shortly thereafter, but this was mainly in White patients. Black and Hispanic patients proportionately did not exhibit increased utilization of this novel agent after 2010.”
Racial Disparities in Prostate Cancer Treatment in a Multi-institutional Regional Collaborative
Early in the COVID-19 pandemic, many cancer resources were diverted, leaving scores of patients—including those with prostate cancer—with limited or no access to surgical treatment. Although early-stage prostate cancer does not always require immediate treatment, in the second study presented in the briefing (Abstract PD03-02), researchers compared prostatectomy rates between Black and White patients with localized prostate cancer during the first wave of the COVID-19 pandemic with pre-pandemic rates.
A little more than 1% of Black men underwent prostatectomy during the initial wave of COVID-19, whereas 26% of White men underwent surgery; however, before the pandemic, there was no difference between either race in the rates of the prostatectomies.
Changes in surgical volume varied by site (33% increase to complete shutdown), with sites that experienced the largest reduction in cancer surgery caring for a greater proportion of Black patients.
Researchers concluded systemic inequities exist within health care and are likely applicable across medical specialties. Public health efforts are needed to fully recognize the unintended consequence of the diversion of cancer resources to the COVID-19 pandemic to develop balanced mitigation strategies as viral rates continue to fluctuate.
Molecular Profiling of Prostate Cancer Reveals Increased Inflammatory Markers and Poor Clinical Outcomes in Black Men
For years, researchers have been trying to understand why African American men tend to harbor more aggressive prostate cancer than men of other racial and ethnic groups; however, the underlying cause continues to remain controversial. These limited data prompted researchers in Michigan to explore the differences in tumor biology for African American and European American men with prostate cancer to better assess the impact on their outcomes (Abstract MP60-05).
Analyses of more than 1,500 probes were performed to assess the expression of 517 genes in radical prostatectomy specimens from nearly 640 African American and European American men. The primary endpoint was biochemical recurrence, and the secondary endpoint was prostate cancer–specific mortality.
A total of 24% of African American men and 18% of European American men developed biochemical recurrence.
African American men with Gleason grade 1 or 2 disease had a higher incidence of biochemical recurrence compared with Eastern European men following radical prostatectomy, suggesting a more aggressive biological behavior in African American men with early-stage disease. However, the biochemical recurrence risk was not significantly different between African American and European American men with Gleason grade 3 to 5 disease.
Differential gene expression and gene set enrichment analysis revealed upregulation of inflammation, TNF-alpha signaling, apoptosis, androgen response, and epithelial-to-mesenchymal transition—among other pathways—in African American men compared with European American men. The molecular profile of prostate cancer in African American men is different from that of European American men, with inflammation playing a prominent role.
"These studies highlight important research in better predicting the behavior and outcomes of prostate cancer in Black men compared to men of other racial and ethnic groups," concluded Dr. McNeil. "They also illuminate the systemic inequities and opportunities within health care to eliminate the burden of disease in minority populations."
Disclosure: For full disclosures of the study authors, visit auajournals.org.
