Equal access to health care reduces racial disparities in prostate cancer outcomes.

Abstract

The recently published article by Riviere et al,1 in which the authors investigated the survival of African American (AA) and non-Hispanic white (NHW) patients with prostate cancer (PCa) in the Veterans Affairs (VA) health care system, was of great interest to us. It is well documented that the racial disparity in PCa is among the largest in all cancer diagnoses,2 with AA men presenting at a younger age, with more advanced disease, and with increased mortality compared with white men.3 It commonly is accepted that genetic and/or biologic factors play a significant role in the racial differences observed in PCa outcomes, yet there is growing evidence that access-related variables may play an increasingly important role.4 Using the VA health care system, Riviere et al1 were able to evaluate PCa outcomes in an equal-access system and add to the growing literature of access-related variables contributing to the racial disparities noted with regard to PCa outcomes. Their study1 had some interesting outcomes that warrant discussion. First, Riviere et al found that AA men had a significantly lower 10-year prostate cancer–specific morality (PCSM) rate compared with NHW men.1 This was confirmed further in multivariable competing risk analysis after controlling for factors such as age, body mass index, smoking history, stage of disease, clinical T and M classifications, log-transformed prostate-specific antigen (PSA) level, and other variables.1 It is interesting to note that although Riviere et al found that AA men present at a younger age and with a higher PSA level, they were slightly less likely to present with Gleason score 8 to 10 disease, a clinical T classification of ≥3, or distant metastatic disease.1 The study by Riviere et al1 has provided strong evidence against some of the common adages found in the PCa literature. First, AA men did not have significantly higher PCa mortality rates compared with NHW men in the equal-access VA health care system. This result is supported by the recent study by Dess et al,4 who found that after controlling for nonbiological differences such as access to care and standardized treatment, black race was not associated with inferior stage-to-stage PCSM. This large analysis of 306,100 patients included 5 VA hospitals, and within this VA subgroup, the PCSM of AA men was found to be similar to that of NHW men.4 Although Riviere et al1 did find that AA men presented at a younger age and with a higher PSA level compared with NHW men, they did not present with higher grade disease compared with NHW men. This provides evidence that previous studies linking AA race with more aggressive disease at the time of presentation may be a result of access-related variables instead of genetic and/or biologic causes. The paradigm of understanding the racial differences in PCa outcomes is beginning to shift toward investigating the depth to which these health care disparities run. Multiparametric magnetic resonance imaging–ultrasound fusion biopsy is increasingly being used for the evaluation of men with clinical suspicion of PCa because it has been found to increase the detection of clinically significant cancer while decreasing the detection of clinically insignificant cancer compared with the standard 12-core systematic biopsy.5 Our recently published analysis found that biopsy-naive AA men were significantly less likely to receive multiparametric magnetic resonance imaging–ultrasound fusion biopsy compared with white men, thereby providing some evidence of the true depth at which the racial disparities in PCa exist, even extending to how it initially is diagnosed.6 Although it is unclear whether the improved PCSM among AA men noted in the study by Riviere et al1 was due to equal access to health care or factors such as more aggressive PCa screening, similar treatment choices, or consistent follow-up, it provides compelling evidence that equal access to health care may help to reduce the racial disparities noted among PCa outcomes. We are hoping that further studies exploring equitable access and quality of health care can help to better explain the racial differences observed in PCa outcomes. No specific funding was disclosed. The authors made no disclosures.