Racial and Ethnic Disparities in the Use of Prostate Magnetic Resonance Imaging Following an Elevated Prostate-Specific Antigen Test

Nino Abashidze,Richard Duszak,Chad Stecher,Andrew B Rosenkrantz,Danny R Hughes

doi:10.1001/jamanetworkopen.2021.32388

Abstract

Prostate cancer screening and diagnosis exhibit known racial and ethnic disparities. Whether these disparities persist in prostate magnetic resonance imaging (MRI) utilization after elevated prostate-specific antigen (PSA) results is poorly understood. To assess potential racial and ethnic disparities in prostate MRI utilization following elevated PSA results. This cohort study of 794 809 insured US men was drawn from deidentified medical claims between January 2011 and December 2017 obtained from a commercial claims database. Eligible participants were aged 40 years and older and received a single PSA result and no prior PSA screening or prostate MRI claims. Analysis was performed in January 2021. Multivariable logistic regression was used to examine associations between elevated PSA results and follow-up prostate MRI. For patients receiving prostate MRI, multivariable regressions were estimated for the time between PSA and subsequent prostate MRI. PSA thresholds explored included PSA levels above 2.5 ng/mL, 4 ng/mL, and 10 ng/mL. Analyses were stratified by race, ethnicity, and age. Of 794 809 participants, 51 500 (6.5%) had PSA levels above 4 ng/mL; of these, 1524 (3.0%) underwent prostate MRI within 180 days. In this sample, mean (SD) age was 59.8 (11.3) years (range 40-89 years); 31 350 (3.9%) were Asian, 75 935 (9.6%) were Black, 107 956 (13.6%) were Hispanic, and 455 214 (57.3%) were White. Compared with White patients, Black patients with PSA levels above 4 ng/mL and 10 ng/mL were 24.1% (odds ratio [OR], 0.78; 95% CI, 0.65-0.89) and 35.0% (OR, 0.65; 95% CI, 0.50-0.85) less likely to undergo subsequent prostate MRI, respectively. Asian patients with PSA levels higher than 4 ng/mL (OR, 0.76; 95% CI, 0.58-0.99) and Hispanic patients with PSA levels above 10 ng/mL (OR, 0.77; 95% CI, 0.59-0.99) were also less likely to undergo subsequent prostate MRI compared with White patients. Black patients between ages 65 and 74 years with PSA above 4 ng/mL and 10 ng/mL were 23.6% (OR, 0.76; 95% CI, 0.64-0.91) and 43.9% (OR, 0.56; 95% CI, 0.35-0.91) less likely to undergo MRI, respectively. Race and ethnicity were not significantly associated with mean time between PSA and MRI. Among men with elevated PSA results, racial and ethnic disparities were evident in subsequent prostate MRI utilization and were more pronounced at higher PSA thresholds. Further research is needed to better understand and mitigate physician decision-making biases and other potential sources of disparities in prostate cancer diagnosis and management.

Highlights

In the US, racial and ethnic disparities have been identified in multiple aspects of prostate cancer diagnosis and treatment.[1,2,3,4] Black patients are less likely to undergo appropriate prostate-specific antigen (PSA) screening,[5] less likely to undergo intensive follow-up while on close monitoring for low-risk prostate cancer,[6,7] and less likely to undergo PSA surveillance after radical prostatectomy.[8]
Compared with White patients, Black patients with PSA levels above 4 ng/mL and 10 ng/mL were 24.1% and 35.0% (OR, 0.65; 95% CI, 0.50-0.85) less likely to undergo subsequent prostate magnetic resonance imaging (MRI), respectively
Asian patients with PSA levels higher than 4 ng/mL (OR, 0.76; 95% CI, 0.58-0.99) and Hispanic patients with PSA levels above 10 ng/mL (OR, 0.77; 95% CI, 0.59-0.99) were less likely to undergo subsequent prostate MRI compared with White patients

Summary

Introduction

In the US, racial and ethnic disparities have been identified in multiple aspects of prostate cancer diagnosis and treatment.[1,2,3,4] Black patients are less likely to undergo appropriate prostate-specific antigen (PSA) screening,[5] less likely to undergo intensive follow-up while on close monitoring for low-risk prostate cancer (ie, active surveillance),[6,7] and less likely to undergo PSA surveillance after radical prostatectomy.[8] Such variation in care contributes to increased mortality in Black patients diagnosed with prostate cancer.[4,9]. Accurate prostate cancer diagnoses can help reduce disparities in health outcomes. A prostate MRI may obviate the need for biopsy, decreasing the overdiagnosis of insignificant prostate cancer.[20]

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