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Blacks receive inferior care for localized prostate cancer

Key clinical point: Compared with whites, black patients with localized prostate cancer received lower quality of care.

Major finding: Blacks were less likely to undergo lymph node dissection than whites (52.8% vs. 61.5%; OR, 0.76; P less than .001), and had more postoperative complications, emergency department visits, and readmissions (P less than .05 for all comparisons).

Data source: A retrospective analysis of Medicare billing records of 26,482 patients (7.6% blacks and 92.4% non-Hispanic whites) who underwent radical prostatectomy from 1992 through 2009.

Disclosures: Dr. Schmid reported having no relevant financial disclosures. Several of her coauthors reported financial ties to several industry sources.

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Clear evidence that quality of care differs by race

The findings of the study by Dr. Schmid and her colleagues point to racial health inequalities in the United States and are applicable to medical care of the American population in general, not just to men with prostate cancer.

Dr. Otis Brawley

Despite the fact that black patients in this study had insurance and access to care and were considered healthy enough for surgery, there was still a disparity in quality of care. Interestingly, there were no differences between the groups in all-cause or cancer-specific mortality. This is hard evidence that the biology of prostate cancer is similar for black and white men with localized disease.

Is the disparity in quality of care due to racism on the part of physicians? Probably not. More likely, 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.

Even though a significant proportion of blacks received inferior treatment, similar outcomes for the two groups suggests that some patients with localized prostate cancer are overtreated, and the medical community should be more discerning in who receives treatment.

Dr. Otis Brawley is the chief medical officer for the American Cancer Society and professor of hematology, oncology, medicine, and epidemiology at Emory University, Atlanta. These remarks were part of an editorial accompanying the report (JAMA Oncol. 2015 Oct 22. doi: 10.1001/jamaoncol/2015.3384). Dr. Brawley reported having no relevant financial disclosures.


 

FROM JAMA ONCOLOGY

References

Black patients with localized prostate cancer who underwent radical prostatectomy received inferior surgical care, compared with whites, as evidenced by fewer lymph node dissections and longer delays from diagnosis to treatment, among other indicators, researchers reported.

The time from diagnosis to treatment was longer in blacks than whites (79 vs. 71 days, P = .001). Overall, 57.7% of blacks had surgery without adjuvant therapy, compared with 61.3% of whites (P = .001). Blacks were less likely to undergo lymph node dissection (52.8% vs. 61.5%, P less than .001). The difference persisted but was not significant when the lymph node dissection analysis was restricted to patients with intermediate- and high-risk disease. Blacks were more likely to visit the emergency department within 30 days (P = .04) and beyond 30 days (P = .006) (JAMA Oncol. 2015 Oct 22. doi: 10.1001/jamaoncol/2015.3384).

When the lymph node dissection analysis was adjusted for geographic location (health service area), there were no differences between groups, which suggests that geographic variation in quality of care is tightly linked to racial disparities and may account for a large proportion of the differences.

The retrospective analysis of Medicare billing records evaluated 26,482 patients (2,020 blacks [7.6%] and 24,462 non-Hispanic whites [92.4%]) who underwent radical prostatectomy from 1992 through 2009.

Prostate cancer–specific mortality was not significantly different between blacks and whites. Unadjusted overall mortality was increased in blacks, but after adjustment for geographic location, overall mortality was similar between groups.

“Despite important constellations of poor quality of care for blacks undergoing [radical prostatectomy], we did not detect significant differences in overall and cancer-specific survival,” wrote Dr. Marianne Schmid of Brigham and Women’s Hospital, Harvard Medical School, Boston, and her colleagues. Furthermore, the research revealed no regional variation in cancer-specific mortality among patients who underwent surgery.

“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 for [prostate cancer] or other factors that differentiate who makes it to the operating table,” the researchers noted.

Median total calculated costs were lower for blacks ($13,015 vs. $15,758), but surgical treatment was associated with higher incremental annual costs, with the top 50% spending $1,185 more. Increased costs are likely due to the higher prevalence of radiotherapy and androgen deprivation therapy, and increased rates of emergency department visits, rather than the use of newer, more expensive technologies.

The research indicates that unfavorable quality of care for black patients did not translate to worse overall survival and cancer-specific survival. Rather, lower survival among black patients with prostate cancer may result from barriers to definitive treatment, according to the investigators.

Dr. Schmid reported having no relevant financial disclosures. Several of her coauthors reported financial ties to several industry sources.

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