Understanding variation and equity in the use of advanced testing is particularly important because early imbalances in testing may exacerbate deep existing disparities in prostate cancer care, such as significantly higher disease mortality among Black versus White patients.5 As these tools represent a new “state of the art” for prostate cancer care, we sought to evaluate the existing evidence about geographic variation and racial disparity in the use of testing.
Most studies evaluating the racial disparities in prostate MRI use are retrospective database analyses of usage differences amongst different groups.1,6,7 These studies have consistently shown that Black patients with prostate cancer are less likely to receive a prostate MRI as compared with White patients. For example, in one study of Medicare Advantage and privately insured men, Black patients were significantly less likely to undergo prostate MRI than White patients (odds ratio, OR 0.60, 95% CI 0.47-0.88, p<0.01), and in another study of Surveillance, Epidemiology, and End Results (SEER) Medicare patients, Black patients also experienced decreased odds of prostate MRI use (OR 0.72 (95% CI 0.55–0.93); p < 0.04)).7,8 We highlight one study from our group that used mediation analysis to estimate the extent to which clinical, sociodemographic, and structural processes (including racialized residential segregation) may underlie the observed disparity in receipt of prostate MRI. In this analysis, 81% of the Black versus White disparity in prostate MRI use was attributed to identified mediators including geographic variation, neighborhood level socioeconomic status, racialized residential segregation, and individual-level socioeconomic status. Notably, patient prostate cancer clinical features were not significant mediators.2
Prior studies have also examined variation in the use of genomic testing. Among commercially-insured patients with prostate cancer, there was marked variation in testing between regions. Regions that adopted genomic testing more rapidly generally had higher median income, education, urologist density, and higher rates of PSA testing.9 These findings suggest some alignment between early uptake of new technologies and other measures of healthcare access. Less information on racial disparities at the patient level is available and suggests important opportunities for study in the future.
In summary, these findings highlight that the development and clinical integration of new risk assessment technologies in prostate cancer have unfortunately been accompanied by marked sociodemographic variation and racial disparity. Given the potential to worsen imbalances in prostate cancer detection, treatment, and outcome, a better understanding of the sources of variation, as well as clearer clinical guidelines for testing may be informative for further standardizing care. To this end, future work may also explore implementation strategies such as education, decision-support, and performance feedback to improve prostate cancer care quality.
Written by:
- Folawiyo Laditi, Yale University School of Medicine, New Haven, CT, USA
- Michael S. Leapman, MD, MHS, Department of Urology, Yale School of Medicine, New Haven, CT, USA
- Leapman, M. S. et al. Association between prostate magnetic resonance imaging and observation for low-risk prostate cancer. Urology 124, 98–106 (2019).
- Leapman, M. S. et al. Adoption of new risk stratification technologies within US hospital referral regions and association with prostate cancer management. JAMA Netw. Open 4, e2128646 (2021).
- Cole, A. P. et al. Geographic variability, time trends and association of preoperative magnetic resonance imaging with surgical outcomes for elderly United States men with prostate cancer: A surveillance, epidemiology, and end results-medicare analysis. J. Urol. 208, 609–617 (2022).
- Rajwa, P. et al. The prognostic association of prostate MRI PI-RADSTM v2 assessment category and risk of biochemical recurrence after definitive local therapy for prostate cancer: A systematic review and meta-analysis. J. Urol. 206, 507–516 (2021).
- Wen, W., Luckenbaugh, A. N., Bayley, C. E., Penson, D. F. & Shu, X.-O. Racial disparities in mortality for patients with prostate cancer after radical prostatectomy. Cancer 127, 1517–1528 (2021).
- Abashidze, N., Stecher, C., Rosenkrantz, A. B., Duszak, R., Jr & Hughes, D. R. Racial and ethnic disparities in the use of prostate magnetic resonance imaging following an elevated prostate-specific antigen test. JAMA Netw. Open 4, e2132388 (2021).
- Kim, S. P. et al. Contemporary trends in magnetic resonance imaging at the time of prostate biopsy: Results from a large private insurance database. Eur. Urol. Focus 7, 86–94 (2021).
- Fam, M. M. et al. Increasing utilization of multiparametric magnetic resonance imaging in prostate cancer active surveillance. Urology 130, 99–105 (2019).
- Leapman, M. S., Wang, R., Ma, S., Gross, C. P. & Ma, X. Regional adoption of commercial gene expression testing for prostate cancer. JAMA Oncol. 7, 52–58 (2021).