Costs, adverse event rates higher among black men who undergo radical prostatectomy

Black men who underwent radical prostatectomy for localized prostate cancer appeared more likely to experience adverse events and incur higher costs than non-Hispanic white men, according to results of a retrospective analysis.

However, despite these disparities, researchers observed no difference in prostate cancer-specific or all-cause mortality based on patients’ race.

Marianne Schmid, MD, of the Center for Surgery and Public Health within Brigham and Women’s Hospital’s division of urologic surgery, and colleagues used the SEER database to identify 26,482 men aged 65 years and older with localized prostate cancer who underwent radical prostatectomy between 1992 and 2009.

The analysis included 24,462 (92.4%) non-Hispanic white men and 2,020 (7.6%) black men, all of whom underwent radical prostatectomy within the first year of prostate cancer diagnosis.

The researchers used Cox proportional hazards regression to evaluate process of care — including time to treatment and receipt of lymph node dissection — as well as outcome measures, which included complications, ED visits, hospital readmissions, costs, prostate cancer-specific mortality and all-cause mortality.

Schmid and colleagues used multivariable conditional logistic regression and quantile regression to assess the associations between racial disparities and either process of care and outcome measures.

A lower percentage of black men than white men underwent radical prostatectomy within 90 days (59.4% vs. 69.5%; P < .001). Multivariable analyses showed black patients were less likely to undergo radical prostatectomy within 3 months of diagnosis (OR = 0.65; 95% CI, 0.59-0.71).

Quantile regression of the top 50% of patients showed black men experienced a treatment delay compared with white patients (mean, 79 days vs. 71 days; P = .001). This disparity persisted at 6 months — by which time 18% of black patients and 11% of white patients had not undergone surgery — and at 9 months, when 12.3% of black patients and 7% of white patients had not undergone surgery (P < .001).

Results showed black patients were less likely than white patients to undergo lymph node dissection (OR = 0.76; 95% CI, 0.66-0.8). This disparity remained intact in sensitivity analyses limited to intermediate-risk patients (OR = 0.96; 95% CI, 0.77-1.1) and high-risk patients (OR = 0.92; 95% CI, 0.67-1.05).

After radical prostatectomy, black patients appeared more likely than white patients to have postoperative visits to the ED within 30 days (OR = 1.48; 95% CI, 1.18-1.86) and after 30 days (OR = 1.45; 95% CI, 1.19-1.76). They also were more likely to have readmissions within 30 days (OR = 1.28; 95% CI, 1.02-1.61) and after 30 days (OR = 1.27; 95% CI, 1.07-1.51).

Black men also incurred significantly higher incremental annual costs, with the top 50% of black men spending $1,185.50 more than the top 50% of white men (95% CI, $804.85-$1,566.10).

Despite these disparities, results of a sensitivity analysis — restricted to patients treated between 1992 and 1999, with median follow-up of 150 months — revealed no significant difference in prostate cancer-specific mortality (HR = 1.02; 95% CI, 0.9-1.15) or all-cause mortality (HR = 0.95; 95% CI, 0.65-1.38) between black men and non-Hispanic white men.

Otis W. Brawley

“We provide robust evidence for the existence of a substantial difference in the quality of surgical care of localized prostate cancer in [black men],” Schmid said. “Because the unfavorable quality of care did not translate into worse overall and cancer-specific survival in our sample, the commonly perceived detrimental survival in black patients with [prostate cancer] may be the sequelae of barriers and selection bias in definitive treatment. Public and professional awareness needs to be raised to address these concerning issues and identify their underlying causes.”

In a related editorial, Otis W. Brawley, MD, MACP, chief medical officer of the American Cancer Society and a HemOnc Today Editorial Board member, said he did not believe the disparities were driven by racism.

“My hypothesis is that 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,” Brawley wrote. “It is widely established that physicians and hospitals that have high volumes of radical prostatectomy have better outcomes.”

Regardless of the cause, the disparities are “unsettling” and need to be addressed, Brawley wrote.

“Health care is a basic human right,” Brawley wrote. “While many blacks get superb health care, being black in America means one is less likely to receive quality care and more likely to have a bad outcome. Schmid and colleagues show this in localized prostate cancer, and it is likely true for other diseases.

“This is an ethical issue,” he added. “This is an issue of social injustice and a very unsettling point. Adequate high-quality care for all, regardless of race and social status, should be a priority for medicine and for society in general if this country is to reach its maximal potential.” – by Jennifer Byrne

Disclosure: Schmid reports no relevant financial disclosures. Please see the full study for all other researchers’ relevant financial disclosures. Brawley reports no relevant financial disclosures.

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Sources/Disclosures

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Source:

Schmid M. JAMA Oncol. 2015;doi:10.1001/jamaoncol.2015.3384

Brawley OW. JAMA Oncol. 2015;doi:10.1001/jamaoncol.2015.3615.