Black men far less likely than white men to undergo prostate cancer surgery amid pandemic
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Black men with untreated, nonmetastatic prostate cancer appeared significantly less likely than their white counterparts to undergo prostatectomy during the first wave of the COVID-19 pandemic, according to a study published in JAMA Oncology.
Results of the multicenter, retrospective cohort study suggest systemic inequities exist within health care and likely are applicable across specialties, researchers concluded.
“The study was prompted by early reports showing that minority populations were disproportionately adversely affected by the COVID-19 pandemic,” Andres F. Correa, MD, assistant professor in the division of urology and urologic oncology in the department of surgical oncology at Fox Chase Cancer Center, told Healio. “As a result, we aimed to assess how a significant stressor, such as the lockdown, affected delivery of prostate cancer care within the region.”
Correa and colleagues used the Pennsylvania Urologic Regional Collaborative — a prospective collaborative of 11 urology practices in Pennsylvania and New Jersey — to compare prostatectomy rates among Black vs. white men with untreated nonmetastatic prostate cancer during the start of COVID-19 pandemic, from March 16 to May 15, 2020 (n = 269) and during the same period a year earlier, from March 11 to May 10, 2019 (n = 378). Among all 647 men, 26.6% were Black and 73.4% were white.
Correa and colleagues defined the primary outcome as the difference in surgical management of untreated nonmetastatic prostate cancer between Black men and white men during the lockdown.
Results showed that during the initial pandemic lockdown, only 1.3% of Black men underwent prostatectomy compared with 25.9% of white men (P < .001), despite similar COVID-19 risk factors and biopsy Gleason grade groups, and comparable prostatectomy rates before the pandemic. In the pre-pandemic reference cohort, researchers observed no difference in the rate of prostatectomy among white (19.1%) and Black (17.7%) men.
Researchers also found Black men had higher median PSA levels prior to biopsy (8.8 ng/mL vs. 7.2 ng/mL; P = .04).
“Unfortunately, we were honestly not surprised to find that Black [men with prostate cancer] were less likely to undergo nonemergent surgery during the pandemic lockdown,” Correa said. “Prostate cancer treatment can be safely deferred up to a year and, thus, during that initial period of great uncertainty, we expected to see a decline in prostate cancer surgery for all patients. However, the differential decrease was notable, as it demonstrated that routine health care was more greatly restricted for certain communities.”
Black men were 94% less likely to undergo surgery during the pandemic compared with Black men in the pre-pandemic reference cohort (OR = 0.06; 95% CI, 0.01-0.35) and 97% less likely compared with white men during the lockdown (OR = 0.03, 95% CI, 0.004-0.25).
Meanwhile, among white men, the likelihood of surgery was not significantly different during vs. prior to the pandemic (OR = 1.41; 95% CI, 0.81-2.44).
The disparities continued after the initial lockdown, Correa said.
“We were surprised not to see an increased rate of prostatectomies being performed in Black men once the lockdown was lifted, and all sites return to near-baseline surgical volume,” he said. “The lack of a rebound in prostatectomy rates demonstrates the lack of a robust safety net for minority populations following emergency situations that would allow them to prioritize their health over other competing essential needs (housing, food, child care, etc.).”
Researchers reported that changes in volume varied by site, from a 33% increase to complete shutdown, and sites that cared for more Black patients were affected most by the lockdown. At the top 2 most affected practice sites, 40.5% of patients were Black, whereas 81.7% of patients at three less-affected hospitals were white, according to the researchers.
“This study highlights the structural biases that affect minority communities on a regular basis, which were further amplified by an emergency event such as the COVID-19 pandemic,” Correa said. “As we continue to navigate cancer care during an ongoing pandemic, as an oncological community we need to further leverage our resources to establish outreach programs aimed to leveling the playing field for minority communities.”
Correa noted that the study was limited to men already diagnosed with prostate cancer and, thus, integrated into the health care system. He said the results may have been even more pronounced for underinsured or uninsured men and that further research is needed.
The data from Correa and colleagues “are consistent with other research demonstrating how the COVID-19 pandemic disproportionately affects poor Black, Indigenous and Hispanic communities,” Randy A. Vince Jr., MD, MS, Society of Urologic Oncology fellow in the urology department at University of Michigan, wrote in an accompanying editorial.
Vince also noted that similar unintended consequences occurred in government relief efforts during the pandemic.
“In an analysis of Coronavirus Aid, Relief, and Economic Security (CARES) Act funding conducted by the Kaiser Family Foundation, hospitals receiving the top 10% of private insurance funding received more than double the relief funds per patient bed than hospitals receiving the lowest 10% of private insurance revenue,” Vince wrote. “This is just one example of how policies may exacerbate the disparities that extend past those uncovered in the article by Bernstein and colleagues.”
References:
Bernstein AN, et al. JAMA Oncol. 2021;doi:10.1001/jamaoncol.2021.2755.
Vince R. JAMA Oncol. 2021;doi:10.1001/jamaoncol.2021.2750.
For more information:
Andres F. Correa, MD, can be reached at Division of Urologic Oncology, Fox Chase Cancer Center, 300 Cottman Ave., Philadelphia, PA 19111; email: andres.correa@fccc.edu.
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